Draft a memo outlining the readiness of the organization to implement the change strategy: SWOT analysis, discussion of challenges see attached, recommendation.
Healthy Student 
Cancerpatients.pdf
Mini Review
Maryam Beigom Mobasheri1, Rahim Behtar2, Sanambar Sadighi3
A B S T R A C T
According to the studies the rate of emergency departments use among cancer pa- tients exceed those of general population; however, there are differences based on cancer type, initial treatments, socioeconomic status, disease stages, health insurance status and so on. Patients’ symptoms and the severity of complications are varied as well. The emergency departments are actively involved in different stages of cancer management such as primary diagnosis, ongoing treatments and end-of-life period. Cancer patients usually have more serious complications and need more specialized cares at the end of life period, during chemotherapy and surgical treatments. Under- standing the reasons for such visits could be useful in the development of dedicated interventions for preventing unnecessary emergency department visits, which is dis- cussed in this mini-review.
Keywords: Cancer emergency, Emergency Department, Acute cancer representa-
tions, Emergency cancer management, End-of-life care
BCCR 2019; 11(2):103-107
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Received: May 2019 Accepted: June 2019
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Cancer Research Center, Cancer Institute of Iran, Tehran University of Medical Sciences, Tehran, Iran. Medical Emergency Department, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran. Department of Medical Oncology, Cancer Research Center, Cancer Institute of Iran, Tehran University of Medical Sciences, Tehran, Iran.
Challenges with the Emergency Departments Use among Cancer Patients; a Mini Review
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*Corresponding Authors: Maryam Beigom Mobasheri Cancer Research Center, Cancer Institute of Iran, Tehran University of Medical Sciences, Tehran, Iran. Tel: (+98)21 66581638 Email: [email protected]
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INTRODUCTION:
The International Agency for Cancer Research (IARC) reported that 18.1 million new cancer cases and 9.6 million cancer deaths happened in 2018 based on the global cancer statistics with focusing on geographic diversity in 20 regions of the world1. The most common cancers in males were the stomach, pros- tate, colorectal, bladder, and lung cancers while breast, colorectal, stomach, thyroid cancers and leukemia were the most common cancers among females1. It reported that about 110,000 cancer cases and nearly 56,000 pa- tients died of cancer in Iran in 20182. Cancer increasingly recognized as a chronic disease rather than a fatal illness. Recently there are substantial achievements, related to the different biomarkers and predictive factors, novel molecular targeted therapeu- tics and improved imaging and surgical techniques. However, there is much work to do for patients to re- ceive ongoing high-quality care with the right special- ized expert oversight in a suitable place at the appro- priate time. Emergency representations are another aspect of can- cer treatment. The aim of the present review is showing the emergency representation involvement in different stages of cancer management such as primary diagno- sis, ongoing therapies and end-of-life period.
Primary diagnosed cancer patient in emergency departments In the United Kingdom, about 20%–25% of new cancer cases diagnosed following an initial presentation to the hospital emergency departments with the age of older than 70 years3. Patients who primary diagnosed with cancer in the emergency departments have more ad- vanced disease and poorer outcomes. Chest complaints, anemia, bowel obstruction, abdominal pain, and gen- eralized weakness are included in the symptoms on presentation3. According to a study in emergency de-
partment use by recently diagnosed cancer patients in California, the most emergency department visits (68%) occurred within 180 days of diagnosis. The inci- dence of emergency department use for all cancer types was 17% in 30 days, 35% in 180 days and 44% in 365 days of diagnosis4.
Factors associated with emergency de- partment attendance in cancer patients The emergency department uses varied according to the age groups, ethnicity, health insurance, socioec- onomic status, disease stages and initial treatments. Patients with higher stages of cancer visited the emer- gency departments more than whom with lower stages. Frothy percent of Patients who treated with chemother- apy, 48.6% of patients with surgical removals, 27.1% of whom with radiation therapy and 9.5% of patients who exposed to hormone therapies visited the emergen- cy departments within 180 days of diagnosis. Patients with lung, breast, colon and prostate cancers were the most emergency department visitors within 180 days of diagnosis4. Bringing together data from 30 original studies and more than one million patients in five countries identi- fied three demographics, five clinical, and 13 environ- mental factors associated with emergency departments attendance by patients with cancer in their last month of life5. The demographic factors (men; 58.2% and black race), clinical factor (lung cancer; 59.5%), and environmen- tal factors (low socioeconomic status and no palliative care 59.4%) was associated with an increased risk of emergency department attendance by patients with can- cer in their last month of life5.
Initial treatments and symptoms The causes of emergency department visits in cancer patients treated with antineoplastic were; 63% due to the tumor, 31% due to the chemotherapy toxicity and
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6% due to other causes. Fever or infection in 65%, pain in 50% and febrile neutropenia in 42% of the patients with chemotherapy toxicity was reported. Management of the pain, fever and the neutropenia declared as the most pressing concerns with the patients6. Cancer patients in their last month of life who suffer from more significant comorbidity, lung or head and neck cancer and a higher number of previous emergen- cy department visits are among whom visited the emer- gency departments multiple times7. Among the advanced cancer patients who died in the hospital within seven days of an emergency depart- ment visit, the most common symptoms in order are breathlessness, pain, body weakness or lethargy, and decreased appetite or anorexia. These are general symptoms associated with progression of the disease and may indicate that the patient is approaching the ter- minal phase8,9. In the emergency departments attendance with cancer in six final months to two last weeks of life, the most common reasons of the visit were abdominal pain, dyspnea, pneumonia, malaise and fatigue, and pleural effusion10. Results of a study in the United States in six years esti- mated that among a total of 696 million emergency de- partment visits in adult patients, a total of 29.5 million (4.2%) made by cancer patients11. The most common cause of emergency department visit was breast, pros- tate and lung cancer. Pneumonia in 4.5%, nonspecific chest pain in 3.7% and urinary tract infection in 3.2% of adult cancer patients were the most common primary reasons for their attendance. Septicemia and intestinal obstruction were associated with the highest odds of in- patient admission11. The study of three health centers in Texas from a total of 3.4 million emergency department visits, cancer pa- tients were older and more hospitalized than non-can- cer patients. Pneumonia, influenza, fluid and electrolyte
disorders, and fever were significant predictive factors for hospitalized cancer patients while coronary artery disease, cerebrovascular disease, and heart failure were essential factors for non-cancer patients’ hospitaliza- tion12.
DISCUSSION: Studies show that the rates of emergency departments use among cancer patients exceed those of the general population. However, there are differences in study pop- ulations by cancer type, initial treatments, age groups, socioeconomic status, disease stage and health insur- ance status. Patients’ symptoms varied according to the cancer type, disease stage and initial treatments. Cancer patients in their end of life period usually have more se- vere complications as well as those with chemotherapy and surgical procedures. These patients typically need more specialized attention than none-cancer patients visiting the emergency departments. Numerous patients usually crowd emergency depart- ments and the staffs are generally busy with their work, so the cancer patient, especially whom with low immu- nity and upper disease stages, may not receive adequate cares in the proper time. It is essential to identify whether patients with cancer were attending emergency depart- ments because of the low facilities of oncology clinics to accommodate them, and emphasized that emergen- cy department staffs need to be adequately trained and supported to offer optimum care to these patients13. Cancer patients consumed more emergency department resources than Non-cancer patients. Given the differ- ences in characteristics and diagnoses between these two groups, emergency department physicians must pay special attention to cancer patients and be familiar with their unique set of oncologic emergencies12. Nurses usually play an essential role in cancer treat- ment, training of the patients and management of the cancer symptoms and also developing a patient-cen-
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tered treatment. Nurses may have an active collabora- tion to improve the quality of care and reduce poten- tially avoidable emergency department visits13. Close to the end of life period of many of the cancer patients, emergency department visits may be avoida- ble. Realizing the reasons for emergency departments visits could be helpful in the development of appropri- ate interventions for preventing their occurrence10. It must be focused on pre-emptive management of breathlessness and pain to improve end of life care strategies. The patients’ families should be prepared for symptoms like body weakness and appetite loss, which may signal a progression of the disease by the community programs. Supportive and palliative care interventions will need to implemented in the emer- gency department setting for managing the advanced cancer patients8. Chemotherapy-related emergency department pres- entations have considerable clinical and cost implica- tions for patients and the healthcare system. Strategies to improve emergency department management of chemotherapy complications which have significant clinical and cost implications for patients and reduction in preventable emergency department presentations have substantial effects to boost cancer patients’ quali- ty of life and reducing the cost of cancer care. After re- ceiving chemotherapy, Patients require the specialized care to manage distressing symptoms, as they are at significant clinical risk because of immunosuppression and may not exhibit the usual signs of critical illness. A team approach in emergency department staffs may improve care for patients receiving chemotherapy and increase the effective use of healthcare resources14.
CONFLICT OF INTERESTS: The authors have no conflict of interests to declare.
ACKNOWLEDGMENT: This research supported by the Cancer Research
Center, Tehran University of Medical Sciences.
REFERENCES:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN esti- mates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: a cancer journal for clinicians. 2018 Nov;68(6):394-424. Zendehdel K. Cancer Statistics in IR Iran in 2018. Basic & Clinical Cancer Research. 2019 Jan 2;11(1): 1-4 Young A, Marshall E, Krzyzanowska M, Robinson B, Brown S, Collinson F, Seligmann J, Abbas A, Rees A, Swin- son D, Neville-Webbe H. Responding to acute care needs of patients with cancer: Recent trends across continents. The oncologist. 2016 Mar 1;21(3):301-7. Lash RS, Bell JF, Bold RJ, Joseph JG, Cress RD, Wun T, Brunson AM, Romano PS. Emergency department use by recently diagnosed cancer patients in California. Journal of Community and Supportive Oncology. 2017 Mar 1;15(2):95- 102. Henson LA, Gao W, Higginson IJ, Smith M, Davies JM, El- lis-Smith C, Daveson BA. Emergency department attendance by patients with cancer in their last month of life: a system- atic review and meta-analysis. Journal of Clinical Oncology. 2015 Feb 22;33(4):370-6. Buendía SB, González EH, García RS, Arrabal PD, Sánchez MF, Sanjurjo MS. Causes of the emergency department visits in cancer patients: postchemotherapy toxicity. Far- macia hospitalaria: organo oficial de expresion cientifica de la Sociedad Espanola de Farmacia Hospitalaria. 2015 Nov;39(6):333-7. De Palma R, Fortuna D, Hegarty SE, Louis DZ, Melotti RM, Moro ML. Effectiveness of palliative care services: a pop- ulation-based study of end-of-life care for cancer patients. Palliative medicine. 2018 Sep;32(8):1344-52. Yang GM, Ng E, Lian S, Ong ME. Reasons for emergency department visits among advanced cancer patients in their last week of life. Proceedings of Singapore Healthcare. 2018 Mar;27(1):59-62. Tsai JS, Wu CH, Chiu TY, Hu WY, Chen CY. Symptom patterns of advanced cancer patients in a palliative care unit. Palliative Medicine. 2006 Sep;20(6):617-22. Barbera L, Taylor C, Dudgeon D. Why do patients with cancer visit the emergency department near the end of life?. Cmaj. 2010 Apr 6;182(6):563-8. Rivera DR, Gallicchio L, Brown J, Liu B, Kyriacou DN, Shelburne N. Trends in adult cancer–related emergency de-
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107
Maryam Beigom Mobasheri et al...
12.
partment utilization: an analysis of data from the Nationwide Emergency Department Sample. JAMA oncology. 2017 Oct 1;3(10):e172450-. Yang Z, Yang R, Kwak MJ, Qdaisat A, Lin J, Begley CE, Reyes-Gibby CC, Yeung SC. Oncologic emergencies in a cancer center emergency department and in general emer- gency departments countywide and nationwide. PloS one. 2018 Feb 20;13(2):e0191658.
13.
14.
Lash RS, Bell JF, Reed MS, Poghosyan H, Rodgers MJ, Kim KK, Bold RJ, Joseph JG. A systematic review of emergency department use among cancer patients. Cancer nursing. 2017 Mar;40(2):135–144. Considine J, Livingston P, Bucknall T, Botti M. A review of the role of emergency nurses in management of chemother- apy-related complications. Journal of clinical nursing. 2009 Sep;18(18):2649-55.
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