Abstract
BackgroundDiagnosis of cancer as an emergency is associated with poor outcomes but has a complex aetiology. Examining determinants and time trends in diagnostic routes can help to appreciate the critical role of general practice over time in diagnostic pathways for patients with cancer.AimTo examine sociodemographic, cancer site, and temporal associations with type of presentation among patients with cancer diagnosed as emergencies.Design and settingAnalysis of Routes to Diagnosis data, 2006–2015, for patients with cancer in England.MethodThe authors estimated adjusted proportions of emergency presentation after emergency GP referral (GP-EP) or presentation to accident and emergency (AE-EP), by patient sex, age, deprivation group, and year of diagnosis using multivariable regression.ResultsAmong 554 621 patients presenting as emergencies, 24% (n = 130 372) presented as GP-EP, 62% as AE-EP (n = 346 192), and 14% (n = 78 057) through Other-EP sub-routes. Patients presenting as emergencies were more likely to have been GP-referred if they lived in less deprived areas or were subsequently diagnosed with pancreatic, gallbladder, or ovarian cancer, or acute leukaemia. During the study period the proportion and number of GP-EPs nearly halved (31%, n = 17 364, in 2006; 17%, n = 9155 in 2015), while that of AE-EP increased (55%, n = 31 049 to 68%, n = 36 868).ConclusionPatients presenting as emergencies with cancers characterised by symptoms/signs tolerable by patients but appropriately alarming to doctors (for example, pancreatic cancer manifesting as painless jaundice) are over-represented among cases whose emergency presentation involved GP referral. Reductions in diagnoses of cancer through an emergency presentation likely reflect both the continually increasing use of 2-week-wait GP referrals during the study period and reductions in emergency GP referrals.
Highlights
Patients presenting as emergencies were more likely to have been GP-referred if they lived in less deprived areas or were subsequently diagnosed with pancreatic, gallbladder, or ovarian cancer, or acute leukaemia
Patients presenting as emergencies with cancers characterised by symptoms/signs tolerable by patients but appropriately alarming to doctors are over-represented among cases whose emergency presentation involved GP referral
Around one in five patients with cancer are diagnosed as an emergency, which is associated with worse clinical and patient experience outcomes compared with other diagnostic routes; these poorer outcomes are partially explained by later stage at diagnosis and disease-related complications.[1,2,3,4,5]
Summary
Around one in five patients with cancer are diagnosed as an emergency, which is associated with worse clinical and patient experience outcomes compared with other diagnostic routes; these poorer outcomes are partially explained by later stage at diagnosis and disease-related complications.[1,2,3,4,5] Welcome reductions in the proportion of patients with cancer who are diagnosed as emergencies have been reported,[6] but there is uncertainty about the responsible mechanisms involving tumour, patient and healthcare system factors, and how to achieve further reductions.[7,8]. Diagnostic processes leading to emergency presentations can involve general practice in two different ways. About two-thirds of all patients with cancer who are diagnosed as emergencies would have had prior GP consultations with relevant symptoms, often leading to investigations or referrals.[9,10] Second, GPs can be involved in the emergency presentation care episode itself. Examining determinants and time trends in diagnostic routes can help to appreciate the critical role of general practice over time in diagnostic pathways for patients with cancer
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