Supportive Care in Cancer

, Volume 14, Issue 10, pp 1038–1045 | Cite as

Progressive disease in patients with cancer presenting to an emergency room with acute symptoms predicts short-term mortality

  • Jane M. GeraciEmail author
  • Walter Tsang
  • Rosalie V. Valdres
  • Carmen P. Escalante
Original Paper



Patients with symptomatic, advanced cancer continue to be referred late or not at all for hospice or palliative care. We conducted a retrospective cohort study to determine whether evidence of cancer progression is an independent predictor of short-term mortality in acutely symptomatic cancer patients.

Patients and methods

We reviewed the records of 396 patients who visited the emergency center at a comprehensive cancer center in January 2000. Records were reviewed for clinical characteristics, including symptoms, type and extent of cancer, and whether the patient’s cancer was stable or progressing (uncontrolled) at the time of the emergency center visit. Cox regression analysis was used to assess survival at 90 and 180 days, after controlling for patient characteristics.

Main results

Patients who died within 14, 90, or 180 days were more likely to have disease progression than those who did not. Dyspnea on emergency center presentation and disease progression were independent predictors of death within 90 or 180 days, after controlling for patient age, symptoms, signs, and the presence of metastases. The odds ratios for death within 90 and 180 days were 3.97 and 4.34, respectively (95% confidence intervals: 1.44, 10.94 and 1.87, 10.09).


Cancer disease progression is a clinical measure of increased risk of short-term mortality in acutely symptomatic cancer patients. Future studies should examine whether the use of this characteristic enhances identification of patients who could benefit from timely referral to hospice or palliative care.

Shortened abstract

Symptomatic cancer patients presenting to a cancer center emergency room were more likely to die within 14, 90, or 180 days if they had evidence of recent progression of their cancer. Among patients with disease progression, 47% died within 90 days and 61% within 180 days.


Cancer progression Mortality prediction Survival 



The authors thank Tony Lam and Jing Wang for their invaluable assistance with programming and statistical analyses, and Mrs. Sandra Pontello for assistance with manuscript formatting.


  1. 1.
    (1995) A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). The SUPPORT Principal Investigators. JAMA 274:1591–1598Google Scholar
  2. 2.
    Christakis NA (1999) Death foretold: prophecy and prognosis in medical care. 1st edn. University of Chicago Press, ChicagoGoogle Scholar
  3. 3.
    Christakis NA, Lamont EB (2000) Extent and determinants of error in doctors’ prognoses in terminally ill patients: prospective cohort study. BMJ 320:469–472CrossRefPubMedGoogle Scholar
  4. 4.
    Daugherty CK, Steensma DP (2002) Overcoming obstacles to hospice care: an ethical examination of inertia and inaction. J Clin Oncol 20:2752–2755PubMedGoogle Scholar
  5. 5.
    Earle CC, Neville BA, Landrum MB, Ayanian JZ, Block SD, Weeks JC (2004) Trends in the aggressiveness of cancer care near the end of life. J Clin Oncol 22:315–321CrossRefPubMedGoogle Scholar
  6. 6.
    Escalante CP, Martin CG, Elting LS, Cantor SB, Harle TS, Price KJ, Kish SK, Manzullo EF, Rubenstein EB (1996) Dyspnea in cancer patients. Etiology, resource utilization, and survival implications in a managed care world. Cancer 78:1314–1319CrossRefPubMedGoogle Scholar
  7. 7.
    Escalante CP, Martin CG, Elting LS, Price KJ, Manzullo EF, Weiser MA, Harle TS, Cantor SB, Rubenstein EB (2000) Identifying risk factors for imminent death in cancer patients with acute dyspnea. J Pain Symptom Manage 20:318–325CrossRefPubMedGoogle Scholar
  8. 8.
    Giordano SH, Buzdar AU, Smith TL, Kau SW, Yang Y, Hortobagyi GN (2004) Is breast cancer survival improving? Cancer 100:44–52CrossRefPubMedGoogle Scholar
  9. 9.
    Hauser TH, Ho KK (2001) Accuracy of on-line databases in determining vital status. J Clin Epidemiol 54:1267–1270CrossRefPubMedGoogle Scholar
  10. 10.
    Huang J, Boyd C, Tyldesley S, Zhang-Salomons J, Groome PA, Mackillop WJ (2002) Time spent in hospital in the last six months of life in patients who died of cancer in Ontario. J Clin Oncol 20:1584–1592CrossRefPubMedGoogle Scholar
  11. 11.
    Kapo J, Harrold J, Carrol JT, Rickerson E, Casarett D (2005) Are we referring patients to hospice too late? Patients’ and families’ opinions. J Palliat Med 8:521–527CrossRefPubMedGoogle Scholar
  12. 12.
    Lamont EB, Christakis NA (1999) Some elements of prognosis in terminal cancer. Oncology (Williston Park) 13:1165–1170; discussion 1172–1174:1179–1180Google Scholar
  13. 13.
    Lamont EB, Christakis NA (2002) Physician factors in the timing of cancer patient referral to hospice palliative care. Cancer 94:2733–2737CrossRefPubMedGoogle Scholar
  14. 14.
    Lamont EB, Siegler M (2000) Paradoxes in cancer patients’ advance care planning. J Palliat Med 3:27–35CrossRefPubMedGoogle Scholar
  15. 15.
    Lynn J, Arkes HR, Stevens M, Cohn F, Koenig B, Fox E, Dawson NV, Phillips RS, Hamel MB, Tsevat J (2000) Rethinking fundamental assumptions: SUPPORT’s implications for future reform. Study to Understand Prognoses and Preferences and Risks of Treatment. J Am Geriatr Soc 48:S214–S221PubMedGoogle Scholar
  16. 16.
    Maltoni M, Pirovano M, Scarpi E, Marinari M, Indelli M, Arnoldi E, Gallucci M, Frontini L, Piva L, Amadori D (1995) Prediction of survival of patients terminally ill with cancer. Results of an Italian prospective multicentric study. Cancer 75:2613–2622PubMedCrossRefGoogle Scholar
  17. 17.
    Maltoni M, Caraceni A, Brunelli C, Broeckaert B, Christakis N, Eychmueller S, Glare P, Nabal M, Vigano A, Larkin P, De Conno F, Hanks G, Kaasa S (2005) Prognostic factors in advanced cancer patients: Evidence-based clinical recommendations—a study by the Steering Committee of the European Association for Palliative Care. J Clin Oncol 23:6240–6248CrossRefPubMedGoogle Scholar
  18. 18.
    Meyers FJ, Linder J (2003) Simultaneous care: disease treatment and palliative care throughout illness. J Clin Oncol 21:1412–1415CrossRefPubMedGoogle Scholar
  19. 19.
    Pound CR, Partin AW, Eisenberger MA, Chan DW, Pearson JD, Walsh PC (1999) Natural history of progression after PSA elevation following radical prostatectomy. JAMA 281:1591–1597CrossRefPubMedGoogle Scholar
  20. 20.
    Reuben DB, Mor V, Hiris J (1988) Clinical symptoms and length of survival in patients with terminal cancer. Arch Intern Med 148:1586–1591CrossRefPubMedGoogle Scholar
  21. 21.
    Solomayer EF, Diel IJ, Meyberg GC, Gollan C, Bastert G (2000) Metastatic breast cancer: clinical course, prognosis and therapy related to the first site of metastasis. Breast Cancer Res Treat 59:271–278CrossRefPubMedGoogle Scholar
  22. 22.
    Steensma DP, Loprinzi CL (2000) The art and science of prognosis in patients with advanced cancer. Eur J Cancer 36:2025–2027CrossRefPubMedGoogle Scholar
  23. 23.
    Vigano A, Dorgan M, Bruera E, Suarez-Almazor ME (1999) The relative accuracy of the clinical estimation of the duration of life for patients with end of life cancer. Cancer 86:170–176CrossRefPubMedGoogle Scholar
  24. 24.
    Vigano A, Dorgan M, Buckingham J, Bruera E, Suarez-Almazor ME (2000) Survival prediction in terminal cancer patients: a systematic review of the medical literature. Palliat Med 14:363–374CrossRefPubMedGoogle Scholar
  25. 25.
    Weeks JC, Cook EF, O’Day SJ, Peterson LM, Wenger N, Reding D, Harrell FE, Kussin P, Dawson NV, Connors AF Jr, Lynn J, Phillips RS (1998) Relationship between cancer patients’ predictions of prognosis and their treatment preferences. JAMA 279:1709–1714CrossRefPubMedGoogle Scholar
  26. 26.
    Wilke HJ, Van Cutsem E (2003) Current treatments and future perspectives in colorectal and gastric cancer. Ann Oncol 14(Suppl 2):ii49–ii55CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag 2006

Authors and Affiliations

  • Jane M. Geraci
    • 1
    Email author
  • Walter Tsang
    • 1
  • Rosalie V. Valdres
    • 1
  • Carmen P. Escalante
    • 1
  1. 1.Department of General Internal Medicine, Ambulatory Treatment and Emergency CareThe University of Texas M.D. Anderson Cancer CenterHoustonUSA

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