Emergency Presentations of Cancer: Quarterly Data, Q1 to Q3 2021/22 (Apr to Dec 2021)

Emergency presentation is an important predictor of cancer outcomes; patients with cancers that typically present as an emergency typically suffer significantly worse outcomes.

The 2015-2020 cancer strategy for England recommended that the proportion of emergency presentations should be regularly reported and reviewed. This metric estimates the proportion of emergency presentations using first admissions to hospital via emergency route (see Definitions and methods section for more information) as a proxy for emergency diagnosis. This method allows for more rapid reporting of this metric. The Rapid cancer registration dataset, which provides a quicker indicative source of cancer data compared to finalised cancer registrations, can also provide an alternative view on the data but is not a replacement to the full registration process that is used for all the National Statistics publications.

New ICD-10 revision 5 codes were added to the definitions used to define cancer groups. In HES these codes appear as early as 2010, whilst they appear from 2013 in the National Cancer Registration Dataset (used to help determine first tumour in HES, for full details of the methodology, please refer to the specifications of the Emergency Presentations metric). Any trends must be interpreted with caution as this could be an artefact of a changing coding system rather than any true changes in incidence or mortality over time. See Impact paper on ICD-10 revision 5 for more detail.

The first case of COVID-19 was recorded in England in January 2020, and the first COVID-19 lockdown began on 23 March 2020. Data  from January 2020 onwards are therefore likely to be influenced by the following potential factors:

1. The number of new diagnoses will be affected by changes in patient behaviour, with fewer people thought to be reporting possible cancer symptoms to General Practitioners (GPs). Decreases were seen during the initial lockdown period in the numbers of General Practitioner  appointments and of people urgently referred for suspected cancer. With people encouraged to continue reporting worrying symptoms to their doctor, and doctors encouraged to refer patients as usual, the number of referrals increased after the initial lockdown although remained lower than usual for several months.
2. The number of patients diagnosed with cancer is likely affected by additional pressures on imaging capacity or endoscopy due to increased use related to COVID-19 or reduced overall capacity resulting from additional infection control measures, for example, measures related to the potential aerosol generation from endoscopy procedures.
3. For breast, colorectal and cervical cancers, the number of new cancer diagnoses will be affected by a reduction in screening activity (particularly during the initial peak of the COVID-19 pandemic) with the return to normal levels taking a varying amount of time across the country and by screening programme.
4. The number of patients diagnosed with cancer and those presenting as an emergency could be affected by the healthcare restrictions imposed during 2020 which have remained in place, for example many GPs are still triaging via telephone or virtual appointments, prior to seeing patients face to face, adding a step or potential delay in the pathway to cancer diagnosis.

There are some cancers where emergency presentation may be the most appropriate route to diagnosis, for example, for children where the first symptom of underlying cancer is likely to result in an emergency presentation on the advice of their GP.

While a fall in emergency presentations may correlate with improved survival, this is not necessarily a direct cause and many other factors will be involved.

The indicator is not adjusted to take account of factors that could influence the health of patients in a geographical area. Geographical areas with an older population can expect to see a larger number of emergency presentations. Geographical areas with a larger number of lung cancers (due to smoking prevalence) or smaller number of breast cancers (due to broader socio-economic factors) can also expect to see a larger proportion of emergency presentations.

The number of cancer patients reported in each quarterly set of emergency presentation results can change over time, due to additional cancer registration information becoming available. As such, the historical quarterly proportions reported may also be subject to small changes.

Smaller populations will have more variability in their estimates than areas with larger populations and will therefore have larger confidence intervals. In addition, small populations (CCGs) will have a larger range of estimates compared to larger populations (CAs), this is because estimates for larger populations are the averages of the estimates of smaller populations.

HES

Hospital episode statistics (HES) is a database of details for: all hospital admissions (known as Admitted Patient Care), Accident and Emergency (A&E) attendances and outpatient appointments at NHS hospitals in England. In this bulletin only the Admitted Patient Care dataset is used to determine first presentations.

Emergency presentation

In this bulletin, an emergency presentation for cancer is defined as a first inpatient admission where the diagnostic code indicates a presentation of cancer, and where there is an emergency method of admission identified from Admitted Patient Care (HES).

A first presentation is considered an emergency if the method of admission is either:

• Emergency: via Accident and Emergency (A&E)
• Emergency: via general practitioner
• Emergency: via Bed Bureau (this is emergency occurring while an inpatient (excluding A&E) for another reason)
• Emergency: via other means including A&E department of another trust.

‘Emergency: via consultant outpatient clinic’ is not considered an emergency presentation. This is because the patient was already within a secondary care setting when referred to the inpatient appointment and therefore the patient’s entry into secondary care is unlikely to be an emergency.

First inpatient admissions for cancer

The denominator is the number of first inpatient admissions having a primary diagnostic code indicating a presentation of cancer identified from Admitted Patient Care (HES). The diagnosis codes in HES may not always include references to cancer for care that is not thought to be related to a cancer diagnosis at the time it was given. This means the metric may not include all tumours registered in the National Cancer Registration Dataset and the results presented here may differ from publicly available results such as Routes to Diagnosis. For full details of the methodology, please refer to the specifications of the Emergency Presentations metric.

Crude proportion

The number of first inpatient admissions for cancer presenting as an emergency, divided by, the total number of first inpatient admissions for cancer, multiplied by 100.

Statistical tests

The likelihood ratio test and two-sided proportions Z-test were used to test whether counts or proportions, respectively, were different from each other. A p-value of 0.05 was used to determine if the test was statistically significant.

1-year rolling proportion

The 1-year rolling proportion for a stated quarter includes the previous 3 quarters’ worth of data meaning a full 12 months of data is used. The denominator is then the total number of cancer presentations for those 4 quarters and the numerator is the total emergency presentations for those 4 quarters.

Other information related to this release are available:

• Cancer Outcome Metrics
• Routes to Diagnosis

Other statistics on cancer are available:

• Cancer registration statistics for England
• Cancer survival for England
• Case-mix adjusted percentage cancers diagnosed at stages 1 and 2 in England

For queries relating to this bulletin contact [email protected]