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Grewal and Varner discuss the projections for cancer diagnoses in Canada in 2024, highlighting the challenges faced by individuals in obtaining a timely diagnosis and treatment. The increase in the absolute number of people receiving a cancer diagnosis is driven by population growth and aging, despite overall declines in cancer incidence and mortality. They emphasize the failure of health care systems to support adequate primary care-initiated pathways for the diagnosis of suspected cancer. They also highlight the increasing trend of receiving a cancer diagnosis in emergency departments, which is associated with worse outcomes and lack of privacy. They suggest that expanding access to streamlined paths for cancer diagnosis and implementing single-entry referral models could improve patient outcomes. Additionally, increasing access to diagnostic clinics for suspected cancers may help ensure timely workup and management.

Several facts about tumour lysis syndrome (TLS) are presented. Among other things, TLS is caused by a rapid breakdown of malignant cells releasing cellular contents into the blood. Most often, TLS occurs early after the start of chemotherapy, although it can spontaneously occur before treatment, or with radiation, steroid or targeted treatments in children and adults.Mortality may be as high as 20%.

ABSTRACTBackgroundAlthough suspicions of cancer may be raised in patients who visit the emergency department, little is known about emergency department use before a cancer diagnosis. We sought to describe emergency department use among patients in Ontario within the 90 days before confirmed cancer diagnosis and to evaluate factors associated with this emergency department use. MethodsWe conducted a retrospective, population-based study of patients aged 18 years or older who had a confirmed cancer diagnosis in Ontario from 2014 to 2021 using linked administrative databases. The primary outcome was any emergency department visit within 90 days before the cancer diagnosis date. We used multivariable logistic regression to evaluate factors associated with emergency department use, such as demographics (e.g., age, sex, rurality, Ontario Health region, indicators of marginalization), comorbidities, previous emergency department visits and hospital admissions, continuity of primary care, type of cancer, and year of cancer diagnosis. ResultsWe included 651 071 patients with cancer. Of these, 229 683 (35.3%) had an emergency department visit within 90 days before diagnosis, 51.4% of whom were admitted to hospital from the emergency department. Factors associated with increased odds of emergency department use before cancer diagnosis included rurality (odds ratio [OR] 1.15, 95% confidence interval [CI] 1.13–1.17), residence in northern Ontario (North East region OR 1.14, 95% CI 1.10–1.17 and North West region OR 1.27, 95% CI 1.21–1.32, v. Toronto region), and living in the most marginalized areas (material resources OR 1.37, 95% CI 1.35–1.40 and housing OR 1.09, 95% CI 1.06–1.11, v. least marginalized quintile). We observed significant variation in emergency department use by cancer type, with high odds of emergency department use among patients with intracranial, pancreatic, liver or gallbladder, or thoracic cancer. InterpretationEmergency department use is common before cancer diagnosis, with about one-third of patients with cancer in Ontario using the emergency department before diagnosis. Understanding why patients visit the emergency department before cancer diagnosis is important, particularly for patients who live in rural or marginalized areas, or those who have specific cancer types.

Intracranial hemorrhage (ICH) after head injury is a concern among older adult patients on anticoagulation. We evaluated the risk of ICH after an emergency department visit for head injury among patients 65 years and older taking warfarin or a direct oral anticoagulant (DOAC) compared with patients not taking anticoagulants. We also evaluated risk of 30-day mortality and neurosurgical intervention among patients with ICH. In this retrospective cohort study, we used population-based data of patients 65 years and older seen in an Ontario emergency department with a head injury. We matched patients on the propensity score to create 3 pairwise-matched cohorts based on anticoagulation status (warfarin v. DOAC, warfarin v. no anticoagulant, DOAC v. no anticoagulant). For each cohort, we calculated the relative risk of ICH at the index emergency department visit and 30-day mortality. We also calculated the hazard of neurosurgical intervention among patients with ICH. We identified 77 834 patients with head injury, including 64 917 (83.4%) who were not on anticoagulation, 9214 (11.8%) who were on DOACs and 3703 (4.8%) who were on warfarin. Of these, 5.9% of patients had ICH at the index emergency department visit. Patients on warfarin had an increased risk of ICH compared with matched patients on DOACs (relative risk [RR] 1.43, 95% confidence interval [CI] 1.20–1.69) and patients not on anticoagulation (RR 1.36, 95% CI 1.15–1.61). We did not observe a difference in ICH between patients on DOACs compared with matched patients not on anticoagulation. In patients with ICH, 30-day mortality did not differ by anticoagulation status or type. Patients on warfarin had an increased hazard of neurosurgery compared with patients not on anticoagulation. Patients on warfarin seen in the emergency department with a head injury had higher relative risks of ICH than matched patients on a DOAC and patients not on anticoagulation, respectively. The risk of ICH for patients on a DOAC was not significantly different compared with no anticoagulation. Further research should confirm that older adults using warfarin are the only group at higher risk of ICH after head injury.

Direct oral anticoagulants (DOACs) are increasingly being used over low molecular weight heparin (LMWH) and vitamin K antagonists for the treatment of venous thromboembolism (VTE). The objective of this study was to examine predictors of anticoagulant type (DOAC vs. LMWH) prescribed at discharge from the emergency department (ED) among patients diagnosed with VTE in the ED. We conducted a retrospective chart review of adult (>17 years) patients discharged from an Ontario, Canada ED in a tertiary care centre with an ED diagnosis of deep vein thrombosis or pulmonary embolism from January 2019 to December 2021. A multivariable logistic regression model was used to examine the predictors of the anticoagulant (DOAC vs. LMWH) prescribed at discharge. Covariables included: age, sex, history of major bleeding, history of cancer, and previous anticoagulation. VTE was confirmed in 390 ED visits by 365 unique patients. Among unique patients, 239 (65.5 %) patients were discharged from the ED and included in analysis. Of the 239 patients included, 12.1 % of patients were over the age of 80, 46.4 % were female and 29.7 % had a history of cancer. The majority of patients discharged from the ED were prescribed DOACs (70.7 %,169/239). Cancer history was associated with anticoagulation with LMWH (vs. DOAC) on discharge (adjusted odds ratio [aOR] =12.81, 95 % CI: 6.60–25.90). While most patients diagnosed with VTE in the ED setting were discharged with DOACs, most cancer patients included in our study were treated with LMWH over DOACs, despite increasing evidence around the efficacy and safety of DOACs in most cancer patients. Further research is needed to understand longitudinal trends in anticoagulation.

Patients with cancer have complex care requirements and frequently use the emergency department. The purpose of this study was to determine whether continuity of care, cancer expertise of an institution or both affect outcomes in patients with cancer in the emergency setting. We conducted a retrospective cohort study using administrative databases from Ontario, Canada, involving records of patients aged 20 years and older who received chemotherapy or radiation in the 30 days before a cancer-related visit to the emergency department between 2006 and 2011. Patients seen in an emergency department at an alternative hospital (not the site where cancer treatment was given) were matched based on propensity score to patients who visited their original hospital (site where cancer treatment was given). Next, patients seen at an alternative emergency department that was in a general hospital (i.e., not a cancer centre) were matched to patients who visited their original hospital or a cancer centre. Outcomes were admission to hospital at the index visit to the emergency department, 30-day mortality, having imaging with computed tomography and return visits to the emergency department. We found 42 820 patients who were eligible for our study. Patients seen in the emergency departments at alternative hospitals were less likely to be admitted to hospital (odds ratio [OR] 0.78, 95% confidence interval [CI] 0.74–0.83) and had higher hazards of return visits to the emergency department than matched patients at original hospitals (hazard ratio [HR] 1.06, 95% CI 1.03–1.11). In comparison, patients at alternative general hospitals also had lower odds of admission to hospital (OR 0.83, 95% CI 0.79–0.88) and higher hazards of return visits to the emergency department (HR 1.07, 95% CI 1.03–1.11) compared with matched counterparts; however, these patients had higher 30-day mortality (OR 1.13, 95% CI 1.05–1.22) and lower odds of having CT imaging (OR 0.74, 95% CI 0.69–0.80). Cancer expertise of an institution rather than continuity of care may be an important predictor of outcomes following emergency treatment of patients with cancer.