Diagnosing Cancer in the ED ‘Becoming Routine’ in Canada

Despite overall declines in cancer incidence and mortality, population growth and aging are predicted to drive an increase in the absolute number of people receiving a cancer diagnosis this year. Many of those diagnoses will be given in a hospital emergency department (ED), according to Keerat Grewal, MD, an emergency physician at Mount Sinai Hospital and assistant professor at the University of Toronto, Toronto, Ontario, Canada, and Catherine Varner, MD, deputy editor of the Canadian Medical Association Journal.

Receiving a cancer diagnosis in the ED is becoming “routine” in Canada, Grewal and Varner wrote in an editorial published online on May 13. The perception among clinicians is that the proportion of patients being diagnosed with cancer in the ED has “increased substantially” from the 26.1% of patients who received that diagnosis in Ontario between 2012 and 2017.

“These diagnoses are being delivered at a time when EDs across Canada are facing overcrowding and long waits, with patients routinely being seen in hallways and waiting rooms,” Grewal told Medscape Medical News. “This chaotic environment makes it a difficult place to deliver this potentially life-altering news to patients with a suspected cancer diagnosis.

“We do not yet have data to say that diagnosis of cancer in the ED is becoming more common. However, anecdotally, it seems as though we are seeing this more and more,” she added. “We are currently conducting a study to better understand these rates.”

Definitive Diagnosis Rare

“I have essentially diagnosed every form of cancer you can think of at some point in patients in the ED,” Fraser Mackay, MD, chair of the Rural Remote and Small Urban Section of the Canadian Association of Emergency Physicians (CAEP), told Medscape Medical News. “I say diagnosed, but it’s rare that we have a definitive diagnosis. And one of the hardest things is to tell patients, ‘We think this might be an aggressive cancer, but it might not be, and we’re not going to get that answer tonight’. Then you have to manage both the physical symptoms and the psychological impact of that. It happens every few weeks, at least, and often I come across something quite unexpected and quite devastating.”

Howard Ovens, MD, staff emergency physician at Sinai Health and professor of family and community medicine at the University of Toronto’s Temerty Faculty of Medicine, Toronto, Ontario, Canada, has had similar experiences in an urban setting.

“We’ve all made cancer diagnoses in the ED many times,” he told Medscape Medical News. “The times when it weighs most heavily is when circumstances don’t allow me to have a clear next step for the patient. It’s one thing to deal with the emotional aspect of breaking bad news. It’s another thing if it’s complicated by a frustrating, intellectually challenging decision about what to do with and for this person, in terms of their next step.”

Ovens and Mackay, who work in southern New Brunswick, have had cases in which they identified a lesion that was most likely cancerous but did not have tissue to confirm the diagnosis. Often, oncologists are unwilling to see a patient until the cancer has been biopsy-confirmed as a type they are familiar with and that their specialty is equipped to manage.

Most EDs “do not routinely have processes in place to confirm a cancer diagnosis, such as arranging and following up on biopsies or ordering other diagnostic tests that are often necessary for referral to a cancer specialist,” as Grewal and Varner wrote.

The situation is especially difficult in a rural setting, said Mackay. In remote locations in northern Canada, the ED can be as much as 12 hours away from a tertiary center where a patient can get a CT scan or an MRI.

“You have to send them away for that, and, depending on the location, the patient will need resources for transportation,” he said. “Then you have to get the results back, and from there, the patient may need a biopsy or maybe a procedure such as a bronchoscopy. You then have to track the patient down, explain the equivocal findings, arrange a consultation with a specialist who might be in another location, and arrange transport there. Then, especially if the patient doesn’t have a primary care physician, where do those results go?”

Primary Care “Falling Apart”

“Healthcare system issues that fail to adequately support primary care-initiated pathways for the diagnosis of suspected cancer” are among the forces that are likely driving patients with suspected cancer to the ED, said Grewal. “Given challenges with access to primary care, and wait times associated with the diagnostics that are often needed to confirm a cancer diagnosis, patients may require the ED to access care for signs or symptoms that may be related to cancer because they are unable to access timely care elsewhere.”

Mackay agreed. “The difficulty, more and more, is that the healthcare system…we work in isn’t providing the support, and we’re left dealing with patients that we really aren’t set up to deal with. We run into walls very quickly because we are not designed for primary care, and we are not designed for long-term care. But the ED has become the default for an unfortunately large section of our population. This is not an emergency medicine problem at all. It’s simply that the suffering is most visible in the ED.”

“Many cancers are actually becoming either less frequent or less catastrophic because a cancer that 30 years ago was terminal now is treatable in some situations,” he continued. But the absolute numbers of patients with cancer increase as the overall population grows.

“With primary care falling apart around us, there are more and more people with less and less access to healthcare, and so these disease processes evolve further before people seek care,” said Mackay. “By the time they seek care, they come to the ED, and they’re really quite ill. But an advanced cancer is not something we’re really set up to manage.”

What’s Being Done?

Single-entry referral models for patients with suspected cancer may be a solution to facilitate further testing and improve access to specialist follow-up, Grewal and Varney suggested in their editorial. “Patients may not need an emergency department visit at all if access to outpatient clinics that streamline the diagnosis of suspected cancer is increased.”

Indeed, some locations in southern New Brunswick have integrated programs and clinics that can facilitate some of the steps needed to confirm and manage a cancer diagnosis made in the ED, said Mackay. For example, there is a dedicated lung cancer triage group to which ED physicians can send patients with a suspected diagnosis for a CT scan. “Once that’s done, there’s a group of specialists, and we send the referral in, and that’s it,” he said.

Similarly, ED clinicians can make a referral to some clinics in the Toronto area when a diagnosis of lung cancer, breast cancer, or pancreatic cancer is suspected but uncertain, said Ovens. “They will see patients quickly and sort out the next steps,” he said. But such clinics may not exist in other areas of Canada, or they may exist only for other types of cancers, he noted.

When those clinics aren’t available, the ED clinician may try to refer the patient to a generalist. For example, if they see a potential gynecological problem, they may refer the patient to a gynecologist, who could then arrange a biopsy, or to an otolaryngologist for suspected head and neck cancer, said Ovens. However, there may be long wait times for such appointments.

“All EDs should have access to a single, streamlined, and uniform process for any patient with a new suspected diagnosis of cancer,” Grewal and Varney wrote. Furthermore, efforts to increase awareness of early cancer symptoms, reduce barriers to screening, and increase capacity for early diagnoses of cancer in primary care and hospitals are critical.

“In the 19th century, Rudolf Virchow said, ‘Medicine is a social science‘, and we as physicians have the obligation to point out problems and suggest their theoretical solutions,” said Mackay. “But it is the politician who must find the means for that solution.”

In Canada, he said, “Doctors across the country, in emergency medicine and in primary care, have been loud and clear for a long time that we need to be training more physicians.” The job must be made more attractive, and physicians must be provided with needed resources, he added. “Lack of resources, too few hospital beds, all the delays, and lack of access to care are problems that individual physicians have absolutely no ability to impact.”

CAEP recently released the EM:POWER Task Force report The Future of Emergency Care with the goal of taking a leading role in addressing the “dire state” of emergency care across Canada. The report presents context for the problems the ED currently faces, as well as a range of recommended solutions.

Grewal reported funding from the Canadian Institutes of Health Research and the Canadian Association of Emergency Physicians. Varner’s competing interests can be found at www.cmaj.ca/staff. Oven and Mackay reported no relevant financial relationships.

Marilynn Larkin, MA, is an award-winning medical writer and editor whose work has appeared in numerous publications, including Medscape Medical News and its sister publication MDedge, The Lancet (where she was a contributing editor), and Reuters Health.