For many cancer patients, immune checkpoint inhibitors (ICIs) can be life-saving. However, the immune-related adverse events (irAEs) from ICIs can be debilitating and can quickly become severe or even be fatal. Often, irAEs will precipitate visits to the emergency department (ED). Therefore, early recognition and the decision to admit, observe, or discharge these patients from the ED can be key to a cancer patient’s morbidity and mortality. ED clinicians typically make their decision for disposition (admit, observe, or discharge) within 2–6 h from their patient’s ED presentation. However, irAEs are particularly challenging in the ED because of atypical presentations, the absence of classic symptoms, the delayed availability of diagnostic tests during the ED encounter, and the fast pace in the ED setting. At present, there is no single sufficiently large ED data source with clinical, biological, laboratory, and imaging data that will allow for the development of a tool that will guide early recognition and appropriate ED disposition of patients with potential irAEs. We describe an ongoing federally funded project that aims to develop an immune-related emergency disposition index (IrEDi). The project capitalizes on a multi-site collaboration among 4 members of the Comprehensive Oncologic Emergency Research Network (CONCERN): MD Anderson Cancer Center, Ohio State University, Northwestern University, and University of California San Diego. If the aims are achieved, the IrEDi will be the first risk stratification tool derived from a large racial/ethnically and geographically diverse population of cancer patients. The future goal is to validate irEDi in general EDs to improve emergency care of cancer patients on ICIs.
Whether they are spinal metastases or primary spinal neoplasms, spinal tumors cause a myriad of complications given their critical location. Spinal tumors can be extradural, intradural extramedullary, or intramedullary, with extradural metastatic tumors the most commonly encountered. Spinal cord and/or cauda equina compression is one of the most devastating complications of cancer and represents a true oncologic emergency. Patients present with progressive paralysis, paresthesiae, and/or autonomic dysfunction. In addition to spinal cord compression (SCC), extradural spinal tumors can cause mechanical spinal instability and axial loading pain which often warrant surgical consultation. The diagnosis of SCC begins with clinical suspicion even before neurological deficits ensue. Patients presenting with back or neck pain who have a history of cancer should be evaluated carefully for SCC. MRI is the imaging modality of choice. Management of SCC generally requires a multidisciplinary approach, with goals of symptom control and prevention of irreversible functional loss. Patients with metastatic epidural SCC who undergo surgical decompression and reconstruction followed by radiotherapy exhibit better outcomes in preservation of function and symptom control than do those undergoing radiotherapy alone. Recent advances in the surgical management of SCC include minimally invasive spinal surgery (MISS), spinal laser interstitial thermotherapy (SLITT), and vertebral augmentation of pathologic vertebral compression fractures. Generally, SCC in patients with cancer serves as evidence of uncontrolled and aggressive disease. Although it is associated with poor outcome in most patients, effective palliation is possible with early diagnosis and careful application of modern surgical techniques for the elimination of cord compression, prevention or reversal of neurological deficits, and restoration of mechanical spinal stability. In addition to SCC from spinal tumors, other spinal complications can be seen in cancer patients who develop spine infections such as surgical site infection (SSI), spinal epidural abscesses (SEA), subdural empyema (SDE), or vertebral osteomyelitis. These complications can be due to inoculation from the spinal surgery itself or as a result of the patients’ immunocompromised state. This article provides a scoping review of the clinical presentation, pathophysiology, and diagnosis of major spinal oncologic emergencies and summarizes current modes of surgical and nonsurgical management.
Background Though decreasing in incidence and mortality in the USA, lung cancer remains the deadliest of all cancers. For a significant number of patients, the emergency department (ED) provides the first pivotal step in lung cancer prevention, diagnosis, and management. As screening recommendations and treatments advance, ED providers must stay up-to-date with the latest lung cancer recommendations. The purpose of this review is to identify the many ways that emergency providers may intersect with the disease spectrum of lung cancer and provide an updated array of knowledge regarding detection, management, complications, and interdisciplinary care. Findings Lung cancer, encompassing 10–12% of cancer-related emergency department visits and a 66% admission rate, is the most fatal malignancy in both men and women. Most patients presenting to the ED have not seen a primary care provider or undergone screening. Ultimately, half of those with a new lung cancer diagnosis in the ED die within 1 year. Incidental findings on computed tomography are mostly benign, but emergency staff must be aware of the factors that make them high risk. Radiologic presentations range from asymptomatic nodules to diffuse metastatic lesions with predominately pulmonary symptoms, and some may present with extra-thoracic manifestations including neurologic. The short-term prognosis for ED lung cancer patients is worse than that of other malignancies. Screening offers new hope through earlier diagnosis but is underutilized which may be due to racial and socioeconomic disparities. New treatments provide optimism but lead to new complications, some long-term. Multidisciplinary care is essential, and emergency medicine is responsible for the disposition of patients to the appropriate specialists at inpatient and outpatient centers. Conclusion ED providers are intimately involved in all aspects of lung cancer care. Risk factor modification and referral for lung cancer screening are opportunities to further enhance patient care. In addition, with the advent of newer cancer therapies, ED providers must stay vigilant and up-to-date with all aspects of lung cancer including disparities, staging, symptoms of disease, prognosis, treatment, and therapy-related complications.
Background Lung cancer (LC) is the most common solid tumor type in the intensive care unit (ICU). This study investigated the characteristics of LC patients admitted to the ICU, the major reasons for their admission, short-term mortality, and associated risk factors. Methods Patients with LC were retrospectively identified in the publicly available, large-scale, single-center database Medical Information Mart for Intensive Care (MIMIC) III. Demographic and clinical characteristics, including age, sex, smoking history, comorbidities, type of admission to ICU, major diagnoses, illness severity score as assessed by the Simplified Acute Physiology Score (SAPS) II and the Sequential Organ Failure Assessment (SOFA), ICU length of stay (LOS), use of mechanic ventilation (MV) or vasopressors, the existence of do-not-resuscitate (DNR) orders, and metastatic status were collected. The major reasons for ICU admission were analyzed in subgroups. The multivariate logistic regression analysis was used to determine the factors associated with the 28-day and 6-month mortality. Results A total of 1242 ICU admissions were included. Diseases of respiratory (42.7%), nervous (14.3%), and cardiovascular (11.9%) systems accounted for the top reasons for admission. Pneumonia/pneumonitis, respiratory failure, and sepsis were the primary reasons for ICU admission. The median survival was 2.93 (95% CI : 2.42–3.43) months. The 28-day inhospital and the 6-month mortality were 30.6% and 68.2%, respectively. Sepsis (63.9%), respiratory failure (47.0%), and pleural effusion (40.9%) accounted for the top three highest 28-day ICU mortality in all causes. An age ≥ 65 years, a SAPS II ≥ 37, a SOFA ≥ 3, metastasis, and MV use were independent risk factors for an inferior 28-day survival rate, while only metastatic status and SOFA score were associated with the 6-month mortality. SAPS II was accepatable and better than SOFA in predicting 28-day ICU [area under the curve (AUC): 0.714 and 0.658, respectively] or 28-day inhospital mortality ( AUC : 0.717 and 0.660, respectively). Conclusion The 6-month prognosis for LC patients admitted to ICU was dismal. Multidisciplinary collaboration between intensivists and oncologists to identify high-risk patients and to determine a risk-benefit ratio of ICU treatment may improve survival prospects.
Background People with cancer frequently use urgent and emergency care. Reviews of research have focussed on the incidence and predictors of service use in this population, rather than how people make decisions about which service to access. Understanding what factors influence these choices will inform ways in which we might enable people with cancer to effectively access services. Aims (1) Describe research undertaken about choices made by people with cancer about routes to access urgent and emergency care; (2) characterise decisions made by patients and informal caregivers to use certain services, with specific reference to work involved in navigating access; and (3) identify research priorities. Methods Scoping review of qualitative and mixed methods studies. Electronic database searches (AMED, CINAHL, Embase, MEDLINE, PsycInfo) and ‘berrypicking’ identified 18 papers. Study, participant, and service characteristics were mapped, and Turnbull et al.’s Model of Urgent Care Help-seeking informed a directed qualitative content analysis. Results Studies have involved people with advanced cancer to the relative exclusion of people with curable disease, receiving anticancer treatment, and who are multi-morbid. Six subcategories of navigation work were identified: (1) making decisions with, and seeking help from, specialists, (2) seeking safety, (3) positioning to access desired treatment, (4) negotiating tortuous pathways to help, (5) making decisions in collaboration with caregivers, and (6) managing isolation from services and social networks. Conclusion There are significant knowledge gaps and a need for more research, particularly studies of how different patient groups prepare for potential deterioration and make sense of systems of urgent and emergency care.
