Official Statistics

Emergency presentations of cancer: data up to December 2020

Published 11 June 2021

Applies to England

Main points

The main observations from the data are:

• the number of cancer patients first seen in hospital in England rose from 60,678 in July to September 2020 to 64,792 in October to December 2020
• the number of cancer patients seen in hospital which are emergency presentations has fallen from 14,813 in July to September 2020 to 12,845 in October to December 2020
• between the end of January to March 2020 and the end of October to December 2020 the one year rolling proportions of emergency presentations have risen for England, 78 out of 106 Clinical Commissioning Groups (CCGs) and all 21 Cancer Alliances (CAs)

Note: An online visualisation tool accompanies this release and can be used to explore the data at cancerdata.nhs.uk.

October to December 2020

Cancer presentations in England

The total number of cancer patients first seen as an inpatient in hospital in England rose from 60,678 during July to September 2020 to 64,792 during October to December 2020. This number is starting to return to, although is still significantly lower than, levels observed before the first national COVID-19 lockdown in England, which began 23 March 2020; there was a quarterly average of 66,906 patients first seen in hospital between January to March 2016 and January to March 2020.

The number of emergency presentations has fallen from 14,813 during July to September 2020 to 12,845 during October to December 2020. This number is similar to the average number (12,956) of emergency presentations over the 4 years (between January to March 2016 and January to March 2020) before the first national COVID-19 lockdown in England, which began 23 March 2020.

The proportion of new cancer patients presenting as an emergency presentations has also fallen from 24.4% during July to September 2020 to 19.8% during October to December 2020. This proportion is significantly higher than the average proportion (19.4%) over the 4 years before the first national COVID-19 lockdown (between January to March 2016 and January to March 2020).

Figure 1 provides the quarterly number of cancer patients first seen in hospital (written as total in the legend of figure 1), emergency presentations, and non-emergency presentations from January to March 2016 (financial year 2015, quarter 4) to October to December 2020 (financial year 2020, quarter 3).

Figure 1 shows a steep decline in the total number of cancer patients first seen in hospital during April to June 2020, with numbers starting to rise towards previous levels during July to September 2020 and October to December 2020. A similar trend in the number of non-emergency presentations is also shown; however the number of emergency presentations has stayed relatively consistent over time. This suggests that the increase in the proportion of emergency presentations is predominantly driven by the decrease in non-emergency presentations, and not by an increase in the number of emergency presentations.

Figure 1: Quarterly numbers of first hospital cancer admissions for England

Variation over the Clinical Commissioning Groups

Across the 106 Clinical Commissioning Groups (CCGs), the proportion of cancer patients presenting as an emergency during October to December 2020 varied from 14.5% to 31.5% with an interquartile range of 4.0% (from 18.0% to 22.1%). There are no obvious geographical patterns to the CCG variation.

Variation over the Cancer Alliances

Across the 21 Cancer Alliances (CAs), the proportion of cancer patients who first presented as an emergency during October to December 2020 varied from 23.8% to 17.3% with an interquartile range of 2.2% (from 18.2% to 20.3%). There are no obvious geographical patterns to the CA variation.

Trends in one year rolling proportion

In England, the one year rolling proportion of cancer patients who first presented as an emergency has been gradually falling over the last five years up until the period April 2019 to March 2020 (18.8%). The one year rolling proportion of emergency presentations was significantly higher in the period July 2019 to June 2020 (20.2%) (including the first national COVID-19 lockdown) than during any other one year period in the previous 5 years from April to June 2016 to April to June 2020. The one year rolling proportion has continued to increase to 22.0% for the period January to December 2020.

Between April 2015 to March 2016 and April 2019 to March 2020, the one year proportion of emergency presentations had not changed significantly for 72 CCGs, had fallen significantly for 32 CCGs, and had risen significantly for 2 CCGs. However, between April 2019 to March 2020 and January to December 2020 the one year rolling proportion of emergency presentations has risen significantly for 78 CCGs and has not changed significantly for 28 CCGs, with the proportion falling in none of the CCGs.

Between April 2015 to March 2016 and April 2019 to March 2020, the proportion of 1- year rolling emergency presentations had fallen significantly for most CAs (15 CAs) and had not changed significantly for 6 CAs. However, between the April 2019 to March 2020 and January to December 2020 the proportion of one year rolling emergency presentations has risen significantly for all 21 CAs.

Things you need to know about this release

Background

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

The 2015 to 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 emergency presentation section for definitions) 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, 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.

Points to consider when interpreting these statistics

The first COVID-19 lockdown began in England on 23 March 2020. Data from April to June 2020 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. 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 and with the return to normal levels taking a varying amount of time across the country and by screening programme.

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 larger confidence intervals.

Definitions and methods

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.

Confidence Intervals

Wilson score method is used to give 95% confidence intervals for all the proportions presented.

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.

Further information

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 a stages 1 and 2 in England

Authors

Responsible statistician: Roger Hill

Production team: Chloe Bright, John Broggio, Thomas Higgins, Roger Hill, Ann Saxton, Wouter Verstraete For queries relating to this bulletin contact ncrasenquiries@phe.gov.uk.

Acknowledgements

Data for this work is based on patient-level information collected by the NHS, as part of the care and support of cancer patients. The data is collated, maintained and quality assured by the National Cancer Registration and Analysis Service, PHE.