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CONCERN for Cancer
CONCERN for Cancer
New National Institutes of Health Network to Focus on Cancer Patients in the Emergency Department
by JAN GREENE Special Contributor to Annals News & Perspective
T
he National Cancer Institute (NCI) held its first-ever meeting focused exclusively on cancer and emergency medicine in late March. Emergency physicians and oncologists who attended were excited about the idea that a long-neglected area of patient care would get some research attention (Figure). “This was a major achievement just having the meeting and having someone at NCI be really interested and want to find the research gaps and help us find research money,” said Corita Grudzen, MD, an emergency physician at NYU Langone Medical Center who investigates palliative care. “This will help so much.” The meeting and a new research consortium, called the Comprehensive Oncologic Emergencies Research Network, or CONCERN, are the result of cooperation between NCI and the National Institutes of Health’s relatively new Office of Emergency Care Research, fewer than 3 years old. Jeremy Brown, MD, an emergency physician and first permanent director of the office, said the initiative is the result of conversations with NCI’s Nonniekaye Shelburne, MS, CRNP, program director of the clinical and translational epidemiology branch. Volume 66, no. 1 : July 2015
“We both noticed there was really a lack of emphasis on emergency care in oncology in NCI’s research portfolio, and they wanted to take steps to address that,” Dr. Brown said. Shelburne referred to the lack of data on the topic as “a black hole.” Although NCI has no research dollars specifically earmarked for the work, Shelburne’s office will offer its assistance in coordinating researchers’ work in oncologic emergencies. Meanwhile, CONCERN will identify research needs, develop research projects, and seek funding for them. Demetrios Kyriacou, MD, professor of emergency medicine at Northwestern University’s Feinberg School of Medicine, is the chairman. He’s enthused about focusing on a growing population of patients with unique needs. “We don’t have a really good handle on how many cancer patients we see in the emergency department [ED], what issues they have to deal with, and how we could initiate a treatment plan in the ED that would best serve those patients,” Dr. Kyriacou said. “We could make the emergency department a better place for cancer patients.” One of the first orders of business is defining terms and finding baseline data about this population. That isn’t easy because the existing emergency care databases don’t specifically
identify patients who are being treated for cancer, nor do most electronic medical record systems. So no one knows exactly how many there are; Dr. Brown said the closest guess he’s seen is that about 3% of ED visits are directly related to cancer or cancer treatment. “One of the things we need to do is devise new ways to identify these patients,” said Jeffrey Caterino, MD, associate professor of emergency medicine and internal medicine and director of clinical research for Ohio State University’s Department of Emergency Medicine. There’s also the question of how to define “cancer patient” and whether it includes people who have been in remission for many years but whose past disease or treatment could be relevant to an emergency visit. Anecdotally, though, emergency physicians regularly treat cancer patients. And that trend is likely to continue as more patients live with their cancer as a chronic disease and receive ongoing treatment and need help with adverse effects. “The number of oncology patients is only going to increase, so when they have problems in the middle of the night or weekends and can’t get care from their oncologists, they’ll come to us,” Dr. Kyriacou said.
DEFINING THE PROBLEM
T
o help define the scope of the problems that bring cancer patients to the ED, the consortium is developing a multicenter cohort study to follow a group of oncology patients and track their emergency visits. The resulting data will generate proposals for other studies. Annals of Emergency Medicine 13A
Comprehensive Oncologic Emergencies Research Network
CONCERN Figure. The network’s new logo.
The leading issue for cancer patients in the ED is febrile neutropenia. These patients have often been admitted to the hospital for treatment, but increasingly there are questions about whether the hospital is the best place for them and whether they could be managed at home. Dr. Kyriacou also noted that the literature has not provided clear advice on the timing of antibiotics: “[W]e need to do a really good study that adjusts for confounders.” Another common complaint is pain. “We want to get much better at treating pain in oncology patients,” said Dr. Kyriacou. Spinal cord compression, caused by a tumor near the spine, can also bring patients to the ED, he noted. Research on the best treatments and outcomes for these situations is particularly important for emergency physicians, who are under pressure to quickly carry out the most effective treatment and move on to the next patient, said Dr. Kyriacou. “In emergency medicine, we’re always looking at time, how quickly we can care for somebody and how that affects their outcomes,” he said. “We’re constantly told we need to do this better or that better, but we don’t really budge until we see evidence that it makes a difference. You really want to see the evidence because [a new intervention] could take time away from another patient.”
COORDINATING CARE WITH OTHER SPECIALTIES
F
or patients who have a cancer care plan in place or are being treated by a palliative care team through their hospital or hospice, it’s
14A Annals of Emergency Medicine
particularly important to coordinate with the emergency physician to avoid overlap or unwanted tests and procedures in the ED. Avoiding overtreatment is particularly a concern for patients who are receiving palliative care or are in hospice, noted Dr. Grudzen. “Some patients are on a care trajectory, but the family panics and calls 911,” she said. “If we can identify those patients immediately,” they can avoid an unnecessary admission. Another possibility, Dr. Grudzen said, is linking in the emergency medical services system to treat such patients at home and not transport them. Dr. Grudzen is interested in encouraging ED personnel—such as triage nurses, physician assistants, and nurse practitioners—to learn palliative care techniques so they can quickly assess the goals of care with such patients without needing to call in a palliative care team. It’s challenging to take that extra step when someone comes in with severe symptoms or who needs life-prolonging therapies immediately. “It comes down to a key question: How can you quickly assess where someone is—their prognosis, their hopes for this visit—and change course instead of always doing pedal-to-themetal intubation,” Dr. Grudzen said. She also encourages emergency physicians to learn primary palliative care skills so patients can receive expanded access to improved symptom control and referral to social services, which, Dr. Grudzen said, improves outcomes. Another trend may provide helpful evidence on caring for this population: cancer centers are opening their own
EDs to provide specialized care. In April, Ohio State University’s new hospital opened a dedicated section of its ED for cancer patients, who go to a separate waiting area. The project required collaboration between oncologists and emergency physicians, who continue to meet in case conferences on specific patients, explained Dr. Caterino. “This has allowed the emergency medicine providers to develop specific expertise and become more efficient,” said Dr. Caterino. “The patients appreciate that degree of focus both from nursing and physicians. Something about that is kind of reassuring.”
SPEAKING THE SAME LANGUAGE
J
oseph Flynn, DO, a hematologist/ oncologist at Ohio State’s James Cancer Hospital, agrees that the collaboration is good for patients. “We developed programs that transcend the historical differences between the 2 fields,” Dr. Flynn said. A major goal is to keep from admitting patients when it isn’t necessary and ensuring that a care plan doesn’t get derailed in the ED. “I’ve already seen that with patients of mine who have come through the emergency department; everybody’s speaking the same language to them,” Dr. Caterino continued. “That brings a sense of calm.” Other cancer centers also provide emergency care. MD Anderson Cancer Center in Houston has a 44-bed Emergency Center, while Memorial Sloan Kettering Cancer Center in New York sees emergencies through its Urgent Care Center. MD Anderson also has had an academic department of emergency medicine since 2010, with research interests that include oncologic Volume 66, no. 1 : July 2015
emergencies, pain treatment, health disparities, palliative care, and the role of obesity and diabetes in breast cancer. The department has created a fellowship in oncologic emergency medicine providing advanced training in the emergency treatment of cancer patients. One likely result of the research network will be the development of treatment guidelines that will include recommendations about how various specialties can best coordinate care. The National Comprehensive Cancer Network, for instance, writes many of the guidelines for cancer care. “There isn’t a lot in there about the cancer patient who goes to the ED,” noted Shelburne. “We may need to translate those guidelines for the ED environment.”
EMERGENCY PHYSICIANS’ RESEARCH TOPICS WELCOME
N
CI staff is working with the research network to produce a proceedings document to summarize the issues that came up during
Volume 66, no. 1 : July 2015
the March meeting and describe a research agenda going forward. It is expected to be complete by fall. The cancer institute is also carrying out an analysis of adult cancer patients in the ED, which Shelburne said should be published later this year. It’s patterned on a similar analysis of pediatric patients that was published in late 2014.1 That study found that fever and febrile neutropenia were the most common diagnoses in the ED, accounting for about 20% of visits, and up to 82% of the patients with febrile neutropenia ended up being admitted to the hospital. Dr. Kyriacou expects funding to come through the National Institutes of Health grant process and support from foundations such as the American Cancer Society. The network is still in the development phase, with organizers developing a steering committee and a scientific advisory committee stocked with people with backgrounds in epidemiology and advanced research methods. Leaders say new members are welcome; an NCI-sponsored Web site should be up shortly.
Once the network is up and running, its leaders will welcome emergency physicians’ ideas in regard to good research topics. “We want to get the message out that we are interested in funding high-quality projects,” said Dr. Brown. Section editor: Truman J. Milling, Jr, MD Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The author has stated that no such relationships exist. The views expressed in News and Perspective are those of the authors, and do not reflect the views and opinions of the American College of Emergency Physicians or the editorial board of Annals of Emergency Medicine. http://dx.doi.org/10.1016/j.annemergmed. 2015.05.015
REFERENCE 1. Mueller EL, Sabbatini A, Gebremariam A, et al. Why pediatric patients with cancer visit the emergency department: United States, 2006-2010. Pediatr Blood Cancer. 2015;62: 490-495.
Annals of Emergency Medicine 15A
New National Institutes of Health Network to Focus on Cancer Patients in the Emergency Department
by JAN GREENE Special Contributor to Annals News & Perspective
T
he National Cancer Institute (NCI) held its first-ever meeting focused exclusively on cancer and emergency medicine in late March. Emergency physicians and oncologists who attended were excited about the idea that a long-neglected area of patient care would get some research attention (Figure). “This was a major achievement just having the meeting and having someone at NCI be really interested and want to find the research gaps and help us find research money,” said Corita Grudzen, MD, an emergency physician at NYU Langone Medical Center who investigates palliative care. “This will help so much.” The meeting and a new research consortium, called the Comprehensive Oncologic Emergencies Research Network, or CONCERN, are the result of cooperation between NCI and the National Institutes of Health’s relatively new Office of Emergency Care Research, fewer than 3 years old. Jeremy Brown, MD, an emergency physician and first permanent director of the office, said the initiative is the result of conversations with NCI’s Nonniekaye Shelburne, MS, CRNP, program director of the clinical and translational epidemiology branch. Volume 66, no. 1 : July 2015
“We both noticed there was really a lack of emphasis on emergency care in oncology in NCI’s research portfolio, and they wanted to take steps to address that,” Dr. Brown said. Shelburne referred to the lack of data on the topic as “a black hole.” Although NCI has no research dollars specifically earmarked for the work, Shelburne’s office will offer its assistance in coordinating researchers’ work in oncologic emergencies. Meanwhile, CONCERN will identify research needs, develop research projects, and seek funding for them. Demetrios Kyriacou, MD, professor of emergency medicine at Northwestern University’s Feinberg School of Medicine, is the chairman. He’s enthused about focusing on a growing population of patients with unique needs. “We don’t have a really good handle on how many cancer patients we see in the emergency department [ED], what issues they have to deal with, and how we could initiate a treatment plan in the ED that would best serve those patients,” Dr. Kyriacou said. “We could make the emergency department a better place for cancer patients.” One of the first orders of business is defining terms and finding baseline data about this population. That isn’t easy because the existing emergency care databases don’t specifically
identify patients who are being treated for cancer, nor do most electronic medical record systems. So no one knows exactly how many there are; Dr. Brown said the closest guess he’s seen is that about 3% of ED visits are directly related to cancer or cancer treatment. “One of the things we need to do is devise new ways to identify these patients,” said Jeffrey Caterino, MD, associate professor of emergency medicine and internal medicine and director of clinical research for Ohio State University’s Department of Emergency Medicine. There’s also the question of how to define “cancer patient” and whether it includes people who have been in remission for many years but whose past disease or treatment could be relevant to an emergency visit. Anecdotally, though, emergency physicians regularly treat cancer patients. And that trend is likely to continue as more patients live with their cancer as a chronic disease and receive ongoing treatment and need help with adverse effects. “The number of oncology patients is only going to increase, so when they have problems in the middle of the night or weekends and can’t get care from their oncologists, they’ll come to us,” Dr. Kyriacou said.
DEFINING THE PROBLEM
T
o help define the scope of the problems that bring cancer patients to the ED, the consortium is developing a multicenter cohort study to follow a group of oncology patients and track their emergency visits. The resulting data will generate proposals for other studies. Annals of Emergency Medicine 13A
Comprehensive Oncologic Emergencies Research Network
CONCERN Figure. The network’s new logo.
The leading issue for cancer patients in the ED is febrile neutropenia. These patients have often been admitted to the hospital for treatment, but increasingly there are questions about whether the hospital is the best place for them and whether they could be managed at home. Dr. Kyriacou also noted that the literature has not provided clear advice on the timing of antibiotics: “[W]e need to do a really good study that adjusts for confounders.” Another common complaint is pain. “We want to get much better at treating pain in oncology patients,” said Dr. Kyriacou. Spinal cord compression, caused by a tumor near the spine, can also bring patients to the ED, he noted. Research on the best treatments and outcomes for these situations is particularly important for emergency physicians, who are under pressure to quickly carry out the most effective treatment and move on to the next patient, said Dr. Kyriacou. “In emergency medicine, we’re always looking at time, how quickly we can care for somebody and how that affects their outcomes,” he said. “We’re constantly told we need to do this better or that better, but we don’t really budge until we see evidence that it makes a difference. You really want to see the evidence because [a new intervention] could take time away from another patient.”
COORDINATING CARE WITH OTHER SPECIALTIES
F
or patients who have a cancer care plan in place or are being treated by a palliative care team through their hospital or hospice, it’s
14A Annals of Emergency Medicine
particularly important to coordinate with the emergency physician to avoid overlap or unwanted tests and procedures in the ED. Avoiding overtreatment is particularly a concern for patients who are receiving palliative care or are in hospice, noted Dr. Grudzen. “Some patients are on a care trajectory, but the family panics and calls 911,” she said. “If we can identify those patients immediately,” they can avoid an unnecessary admission. Another possibility, Dr. Grudzen said, is linking in the emergency medical services system to treat such patients at home and not transport them. Dr. Grudzen is interested in encouraging ED personnel—such as triage nurses, physician assistants, and nurse practitioners—to learn palliative care techniques so they can quickly assess the goals of care with such patients without needing to call in a palliative care team. It’s challenging to take that extra step when someone comes in with severe symptoms or who needs life-prolonging therapies immediately. “It comes down to a key question: How can you quickly assess where someone is—their prognosis, their hopes for this visit—and change course instead of always doing pedal-to-themetal intubation,” Dr. Grudzen said. She also encourages emergency physicians to learn primary palliative care skills so patients can receive expanded access to improved symptom control and referral to social services, which, Dr. Grudzen said, improves outcomes. Another trend may provide helpful evidence on caring for this population: cancer centers are opening their own
EDs to provide specialized care. In April, Ohio State University’s new hospital opened a dedicated section of its ED for cancer patients, who go to a separate waiting area. The project required collaboration between oncologists and emergency physicians, who continue to meet in case conferences on specific patients, explained Dr. Caterino. “This has allowed the emergency medicine providers to develop specific expertise and become more efficient,” said Dr. Caterino. “The patients appreciate that degree of focus both from nursing and physicians. Something about that is kind of reassuring.”
SPEAKING THE SAME LANGUAGE
J
oseph Flynn, DO, a hematologist/ oncologist at Ohio State’s James Cancer Hospital, agrees that the collaboration is good for patients. “We developed programs that transcend the historical differences between the 2 fields,” Dr. Flynn said. A major goal is to keep from admitting patients when it isn’t necessary and ensuring that a care plan doesn’t get derailed in the ED. “I’ve already seen that with patients of mine who have come through the emergency department; everybody’s speaking the same language to them,” Dr. Caterino continued. “That brings a sense of calm.” Other cancer centers also provide emergency care. MD Anderson Cancer Center in Houston has a 44-bed Emergency Center, while Memorial Sloan Kettering Cancer Center in New York sees emergencies through its Urgent Care Center. MD Anderson also has had an academic department of emergency medicine since 2010, with research interests that include oncologic Volume 66, no. 1 : July 2015
emergencies, pain treatment, health disparities, palliative care, and the role of obesity and diabetes in breast cancer. The department has created a fellowship in oncologic emergency medicine providing advanced training in the emergency treatment of cancer patients. One likely result of the research network will be the development of treatment guidelines that will include recommendations about how various specialties can best coordinate care. The National Comprehensive Cancer Network, for instance, writes many of the guidelines for cancer care. “There isn’t a lot in there about the cancer patient who goes to the ED,” noted Shelburne. “We may need to translate those guidelines for the ED environment.”
EMERGENCY PHYSICIANS’ RESEARCH TOPICS WELCOME
N
CI staff is working with the research network to produce a proceedings document to summarize the issues that came up during
Volume 66, no. 1 : July 2015
the March meeting and describe a research agenda going forward. It is expected to be complete by fall. The cancer institute is also carrying out an analysis of adult cancer patients in the ED, which Shelburne said should be published later this year. It’s patterned on a similar analysis of pediatric patients that was published in late 2014.1 That study found that fever and febrile neutropenia were the most common diagnoses in the ED, accounting for about 20% of visits, and up to 82% of the patients with febrile neutropenia ended up being admitted to the hospital. Dr. Kyriacou expects funding to come through the National Institutes of Health grant process and support from foundations such as the American Cancer Society. The network is still in the development phase, with organizers developing a steering committee and a scientific advisory committee stocked with people with backgrounds in epidemiology and advanced research methods. Leaders say new members are welcome; an NCI-sponsored Web site should be up shortly.
Once the network is up and running, its leaders will welcome emergency physicians’ ideas in regard to good research topics. “We want to get the message out that we are interested in funding high-quality projects,” said Dr. Brown. Section editor: Truman J. Milling, Jr, MD Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The author has stated that no such relationships exist. The views expressed in News and Perspective are those of the authors, and do not reflect the views and opinions of the American College of Emergency Physicians or the editorial board of Annals of Emergency Medicine. http://dx.doi.org/10.1016/j.annemergmed. 2015.05.015
REFERENCE 1. Mueller EL, Sabbatini A, Gebremariam A, et al. Why pediatric patients with cancer visit the emergency department: United States, 2006-2010. Pediatr Blood Cancer. 2015;62: 490-495.
Annals of Emergency Medicine 15A