July 20: We tend to think of cancer being caught during a mammogram, a colonoscopy or a conversation with a primary care doctor. Yet for many older Americans, the diagnosis comes in a crisis, inside an emergency department. A new national study led by UNC concludes that more than one in four older adults are diagnosed this way and their chances of surviving the first year are significantly lower.
Published in the Journal of the National Cancer Institute, researchers examined nearly 930,000 Medicare patients diagnosed with one of 16 common cancers between 2008 and 2017. About 28% were diagnosed after an emergency department visit, known as an emergency presentation.
These patients were separated into two groups: those admitted to the hospital straight from the ED and those discharged to complete their workup as outpatients. Researchers found that one year after diagnosis, 81% of patients diagnosed through routine outpatient care were still alive. Among patients admitted from the ED, only 36% were. The outpatient emergency‑presentation group fell in between, at 60%.
“These gaps held up even after we accounted for age, cancer stage, other illnesses, and frailty,” said Caroline Thompson, PhD, MPH, lead author, associate professor of epidemiology at the UNC Gillings School of Global Public Health and member of the UNC Lineberger Comprehensive Cancer Center. “How a cancer is found carries information about a patient’s outlook that goes beyond the tumor itself.”
Thompson notes that the findings challenge long‑standing assumptions about emergency cancer diagnosis. After accounting for patients who were older and experiencing more severe comorbidities and more advanced disease, researchers still found that an emergency presentation predicted higher mortality. This pattern also appeared in cancers that are often considered more treatable or commonly detected through screening, including breast, prostate, bladder and blood cancers. Another finding involved the outpatient group, which revealed an unexpected pattern.
“These patients, sent home from the ED to finish their workup, are a distinctly American phenomenon that international definitions of emergency presentation miss entirely,” said Thompson. “And they were not disconnected from the healthcare system. Their primary care use before diagnosis looked much like patients diagnosed the standard way. So, the story is not simply that these patients avoided doctors. Opportunities to diagnose them earlier may have been missed.”
Thompson shares that knowing a patient was diagnosed through an emergency is useful information for clinicians to act on. It can inform honest conversations about what to expect, decisions about how aggressively to treat and when to bring in palliative care and advance care planning, especially for older patients. The findings also highlight that health systems should monitor how often people are diagnosed with cancer in the emergency room, because it can reveal problems in how quickly cancers are being found. Catching cancer earlier can prevent patients from reaching the point of needing an emergency visit. Targeted efforts to improve public symptom awareness, expand primary care access and strengthen diagnostic coordination may help decrease cancers diagnosed as emergencies and improve survival.
“At the system level, the emergency department is where these patients surface, but it is not built to coordinate a cancer workup,” said Thompson. “Patients sent home with a suspected cancer can fall through the cracks between the ED and oncology. Building deliberate pathways to catch and move these patients quickly is a concrete opportunity to improve outcomes.”
