Emergency 2016; 4 (3): 145-150 OR I G I N A L RE S E A RC H Epidemiology and Death-Related Factors of Oncology Pa- tients in Emergency Department Bahram Mofid1, Kambiz Novin1, Elham Sadat Roointan1, Mohammad Mehdi Forouzanfar2∗ 1. Department of Radiation Oncology, Shohadaye Tajrish Hospital, Shahid Beheshti University of Medical sciences, Tehran, Iran. 2. Emergency Department, Shohadaye Tajrish Hospital, Shahid Beheshti University of Medical sciences, Tehran, Iran. Received: May 2015; Accepted: September 2015 Abstract: Introduction: Accurate diagnosis and proper treatment of oncology patients presented to emergency depart- ment (ED) can dramatically enhance their quality of life and decrease their mortality rate. Therefore, the present study aimed to evaluate these patients from an epidemiologic point of view as well as identifying death-related factors. Methods: In this retrospective cross-sectional study, all the oncology patients presented to ED during one year were evaluated using census sampling. A checklist that consisted of clinical and demographic data as well as patients outcome was filled for each patient. Using SPSS 21, multivariate stepwise logistic regression analysis was done to identify independent death-related factors. Results: 568 patients with the mean age of 53.64 ± 18.99 years were studied (56.5% male). The most common locations of tumor were brain (32.7%) and gastrointestinal tract (27.1%). Pain (32.5%) was the most frequent chief complaint on ED arrival. The over- all mortality rate of studied patients was 154 (27.1%), 25 (16.2%) of them in ED. Among the evaluated factors, marital status, visiting on a weekday, arrival to ED via ambulance, type of cancer, stage of cancer, presence of metastasis, being under treatment with chemo-radiotherapy, chief complaint on arrival, tumor location, and admission to intensive care unit (ICU) correlated significantly with in-hospital mortality. Conclusion: The most common type of cancer in the studied patients was solid, located in the brain or gastrointestinal tract, in stage III and IV, metastatic, and under chemo-radiotherapy. Independent death-related factors included ICU admission, presentation with loss of consciousness or bleeding, arrival via ambulance, cancer stage > II, neuroendocrine and genitourinary location of cancer, and being under chemo-radiotherapy. Keywords: Oncology service, hospital; hospital mortality; epidemiology; emergency medicine © Copyright (2015) Shahid Beheshti University of Medical Sciences Cite this article as: Mofid B, Novin K, Roointan ES, Forouzanfar MM. Epidemiology and Death-Related Factors of Oncology Patients in Emer- gency Department . Emergency. 2016; 4(3):145-150. 1. Introduction C ancer is the second cause of death behind cardiovas- cular diseases, worldwide (1). Based on the report of international agency for research on cancer (IARC) in GLOBOCAN 2012, the most common location and high- est mortality rate belongs to pulmonary cancer in men and breast cancer in women. Based on the same report, risk of developing cancer before the age of 75 years old is 18.5% for both sexes, while the risk of mortality due to cancer is 10.5% in the same age range. IARC reported the most com- mon cancers in both sexes to be pulmonary, breast, colorec- ∗Corresponding Author: Mohammad Mehdi Forouzanfar; Emergency De- partment, Shohadaye Tajrish Hospital, Tajrish Square, Tehran, Iran; Tel/Fax: 00989123708649; Email: drfrouzanfar@yahoo.com. tal, prostate, and gastric cancers, in the mentioned order (2). Developing new treatment strategies for cancer patients has led to an increase in their life-span and frequency of emer- gency department (ED) visits (3). ED is one of the most im- portant places for rapidly addressing the complaints of these patients. Most of these patients visit ED at least once over the course of their disease (4). Recently, many studies have been done to evaluate the different aspects of oncology pa- tients in ED (1, 3–11). Accurate diagnosis and proper treat- ment of these patients in ED can dramatically enhance their quality of life and decrease their mortality rate (8). Having enough epidemiologic data and a proper plan for managing these patients in ED are necessary for reaching this purpose. Therefore, the present study was designed, aiming to evalu- ate oncology patients presented to ED from an epidemiologic point of view as well as identifying death-related factors. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com drfrouzanfar@yahoo.com Mofid et al. 146 2. Methods 2.1. Study design and setting In the present retrospective cross-sectional study, all the on- cology patients presented to the ED of Shohadaye Tajrish Hospital, Tehran, Iran, during one year from April 2014 to March 2015, were evaluated using census sampling. No age or sex limitations were implemented in this study. If the pa- tient died on their way to the hospital, they were excluded. The present study was approved by the Ethics Committee of Shahid Beheshti University of Medical Sciences. All the re- searchers adhered to the principles of Helsinki Declaration during the course of the study. 2.2. Data gathering A checklist that consisted of demographic data (age, sex, marital status, living area, employment), type of arrival to ED, day and time of ED visit, history of visits, patient complaints on arrival, cancer characteristics (type, location, stage, pres- ence and location of metastasis), special treatment charac- teristics (chemotherapy, radiotherapy, chemo-radiotherapy), and ED disposition and final outcome (discharge from ED, hospitalization in oncology ward or intensive care unit (ICU), mortality) was filled for each patient. The data were extracted from the patients clinical profiles. By searching in the med- ical records unit, all dead, hospitalized, and discharged on- cology patients in ED were evaluated. 2.3. Statistical analysis All statistical analyses were done using SPSS version 21. Qualitative variables were reported as frequency and per- centage, and quantitative ones as mean and standard devia- tion. Chi square and Fisher’s tests were used to identify vari- ables that had significant correlation with mortality. In ad- dition, multivariate stepwise logistic regression analysis was done on significant factors to identify independent death- related factors. Type I error (a) was considered 0.05. 3. Results 568 patients with the mean age of 53.64 ± 18.99 years (2– 94) had visited during the study period (56.5% male). 500 (88%) patients experienced their first visit and 367 (64.7%) were presented in the night shift. 372 (65.5%) patients ar- rived at the ED in a private car. The most common location of tumor were brain (32.7%) and gastrointestinal (27.1%). 247 (43.5%) of the tumors were metastatic. Tables 1 and 2 depict the baseline characteristics of the patients based on their sur- vival. In addition, table 3 summarizes the final outcome of the patients. The overall mortality rate of studied patients was 154 (27.1%), 25 (16.2%) of them in ED. Among the eval- uated factors marital status (p = 0.009), visiting on a week- day (p = 0.044), arrival to ED via ambulance (p < 0.001), type of cancer (p = 0.048), stage of cancer (p < 0.001), pres- ence of metastasis (p < 0.001), being under treatment with chemoradiotherapy (p < 0.001), chief complaint on arrival (p < 0.001), tumor location (p = 0.04), and hospitalization in ICU (p < 0.001) correlated with inhospital mortality (tables 1 and 2). Table 4 shows the results of stepwise logistic regres- sion analysis. 4. Discussion Based on the results, the most common type of cancer in the studied patients was solid (94.5%), located in the brain (32.7%) or gastrointestinal tract (27.1%), in stage IV (50.4%), metastatic (43.5%), and under treatment with chemoradio- therapy (49.9%). Finally, 154 (27.1%) patients had died (16.2% in ED) and more than 90% of those who had visited ED had needed hospitalization in the oncology ward. The in- dependent death-related factors were hospitalization in ICU, ED presentation with loss of consciousness or bleeding, ar- rival via ambulance, cancer stage > II, neuroendocrine and genitourinary location of cancer, and being under chemo- radiotherapy. Currently, despite the advances in cancer treatment, it is still a major health problem and cancer patients commonly face medical emergencies and unexpected life-threatening dis- eases (3, 12). These patients are most commonly admitted to ED for decreasing the cancer-related symptoms, controlling treatment side effects, oncology emergencies, simultaneous diseases, or palliative care (7, 13, 14). Mean age of oncology patients visiting the ED has been estimated to be between 60 to 68 years in various studies (1, 11, 15, 16). In the present study, mean age of patients was 53.64±18.99 years (2–94) and most were in the 50–75 age range. Regarding sex distribution, the findings of the present study were in line with previous studies (4, 7, 8). Epigastric pain, nausea and vomiting, and shortness of breath are among the frequent reported causes of ED visit in previous studies (7, 8, 11). While, in the present study, the most common chief complaint of the patients on ED admis- sion was pain, which is in line with the findings of Kraft Ro- vere et al., Mayer et al., and Barbera et al. (7, 9, 10, 15). In the present study, most cancers were solid (73.7%), which is similar to the Bozdemir et al. study result (88%) (11). The most common location of tumor in our study was brain (32.7%), followed by gastrointestinal tract (27.1%). The most frequent reported tumor locations are lung, gastrointestinal, and respiratory tracts in similar studies (1, 4, 7, 9–11). Out of the 568 cancer patients presented to the ED, 90.3% were subsequently hospitalized in the oncology department, 5.3% were discharged, and 4.4% died. Death rate in the ED was estimated to be 8-9% in various studies (4, 8). Lower ED mor- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com 147 Emergency 2016; 4 (3): 145-150 Table 1: Comparison of baseline characteristics between survived and dead patients Variable Total Survival Death P value Sex Female 247 (43.5) 178 (72.1) 69 (27.9) 0.385 Male 321 (56.5) 236 (73.5) 85 (26.5) Age (year) 1–24.9 39 (6.8) 33 (84.9) 6 (15.4) 0.003 25–49.9 173 (30.4) 136 (78.6) 37 (21.4) 50–74.9 271 (47.7) 195 (72) 76 (28) 75–99.9 85 (14.9) 50 (58.8) 35 (41.2) Marital status Single 63 (11.1) 54 (85.7) 9 (14.3) 0.009 Married 505 (88.9) 360 (71.3) 145 (28.7) Employment Employed 316 (55.6) 229 (72.5) 87 (27.5) 0.961 Unemployed 240 (42.3) 176 (73.3) 64 (26.7) Time of arrival Day 200 (35.2) 140 (70) 60 (30) 0.236 Night 367 (64.7) 274 (74.7) 93 (23.3) Day of arrival Weekend 88 (15.5) 57 (64.8) 31 (35.2) 0.044 Weekday 480 (84.5) 357 (74.4) 123 (25.6) Living area Urban 550 (96.8) 399 (72.5) 151 (27.5) 0.235 Rural 18 (3.2) 15 (83.3) 3 (16.7) Transportation to ED Ambulance 182 (32) 70 (38.5) 112 (61.5) < 0.001 Private car 372 (65.5) 334 (89.8) 38 (10.2) Number of ED visits 1 500 (88) 360 (72) 140 (28) 0.3332 64 (11.3) 50 (78) 14 (21.9) 3 3 (5) 3 (100) 0 (0) Type of cancer Solid 537 (94.5) 396 (73.7) 141 (26.3) 0.048 Hematologic 31 (5.5) 18 (58.1) 13 (41.9) Stage of cancer I 29 (5.1) 27 (93.1) 2 (6.9) < 0.001II 100 (17.6) 96 (96) 4 (4) III 128 (22.5) 102 (79.7) 26 (20.3) IV 286 (50.4) 167 (58.4) 119 (41.6) Multiple cancers Yes 32 (5.6) 23 (71.9) 9 (28.1) 0.517 No 536 (94.4) 391 (72.9) 145 (27.1) Metastasis Positive 247 (43.5) 147 (59.5) 100 (40.5) < 0.001 Negative 320 (56.3) 266 (83.1) 54 (16.9) Treatment Chemotherapy 140 (24.6) 95 (67.9) 45 (32.1) < 0.001Radiotherapy 32 (5.6) 22 (68.8) 10 (31.3) Chemo-radiotherapy 59 (57.3) 178 (72.1) 44 (42.7) None 293 (51.6) 238 (81.2) 55 (18.8) tality rate (4.4%) in the present study might be due to rapid disposition of the patients to other wards and their higher rate of hospitalization. In other words, ED mortality rate has decreased in return to a rise in other wards mortality rate. Based on the findings of the present study, independent death-related factors in this study included hospitalization in ICU, visiting due to loss of consciousness or bleeding, arrival via ambulance, higher stage of cancer, tumor type, and being This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com Mofid et al. 148 Table 2: Comparison of baseline characteristics between survived and dead patients (continued) Variable Total Survival Death P value ICU admission Yes 20 (3.9) 6 (30) 14 (70) < 0.001 No 482 (24.1) 371 (77) 111 (23) ED chief complaints Fever 12 (2.1) 11 (91.7) 1 (8.3) < 0.001 Loss of consciousness 132 (23.2) 65 (49.2) 67 (50.8) Respiratory distress 51 (8.9) 30 (58.8) 21 (41.2) Gastrointestinal disorder 42 (7.3) 35 (83.3) 7 (16.7) Pain 185 (32.5) 149 (80.5) 36 (19.5) Focal neurologic deficit 91 (16.0) 81 (89) 10 (11) Bleeding 16 (2.8) 12 (75) 4 (25) Ulcer 13 (2.2) 8 (61.5) 5 (38.5) Mass 22 (3.8) 21 (95.5) 1 (4.5) Extremity edema 4 (0.7) 2 (50) 2 (50) Tumor location Brain 186 (32.7) 156 (83.9) 30 (16.1) < 0.004 Breast 56 (9.9) 40 (71.4) 16 (28.6) Prostate 31(5.5) 18 (58.1) 13 (41.9) Gastrointestinal 154 (27.1) 106 (68.8) 48 (31.2) Respiratory 24 (4.2) 15 (62.5) 9 (37.5) Genitourinary 79 (13.9) 51 (64.6) 28 (35.4) Lymphoma 4 (0.7) 4 (100) 0 (0) Skin 4 (0.7) 3 (75) 1 (25) Neuroendocrine 20 (3.5) 15 (75) 5 (25) Liposarcoma 1 (0.2) 0 (0) 1 (100) Bone 3 (0.5) 3 (100) 0 (0) Neck 2 (0.4) 2 (100) 0 (0) Heart 1 (0.2) 0 (0) 1 (100) Cholangiocarcinoma 2 (0.4) 1 (50) 1 (50) Muscle 1 (0.2) 0 (0) 1 (100) Location of metastasis Brain 21 (9) 13 (61.9) 8 (38.1) < 0.332 Bone 36 (15.5) 28 (77.8) 8 (22.2) Lung 36 (15.5) 22 (61.1) 14 (8.1) Multiple 57 (24.5) 24 (42.1) 33 (57.9) Pleura 7 (3.0) 5 (71.4) 2 (28.6) Uterus 3 (1.2) 3 (100) 0 (0) Bladder 4 (1.7) 2 (50) 2 (50) Liver 47 (20.2) 28 (59.6) 19 (40.4) Pancreas 3 (1.2) 2 (66.7) 1 (33.3) Kidney 4 (1.7) 2 (50) 2 (50) Rectum 1 (0.4) 0 (0) 1 (100) Peritoneum 3 (1.2) 2 (66.7) 1 (33.3) Colon 3 (1.2) 2 (66.7) 1 (33.3) Pelvic organs 1 (0.4) 1 (100) 0 (0) Stomach 1 (0.4) 1 (50) 1 (50) Abdominal 2 (0.8) 1 (50) 1 (50) Neck 2 (0.8) 2 (100) 0 (0) ED: emergency department; ICU: intensive care unit. under chemo-radiotherapy. As can be seen, most of these factors are related to severity of disease on admission. For instance, in the studied ED, most of the patients who had ar- rived via an ambulance were in a worse condition compared to those who had arrived by themselves or accompanied by relatives, and therefore died more. On the other hand, pa- tients in a more severe condition were more commonly ad- mitted to ICU and naturally had a higher death rate. It seems that patients who visited the studied ED were simi- lar to the participants of other studies from an epidemiologic This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com 149 Emergency 2016; 4 (3): 145-150 Table 3: Outcome of the studied patients Outcome Number (%) Emergency ward Discharge 30 (5.3) Death 25 (4.4) Hospitalization 513 (90.3) Oncology ward Discharge 384 (74.9) Death 129 (25.1) Table 4: The results of multivariate stepwise logistic regression analysis Variables Odds ratio (95% CI) P value ICU admission Yes 4.90 (1.36- 160.61) 0.027 Chief complaint Loss of consciousness 3.01 (1.66- 5.44) < 0.001 Bleeding 5.20 (0.98- 27.60) 0.052 Transportation to ED Private car 0.09 (0.5- 0.17) < 0.001 Stage of cancer II 0.17 (0.05- 0.53) 0.002 Treatment Chemo-radiotherapy 2.16 (1.15- 4.04) 0.016 Tumor location Neuroendocrine 4.46 (1.05- 18.94) 0.043 Genitourinary 3.85 (1.78- 8.29) 0.001 CI: confidence interval; ICU: intensive care unit. point of view and the differences present are a result of the natural differences in hospitals regarding patient admission policies and available specialties. Multi-centric studies can be helpful in this respect. We should be cautious about us- ing the results of this study since the study design has some limitations for this kind of conclusion. 5. Conclusion Based on the results, the most common type of cancer in the studied patients was solid, located in the brain or gas- trointestinal tract, in stage III and IV, metastatic, and under chemo-radiotherapy. The factors correlating with hospital mortality included hospitalization in ICU, ED presentation with loss of consciousness or bleeding, arrival via ambulance, cancer stage > II, neuroendocrine and genitourinary location of cancer, and being under chemo-radiotherapy. 6. Appendix Acknowledgements The authors appreciate the insightful cooperation of Emer- gency Department staff. Author contribution All authors passed four criteria for authorship contribution based on recommendations of the International Committee of Medical Journal Editors. Funding None. Conflict of interest None. 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