SAN FRANCISCO — Nearly a quarter of colorectal cancer patients presented to the emergency department in a Canadian study, and those patients tended to be older and sicker than those diagnosed in a physician's office.
Dr. Alex D. Mitchell, of the department of surgery at Dalhousie University in Halifax, Nova Scotia, studied 455 patients undergoing resection for colorectal cancer during a 2-year period. The initial site of presentation was the emergency department (ED) for 108 patients (24%), Dr. Mitchell reported at a symposium sponsored by the American Society of Clinical Oncology. Obstruction was the most common presentation, found in 43% of ED patients, followed by bleeding and/or anemia in 32%, pain in 23%, and other symptoms in 2%.
The mean age of the patients admitted through the ED was 71 years, significantly older than the mean age of 67 in patients admitted nonemergently. No differences were seen between the two groups in patients' socioeconomic status, area of residence, or education.
An intriguing association was found with weight, however. Among 24 patients with a body mass index (BMI) of 40 kg/m
Dr. Mitchell said that in Canada, as in the United States, morbidly obese patients tend to have lower incomes and are less likely to receive colorectal cancer screening and early diagnosis, compared with patients of normal weight. “At present we can only speculate on reasons why obesity is associated with emergency room presentation,” he said in an interview.
“It is highly unlikely that this is a result of differences in tumor biology in obese individuals. It is more likely that this is related to issues with access to care and patient motivation to access care,” he added.
Dr. Mitchell and his associates, including Dr. Geoffrey A. Porter, interim chief of surgery, also considered the possibility that psychological traits that contribute to morbid obesity might play a role in delaying patients from seeking care at the first sign of colorectal cancer symptoms.
Clearly, patients who did present to the emergency department tended to have later-stage disease. Nearly 40% of stage IV patients presented to the ED, compared with just 7% of patients with stage I disease. (See chart.)
Hospital stays were longer among patients admitted through the ED (10 days vs. 8 days), and perioperative mortality rates were greater among ED-admitted patients (7.4% vs. 2.3%).
Previous research has shown that colorectal cancer patients who initially present to the ED have greater 30-day mortality rates and worse 5-year survival rates than do patients diagnosed in a physician's office or clinic.
“The known negative prognostic impact of emergency room presentation, combined with the increased perioperative mortality and length of stay, would suggest a potential benefit to targeted strategies aimed at reducing the use of the emergency room in the diagnosis and treatment of colorectal cancer,” Dr. Mitchell and his colleagues concluded in a poster presentation.
The meeting was also sponsored by the American Gastroenterological Association, the American Association for Therapeutic Radiology and Oncology, and the Society of Surgical Oncology.
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