Diagnosis Setting and Colorectal Cancer Outcomes: The Impact of Cancer Diagnosis in the Emergency Department

Background: The rate of diagnosis of colorectal cancer (CRC) in the emergency department (ED), its characteristics, and its effect on outcomes have been poorly described. Materials and methods: Chart review was conducted to identify presenting clinical setting leading to diagnosis, symptoms, and history of colonoscopy for patients diagnosed with CRC at a single institution from 2012-2014. Patients diagnosed with CRC as a result of an ED visit (EDDx) were compared with those diagnosed after presentation to other settings (non-EDDx). Results: Of 638 patients meeting inclusion criteria, 271 (42.4%) were EDDx patients. These patients were more likely to be older than 80 y (29.89% versus 19.35%), have Medicare (59.78% versus 42.78%) or Medicaid (23.62% versus 12.81%) insurance, have stage IV cancer (45.02% versus 18.26%), and were symptomatic at the time of presentation (94.83% versus 64.03%). EDDx patients were less likely to ever have had a colonoscopy (21.77% versus 41.69%). In a model adjusted for patient demographics, cancer stage, presence of symptoms, and history of prior colonoscopy, EDDx was associated with increased mortality (hazard ratio, 1.89; 95% confidence interval, 1.3-2.8). On stratifying survival by stage, it was found that for all stages, EDDx was associated with decreased survival. Conclusions: More than 40% of patients with CRC received their diagnosis through the ED. EDDx was associated with a nearly twofold mortality risk increase. EDDx should be considered a marker of poor outcomes for CRC and may be related to unaccounted patient-level or systems-level factors. Efforts should be made to identify modifiable risks of cancer diagnosis in the ED to improve cancer outcomes.