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10.1245/s10434-006-9245-z
Annals of Surgical Oncology 14:1099-1104 (2007)
© 2007 Society of Surgical Oncology
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Original Article

Emergency Room Presentation of Colorectal Cancer: A Consecutive Cohort Study

Alex D. Mitchell, MD1, Karen M. Inglis, RN1, John M. Murdoch, MD, FRCSC, FACS2 and Geoffrey A. Porter, MD, FRCSC, FACS1

1 Division of General Surgery, Dalhousie University, Halifax, NS, Canada
2 Department of Surgery, Dartmouth General Hospital, Dartmouth, NS, Canada

Correspondence: Address correspondence and reprint requests to: Alex D. Mitchell, MD; Room 7017 Victoria Building, QE II Health Sciences Centre, 1278 Tower Road, B3H 2Y9, Halifax, NS, Canada; E-mail: admitche{at}dal.ca


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Background: Emergency room presentation (ERP) in colorectal cancer (CRC) is associated with worse cancer-related outcomes. The goal of this study was to determine the frequency of ERP and identify factors associated with ERP of CRC.

Methods: We performed a prospective consecutive cohort study of all patients undergoing resection for CRC from 02/2002 to 02/2004. Standardized data collection involved hospital record review, patient interview, and prospective follow-up. ERP was defined as the diagnosis and/or surgical treatment of CRC as a result of presentation to the emergency department.

Results: Of the 455 patients in the study 108 (24%) had ERP. Presentation of those with ERP was obstruction in 46 (43%), bleeding/anemia in 35 (32%), pain in 25 (23%), and other (2%). The ERP cohort was older (mean age 70.8 vs. 67.0 years, P = 0.005). ERP was more common amongst females (29.7 vs. 18.2%, P = 0.004) and obesity appears to be associated with increased rates of ERP. ERP of CRC was associated with more advanced TNM stage. The ERP cohort had longer length of stay in hospital (median 10 vs. 8 days respectively, P < 0.001). Peri-operative mortality was higher in ERP patients (7.4 vs. 2.3%, P = 0.03).

Conclusions: ERP in CRC was not infrequent and appeared to be associated with female gender and weight. The known negative prognostic impact of ERP, combined with the increased peri-operative 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 CRC.

Key Words: Colorectal cancer • Obstruction • Perforation • Emergency • Gender • Obesity


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Colorectal cancer (CRC) remains one of the leading causes of cancer related morbidity and mortality in the western world and is the second most common cause of cancer death in Canada.1,2 Despite the evidence and advocacy for CRC screening, 6–30% of patients will present with late symptoms requiring emergency intervention.3–5 Patients with emergency room presentation (ERP) of CRC have increased 30-day mortality and decreased 5-year survival compared to elective patients.6,7 Some authors have suggested that rates of emergency admission due to obstruction and perforation of colorectal cancer may be a useful quality indicator of cancer care and screening programs. In aggregate, this suggests a better understanding of the cohort of patients presenting emergently with late symptoms of CRC would be useful in planning interventions directed at reducing the incidence of ERP of CRC.

The goal of this study was to determine the frequency of ERP in a consecutive cohort of CRC patients. In addition, we sought to identify factors associated with the ERP of CRC, and examine the impact of ERP on peri-operative mortality.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
A prospective consecutive cohort study of all patients undergoing resection for colon and/or rectal carcinoma in a single health district over a 2-year period (February 2002–February 2004) was performed. Patients undergoing resection for CRC were identified during hospital admission using the computer based operating room log. Only patients undergoing resection were included in this study to allow comparisons of outcomes between the groups without significant heterogeneity. Those not undergoing surgery are likely unresectable or non-operative candidates and represent a much different patient cohort. Upon identification a detailed review of hospital records, and surgeons’ office records by a research nurse was conducted. Based on this review patients meeting eligibility criteria were contacted by the study nurse on the second or third post-operative day. At this time the research nurse explained the study and scheduled a 30 min interview with the patient on the third to seventh post operative day. Data pertaining to presentation, demographics, outcomes (length of stay, 30-day mortality), diagnosis, surgical interventions, pathology results, and staging were collected from the hospital and office records. The face-to-face interview involved standardized questioning regarding co-morbidities, personal and family history of CRC or polyps, previous screening tests, and expanded demographical information (household income, race, education level, smoking history, access to primary care physician). CRC screening was defined as fecal occult blood testing, barium enema, or endoscopy in an asymptomatic patient; no organized CRC screening program was in place during the study period. The details of the presentation/diagnosis, its timing, and its investigation were also elicited during this interview. Data regarding surgical resection, outcomes, pathology/staging and follow-up were prospectively collected from hospital and surgeons office records. Diagnosis was defined by the presence of colorectal cancer on preoperative tissue biopsy, or, if no preoperative tissue biopsy was obtained, by the investigation leading to surgical resection (e.g. colonoscopy, barium enema, abdominal computed tomography).

From this population of patients undergoing resection for CRC a subset of patients with ERP of CRC were identified. ERP was defined as the diagnosis and/or surgical treatment of CRC as a result of presentation to the emergency department. Patients with ERP were then compared to those undergoing elective resection (EL).

Two-tailed tests were used at all times, and statistical significance was set a priori at P < 0.05. Statistical analyses were performed using the statistical software package SPSS for Windows 13.0 (Chicago, Ill.). All univariate analyses employed the student’s T-test, ANOVA, or Chi-square test as appropriate. Non-parametric methods were used when the distribution of continuous data did not approximate the normal distribution (e.g. most time data). All surgeons and patients agreed to participate in the study. Informed consent was obtained for medical record review and patient interview. The study was granted approval by the local research ethics committee.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
A total of 455 consecutive patients undergoing resection for CRC were included in the study cohort. The mean age of the cohort was 68.0 years and 52% of patients were male. One hundred and eight (24%) patients were defined to have ERP of CRC. Among these, obstruction was the most common presentation (43%), followed by bleeding/anemia (32%), and pain (23%). Of those with ERP, 93 (86%) underwent surgery on the same admission and 26 (24.1%) made more than one visit to the emergency department prior to diagnosis and/or surgical resection. In the elective group (n = 347), 11% (39) were asymptomatic and were diagnosed via screening. The remaining patients in the elective group underwent diagnostic testing as a result of the following symptoms; bleeding/anaemia (57%), change in bowel habits (17%), obstruction (2%), pain (8%), weight loss (3%), other (4%).

The mean age of ERP patients was higher than EL patients (70.8 vs. 67.0 years; P = 0.005). The frequency of ERP according to other demographic and clinical factors is shown in Table 1Go. A higher rate of ERP was found in women compared to men (29.7 vs. 18.2%, respectively; P = 0.004). A significant association between body mass index and ERP was found; severely obese, as well as normal/underweight patients were found to have the highest rates of ERP of CRC. Socioeconomic status, education, smoking, family history of CRC, or previous use of CRC screening were not significantly associated with ERP. ERP was not associated with a lack of primary care physician nor was it associated with the length of the relationship with the primary care physician. Pathologic findings of ERP and EL patients are shown in Table 2Go. The association between ERP and advanced stage was due primarily to a significantly higher incidence of stage IV disease in ERP patients, and a significantly higher incidence of stage I disease in EL patients. ERP patients were more likely to have lymphovascular invasion, although no significant differences in tumor grade, nodal status or margin positivity were found.


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  		TABLE 1. Demographic and clinical associations with ERP
 

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  		TABLE 2. Pathologic variables amoung ERP and EL patients
 
Data on prior screening for CRC was obtained. In total only 40 patients had undergone a screening test, which lead to their diagnosis (Table 3Go), of which 30 (75%) had colonscopy as the primary screening exam. The remaining patients undergoing fecal occult blood testing (FOBT), digital rectal exam (DRE), or barium enema (BE) with abnormal results all underwent colonscopy where the CRC diagnosis was made.


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  		TABLE 3. Short term surgical outcomes
 
Short-term surgical outcomes were compared between ERP and EL patients. Patients with ERP had longer length of stay in hospital compared with EL patients (median 10 vs. 8 days, respectively; P < 0.001) as well as increased peri-operative mortality (7.4 vs. 2.3%, respectively; P = 0.030).


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
Potential implications of ERP in CRC relate to (1) its impact on short-term surgical outcomes, (2) its impact on disease-related outcomes, and (3) its usefulness as a quality indicator of health care system and process for CRC screening, diagnosis and management.

In terms of short-term surgical outcomes, this study demonstrated that perioperative mortality and length of stay were increased in patients with ERP, compared to patients undergoing elective resection. Other literature has shown increased mortality rates in patients undergoing emergent surgery for CRC, with reported short-term mortality rates of 5–40%.8–10,13,14 The differences in length of stay may be explained by the fact that ERP patient cohort was more likely to be older, sicker, and at increased risk for postoperative morbidity resulting in longer admissions. Although we did not systematically measure postoperative complications in this study, recent work has demonstrated increased morbidity with emergency colorectal cancer surgery.11

Cancer-related outcomes have been shown to be inferior in patients presenting with perforated or obstructed CRC.12–18 In a population-based Swedish study, Jestin et al.19 showed higher cancer-specific mortality, adjusted for stage, in CRC patients presenting as an emergency. Although the present study did not examine cancer-related outcomes, the more advanced pathologic features (stage, lymphovascular invasion) identified in ERP patients would be congruent with inferior cancer-related outcomes.

Our study is the first to report an increased risk of ERP associated with female gender in a prospective cohort. In a population-based retrospective cohort study, Rabeneck et al.11 found a modest increase in the risk of emergency presentation with obstruction and/or perforation of a colorectal cancer in women (odds ratio = 1.17). This group of Canadian researchers have recently published further retrospective population based data showing strong associations between emergency presentation and female gender as well as socioeconomic status.20 Although a conclusive explanation for the increased ERP rates in women cannot be derived from our data, it may relate to biological, cultural, and sociologic issues in the work-up of CRC symptomatology. There does appear to be issues with women’s willingness to undergo colonoscopy due to fears of pain embarrassment, and specifically embarrassment at having a male physician conduct the exam.21–23 Certainly these barriers to colonscopy may result in women presenting with late stage disease. Analogous examples of such gender-related differences are found in the work-up of chest pain where women are significantly less likely than males to receive an early coronary angiogram.24,25

This study also identified significant variability in ERP rates according to BMI, with the highest rates of ERP found among morbidly obese (BMI > 40, 41.7% ERP rate) and normal/underweight patients (BMI < 25, 31.8% ERP rate). Obesity has been shown to be both a risk factor and poor prognostic factor in CRC.26–28 The increased risk of ERP for patients with normal or low BMI in this study may be due to substantial CRC-related weight loss due to more advanced disease (we did not measure pre-morbid weight in this study, e.g., 6 months prior to admission). Although the increased ERP rates seen in morbidly obese patients may be based on differences in tumour biology, we feel it is more likely that differences in access to care, patient psychology, and the challenges in diagnosis associated with morbid obesity are contributory. Perhaps the same psychological traits that contribute to a lifestyle promoting morbid obesity also play a role in delaying patients from seeking early intervention when symptoms first appear. Further exploration of this cohort of patients is needed to better explain the results of this study. A prospective study focused on morbidly obese patients presenting with CRC may be helpful in understanding contributing factors to the high rate of ERP in this population.

The effects of poverty, poor education and poor access to primary care have been cited extensively as barriers to early diagnosis and treatment in this population. Other Canadian researchers have illustrated an association of higher income status with increased rates of colonoscopy and decreased rates of emergency presentation.20,21 We did not identify any significant association between these factors and ERP, although it is possible that patient factors, such as gender and BMI, are more important than measures of "ad hoc" CRC screening, which is uncommon in the absence of an organized screening program.

It is unclear, from this study whether ERP can be used as a quality indicator for CRC screening. Firstly, no organized CRC screening program was in place over the study period, as is the case throughout all of Canada. In addition, the use of screening was very low in this patient cohort with only 60 (7.4%) cases detected via screening, and only 24% of patients ever having had a screening test for CRC. Another recent Canadian study found population based screening rates in eligible patients to be as low as 21%.20

Our data and that of other Canadian researchers clearly illustrate the need for further evaluation and use of screening for CRC. The use of Fecal Occult Blood Test (FOBT) and flexible sigmoidoscopy (FS) have both been found to result in significant reductions in rates of late stage CRC presentation, and reductions in overall CRC mortality. Both of these modalities are endorsed by the Canadian Task Force on Preventive Health Care.25 Population based endoscopic screening would most certainly impact the rates of ERP. A significant barrier to colonscopy and FS in Canada relates to financial and manpower resource constraints in a public health care system, which limits access to care. There continues to be much debate and discussion in Canada regarding the best ways to provide adequate access to endoscopic diagnosis and screening. Proposals for solutions to this resource issue is beyond the scope of this paper. We will, however, cite one interesting paper, which found nonphysician endoscopists conducting screening flexible sigmoidscopy were similar in accuracy and safety with much lower cost than gastroenterologists.30

Public awareness strategies are needed to target the groups at highest risk of late stage presentation and lowest rates of screening. Addressing women’s concerns and perceptions of colonscopy may prompt more to seek attention. Increasing the numbers of female endoscopists has been proposed previously as yet another solution. Public awareness campaigns are needed to target low socioeconomic groups and those with morbid obesity. It is imperative that we educate those providing primary care about the benefits of screening and about the groups that are being missed by current practices. Research such as ours needs to be shared with our primary care colleagues such that they might begin to better identify those patients with the poorest access to care and highest risk. Our current study does not provide enough evidence to suggest a high risk screening strategy of women and those with morbid obsesity at this time. Secondary prevention can be effective for CRC but only if we utilize it. Public awareness and compliance will of course only be effective if the health care system has adequate resources in place to deal with the increase in demand for these services.

There are several limitations to the results of this study. Lack of long-term follow-up limits the analysis to short term outcomes; we are unable to comment on the effect of ERP on 5-year survival rates in this patient cohort. Although demographic factors such as geographic location, socioeconomic status (SES), and time with family doctor were not found to be associated with ERP, small differences may have been missed by the moderate sample size of this study. The study population was in a single health district, which is predominantly urban/sub-urban, served by a tertiary health care centre, our SES data shows that over 60% of the patients reported household incomes greater than $50,000. This is unlikely a population representative of an overall provincial or Canadian population from a SES perspective.

The present study only included those undergoing surgical management of CRC, likely resulting in an underestimation of the incidence of ERP in our population. Patients presenting with ERP who died prior to surgical management or were treated non-operatively were not included. Finally, although the results of this study imply relationships between emergency presentation of CRC and various clinicodemographic factors, further work must be done to explore how these relationships might be exploited to reduce the incidence of ERP. Our data would suggest that any such strategies need to emphasize female and obese patients.

In conclusion, ERP of CRC was not infrequent and appears to be associated with female gender, obesity, later stage lesions and increased 30-day mortality. The fact that a quarter of patients undergoing resection presented emergently is deplorable and warrants serious attention. The known negative prognostic impact of ERP combined with the increased peri-operative mortality and length of stay demonstrated in this study, would suggest a potential benefit to targeted strategies aimed at reducing the incidence of emergency presentation of CRC.


   ACKNOWLEDGMENTS
 
The authors would like to thank John Fris for his assistance in data management.

Received for publication March 25, 2006. Accepted for publication August 16, 2006.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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