Poor prognosis after emergency presentation of esophagogastric cancer

Last Updated: 2017-03-29

By Will Boggs MD

NEW YORK (Reuters Health) - Emergency presentation of esophagogastric cancer, more common among older, female, nonwhite individuals, is associated with a poor prognosis, researchers from the UK report.

As many as 30% of UK patients with esophageal and gastric cancer present emergently to hospitals, despite recommendations that patients with dysphagia or weight loss with upper abdominal pain, reflux, and dyspepsia be referred urgently for upper gastrointestinal endoscopy.

Dr. George B. Hanna from Imperial College London and colleagues used data from the Hospital Episode Statistics database to evaluate emergency admission rates for esophagogastric cancer, to identify factors associated with emergency presentation, and to compare the prognosis of patients who had surgery during the index admission versus those who returned for elective readmission following stabilization.

During the 16 years covered by the study, the incidence of primary emergency presentation was 29.4% for esophageal cancer and 39.6% for gastric cancer, according to the March 20 Annals of Surgery online report.

The proportion of patients primarily presenting as an emergency decreased between 1997 and 2012 from 33% to 23.1% for esophageal cancer and from 53% to 28.3% for gastric cancer.

Age 70 years and older, female sex, nonwhite ethnicity, Charlson comorbidity index score 3 and higher, urban location, and more deprived Townsend index independently predicted emergency presentation, whereas high hospital volume was independently associated with reduced emergency presentation.

Emergency presentation was associated with significantly lower five-year survival for esophageal cancer (13.3% versus 21.9% for elective admission) and for gastric cancer (15.1% versus 26.6% for elective admission). For both cancers, emergency presentation was also associated with higher percentages of patients with liver metastases and peritoneal metastases.

In multivariate analyses, emergency presentation was associated with 63% higher odds of five-year mortality from esophageal cancer, 20% higher odds of five-year mortality from gastric cancer, and, for both cancers, higher odds of receiving surgery, both on the index primary admission and on a follow-up admission.

“Future strategies must attempt to further reduce the proportion of patients presenting with emergency diagnosis,” the researchers conclude. “This can be through a combination of raising national esophagogastric cancer awareness, increasing patient acceptability through noninvasive triage testing to streamline referral for endoscopy and targeting vulnerable populations to facilitate early elective diagnosis.”

Dr. Jesper Lagergren from Karolinska Institutet, Stockholm, Sweden, who recently reviewed factors associated with the risk of esophageal and gastric cancer, told Reuters Health by email, "It is surprising that as many as every fourth case of esophageal or gastric cancer in England still presents for healthcare as an emergency admission. This finding indicates that many individuals with yet undiagnosed cancer of the esophagus or stomach postpone or avoid seeking healthcare despite alarm symptoms, e.g., dysphagia and involuntary weight loss.”

“Delay in seeking healthcare is a well-established poor prognostic factor for these aggressive tumors,” he said. “The situation might be improved by increasing the general awareness of alarm symptoms. However, such information needs to reach the entire community, not only to those with the highest education and highest interest in a healthy lifestyle. Awareness campaigns need to reach out to individuals of older age, with medical comorbidity, ethnic minorities, and deprived socio-economic classes, which might be particularly challenging.”

Dr. Hanna did not respond to a request for comments.

SOURCE: http://bit.ly/2oaLOJ7

Ann Surg 2017.