Single Center Experience on Causes of Cancer Patients Visiting the Emergency Department in Southwest Turkey

Although the developments in its medical and surgical treatments modalities, cancer is a most common health an public problem in today. Cancer patients often face with oncological or general emergencies and unexpected lifethreatening due to deteriorated medical conditions (Yates and Barrett, 2009; Mayer et al., 2011; Ahn et al., 2012; Yucel et al., 2012). Emergency departments (ED) are often visited by cancer patients for palliation of cancer-related symptoms, management of treatment-related side effects, oncologic emergencies, co-morbidities, and/or end of life care (EOLC) (Barbera et al., 2010, Guddati et al., 2013). To interfere with a multidisciplinary approaches to cancer patients in ED is a most ideally. In this study, we aimed to identify the characteristics of cancer patients admitted to the emergency medicine in Southwest Turkey.


Introduction
Although the developments in its medical and surgical treatments modalities, cancer is a most common health an public problem in today.Cancer patients often face with oncological or general emergencies and unexpected lifethreatening due to deteriorated medical conditions (Yates and Barrett, 2009;Mayer et al., 2011;Ahn et al., 2012;Yucel et al., 2012).Emergency departments (ED) are often visited by cancer patients for palliation of cancer-related symptoms, management of treatment-related side effects, oncologic emergencies, co-morbidities, and/or end of life care (EOLC) (Barbera et al., 2010, Guddati et al., 2013).
To interfere with a multidisciplinary approaches to cancer patients in ED is a most ideally.In this study, we aimed to identify the characteristics of cancer patients admitted to the emergency medicine in Southwest Turkey.

Materials and Methods
This study has been planned as a descriptive and retrospectively study which aims to identifying the features of admission of cancer patients to ED in Southwest Turkey.It was conducted at an ED associated with a education hospital in Mugla province.Our hospital serves a population of a quarter million with the surrounding districts, but is an increase in population during the summer months due to tourism.

Single Center Experience on Causes of Cancer Patients Visiting the Emergency Department in Southwest Turkey
Ozgur Tanriverdi 1 *, Halil Beydilli 2 , Birdal Yildirim 3 , Ulku Karagoz 3 We excluded patients for who were younger than 18 years of age, who diagnosis with hematological malignancies, and patients whom clinical information could not been reached at the statistical analyses.
A total of 304 emergency department admissions of 102 cancer patients between August 2011 and September 2013.whose medical file information was complete and who did not meet the exclusion criteria were enrolled in this study.
For type of malignancy recorded as the cause of admissions for each patient, we used the International Classification of Diseased (ICD)-10 codes for Turkey.Patients visits made to the our ED were determined by special files of Department of Medical Oncology, records of home care unit, hospital automation system, and Death Notification System of the Ministry of Health.

Ethics
The protocol for this retrospective study was compatible with the local ethical guidelines.The study was approved by the Academic Committees of our institution.

Statistical analyses
The data are expressed as the mean±standard deviation or the median and interquartile range (25-75%).The distribution of variables was analysed with the Kolmogorov-Smirnov test.Quantitative variables with normal distributions were analysed with a two-tailed, independent Student's test.Nonparametric variables were analysed with the Mann-Whitney U test.However, qualitative parameters were analysed with the Chi-square test and Fisher's test.
The relationships between the presence of ED visits and other study variables were determined using Spearman's correlation tests and analysis of variance (ANOVA).Additionally, the relationships between clinical and demographic variables (such as age, sex, smoking habits, weight loss, tumour location, stage of cancer, performance status by Eastern Cooperative Oncology Group-ECOG, co-morbidities, agents of pain palliation, treatment options for malignancy, treatment-related toxicity, localization of metastatic lesions, oncologic emergencies, cancer-related symptoms) and the presence of ED visits were determined using a Pearson correlation test.The dependent variable for the multiple logistic regression analysis was the presence of ED visits.Both the adjusted and crude odds ratios (ORs) were calculated with 95% confidence intervals (95%CI) to assess the influences of various independent variables on the presence of ED visits.
A significance value of p<0.05 was accepted as statistically significant.All of the analyses were performed using the Statistical Program for Social Sciences (SPSS) version 15.
Thus, we concluded that the relationship between visits to ED and lung cancer, metastases to lung, and metastatic disease are independent from the other study variables (such as age, sex, smoking habits, weight loss, tumour location, stage of cancer, performance status by Eastern Cooperative Oncology Group-ECOG, comorbidities, agents of pain palliation, treatment options for malignancy, treatment-related toxicity, localization of metastatic lesions, oncologic emergencies, cancer-related symptoms) (Table 3 and Table 4).

Discussion
Our study showed that a significant proportion of cancer patients many repeated visits to ED.Indeed, previous studies reported that rate of cancer patients for emergency service admissions was 12.5 to 15% (Mayer et al., 2012).Additionally, lung was most common primary and metastatic tumor site and dyspnea, pleural effusion and pain were common symptoms for repeated visits to ED in our study.
Emergency services are most important places for oncology patients.Although cancer is a chronic disease, patients with cancer often visit to ED because lifethreatening emergencies and unexpected side effects associated with cancer or treatment.Previous studies reported that lung cancer and advanced disease were most common causes of ED admissions of cancer (Rosenwax et al., 2011;Kraft-Rovere et al., 2012;Wallace et al., 2012;Gorham et al., 2013).Our study also showed similar results with previously studies.Shortness of breath and anxiety in patients with lung cancer may be the major cause of this ratio for ED admissions of lung cancer.
Previous studies in cancer patients admitted to the ED more often found to the female gender, in our study, the majority of patients were male (Bozdemir et al., 2009;Mayer et al., 2011;Yucel et al., 2012;Barbera et al., 2013).This situation can be explained by the fact that men outnumber patients with lung cancer in our study.In addition, the only one hospital and lack of special hospital of pulmonary disease in our city to serve may be the another cause of this condition.
Previous studies have shown applied to the emergency room with the most common cause of pain approximately in 34% of the patients (Swenson et al., 1995;Escalente et al., 2008;Bozdemir et al., 2009).It keeps track of nausea, vomiting and shortness of breath, respectively (Bozdemir et al., 2009;Yates and Barrett, 2010;Mayer et al., 2011;Kraft-Rovere et al., 2012;Yucel et al., 2012).In our study,  the majority of symptoms of shortness of breath.Similarly, this may be related to the incidence of primary lung cancer and metastases to lung from solid tumors.In our study , the most common presenting the reasons for the emergency department found that it was local compression of malign masses (to lung parenchyma or vessels, brain, bile duct, and spinal cord, respectively), infection and the end-of-life care (Bozdemir et al., 2009;Yates and Barrett, 2009;Mayer et al., 2011;Kraft-Rovere et al., 2012;Yucel et al., 2012;Barbera et al., 2013).These results are similar to previous studies .Deteriorated general health may be associated with hypoxia , electrolyte disorders, brain metastases, infection/sepsis, and eating disorders.We did not find sufficient data in the literature on this situation.
The frequency of patients who were hospitalized because of febrile neutropenia was 11% , whereas the rates of chemotherapy -related anemia was 14% (n=4) and thrombocytopenia was 5% (n=1).In this study, 7% of patients with suspected pulmonary embolism, definite diagnosis was 3% of all of patients.The frequency of nausea and vomiting associated with chemotherapy was 8% and this rate was lower than the literature data (Mayer et al., 2011;Yucel et al., 2012).The reason for this may be that these patients resort to the emergency room just for the weekend.Palliation of pain and chemotherapy-related nause-vomiting by the oncologist is done at chemotherapy unit and this situation can reduce this rate.Similarly, previous studies have shown that treatment-related febrile neutropenia causes death in 4-30% of the patients.Our number of all patients is very small and it limitations our study for incidence of treatment-related complications.
Previous studies have found significantly higher than those without cancer, the rate of hospitalization for patients with cancer.The reason for this may create the danger life-threatening symptoms associated with cancer and its treatment (Mayer et al., 2011;Yucel et al., 2012;Barbera et al., 2013).Co-morbidity diseases and chemotherapyrelated toxicities for lung, liver, kidney, and heart in acute symptomatic patients were part of a specific cause.This application can improve the emergency room.
With poor performance status established an important relationship between emergency department visits.In fact, the performance statusof patients reduces pain, fatigue can increase this ratio of ED admissions such situations.Previous studies have shown poor prognostic factor in poor performance status reported that intra-hospital mortality (Bozcuk et al., 2004;Bozdemir et al., 2009;Yucel et al., 2012;Barbera et al., 2013).
In this study, 88% of patients admitted to the ED clinic were evaluated within first 5 days in the oncology outpatient clinic and in 6% of patients, cancer progression was determined by the oncologist.2% of patients were discharged from the emergency department were hospitalized in the oncology outpatient clinic .
As a result, oncology patients need a multidisciplinary team that to work in harmony for well managed.Excluding the oncological treatment decisions, ED is an important part of this team in all other cases situations.Better symptom control and rapid diagnosis/therapy made by emergency team play an important role for reduce mortality and increased quality-of-life in patients with cancer.We would like to draw attention to heterogeneity of cancer patients in the emergency department.It is a heterogeneous group of patients is important to guard against unexpected life-threatening situations concluded .