AAEM NEWS
New Cancer Diagnoses during COVID Sabena Vaswani, MD (@sabenavaswani)
Ever since the coronavirus pandemic began in March, emergency rooms across the country have been experiencing lower volumes and higher acuity. Due to the widespread clinic closures and fear of viral exposure, patients are delaying seeking medical care. Thus, the secondary effects of COVID-19 are rising. Emergency physicians around the country are now seeing more mental health crises, acute on chronic disease, and late stage presentations of new diagnoses. As the first New York coronavirus surge comes to a lull in the late spring, recently, my C-word has not been “COVID,” but “cancer.” For the past few weeks, I have been diagnosing metastatic disease on nearly every shift – from pancreatic adenocarcinoma with hepatic invasion, to ovarian cancer with severe ascites, to esophageal cancer with obstructive dysphagia, to laryngeal carcinoma with stridor. Recently, cancer barged through my family’s front door. Within minutes, our lives were changed. Priorities shifted. Expectations of the future paused. My family member’s story is similar to so many of my patients’ experiences. “I haven’t been feeling well, but I’ve been too scared to see the doctor. I thought I wasn’t supposed to come in...” During the peak of the pandemic, patients were also attributing their symptoms to coronavirus. Fevers – it must be COVID; back pain – possibly viral myalgias; weight loss – perhaps deconditioning from quarantine. As a result, his diagnosis was delayed.
As emergency physicians, we have unparalleled access to lab tests, EKGs, point-of-care ultrasounds, imaging, and consultants. Tests result in minutes to hours. Given our diagnostic power and breadth of knowledge, we can diagnose diseases faster than most other fields of medicine. Emergency physicians can give patients answers the same day. However, diagnoses carry weight. Due to the fast-paced work up, many patients are never warned of the possibility of cancer, making the news even more jarring. Approximately 11% of new cancer diagnoses are ED-mediated.1 Historically, this disproportionately affects medically underserved patients with more advanced disease. COVID is likely pushing even more of these late new cancer diagnoses to the ER. Therefore, it is important for all practitioners to develop a compassionate and deliberate approach when informing patients in the ER. The SPIKES2 framework (setting, perception, invitation, knowledge, empathy, and summary) lays the foundation for breaking bad news in medicine. In addition, I recommend the following methods to supplement SPIKES for ED cancer diagnoses.
Emergency physicians around the country are now seeing more mental health crises, acute on chronic disease, and late stage presentations of new diagnoses.” Discuss the radiology results. Many patients I interviewed with ED-mediated cancer diagnoses said that their primary emergency physician never communicated the radiology results to them. As such, patients incidentally found out from the incoming physician or from the nurse in passing. Therefore, before leaving a shift, it is imperative to ask yourself: does the patient know about the diagnosis? If not, who will tell them, when, and how? During my intern year, I consistently had to train myself that explaining the lab results, diagnosis, and treatment plan to the patient was just as important as the medical work-up. This is especially important with cancer. 18
COMMON SENSE SEPTEMBER/OCTOBER 2020
Say “cancer.” There is no substitute for the word “cancer.” Even the words “malignant,” “metastatic,” or “tumor” will not suffice. If it is high on your differential, it is important to communicate this possibility while still leaving room for alternate diagnoses. Patients will inevitably pepper you with questions about the staging, the treatment plan, and the prognosis, but try to remember your own limitations and encourage them to write down questions for the specialist. It is important to emphasize that nothing is proven until the biopsy.
Pause. After informing the patient, stop and allow them to process the information. I typically walk away to give them a moment of privacy to talk to family while I quickly attend to another task. Within a few minutes, I return to the patient with a glass of water, and I provide them with more details and answer their questions.
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