Keywords
colorectal cancer - emergency department - infections - acute abdomen
Introduction
Colorectal cancer is a common disease. According to the World Health Organization,
this is the third most frequently diagnosed type of cancer in males and the second
in females.[1] It is more common in the sixth and seventh decades of life, and its prevalence is
related to ageing, poor eating habits, smoking, sedentary lifestyle, and obesity.[2]
Nowadays, new forms of treatments—such as radiotherapy for rectal cancer, more-aggressive
resection of metastatic disease, immunotherapy, as well as neoadjuvant and palliative
chemotherapies—have been developed offering new choices to these patients. These new
forms of treatment have almost doubled survival for advanced diseases[3] increasing the need of patient's follow-up by the health staff.
Patients under colorectal cancer treatment may seek the emergency department (ED)
for management of chemotherapy and radiotherapy side effects and for the treatment
of symptoms from the disease itself, such as intestinal obstruction, pain, bleeding,
and surgery complications. According to Caterino et al.,[4] two thirds of ED consultations by cancer patients result in hospital admission,
showing that the ED may act as an important gateway for hospital admissions and help
in the continuum of cancer care.
The studies by Rivera et al.[5] and Mayer et al.[6] have shown that the most common complaints in patients with cancer seeking the ED
are pain, and respiratory or gastrointestinal problems. However, these reasons may
vary according to the type of tumor, the patient's geographical region, and to the
health care offered locally.
Herein, the colorectal cancer patients' frequency and reasons for seeking ED consultation
were studied aiming to obtain information to better prepare the ER staff to meet such
situations. Knowing how cancer patients use EDs is a critical first step to improve
the patient's care. In addition, we compared the differences between genders.
Methods
This is a retrospective study approved by the local Committee of Ethics in Research.
Patients with a confirmed diagnosis of colorectal cancer who attended the ED of a
reference hospital for cancer treatment (Hospital Erasto Gaertner), located in Curitiba,
Southern Brazil, from January to December 2018, were included. The obtained data included
gender, age, disease duration, TNM staging,[7] diagnosis, presence and location of metastases, previous and current treatment,
reasons for seeking the ED, diagnosis, proposed treatment, and discharge from the
ED. Patients with incomplete data in the medical record were excluded.
Data were collected in Microsoft Excel worksheets (Microsoft Corp., Redmond, WA, USA).
The continuous variables were expressed as mean and standard deviation (SD) or median
and interquartile rate (IQR) and compared using the t and Mann-Whitney tests. Categorical
variables were expressed in percentages and compared using the Chi-squared or Fisher
exact test, as appropriate. P-values lower than 5% were considered significant. Tests were performed with the help
of the software GraphPad Prism 6.0 (GraphPad Software Inc., La Jolla, CA, USA).
Results
Four hundred and forty-six patients (221, or 49.5% males, and 225, or 50.5% females)
were included, with ages ranging from 30 to 89 years old (median 63; IQR = 52–70 years).
The rectum was the most common tumor location, and most of the patients had TNM staging
III and IV. Data for the whole sample and the comparison between males and females
is on [Table 1]. This table shows that females were younger, and males had more rectal cancer. Furthermore,
although the number of patients with metastases were similar, males had more lung
metastases (isolated or combined with liver) than females.
Table 1
Studied sample description and comparison between males and females (446 patients
with colorectal cancer)
|
Total
N = 446 (100%)
|
Males
N = 221 (49.5%)
|
Females
N = 225 (50.5%)
|
P (*)
|
|
Median age (years) (IQR)
|
63 (52–70)
|
66 (54–72)
|
60 (50–69)
|
0.0006
|
|
Tumor location
|
|
|
|
0.0002
|
|
Rectum
|
211 (47.3)
|
123 (55.6)
|
88 (39.1)
|
|
|
Rectosigmoid
|
91 (20.4)
|
47 (21.2)
|
44 (19.5)
|
|
|
Right colon
|
76 (17)
|
32 (15.4)
|
44 (19.5)
|
|
|
Left colon
|
40 (8.9)
|
15 (6.7)
|
25 (11.1)
|
|
|
Transverse colon
|
14 (3.1)
|
2 (0.9)
|
12 (5.3)
|
|
|
Not specified
|
14 (3.1)
|
2 (0.9)
|
12 (5.3)
|
|
|
TNM staging
|
|
|
|
0.22
|
|
I
|
7 (1.5)
|
6 (2.7)
|
1 (0.4)
|
|
|
II
|
87 (19.5)
|
42 (19)
|
45 (20)
|
|
|
III
|
148 (33.1)
|
78 (35.2)
|
70 (31.1)
|
|
|
IV
|
147 (32.9)
|
71 (32.1)
|
76 (33.7)
|
|
|
Without staging
|
57 (12.7)
|
24 (10.8)
|
33 (14.6)
|
|
|
Metastasis
|
|
|
|
0.002
|
|
No metastasis
|
296 (66.3)
|
147 (66.5)
|
149 (66.2)
|
|
|
Liver
|
70 (15.6)
|
37 (16.7)
|
33 (14.6)
|
|
|
Lung
|
20 (4.8)
|
13 (5.8)
|
7 (3.1)
|
|
|
Liver and lung
|
18 (4)
|
13 (5.8)
|
5 (2.2)
|
|
|
Peritoneal carcinomatosis
|
9 (2)
|
5 (2.2)
|
4 (1.7)
|
|
|
Liver and peritoneal carcinomatosis
|
7 (1.56)
|
0
|
7 (3.1)
|
|
|
Other
|
26 (5.8)
|
6 (2.7)
|
20 (8.8)
|
|
Abbreviation: IQR, interquartile range.
(*) refers to comparison between males and females.
[Table 2] shows the main complaints in patients seeking the ED and the comparison between
males and females. It shows that females had more lumbar pain and nausea while males
had more bladder symptoms. When the patients' complaints were studied according to
tumor location (colon versus rectum), no differences were found (all with p > 0.05).
Table 2
Main complaints at emergency department in the studied sample and comparison between
male and females
|
Total
446 (%)
|
Males
221 (%)
|
Females
225 (%)
|
P (*)
|
|
Abdominal pain
|
123 (27.5)
|
60 (27.1)
|
63 (28)
|
0.54
|
|
Lumbar pain
|
16 (3.5)
|
2 (0.9)
|
14 (6.2)
|
0.002 [(a)]
|
|
Rectal pain
|
9 (2)
|
3 (1.3)
|
6 (2.6)
|
0.50
|
|
Nausea
|
22 (4.9)
|
6 (2.7)
|
16 (7.1)
|
0.03 [(b)]
|
|
Vomiting
|
7 (1.56)
|
5 (2.2)
|
2 (0.8)
|
0.47
|
|
Diarrhea
|
19 (4.2)
|
10 (4.5)
|
9 (4)
|
0.72
|
|
Constipation
|
13 (2.9)
|
4 (1.8)
|
9 (4)
|
0.12
|
|
Weakness
|
17 (3.8)
|
7 (3.1)
|
10 (4.4)
|
0.42
|
|
Bladder symptoms
|
21 (4.7)
|
17 (7.6)
|
4 (1.7)
|
0.003 [(c)]
|
|
Dyspnea
|
14 (3.13)
|
10 (4.5)
|
4 (1.7)
|
0.09
|
|
Thoracic pain
|
13 (2.9)
|
10 (4.5)
|
3 (1.3)
|
0.08
|
|
Fever
|
14 (3.13)
|
6 (2.7)
|
8 (3.5)
|
0.45
|
|
Complaints on colostomy
|
21 (4.7)
|
12 (5.4)
|
9 (4)
|
0.32
|
|
Complaints on surgical wound
|
13 (2.9)
|
3 (1.3)
|
10 (4.4)
|
0.08
|
|
Change of consciousness
|
13 (2.9)
|
10 (4.5)
|
3 (1.3)
|
0.08
|
(*) – P values refers to comparison between males and females.
(a) OR = 7.2; 95% CI = 1.6–32.3
(b) OR = 2.7; 95% CI = 1.08–6.8
(c) OR = 4.5; 95% CI = 1.5–13.8
Age showed association with abdominal pain (22.6% in those with ≥ 60 years vs 34.2%
in those with < 60 years with p = 0.006; OR = 1.8 (95% CI = 1.1-2.7), weakness (those with ≥ 60 years with 5.4% versus
1.5% in those with < 60 years with p = 0.006; OR = 3.6 (95%CI =1.4–16.5), and problems with surgical wound (those with
≥ 60 years with 4.6% versus 0.5% in those with < 60 years with p = 0.009; OR = 9.3 (95%CI = 1.2–72.1); no other associations were found.
The main diagnosis found in the studied sample are on [Table 3], as well as the comparison of their frequency according to gender.
Table 3
Main diagnosis at emergency department in colorectal cancer patients and comparison
between males and females
|
Total
N = 446
|
Males
N = 221 (%)
|
Females
N = 225 (%)
|
P (§)
|
|
No diagnosis
|
210 (47)
|
−
|
−
|
n/a
|
|
Infections
|
46 (10.3)
|
24 (10.8)
|
22 (9.7)
|
0.54
|
|
Acute abdominal pain
|
41 (9.1)
|
25 (11.3)
|
16 (7.1)
|
0.12
|
|
Complaints on surgical wound
|
18 (4)
|
4 (1.8)
|
14 (6.2)
|
0.01(a)
|
|
Colostomy problems
|
15 (3.3)
|
8 (3.6)
|
7 (3.1)
|
0.78
|
|
Acute diarrhea
|
13 (2. 9)
|
6 (2.7)
|
7 (3.1)
|
0.69
|
|
Chemotherapy side effects
|
9 (2)
|
7 (3.1)
|
2 (0.8)
|
0.10
|
|
Nephrostomy tube problems
|
9 (2)
|
6 (2.7)
|
3 (1.3)
|
0.33
|
|
Thoracic pain
|
8 (1.6)
|
6 (2.7)
|
2 (0.8)
|
0.10
|
|
Cardiac problems
|
7 (1.5)
|
4 (1.8)
|
3 (1.3)
|
0.78
|
|
Gastrointestinal bleeding
|
6 (1.3)
|
2 (0.9)
|
4 (1.7)
|
0.54
|
|
Anxiety
|
6 (1.3)
|
1 (0.4)
|
5 (2.2)
|
0.21
|
|
Acute respiratory insufficiency
|
4 (0.8)
|
2 (0.9)
|
2 (0.8)
|
0.89
|
|
Ascites
|
4 (0.8)
|
4 (1.8)
|
0
|
0.059
|
|
Others
|
50 (11.2)
|
−
|
−
|
|
n/a- not available; (*) – P refers to comparison between males and females.
(a) OR = 3.6; 95% CI = 1.2–10.1.
When the outcomes were compared, the results on [Table 4] were found. Women tended to be discharged back home earlier, while men showed a
tendency towards longer hospitalization.
Table 4
Main outcomes in patients with colorectal cancer that consulted at emergency department
|
Total
N = 446 (%)
|
Males
N = 221 (%)
|
Females
N = 225 (%)
|
P
|
|
Discharged
|
357 (80.0)
|
168 (76.0)
|
189 (84.0)
|
0.03 (*)
|
|
Hospitalization
|
82 (18.3)
|
48 (21.71)
|
34 (15.1)
|
0.07
|
|
Death at the ED
|
5 (1.1)
|
3 (1.35)
|
2 (0.88)
|
0.87
|
|
Sent to another services
|
2 (0.4)
|
2 (0.9)
|
0
|
0.57
|
Abbreviation: ED, emergency department.
P refers to comparison between males and females; (*) - OR = 1.6; 95% CI = 1.02–2.6.
Discussion
The findings of the present survey showed that both males and females with colorectal
cancer, equally, look for consultations at the ED, mainly those with rectal tumor
localization and with advanced disease staging. The most common complaints were abdominal
pain (similarly found in both genders), nausea (seen more frequently in females),
bladder symptoms (more common in males), and problems with the colostomy. The most
common diagnoses were infections and acute abdominal pain, and near 20% of the cases
were admitted to the hospital. Individuals with abdominal pain were younger; those
with weakness and problems with surgical wound were older. These numbers offer important
information on the epidemiological profile of the colorectal cancer patients seeking
ED for consultations as well as the reasons for these consultations contributing to
the understanding of this situation and to establish preventative measures. There
are few studies in the literature in which patients are admitted to the ED with a
diagnosis of colorectal cancer. Most of the available studies evaluate patients who
are diagnosed with colorectal cancer after presenting symptoms in the ED.
Interestingly, a review of 15 other studies has shown that patients with colon and
gynecological cancer are those with higher frequency of ED visits when compared to
patients with cancer in other locations.[8] Currently, among the reasons that drove ED consultations, the most frequently reported
were symptom-related complaints, whose control is important to improve patient's quality
of life. Pain was the leading symptom as found in other works.[5]
[6]
[9]
The use of the ED by individuals with cancer may have negative effects; there is usually
a long waiting time; they may be exposed to infections; and these visits increase
the treatment costs.[10]
[11]
[12] Studies done in the USA[11]
[12] have shown that 30 to 60% of ED visits by individuals with cancer are avoidable.
Therefore, a better care related to symptom control may help preventing such visits.
The prevalence of rectal cancer is lower when compared to that of colon cancer; it
is estimated to be one third of all colorectal cancers.[13] Nevertheless, patients with rectal location of the tumor were those with higher
frequency of ED consultations. Other studies have shown that abdominal pain and obstruction
are more common in patients with colon cancer than in patients with cancer of the
rectum,[14] which may explain the higher rates of emergency presentation in those with colon
cancer. The mainstay of rectal cancer treatment is surgical resection.[15] However, anatomic considerations distinguish rectal cancer from those from the colon;
local narrowing of the pelvis makes surgical resection more difficult, and the lack
of serosa below the peritoneal reflection favors deeper tumor growth, contributing
to locoregional spread.[15] Such differences may favor complications and, consequently, ED visits.
Regarding the outcome found in this study, most patients (80%) progressed to discharge,
similar to what was observed by other authors studying cancer patients treated in
EDs.[11]
[12]
[14] It is believed that these patients, who do not evolve to hospitalization or death,
seek for emergency services in order to have access to drugs not available at other
levels of care, perform low-complexity tests, or for fear of not having effective
outpatient care[12]. Thus, improving guidelines in routine consultations and outpatient follow-up can
be important to prevent visits to the ED. Furthermore, hospital admission after admission
to the ED may be a predictor of increased morbidity and mortality in gastrointestinal
cancer.[16]
This study has limitations; its retrospective nature is one of them. Another limitation
is that a high number of charts did not have the final diagnosis. However, it has
the advantage of studying a particular type of cancer, which highlights the special
needs of this group of patients. It also helps showing the local reality and requirements
to achieve a better cancer care.
Concluding, this study shows that the profile of patients with colorectal cancer seeking
the ED includes advanced disease and similar proportion of males and females. Symptom-driven
complaints were the most frequent reason for consultations. About 80% of patients
were discharged home, while nearly 18% were admitted to the hospital.
