Understanding oncologic emergencies and related emergency department visits and hospitalizations: a systematic review

Abstract

Background

Patients with cancer frequently visit the emergency department (ED) and are at high risk for hospitalization due to severe illness from cancer progression or treatment side effects. With an aging population and rising cancer incidence rates worldwide, it is crucial to understand how EDs and other acute care venues manage oncologic emergencies. Insights from other nations and health systems may inform resources necessary for optimal ED management and novel care delivery pathways. We described clinical management of oncologic emergencies and their contribution to ED visits and hospitalizations worldwide.

Methods

We performed a systematic review of peer-reviewed original research studies published in the English language between January 1st, 2003, to December 31st, 2022, garnered from PubMed, Web of Science, and EMBASE. We included all studies investigating adult (≥ 18 years) cancer patients with emergency visits. We examined chief complaints or predictors of ED use that explicitly defined oncologic emergencies.

Results

The search strategy yielded 49 articles addressing cancer-related emergency visits. Most publications reported single-site studies (n = 34/49), with approximately even distribution across clinical settings- ED (n = 22/49) and acute care hospital/ICU (n = 27/49). The number of patient observations varied widely among the published studies (range: 9 – 87,555 patients), with most studies not specifying the cancer type (n = 33/49), stage (n = 41/49), or treatment type (n = 36/49). Most studies (n = 31/49) examined patients aged ≥ 60 years. Infection was the most common oncologic emergency documented (n = 22/49), followed by pain (n = 20/49), dyspnea (n = 19/49), and gastrointestinal (GI) symptoms (n = 17/49). Interventions within the ED or hospital ranged from pharmacological management with opioids (n = 11/49), antibiotics (n = 9/49), corticosteroids (n = 5/49), and invasive procedures (e.g., palliative stenting; n = 13/49) or surgical interventions (n = 2/49).

Conclusion

Limited research specifically addresses oncologic emergencies despite the international prevalence of ED presentations among cancer patients. Patients with cancer presenting to the ED appear to have a variety of complaints which could result from their cancers and thus may require tailored diagnostic and intervention pathways to provide optimal acute care. Further acute geriatric oncology research may clarify the optimal management strategies to improve the outcomes for this vulnerable patient population.

Introduction

Patients with cancer are frequent users of the emergency department (ED), often incurring multiple visits per patient in a given year [1,2,3]. Approximately one-third of patients with cancer have unplanned ED visits and hospitalizations for symptom management of oncologic emergencies [4], including pain, dyspnea, infection, nausea or vomiting, and other disease- and treatment-related complications [5, 6]. Patients with cancer present to the ED with high triage acuity, many of whom exhibit other comorbidities, thus requiring particularly complex care coordination [7,8,9]. Case complexity may particularly motivate ED visits, as unique constellations of social determinants, clinical conditions, health care infrastructure, and local/regional/federal policy interactions may encourage urgent care seeking [9, 10]. In the US, among patients with cancer, higher ED usage is associated with non-White and African American race/ethnicity, older age, male gender, Medicaid or uninsured status, and receipt of < 100 days of palliative care in advanced cases [9, 11]. Additionally, studies observe a diagnosis of depression, comorbidities, combinations of cancer treatments, delays to treatment initiation, and end-of-life (EOL) predict ED visit frequency with a greater proportion of encounters resulting in admission (58–62%) compared to the general population [9, 10, 12,13,14,15,16,17]. The ED, required to address a spectrum of conditions and acuteness, is a centralized setting that frequently provides care for patients with oncologic emergencies.

EDs are essential to addressing patients’ acute medical needs, yet the structure, financing, and resources of acute unscheduled care delivery vary. In the US, settings range from highly resourced, large-volume (> 50,000 annual visits) urban EDs of tertiary academic medical centers to smaller community-based rural EDs [18, 19]. Internationally, systems of emergency medicine (EM) differ vastly. For example, the National ED Inventories (NEDI) project analyzed EDs in Beijing, China, and Quito, Ecuador; the study revealed all surveyed sites were located in a hospital, with the majority having a contiguous layout (i.e., providing medical and surgical care in one area) and triage to service (i.e., ED patients directed to emergency care from non-EM specialties) [20, 21]. Conversely, many Slovenian EDs are non-hospital-based (i.e., located in health centers rather than a hospital) and may be within other specialty units [19, 22]. Despite these different settings, most EDs report a contiguous design, with only 39% using triage to service [19, 22]. Apart from structural variation, disparities in resources exist across the world [23, 24]. Despite international differences, EDs across the globe share the prevalence of high frequency of ED use among patients with cancer [9, 25,26,27]. Essentially, EDs worldwide face oncologic emergencies subject to the ED’s native infrastructure, practice culture, and community policy.

An international increase in cancer cases underscores the need for care assessment and improvement in oncologic emergency treatment. Therefore, we undertook a systematic review to describe the global management of common oncologic emergencies and related hospital care.

Materials and methods

Study design

We conducted a systematic review of the literature, which was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [28].

Eligibility criteria

We included original research articles that examined oncological emergencies and interventions. We included all cancer types and did not require the publications to articulate strict diagnostic criteria or treatment interventions. We excluded non-English-language publications.

Search strategy

Figure 1 illustrates the detailed search strategy. We searched PubMed, Web of Science, and EMBASE healthcare databases for literature published between January 1st, 2003, to December 31st, 2022. A liaison librarian (JM), in collaboration with the research team, developed the publication search strategy to identify publication abstracts corresponding to the following Medical Subject Headings (MeSH) and keywords: oncologic emergencies, emergency medicine, acute care, and cancer. This search strategy was adapted for each database (e.g., EMBASE). A second liaison librarian (DC) performed a peer review of electronic search strategies (PRESS) to refine the search further. Investigators applied the refined search strategy to additional databases which identified 12,491 citations. Investigators imported these results in Covidence (https://www.covidence.org), a web-based software platform for conducting systematic reviews that additionally eliminates duplicate records

Fig. 1

Detailed search strategy for each database

Study selection

Studies were included if they were (1) empirical, peer-reviewed original research, (2) focused on adult (≥ 18 years) patients with cancer, (3) on cancer as a primary disease in the ED, ICU, hospital, other urgent or acute care settings, (4) included chief complaints at ED or predictors of ED use and had explicitly defined oncologic emergencies [4]. Investigators excluded: (1) abstracts, literature reviews, editorial reviews/commentaries, conceptual papers, or case reports; (2) studies that explored pediatric populations (as part of or the entire sample), and (3) referenced oncologic emergencies without subsequent clinical address or care focus. A group of 12 reviewers (SY, AH, KA, JK, NW, MH, JB, MW, BGR, SH, CRG, CC) screened records from the initial search of the databases and agreed on studies for inclusion. Each record underwent an initial title/abstract screening and a subsequent full-text screening, with each reference reviewed by at least two coders. The research team resolved discrepancies or ambiguities in coding during consensus meetings.

Data extraction and analysis

A study-specific abstraction coding sheet was developed a priori. The study design, country where the study was conducted, number of sites, whether it was an ED or any other acute care setting (e.g., ICU), number of patients, cause of the ED visit/hospitalization (i.e., oncologic emergency specified), intervention(s) used to treat that oncologic emergency, and the outcomes studied were abstracted. Other extracted data included aim and objectives, methods, study population, nature of oncologic emergencies and intervention used in the ED/hospital, outcome measures, results, and conclusions. Given our focus on various types of empirical studies and the exploratory nature of this review, quality assessment was not performed. However, studies were included only if the publication reported specific oncologic emergencies and/or interventions used in the ED. Figure 2 illustrates the review process.

Fig. 2

PRISMA flow diagram

Results

Description of studies

Table 1 notes study characteristics and Table 2 describes the articles in detail [29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77]. The search strategy identified 12,491 citations about cancer-related emergency visits, of which 49 met inclusion criteria (Fig. 2): 28 retrospective cohort studies, 13 prospective cohort studies, four randomized controlled trials (RCTs), three cross-sectional, and one case–control design. Of the papers reviewed, 18 originated from the Americas, 13 were from Europe, 12 were from Asian countries, two from Australia, and four from multi-national studies (Fig. 3). Most studies were conducted in a single site (n = 34/49), with comparable proportions of ED visits (n = 22/49) and acute care hospital/ICU visits (n = 27/49). The study population size varied widely among the identified studies (range 9 – 87,555 participants), with most studies not specifying the cancer type, stage, or treatment types, and over 63% of studies had an average age ≥ 60 years. The earliest publication meeting the study criteria appeared in 2003, with 84% of the remaining papers published after 2010.

Table 1 Demographics and clinical characteristics of studies (n = 49)

Table 2 Detailed description of studies included (n = 49)

Fig. 3

Location of Studies Included (Note: total number is greater than the sample size due to multi-country studies being listed individually)

Oncologic emergencies

The most common oncologic emergencies or predictors of ED use/hospitalization included infection (n = 22/49), pain (n = 20/49), dyspnea or respiratory symptoms (n = 19/49), gastrointestinal (GI) symptoms, including bowel obstructions (n = 17/49), and treatment-related toxicities (n = 13/49). Interventions within the ED or hospital ranged from pharmacological management with opioids (n = 11/49), antibiotics (n = 9/49), corticosteroids (n = 5/49), and invasive procedures (e.g., palliative stenting; n = 13/49) or surgical interventions (n = 2/49).

Management of infection

Infections included sepsis, febrile neutropenia, and pneumonia. Isolated cytokine release syndrome and sepsis caused by pneumonia, enterocolitis, and skin infections in patients with hematological malignancies were managed with life-saving treatments such as vasoactive drugs, non-invasive ventilation, and corticosteroid therapy [31]. Bou Chebl et al. [34] also addressed sepsis, utilizing interventions including IV fluids, vasopressors, and intubation. Some studies which focused on febrile neutropenia in patients with hematological malignancies [35, 56]did not specify ED interventions, while other studies [42, 65] highlighted antibiotic therapy as a crucial treatment. In patients with bacterial pneumonia, Gudiol et al. (2016) [46] noted the necessity for ICU admission, mechanical ventilation, and targeted antibiotic therapy. Additionally, Grewal et al. [45] emphasized the need for specialty consultations and hospital admissions for infections in cancer patients.

Addressing pain

Pain is a common and debilitating symptom in oncological emergencies, often managed with various analgesic strategies. Mercadante et al. (2010, 2017) [53, 54] reported on the management of pain using opioids such as intravenous morphine, oral morphine, transdermal fentanyl, and oral oxycodone. When comparing the efficacy of intranasal fentanyl (INF) versus intravenous hydromorphone (IVH) for severe pain relief, they report that IVH provided superior pain management [32]. Coyne et al. (2021) [40] and Patel et al. (2017) [58] both discussed opioid therapy for pain management, with Coyne et al. (2021) [40] also mentioning acetaminophen as an adjunct treatment. The use of various medications, including opioids and corticosteroids, provided acute symptom management [52]. When explicitly addressing the palliation of malignant large-bowel obstruction in colorectal cancer, palliative stenting or stoma creation was used by Abelson et al. [29]

Assessment of dyspnea and respiratory symptoms

Dyspnea was a focus of several studies. Chou et al. (2012) [38] examined sepsis-related respiratory failure in stage III and IV lung cancer patients, managing the condition with mechanical ventilation and transferring patients to long-term respiratory care if necessary. Cooksley et al. (2020) [39] addressed dyspnea related to immune checkpoint inhibitor toxicity, using steroids and antibiotics as interventions. In patients with advanced lung cancer, Kim et al. (2014) [50] identified multiple causes of dyspnea, such as obstructive pneumonia and chemo-induced lung toxicity, managed through vasoactive agents, hemodialysis, and mechanical ventilation. Additionally, Yilmaz et al. [77] explored the management of dyspnea in lung cancer patients with salbutamol and magnesium sulfate. Peyrony et al. (2021) [59] reported various supportive measures, including oxygen therapy and mechanical ventilation.

Addressing GI symptoms & bowel obstruction

GI symptoms included bowel obstruction, diarrhea, colitis, and nausea. Abelson et al. [29] and Frago et al. (2010) [43] both studied malignant large-bowel obstruction in colorectal cancer, which was treated with palliative stenting or chemotherapy regimens. Castillo et al. (2021) [36] focused on immune-related adverse events such as colitis and diarrhea, which were managed with corticosteroids including dexamethasone and prednisone. Teimouri et al. [68] also highlighted the use of steroids for managing GI toxicities, including colitis and hepatitis. In patients experiencing GI symptoms in the ED, Delgado-Guay et al. (2015) [41] noted the importance of palliative care consultations. Waddle et al. [71] reported on managing various GI symptoms and associated complications without specifying particular interventions.

Other treatment-related toxicities

Treatment-related toxicities are critical oncological emergencies, often requiring immediate intervention due to their potential severity and impact on patients' quality of life. Castillo et al. (2021) [36] explored immune-related adverse events (irAEs) such as colitis, diarrhea, hyperglycemia, and shortness of breath, managed with irAEs-specific treatments, primarily corticosteroids. Similarly, Teimouri et al. [68] focused on managing toxicities like diarrhea/colitis, hepatitis, pneumonitis, nephrotoxicity, and cardiotoxicity with steroids. In patients experiencing dyspnea, diarrhea, and fever related to treatment toxicity, Cooksley et al. (2020) [39] employed corticosteroids and antibiotics as treatment modalities.

Kim et al. (2014) [50] demonstrated a range of toxicities in lung cancer patients, including chemo-induced lung toxicity and radiation pneumonitis, addressing these conditions with interventions including vasoactive agents, hemodialysis, and mechanical ventilation. They emphasized that this comprehensive approach is vital to managing the acute and potentially life-threatening effects of cancer treatments. Xia and Wang (2016) [74] also reported on severe treatment-related toxicities in solid tumor patients, such as respiratory failure, septic shock, and acute renal failure, which necessitated the use of vasopressors, mechanical ventilation, and renal replacement therapy.

Lagman et al. [52] discussed the acute inpatient management of treatment-related complications, including neutropenic fever and radiation-induced pneumonitis, highlighting the use of various medications, invasive procedures, and supportive care measures to stabilize patients. Additionally, Abelson et al. [29] described interventions for malignant large-bowel obstruction secondary to colorectal cancer treatments, including palliative stenting or stoma creation.

Discussion

We conducted a systematic review of oncological emergencies and related interventions from 49 studies [29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77]. We examined the types and management of oncologic emergency-related ED visits and hospitalizations globally using data from multiple published sources. We observed that reports on oncological emergencies [4] varied widely, addressing infections with antibiotics and supportive care, pain with a range of analgesics, dyspnea with ventilatory support and other respiratory interventions, and GI symptoms with palliative procedures and steroid therapy. These interventions mitigate symptoms, improve quality of life, and reduce the impact on hospitalizations and ED visits worldwide.

Our findings are consistent with previous reports and similarly suggest that patients with cancer are at high risk for unplanned hospital use [78]. We expect ED use for oncologic emergencies to increase substantially in the next decade [79]. With over 63% of our identified articles reporting their total study population at an age over ≥ 60 years, we believe healthcare systems should prepare for an increase in patients requiring focused geriatric and supportive cancer care and management strategies in the ED. In accordance with this, we report that most interventions included lifesaving and often invasive procedures such as intubation, mechanical ventilation, and/or surgical procedures [29, 31, 34, 37, 38, 43, 46, 49, 50, 52, 57, 59, 63, 74]. Other prevalent interventions included steroids and/or antibiotics for infection [31, 34, 38,39,40, 42, 46, 57, 60,61,62,63, 65, 77]. and opioids for when patients presented with severe pain [32, 48, 52,53,54, 58, 59, 66, 72, 76]. With an expected increase in ED use by cancer patients, increased training for emergency department physicians may benefit the flow of oncological patients in the ED. Specifically, we recommend developing physician competency measures which ensures treating physicians are well equipped to provide symptom management and treatment related toxicity care. Although a majority of oncological emergencies presented in this review required an ED visit, further research is required to identify if we can minimize ED use by increasing access to management of emergencies in outpatient facilities.

Pain management remains a central concern in oncologic emergencies, with providers relying heavily on opioids, requiring patients and providers to mutually consider both the palliative benefits and associated risks of dependence and side effects. The use of various opioid formulations and adjunctive therapies such as acetaminophen and corticosteroids points to an ongoing need for optimizing pain control while minimizing adverse effects. Similarly, GI symptoms, including bowel obstruction, were frequently managed with palliative interventions such as stenting or specific chemotherapy regimens. The importance of specialized care, including palliative care consultations, reflected the complex nature of managing gastrointestinal complications during cancer treatment. The resources and time required in the ED to address these GI complications are limited; thus, challenges with exacerbations of complications are a primary concern.

The American Society of Clinical Oncology (ASCO) and National Cancer Institute (NCI) guidelines recommend early integration of palliative care as standard care alongside cancer care for patients with cancer. However, in many cases, palliative care is deferred until the EOL, with referrals often occurring in the last month of life (often in an inpatient setting) or not at all. Only one study [41] mentioned palliative care consultation in the ED and another study [70] reported EOL goals of care discussion. We found that pain is one of the most common reasons patients with cancer visit the ED; hence, providing palliative interventions to meet all their needs, including social and spiritual care, might be beneficial. Most importantly, studies focusing on patients admitted to acute inpatient palliative care units also reported administering invasive diagnostic and treatment procedures [52]. Most of the interventions reported as life-prolonging aggressive care suggest that there is a significant gap globally regarding the integration of palliative care in acute care settings.

This review indicates that while a broad array of treatments is available for managing oncologic emergencies, there is a lack of standardized protocols and guidelines, particularly for new cancer therapies such as immune checkpoint inhibitors. This variability in practice highlights the need for further research to develop evidence-based guidelines that can inform clinical decision-making and improve patient outcomes. A comprehensive, and integrative, approach will be crucial in improving the quality of care and outcomes for cancer patients facing emergencies.

Strengths and limitations

Our study identified diverse interventions used in the ED and other acute care settings for cancer-related concerns. We demonstrated a paramount need for palliative, hospice, and advanced care planning among this population. We have noted the need to strengthen endeavors that promote the integration of palliative care into standard emergency care for patients, especially those with cancer.

We restricted article inclusion to English language reviews and those reviews published in academic journals. Regarding the articles included, most studies did not report cancer type and treatment type, and we are unaware of the time required for intervention from these studies. Thus, we are unable to extrapolate the probability of emergent care according to the cancer type and complication. Most studies were conducted in a single site, which may limit the generalizability of findings due to variations in local healthcare practices, resources, and patient demographics. The heterogeneity in patient populations, with a significant proportion of studies not specifying cancer type, stage, or treatment, suggests a need for more granular data better to understand the specific needs of different patient subgroups.

Conclusions

Patients with cancer rely on the hospital for evaluation and management of disease and treatment-related concerns throughout their illnesses. However, studies reporting on oncologic emergencies are limited. These studies primarily focus on infection, pain, dyspnea, and GI symptoms with treatments including an array of interventions (e.g., opioids, invasive procedures). Most studies included older patients, suggesting that tailored interventions and management strategies are necessary to address the complex care needs (including social and palliative) of older patients with cancer. Further research may clarify the optimal management strategies to improve the outcomes for this vulnerable patient population.