Many patients learn they could have cancer in the emergency department

Abdominal and chest pain. Injuries. Breathing difficulty. Infections. Mental health emergencies. Those are some of the most common reasons why people go to the local emergency department.

But the ED is also where a surprisingly large percentage of cancer cases are first diagnosed or suspected.

Gregory Adams, DO, an assistant professor in the University of Colorado Department of Emergency Medicine, is keenly aware of that fact.

“When I was in residency in Cleveland, my dad called me one day and said, ‘My leg hurts.’ He was a runner, a very healthy guy who never smoked a day in his life. I went to look at his leg, and it looked like he had a blood clot. He had no risk factors for that. He said, ‘I guess I’ve been having a bit of belly pain and some nonspecific symptoms.’ He was the generation that took a Tylenol and didn’t think anything about it.”

Adams took his father to the hospital ED, where it was confirmed he had a blood clot in his leg. “Then we did a CT scan of his abdomen, and we found he had stage IV metastatic pancreatic cancer. We were all shocked. It was definitely not what we were expecting.”

Adams’ father passed away a few months later.

 Now, Adams practices in the ED at UCHealth University of Colorado Hospital (UCH), a clinical partner of the CU Department of Emergency Medicine. He recently saw a patient in his 30s who came to the ED with abdominal pain.

“He didn’t primarily speak English, he was having a hard time navigating the health care system, and he was worried about his ability to pay, but he finally came in. We did a CT scan on him and found colon cancer, unfortunately.”

Catching cancer late in the game

Such cases are not uncommon among the 130 million to 155 million annual visits to U.S. EDs.

Estimates vary, but a 2024 study drawing on Medicare-claim data for 2008-2017 estimated that EDs in the United States were involved in the initial identification of cancer for 20% to 25% of patients with cancer.

Various studies indicate higher percentages of ED cancer diagnosis for certain cancer types, such as lung, colorectal, and breast. And presentations at a 2019 American Association for Cancer Research conference said people diagnosed with cancer in the ED were more likely to be lower income or be Hispanic or Black than others.

Adams says that in many cases, “people have symptoms, but they don’t always have access to primary care, so they come into the emergency department to try to get an answer, and at times we do find cancer.”

Depending on the type of cancer, Adams says, “until the mass gets large enough that it starts to push on other structures, or until the cancer spreads to other places, you don’t know you have it. So unfortunately we tend to catch these cancers late in the game.”

He adds, “I’ve seen other patients come in with back pain. After a workup we find they have cancer, but from somewhere else in their body. It finally spread to the back and caused the pain.”

Spidey sense

With experience, emergency providers learn to recognize patterns – things like nonspecific abdominal pain, unexplained weight loss, or fatigue – that suggest a patient might have cancer, Adams says.

“Sometimes your spidey sense is off a bit. It might not be one obvious symptom that makes you think, ‘Oh, this is it.’ We see enough patients who have active cancer that we learn what the signs are, and we can sometimes pick up on them when someone comes in for something else.”

At times, cancer is discovered as an “incidental finding” of imaging, Adams says. When patients come to the ER with trauma, “At times CT imaging is indicated to rule out injuries and incidentally I’ve caught cancer in people.”

More questions than answers

When a mass is discovered, especially at just one site, it’s often not possible to tell a patient right away that they have cancer, Adams says.

“I’m totally honest, but I’m also very careful when I talk to patients. Not every mass is cancer. We use the word ‘tumor,’ but there are non-cancerous tumors. It just means an abnormal growth. To truly diagnose a cancer, you need a biopsy. So I’ll say, ‘We found this thing and I don’t know exactly what it is and normally we have more questions than answers.”

If an ED patient with suspected cancer doesn’t need to be admitted to the hospital, “we have a lot of resources that help them get outpatient follow-up for a definitive diagnosis and connect them to the right people for the next steps,” Adams says.

UCH is a partner of the CU Cancer Center, the state’s only Comprehensive Cancer Center as designated by the National Cancer Institute, offering deep expertise in cancer care and research.  

“We have a phenomenal relationship with all of our oncology colleagues,” Adams says. “One of the most anxiety-provoking things a doctor can tell you is, ‘I think you might have cancer.’ The longer you wait to find out, the worse it feels, so I love to see people get in sooner.”

The hardest conversations

Sometimes, Adams says, a patient with a previous cancer diagnosis will come into the ED with symptoms that turn out to be an indication their cancer has spread.

“Occasionally, we’ll get a person on chemo with stage 1 cancer. They thought they were doing OK, but maybe their belly hurts a little. They come in, we scan them, and we see progression of their cancer. Those are some of the hardest conversations I’ve had with people. Or maybe they had cancer 15 years ago and they thought it was cured, and they find out their cancer has come back.”

A 2017 study citing data from the Nationwide Emergency Department Sample for 2006-2012 found that 4.2% of ED visits were by patients with previous cancer diagnoses who were experiencing related symptoms, such as pneumonia, chest pain, and urinary tract infection.

Adams, whose mother also passed away from cancer, says he has “a very big soft spot for these people, having been on the other side of it. I can’t fix everything for them, but I can try to make their day a little better, and get them to a place where they can get their definitive answers.”