K. C. Lee1,2, E. Lilley1,3, D. Sturgeon1, E. Roeland4, G. N. Mody1,5, Z. Cooper1,6 1Brigham & Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 2University Of California, San Diego,Department Of Surgery,San Diego, CA, USA 3Rutgers-Robert Wood Johnson Medical School,Department Of Surgery,Newark, NJ, USA 4University Of California, San Diego,Moores Cancer Center,La Jolla, CA, USA 5Brigham & Women’s Hospital,Division Of Thoracic Surgery, Department Of General Surgery,Boston, MA, USA 6Brigham & Women’s Hospital,Department Of Surgery,Boston, MA, USA
Introduction: Prior studies have reported 30-day mortality in Emergency General Surgery (EGS) patients with advanced cancer; however, a paucity of data exists on the impact of EGS on longer-term survival and healthcare utilization among these patients. Such information is critical for patient counseling and care planning. We hypothesized that older patients with metastatic cancer who underwent an EGS procedure would have worse survival and higher healthcare utilization in the year after surgery than matched patients without EGS.
Methods: This retrospective cohort study used Surveillance, Epidemiology, and End Results-Medicare data from 2001-2013. Patients included were 65 years or older with Stage IV cancer (lung, colorectal, breast, ovarian, pancreatic, or skin) who had an emergent admission for one of seven EGS procedures (partial colectomy, small-bowel resection, cholecystectomy, peptic ulcer disease surgery, lysis of adhesions, appendectomy, and laparotomy). Patients were exact matched to a non-EGS patient by age, sex, race, cancer type, and time from cancer diagnosis to EGS admission. Multi-variable competing-risks and logistic regression models adjusted for region, comorbidity, and income were used to compare the following outcomes up to one year after EGS admission: 30, 90, and 365-day mortality and healthcare utilization (defined as hospitalization, emergency department (ED) visit, and intensive care unit (ICU) stay). Survival analysis was performed to compare overall survival over the study period between EGS and non-EGS patients.
Results: Among the 1,531 metastatic cancer patients who received EGS, in-hospital mortality was 16.5%. After multivariate adjustment, EGS patients were more likely to die within 30 days (hazard ratio (HR) [95% confidence interval (CI)]: 2.66 [2.03-3.49]), 90 days (2.19 [1.83-2.62]), and 365 days (1.34 [1.19-1.50]). EGS patients had a lower overall median survival after admission (120 v. 281 days, p<0.0001) and were more likely to die over the study period compared to non-EGS patients (1.22 [1.10-1.35]), Figure). EGS patients discharged alive were more likely to be hospitalized (odds ratio (OR)[CI]: 1.66 [1.42-1.95]) but not to have ED visits (1.02 [0.80-1.19]) or ICU stays (1.01 [0.83-1.22]).
Conclusion: Older patients with metastatic cancer who receive EGS have decreased overall survival compared to patients who do not receive EGS. The increased likelihood of dying peaked at 30 days but persists beyond the year after admission. EGS patients discharged alive are more likely to be hospitalized in the year after admission. These findings can inform prognostic estimates, deliberations for surgery, and care planning for older EGS patients with advanced cancer.