Emergency physicians’ experiences managing patients with a suspected cancer diagnosis in Ontario, Canada: a qualitative study

Abstract

Objective

The emergency department (ED) often serves as a crucial pathway for cancer diagnosis. However, little is known about the management of patients with new suspected cancer diagnoses in the ED. The objective of this study was to explore emergency physicians’ experiences in managing patients with a newly suspected cancer diagnosis in the ED.

Design

Between January and April 2024, we conducted a qualitative descriptive study. Interviews were conducted by trained research personnel using a semistructured interview guide. Interviews were conducted until thematic saturation was achieved. The interview transcripts were coded and thematic analysis was used to uncover key themes.

Setting and participants

Emergency physicians practising in Ontario, Canada.

Results

20 emergency physicians were interviewed. Four themes around the management of patients with new suspected cancer diagnoses in the ED were identified: (1) healthcare system-level factors that impact suspected cancer diagnosis through the ED, (2) institutional and provider-level challenges associated with managing patients with a suspected cancer diagnosis in the ED, (3) patient-level characteristics and experiences of receiving a cancer diagnosis in the ED and (4) the need for care coordination for patients with suspected cancer in the ED.

Conclusions

Physicians experienced several unique challenges in managing patients with a suspected cancer diagnosis in the ED. Overall, the findings of this study suggest these challenges often make the ED a difficult environment in which to deliver a suspected cancer diagnosis.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• We used qualitative methodology and double coding to understand emergency physicians’ experiences managing patients with a new suspected cancer diagnosis in the emergency department.

• Only emergency physicians practising in Ontario were interviewed; therefore, results may not represent physicians’ experiences outside of Ontario or Canada.

• There may be response bias associated with the results, with individuals who were interested in this topic being more likely to participate.

• Due to the small sample size and exploratory nature of our study, we could not comment on overall differences in results based on region or site of practice.

Introduction

Cancer is common worldwide.¹ For many patients, the emergency department (ED) plays an important role in the diagnosis of cancer. Previous studies suggest that ED-related cancer diagnoses are common and range from 11% to 36% of all cancer diagnoses.^{2 3} Our recent study found that over one-third of patients in Ontario, Canada, with a newly diagnosed cancer were seen in the ED 90 days prior to their diagnosis.⁴

There are several reasons why patients with suspected cancer may be seen in the ED. There may be delays in accessing primary care or insufficient availability of primary care services, as described in a study of patients who had their lung cancer first suspected/diagnosed during an ED presentation.⁵ Long wait times to access health services, such as imaging or specialist care, may also lead patients to try to expedite their care through the ED.6,8 Additionally, patients with suspected cancer may present to the ED due to acute symptoms associated with cancer (ie, pain, swelling, bleeding, obstruction, etc) that require immediate medical attention.^{9 10}

Despite many patients being seen in the ED with suspected cancer, there are few studies examining the role of the ED during the diagnostic phase of the cancer care continuum. Across Ontario, there are over 160 EDs, with each ED having different access to services and different or no defined processes in place for referral to outpatient specialists, including oncology.¹¹ We previously found that the ED management of Ontario patients with suspected cancer was variable between different EDs and specific to the type of suspected cancer the patient may have.¹² Given this variability and the environment of emergency medicine, where care is often episodic and lacks continuity, emergency physicians may experience unique challenges in managing and arranging follow-up for patients with a suspected cancer diagnosis in the ED. Therefore, the purpose of this qualitative study was to explore the experiences of emergency physicians in Ontario managing patients with newly suspected cancer in the ED.

Methods

Study setting

This was a qualitative study of emergency physicians practising in Ontario EDs. Ontario, Canada, has provincially funded universal healthcare for insured patients for medically necessary care. This study followed the Consolidated criteria for Reporting Qualitative research guidelines.¹³

Study design and population

A semistructured interview guide was developed and pilot tested by the research team in order to explore the experience of emergency physicians in managing patients with a newly suspected cancer diagnosis in the ED. Using our prior survey findings as a guide,¹² which revealed variability in the ED management of patients with a suspected cancer diagnosis based on where physicians practised and the type of cancer, the interview questions focused on access to specialist support from the ED, facilitators and barriers to managing patients with new suspected cancer in the ED and obtaining follow-up care and potential solutions to improve care for patients seen in the ED with suspected cancer. See online supplemental appendix A for the interview guide.

Between January and March 2024, emergency physicians currently practising in Ontario EDs were invited to participate in the study using various methods, including email invitations from the research team, snowball sampling and promotional posts on X (formerly Twitter). We used purposive sampling to ensure recruitment across all six Ontario Health Regions, spanning urban and rural settings. Emergency physicians on the research team were excluded from participating. Physicians interested in participating in the study were asked to contact a research assistant, who then scheduled a telephone interview. Individual telephone interviews with participants were conducted in English by a member of the study team (CM), using the semistructured interview guide. The research assistant, female, did not have any previous relationships with any of the participants and did not have any personal experiences with the study topic. The research assistant (CM) was a graduate student who completed courses in qualitative methods and was previously involved in qualitative work. CM was directly supervised by a clinician scientist in emergency medicine (KG), with input from researchers with qualitative research expertise (BP and JLB). Verbal consent to participate in the study was obtained during the interview. Participants received a $C20 gift card to reimburse their time. No participants dropped out of the study after completing interviews. Sociodemographic information about participants, including the number of years practising emergency medicine and sex, was obtained from the College of Physicians and Surgeons of Ontario physician website (https://www.cpso.on.ca/Public/Doctor-Search?search=general).

Data analysis

Interviews were audio-recorded, anonymised and then transcribed verbatim. Data analysis was conducted in parallel with data collection to monitor emerging themes and areas to explore further in subsequent interviews. There has been very little prior research in this area, and our research team found no suitable framework to apply to this analysis. Therefore, we used an inductive thematic analysis approach.¹⁴ Coding of transcripts was performed using NVivo V.14 (NVivo, QSR International). Transcripts were double-coded by two team members (CM and KG) using open coding, allowing central codes to emerge from the data rather than using predetermined coding categories.¹⁴ A coding guide was developed based on the first 8–10 interviews and revised as needed, and applied to all 20 interviews by the two team members independently. Interviews were conducted until thematic saturation was achieved, and 3–4 interviews no longer provided new insights.¹⁴ No repeat interviews were conducted. Preliminary themes were identified based on coding of the transcripts and discussed between co-investigators until consensus was reached on the key themes.

Patient and public involvement

We had two patient partners with experience of having or caring for family who had ED involvement in a cancer diagnosis. Both patient partners reviewed the study proposal, study question and interview guide and provided feedback. The patient partners were not involved in participant recruitment or data analysis/interpretation.

Results

20 emergency physicians were interviewed, with interviews lasting 15 to 35 min. We interviewed physicians from all six Ontario Health Regions, who practised in a mix of EDs, including academic and community sites. Six (30%) participants had practised emergency medicine for over 10 years, and approximately half (55%) were female (table 1).

Table 1. Description of participants (n=20).

Variable	N (%)
Sex
Female	11 (55.0)
Male	9 (45.0)
Years practising emergency medicine
≤5 years	10 (50.0)
6–10 years	4 (20.0)
11–15 years	2 (10.0)
>15 years	4 (20.0)
Ontario Health regions
Central (Central West, Central, Mississauga Halton, North Simcoe Muskoka)	3 (15.0)
East (Central East, South East, Champlain)	2 (10.0)
North East	1 (5.0)
North West	2 (10.0)
Toronto (Toronto Central)	5 (25.0)
West (Erie St. Clair, South West, Waterloo Wellington, Hamilton Niagara Haldimand Brant)	7 (35.0)

We identified four key themes that were described across interviews around the management of patients with new suspected cancer diagnoses in the ED. These themes were: (1) healthcare system-level factors that impact suspected cancer diagnosis through the ED, (2) institutional and provider-level challenges associated with managing patients with a suspected cancer diagnosis in the ED, (3) patient-level characteristics and patient experiences of receiving a suspected cancer diagnosis in the ED and (4) the need for care coordination for patients with suspected cancer in the ED. Within each theme, several subthemes were identified. Themes and subthemes are further defined in box 1.

Box 1. Description of themes and subthemes.

Healthcare system-level factors:

• Challenges in the broader healthcare system that create systemic gaps and structural barriers that drive both the initial presentation of cancer-related concerns to the emergency department (ED) and the subsequent obstacles emergency physicians face in managing and arranging follow-up care for these patients.

• Subthemes included: inadequate access to primary care and specialist support, prolonged wait times to access services and the ED being a distressing environment for managing patients with a new suspected cancer diagnosis.

Institutional and provider-level challenges:

• Institutional and professional limitations that shape emergency physicians’ experiences managing patients with suspected cancer in the ED.

• Subthemes included: the need for a biopsy to be seen by oncology, fragmented and inconsistent referral pathways with frequent specialist refusals of referrals, unclear ownership and accountability for the patient, access to imaging in the ED, use of general internal medicine and hospital admission to expedite work-up, emergency physicians’ time constraints and a lack of a patient-provider relationship.

Patient-level characteristics and patient experiences:

• Patient-level factors that shape the experience and outcomes of receiving a suspected cancer diagnosis in the ED.

• Subthemes included: geographic barriers to care, marginalised populations that were disproportionately affected by cancer diagnoses through the ED and the psychosocial impact of receiving a suspected cancer diagnosis in the ED.

Need for care coordination:

• Participants’ concern about poorly coordinated care from the ED.

• Subthemes included: the lack of closed-loop communication and the urgent need for system-wide solutions and care coordination to ensure patients receive timely follow-up care for further cancer work-up.

Theme 1: healthcare system factors

This theme captured challenges in the broader healthcare system that create systemic gaps and structural barriers, that drive both the initial presentation of cancer-related concerns to the ED and the subsequent obstacles emergency physicians face in managing and arranging follow-up care for these patients. Within this theme, we identified several subthemes, including inadequate access to primary care and specialist support, prolonged wait times to access services and the ED being a distressing environment for managing patients with a new suspected cancer diagnosis. Many participants described a crisis in healthcare, where the ED has become the only place to obtain timely healthcare for many patients who are unable to seek care elsewhere or who require expedited care that cannot be provided in a timely manner through the outpatient setting.

The emergency department has become a catch-all or, some people think, the garbage can of our healthcare system, and everything that no one else can find out what to do with, they send them to us, and we are left holding the bag to try to figure out how we can care for these poor people that don't have access to what they deserve. (Participant 11, male, community site)

Participants often described that poor access to primary care often leads patients to seek care in the ED for symptoms that may be related to cancer or for expedited work-up of already suspected cancer. Furthermore, a lack of primary care access made it challenging for ED physicians to ensure the patient receives appropriate follow-up after their ED visit and could ‘quarterback’ further care.

There is a huge portion of the population that are unattached, and they don't have any primary care follow-up, so I can't even say if you don't hear, at least talk to your family physician about this, or there’s nothing that I can really do to facilitate their follow-up other than sending a referral. (Participant 17, female, academic site)

Participants also emphasised the importance of access to specialist support from the ED for further diagnostic work-up for patients, which was often dependent on where the ED physician practised. Poor access to specialist support from the ED made it difficult to know where to refer patients for further cancer work-up, which seemed particularly challenging for participants working in smaller or remote hospitals, where they described limited access to local specialists for further work-up and follow-up care.

It’s really unfortunate, though, that if you go to an academic centre, you probably get care quicker than if you are here in my emerg department, for example, because we don't have the services. (Participant 7, male, community site)

Many participants also described that long wait times for patients to see specialists, oncologists or receive further diagnostic testing, such as further imaging or biopsies, negatively impact care. Participants felt that patients often left the ED not knowing how long they would be waiting for their follow-up. Finally, most participants described the ED as a suboptimal environment to disclose a potential cancer diagnosis and subsequently manage these patients. Participants described the overall ED environment as unpleasant, noisy and busy. EDs were described as being overcrowded, with patients routinely being seen and managed in waiting rooms and hallways. Therefore, delivering a suspected cancer diagnosis to patients in the ED was described as likely distressing to patients because of the lack of private spaces to discuss this diagnosis.

I think hallway medicine (is) a big problem, specifically for this population. You can always put them in a different room, but, yeah, that’s, like, certainly what people remember from their visit is they brought me to this spot, or they, you know, alternatively, they told me in the hallway in front of everybody. And that’s, like, awful. (Participant 13, female, academic site)

Theme 2: institutional and provider-level challenges

This theme reflected how institutional and professional limitations shape the emergency physicians’ experience of managing patients with suspected cancer in the ED. Several subthemes were identified, which included the need for a biopsy to be seen by oncology specialists, fragmented and inconsistent referral pathways with frequent specialist refusals of referrals, unclear ownership and accountability for the patient, access to imaging in the ED, use of general internal medicine (GIM) and hospital admission to expedite work-up, emergency physicians’ time constraints and lack of a patient-provider relationship.

Many participants noted that a tissue pathology confirming malignancy was often required before patients could be seen by oncology specialists, which was difficult to arrange and follow from the ED because of the episodic nature of ED care. Because of this requirement, most ED physicians could not refer patients directly to an oncologist and instead had to refer to a specialist who could arrange for a biopsy and follow up on results. Participants described that, although various pathways exist for obtaining a cancer work-up from the ED, the process was often confusing and inconsistent, frequently leading to referral refusals. Pathways for further cancer work-up from the ED were often dependent on the type of cancer and the institution in which the physician practised. A minority of participants described clear referral pathways established locally at their hospitals to facilitate cancer work-up, resulting in infrequent refusal of referrals and timely follow-up. Suspected lung cancer was frequently described as having a very well-established cancer work-up pathway from the ED across multiple sites.

The emergency department is one silo, and then oncology is another silo, and you can't really move between them unless you have a tissue diagnosis. And there’s relatively little resources invested in how to get people from point A to point B… It’s kind of a little bit shocking to me that given how many people cancer affects and how devastating a diagnosis it can be to receive, that we haven't figured this out better. (Participant 14, female, community site)

Participants also described uncertainty around who should take responsibility for patients after they are discharged from the ED to ensure follow-up occurs. Because of the nature of emergency medicine providing episodic care, there are few resources available to follow up with patients who are discharged from the ED. Therefore, there were concerns expressed that providing ongoing care to patients, such as arranging further outpatient imaging or biopsy, would become a logistical issue about who would follow up on such test results.

There’s no one clear person that I can refer to who’s going to take ownership of these investigations. Like, if the patient misses their biopsy date or if there’s some sort of problem, like I’m the emergency doctor, I’m not set up to track that or take responsibility for it. But when people don't have a family doctor who can do that, there’s really no clear place to send them, and it’s a real problem and it’s upsetting. If you don't fall into one of the, I guess, like, more common cancer types or one of the major cancer types where there is a referral pathway established, it’s very unclear how to get a diagnosis. And if you don't have a family doctor, you're really out of luck. (Participant 14, female, community site)

Many participants also discussed whether they should be arranging staging imaging through the ED in order to expedite the diagnostic work-up for patients. Some physicians noted that this practice was discouraged at their institutions; however, others were able to order such imaging but often were reluctant to do so. They were concerned that ordering and waiting for non-urgent imaging in the ED added to ED crowding, and there was concern about responsibility for the results of these diagnostics and any incidental findings.

We should not be ordering CTs for staging … You're left with a horrible choice. You can try and manipulate the system to get the patient a CT in the emerg to speed up their treatment. But you know then that they don't really need that CT, and that slows down things for everybody else. But if you try to order the tests as an outpatient, then you're medically responsible for following it, and as an emergency physician, you can't. (Participant 3, female, academic site)

Due to the challenges in arranging follow-up for patients with suspected cancer diagnoses from the ED, two common approaches to ensure timely work-up involved referring patients to outpatient GIM clinics or admitting them to the hospital to expedite their work-up.

Sometimes, I will tend to consult services in hospital, even though a patient may be able to be managed as an outpatient. I will ask the admitting services to see, to expedite their work-up… It’s easier to do as an inpatient. (Participant 16, male, academic site)

Participants described provider-level challenges unique to emergency medicine that make disclosing a suspected cancer diagnosis in the ED difficult. These included the lack of a patient-physician relationship and time constraints on the ED physician. ED physicians have just met their patients and have likely only spent a short time caring for that patient before having a potentially life-altering conversation regarding a possible cancer diagnosis. The absence of an established patient-physician relationship at the time of such discussions was identified as distressing for both patients and physicians. Participants also discussed having limited time to discuss a suspected cancer diagnosis with patients due to the busy nature of the ED and needing to see and manage other patients.

Our emergency room like everywhere else, and pretty much Canada now are profoundly overcrowded. So you've got very limited access to quiet areas, to privacy. Also, the demands on your time, you know if I'm on, running the department, especially in the mornings, or in the evenings, plus overnight, when you're on by yourself. If you’re the only physician on and this critical patient, having the time to sit down and talk to people is very difficult. And it’s something that under no circumstances should ever be rushed. (Participant 4, female, academic site)

Theme 3: patient-level factors and experiences with receiving a cancer diagnosis in the ED

This theme highlighted how patient-level factors shape the experience and outcomes of receiving a suspected cancer diagnosis in the ED. These factors included geographic barriers to care, marginalised populations disproportionately at risk of being diagnosed with cancer through the ED and the psychosocial impact of receiving a suspected cancer diagnosis in the ED.

Several participants described that access to follow-up care was often determined by the geographic region in which the patient lived. Sometimes, referrals would not be accepted based on where a patient lived, regardless of which hospital the patient was seen at, which made arranging follow-up more challenging for physicians.

If the patient lives just ten minutes north of us, they won't accept them there because they're not in their catchment area. (Participant 7, male, community site).

Several marginalised populations were described as disproportionately affected by various challenges related to receiving a suspected cancer diagnosis in the ED. Factors such as language barriers, health literacy, housing status and access to phones to receive information about follow-up care all impact care in different ways. Patients from these populations often rely on the ED for healthcare, and physicians emphasised the importance of recognising these unique patient-related factors and the challenge of reliably providing them with outpatient follow-up.

I think rural and remote hospitals, who are doing this kind of thing in the emergency department, the patients are getting horrible, different, and worse care. There’s no sort of sense of health equity. Rural, remote, and Indigenous populations are shortchanged… our rates of cancer are higher, our response rates to therapy, in general, are lower, and our death rates are higher from cancers when it goes with the same prognostics because, again, they're found later, they are more common, and people can't access treatments as easily as those in larger centres. (Participant 11, male, community site).

Participants also described the likely detrimental psychosocial impact on patients who receive a suspected cancer diagnosis in the ED. The further uncertainty for patients around when they will be seen for further work-up, what treatment will entail and their prognosis, which is often not known by the ED physician and therefore cannot be discussed, was also identified as likely negatively impacting patients. Participants noted that because cancer findings can often be incidental, patients are not always prepared and do not have support from family and friends in the ED and often receive this information alone.

They aren't expecting to get a cancer diagnosis that day. So they don't come prepared with people that would be there to support them through that conversation…It’s very psychologically distressing to a patient to tell them that they have a new cancer diagnosis. We don't often have enough information to know further what that means, in terms of prognosis, in terms of the types of treatments that they're going to get. Then, to also add on the burden and say, “I also don't know when you're going to be seen,” is just a gut punch for them. (Participant 2, female, academic site)

Theme 4: need for care coordination

This theme captured participants’ concern about poorly coordinated care from the ED. Subthemes identified were the lack of closed-loop communication and the urgent need for system-wide solutions and care coordination to ensure patients receive timely follow-up care for further cancer work-up.

Many participants commented that the lack of closed-loop communication when trying to arrange outpatient follow-up for a suspected cancer diagnosis was disconcerting and resulted in fears of patients being lost to follow-up. Oftentimes, participants described calling the specialist to whom they were referring patients during their shift to ensure the referral was received and the patient would be seen.

We don't have staff who follows up on these things. You send it, I feel, to the ether, right? I don’t even know if someone gets a fax. I have no confirmation that they've received the fax. (Participant 1, female, academic and community site)

Most participants commented on the need for solutions to improve care for patients with suspected cancer in the ED. Several potential solutions were discussed by participants, and these often centred on the need for coordinating care between multiple providers (ie, family physicians, oncologists and other specialists) to ensure follow-up care occurred as planned. One solution that was frequently mentioned was the establishment of standardised pathways and centralised referral systems for patients with any suspected cancer. This would create clear and simplified processes for follow-up across all cancer types and ensure equitable access to care across EDs, regardless of location.

But I have definitely had to stop what I'm doing several times in the emergency to be like, ‘Okay, well, how do I get a biopsy of the thyroid? How do I get this? Who do I call?’ It adds a lot of logistical burden to the work in the emergency, whereas you should be able to say, “Okay, I have this information, this information, this information. There should be a rapid access cancer clarification clinic, where I’m like, ‘I don’t know. Go here’ And then they’ll get you going to the right place. Because it totally derails your day in the emergency. (Participant 12, female, academic and community site)

Whether you’re working downtown or whether you’re working in a smaller community…something that’s connecting Ontario for suspected cancers, so that it’s a centralised process (Participant 20, female, academic and community site)

Other potential solutions that were described included patient navigators from the ED to support the patient until they had a confirmed diagnosis and received appropriate follow-up, scheduling follow-up appointments on discharge from the ED and increased access to support staff (ie, social workers and nurses) in the ED to help manage the psychosocial components of delivering a suspected cancer diagnosis to patients and their families.

…someone who’s a coordinator for cancer diagnosis to do all that kind of administrative work because it gets to the point where it’s now administrative work, right? So if we're going to send a referral somewhere, having someone make sure that it’s followed up on, contact the patient, just make sure that there’s a closed loop and do some of that connecting to the different resources. (Participant 1, female, academic and community site)

I would love to spend more time with patients and family, but, you know, part of the profession is being able to compartmentalise this one terrible diagnosis recognising that there are 30, 40, 50 patients waiting to see you, some others of whom may have life-altering diagnoses that you also need to diagnose and manage… you need a health professional with the time, training, and space to be able to coach families through next steps once they've receive a life-altering diagnosis. (Participant 5, male, academic site)

Discussion

In this qualitative study of emergency physicians across Ontario, participants identified challenges in managing patients with a suspected cancer diagnosis in the ED. These challenges were encountered at multiple levels, including the healthcare system, institutional, provider and patient levels. Furthermore, participants described the detrimental psychosocial aspects of receiving a suspected cancer diagnosis in the ED setting and the need for better care coordination for patients with suspected cancer in the ED. Each theme highlighted distinct, yet interrelated challenges when managing patients with suspected cancer in the ED. Overall, findings from this study suggest that the ED is a difficult environment in which to address the unique needs of patients with suspected cancer diagnoses, and improvements to care are needed.

Due to system-level deficiencies identified in theme 1, such as access to primary care and ambulatory care^{15 16} and long wait times for imaging and specialist follow-up in the outpatient setting,¹⁷ patients are increasingly required to rely on the ED to access healthcare.^{7 18 19} As such, the ED will continue to be an important route to cancer diagnosis.420,22 Unfortunately, as described in theme 2, many participants in our study described the path from a suspected cancer diagnosis in the ED to confirmation of diagnosis and starting treatment as complicated, often dependent on the type of cancer and the setting in which a physician works. Patients with a suspected cancer diagnosis in the ED often require further diagnostic work-up to confirm cancer, staging, etc, which is challenging to both arrange and follow up given the nature of emergency medicine, which provides acute and episodic care with little individual patient continuity.⁷ Most EDs do not have processes in place to ensure appropriate follow-up has occurred for discharged patients and that patients are not lost to follow-up. These structural and institutional challenges were thought to disproportionately affect some marginalised populations, who then face greater obstacles to accessing follow-up care.

In theme 4, participants described the need for better coordination of care for patients with suspected cancer. Care coordination has been described as the organisation of patient care, which is managed by exchanging information between parties responsible for different aspects of care.²³ Previous research has shown that coordinating cancer care is challenging23,25; however, this literature has often focused on care coordination between oncology and primary care once treatment has started. Care coordination is likely more difficult in the ED setting because of limited follow-up by ED physicians with individual patients. Not surprisingly, participants described a fear that patients may be lost to follow-up. Some participants described advocating for hospital admission to expedite work-up. Given hospital and ED crowding that is overwhelming hospitals across Canada, relying on admission to expedite cancer diagnostic work-up, particularly if the patients can be managed in the outpatient setting, is costly and may contribute to further crowding.^{26 27}

Many participants commented that standardised or centralised access to cancer work-up could improve care coordination from the ED and ensure equitable access to further care. Lung diagnostic assessment programme (DAP) clinics were often discussed as excellent models of care, with an easy and reliable referral process. DAP clinics are available across Ontario in several regions for specific types of cancer, such as lung and colorectal cancers.²⁸ These clinics have been shown to improve time to diagnosis and survival.^{29 30} In the UK, the National Health Service has established widely available rapid diagnostic cancer centres for patients with non-specific symptoms of cancer.³¹ Increased regional or hospital availability of diagnostic clinics such as these could streamline access to care for patients with suspected cancer from the ED and other settings, including primary care. Patient navigation, which has been frequently described as a model of care coordination once in the cancer system,²³ was also described by participants as a potential way to improve care from the ED.

Focusing on local and regional solutions to improve care from the ED for further diagnostic work-up is needed to ensure equitable access to further care, regardless of which ED patients are seen in. In addition to the potential solutions described above, we can look to how the management and follow-up care of patients with other disease processes are commonly seen and managed in the ED (such as stroke, acute ST Elevation Myocardial Infarction (STEMI) care, geriatric care, etc) have improved over time. For instance, recognising the importance of the emergency medical system for patients with stroke, minor stroke and transient ischaemic attacks (TIA), the Canadian Stroke Best Practices incorporate the role of the ED in managing patients with these conditions.³² Furthermore, these recommendations advocate for improving access to timely stroke prevention services, including from the ED, which is evidenced by the increasing number of stroke prevention and TIA clinics available across different regions.³³

Overall, our study highlights many challenges associated with managing patients with a suspected cancer diagnosis in the ED. The current processes for caring for patients with suspected cancer from most EDs leave physicians with a lack of clarity and confidence about follow-up, and are likely distressing for both patients and physicians.^{22 34} Previous studies have reported that patients diagnosed with cancer through the ED have worse outcomes, with higher stages at diagnosis and increased mortality.³ Thus, as our study suggests, there is a need to improve timely and reliable care from the ED for patients with suspected cancer. However, this will require multifaceted interventions that address not only clinical processes but also the broader social, institutional and system-level contexts in which emergency and oncology care is delivered.

Limitations

There are several limitations associated with this study. We only interviewed emergency physicians practising in Ontario. Therefore, our results may not represent physicians’ experiences outside of Ontario or Canada. Participation in this study was voluntary, and while we attempted to reach physicians through various methods, there may be response bias associated with the results. Specifically, individuals who were interested in this topic may have been more likely to participate. We did not ask participants to provide feedback on the study results. This study focused on physicians’ experiences of managing patients with a suspected cancer diagnosis in the ED. It is recognised that patient perspectives may differ from those of physicians; therefore, future research to understand the patient experience after receiving a suspected cancer diagnosis through the ED is also needed. Finally, due to the small sample size and exploratory nature of our study, we could not comment on overall differences in results based on region or site of practice.

Conclusions

In this qualitative study of emergency physicians across Ontario, participants described several challenges in managing patients with a suspected cancer diagnosis in the ED. Our results suggest that challenges at various levels, including the healthcare system, institutional, provider and patient level, often render the ED a difficult setting in which to manage patients with a suspected cancer diagnosis and ensure follow-up. Given the prevalence of ED use as a route to cancer diagnosis and the ongoing inefficiencies within our healthcare system, patients will likely continue to be diagnosed with suspected cancer through the ED. Therefore, strategies to improve the management of these patients in the ED are needed.

Data availability statement

No data are available.