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Cancer and Emergency Medicine: Setting the Research Agenda: Report From an OECR-NCI Working Group

March 25-26, 2015

Executive Summary

The Office of Emergency Care Research (OECR) and the Epidemiology and Genomics Research Program of the National Cancer Institute (NCI) convened a working group to identify research opportunities and scientific priorities related to oncologic emergencies managed in the emergency department (ED).  Participants included clinicians and researchers working in oncology, emergency medicine and palliative care, as well as NIH representatives from NCI, OECR and the National Institute of Nursing Research (NINR). The working group identified a series of research questions related to each of the session topics.

Session 1: National Data on Cancer Care in the Emergency Department
The prevalence of all cancers in the U.S. is about 13.7 million cases.  The most common cancers are prostate, breast, lung, colorectal and melanoma. Data were presented about the ED use of patients with cancer, using the National Hospital Ambulatory Medical Care Survey (NHAMCS) and the Nationwide Emergency Department Sample from the Agency for Healthcare Research and Quality. 

ED visits of patients with cancer make up about 3 percent of all ED visits; however, the admission rate for this group of patients is 55 percent, compared with an admission rate of about 16 percent for the general ED population. For cancer patients presenting to the ED, the most common chief complaints were shortness of breath and abdominal pain.

Data from Medicare claims nationwide reveal that in the 6 months before death, ED utilization increases.  It is predicted that only 50 percent of cancer patients will enroll in hospice care prior to death, and this does not increase the closer the patient is to death.

Research Questions:

  • How can we improve the quality and availability of epidemiological data to study ED utilization by patients with cancer?
  • How do we define “cancer-related ED visit” or who is a “cancer patient?”
  • How can we use electronic health records to better capture ED diagnoses and quality data?
  • Can a cancer-specific field added to the NHAMCS be used to obtain better data?
  • How are cancer patients sent to the ED? What role does their health system, oncologist or primary care doctor play in these visits?
  • What is the role of ED observation units in the care of cancer patients as compared to the general ED patient population?
  • Other than the wide difference in admission rates, how do the data from cancer-specific ED visits differ from data on overall ED visits?
  • What is the role of free-standing EDs in addressing these research questions?
  • Can data collected about ED utilization by cancer patients be harmonized with other common data elements, such as the efforts supported by NINR and NCI?
  • Do ED interventions improve oncologic emergency outcomes?

Session 2: Febrile Neutropenia: Current Practice, Gaps in Evidence and Barriers to Translation
Febrile neutropenia (FN) occurs in 10 to 30 percent of chemotherapy patients, and the mortality rate is 3 to 10 percent. Several guidelines on the clinical care of FN have been developed nationally and internationally, but adherence varies widely.  In addition, therapies of uncertain value (like granulocyte-colony stimulating factor) are widely utilized.

The median time to antibiotic delivery in the ED varies greatly, and guidelines on timing are inconsistent and vague. It is challenging to deliver antibiotics within some of the recommended time-frames in busy EDs.  It is also uncertain whether the timing and/or the choice of antibiotic is key to improved outcomes.  Delayed antibiotic administration in FN seems to be related to longer hospital stays, but the effect on mortality is not clear. There are many other potential confounders, including the effect of severity of illness.

Severity of illness is confounding in that sicker patients tend to receive antibiotics earlier. But these patients also tend to have worse outcomes. Together, these facts may lead to the erroneous conclusion that antibiotics cause worse outcomes.

Studies from in-patient data demonstrate that in low-risk patients, antibiotics reduce non-routine discharge and in-hospital mortality. In high-risk patients there is no association with treatment and outcomes.

Neutropenia in solid tumors and blood cancers are very different situations, and risk stratification is very important. The time to get results from a blood test should be part of a hospital’s core measures.

Research Questions:

  • Is early antibiotic administration for FN the key factor in patient outcomes?  We need better data on whether early antibiotics (e.g., administered within one hour in the ED) are really needed.
  • What are the ED barriers that prevent the prompt administration of antibiotics?
  • What are the different definitions of FN that EDs are using?
  • Are there markers (other than neutrophil count) that indicate which patients should get early antibiotics?
  • What is the ideal disposition of the non-neutropenic patient with fever?
  • Have existing risk-stratification tools been validated in the ED?  What are the barriers to implementing risk-stratification tools in the ED?
  • Can we perform a number needed to treat (NNT) analysis?
  • Are there point-of-care biomarkers for FN that could be used earlier than a CBC differential?
  • Is there a role for other markers (e.g., pro-calcitonin) for risk stratification?
  • Is there a relationship between time to antibiotics for FN and ED crowding?

Session 3: Acute Events in ED Cancer Care
Pain is a leading reason for ED visits by cancer patients. Despite this, there is little research on ED cancer pain, and few published studies. Patients often have a mixed type of pain—nociceptive and neuropathic—which makes it more difficult to treat. 

There is no consensus on the definition of breakthrough pain, and it is unclear which are the best tools to assess its severity. Overall, there seem to be no clear difference in effect among morphine, oxycodone and hydromorphone. As a result, frequent ED re-evaluations are needed and titration orders are useful.

Shortness of breath accounts for 12 percent of cancer patients’ chief complaints when presenting to the ED. Dyspnea can be caused by the tumor or chemotherapy treatment and requires quick assessment. 

Medicare data show that pulmonary embolism (PE) is under-diagnosed in the ED, and that 35 percent of those with a PE have a prior cancer diagnosis. In one study of unexpected deaths following ED visits, the complaint of dyspnea had a one of the highest risk ratios. 

Workshop attendees also identified evidence gaps associated with other acute, cancer-related events presenting to the ED, specifically, spinal cord compression, seizures related to brain lesions and thrombosis.  

Research Questions:

  • What is the impact of cancer pain on ED utilization?
  • What are the barriers, skills and attitudes of emergency care providers in the treatment of cancer pain?
  • What is the impact of ED use on quality of life and longevity among cancer patients?
  • Can EDs take best practices for the treatment of sickle cell pain and apply them to the treatment of cancer pain?
  • Are non-ED breakthrough pain methods valid and feasible in the ED environment?
  • Can we develop clinical rules for cancer patients with dyspnea?
  • How can we incorporate patients into decision-making?
  • What are the best interventions for dyspnea?
  • Is there a standard steroid regimen for spinal cord syndrome? How can we use risk stratification to determine which cancer patients with back pain need a spinal MRI?
  • What is the best approach to starting anti-seizure medications in the ED for cancer patients with known or suspected brain lesions?
  • Are there racial or socio-economic gaps in the treatment of cancer patients?

Session 4: Cancer Palliative Care in the ED—Health Care Utilization and Patient Management
There are four ways to die (sudden death, organ failure, frailty, and terminal illness) and each has its own trajectory. For patients in the final stages of a terminal illness, palliative care is an option.

Palliative care is a subspecialty of emergency medicine. There are about 113 ED physicians who are also trained in palliative care, and several emergency physicians now lead this field.

Since its 2013 Choosing Wisely campaign, the American College of Emergency Physicians has encouraged the early referral of appropriate ED patients to palliative care or hospice. Most EDs in the U.S. do not have access to a hospital-based hospice care service, but there are community hospice providers in most communities.

One recent, randomized controlled trial allocated ED patients with advanced cancer to either early referral to palliative care, or usual care. There was no difference in longevity, which should help allay fears that palliative care results in a shorter life.

NINR supports studies of efficacy and is eager to support quality pragmatic trials in this area.

Research Questions:

  • Does palliative care initiated in the ED improve care quality?
  • How does the ED most effectively link with palliative care services across the continuum to improve outcomes?
  • What are the EMS experiences with palliative care that can inform utilization in the ED?
  • How do ED-community hospice partnerships benefit patients?
  • How do we best manage withdrawal of care or removing interventions started in the ED?

Next Steps

  • NCI is establishing a national research consortium to address some of these issues.
  • A white paper reporting on the research agenda will be submitted for publication.

Staff Contacts
Nonniekaye Shelburne, MS, CRNP, AOCN(r)
Program Director, Clinical and Translational Epidemiology Branch,
National Cancer Institute

Jeremy Brown, MD
Office of Emergency Care Research
National Institute of General Medical Sciences

This page last reviewed on April 20, 2015