Study examines relationship between symptom burden and emergency department use in patients with head and neck cancer

Nearly 1 in 5 head and neck cancer patients who report high symptom burden end up in the emergency department (ED) within 14 days, a new study has found.

The study, supported by the CIHR Terry Fox New Investigator Award, was led by Sunnybrook surgeon-scientists Dr. Tony Eskander and Dr. Natalie Coburn, as well as Dr. Christopher Noel, a University of Toronto head & neck surgery resident and PhD candidate, and published today in the Journal of Clinical Oncology. The authors identified 12,000 patients diagnosed with head and neck cancer in Ontario between 2007 and 2018, and examined the relationship between symptom scores and emergency department use.

In an effort to improve symptom detection and management, Ontario developed the largest symptom screening program for cancer patients in the world (ESAS). Patients are asked to rate a variety of symptoms on a scale of 0-10 before each visit to a cancer centre. ESAS looks at pain, tiredness, nausea, depression, anxiety, drowsiness, appetite, well-being and shortness of breath.

Head and neck cancer and its treatment can impact the way a person eats, breathes and swallows. Among all people facing cancer, those with head and neck cancer are known to experience the most significant symptom burden.

Roughly 1 in 3 patients with head and neck cancer will go to the ED during the course of their treatment. Six of the nine individual symptom scores were predictive of ED use with pain, appetite, shortness of breath and tiredness demonstrating the strongest association. Patients with high symptom scores had 10 times higher odds of ED use compared to patients with low symptom scores.

This study helps clinicians identify patients at high risk of ED use and stresses the need for proactive symptom management.

“We knew that we would find a correlation,” said Dr. Noel. “We were surprised at just how tightly linked the ESAS scores and ED visits were.”

Of those patients who went to an emergency department, 80 per cent were sent home and not admitted to the hospital.

“This indicates an unmet need: we are not addressing these symptoms well enough,” Dr. Noel said. “The ESAS score is a good predictor of who will go to an emergency room, better than age, location or type of treatment. Now the question becomes, how can we use these ESAS scores better to help reduce patient symptoms and emergency room visits?”

The next step in this work, he said, will be to determine exactly what made head and neck patients seek ED care. The research team will talk to patients and their families to learn more about their experiences.

“What do the patients need? How can we help patients access these things? Once we sort this out, we will then look towards designing a tool for doctors, nurses and care teams so that we can better address these symptoms, improve the patient experience and the healthcare system.”

This research was supported by the CIHR Terry Fox New Investigator Award, a Harry Barberian Research Grant, a Raymond Ng Doctoral Award, and the Levinsky Waratah Hold’em For Life Oncology Fellowship.