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  • Original Article
  • OPEN ACCESS

Post-diagnosis Emergency Department Presentation and Demographic Factors in Malignant Skin Cancers: A Data-linkage Cohort Study

  • David Izon1,2,
  • Olivia Wawryk1,2,3,
  • Damien McCarthy1,2,3,
  • Jennifer Soon4,5,
  • Sally Philip1,2,3,
  • Chris Kearney1,2,3,
  • Zhiheng Xu6 and
  • Jianrong Zhang1,2,3,7,* 
 Author information 

Abstract

Background and objectives

Emergency department (ED) presentations are associated with higher cancer mortality. This study aimed to investigate the prevalence, frequency, and risk factors in Australian patients diagnosed with malignant skin cancers.

Methods

This data-linkage cohort study examined adult patients presenting to the ED at the Royal Melbourne and Western Health hospitals within 12 months of a malignant skin cancer diagnosis. Multivariable logistic and Poisson regressions were used to analyze factors influencing the prevalence and frequency of ED presentations.

Results

A total of 3,873 patients were diagnosed with skin malignancies between 2010 and 2018, of which 631 were diagnosed with melanoma. The prevalence of ED presentation was 29%, representing 2,119 episodes of care (median: 0; range: 0–14). Risk factors for a higher prevalence and frequency included: age ≥75 years (odds ratio (OR) = 1.78 [95% confidence interval 1.47–2.15]; incidence risk ratio (IRR) = 1.52 [1.35–1.70]); male (OR = 1.17 [1.01–1.36]; IRR = 1.23 [1.12–1.35]); socioeconomic status levels of 0–30% (OR = 1.59 [1.24–2.03]; IRR = 1.69 [1.45–1.96]) and 71–100% (OR = 1.30 [1.07–1.58]; IRR = 1.27 [1.12–1.45]); preferred language other than English (OR = 1.47 [1.17–1.84]; IRR = 1.49 [1.32–1.69]); and experience with any systemic therapy or radiotherapy (OR = 3.77 [2.12–6.71]; IRR = 2.36 [1.82–3.05]). Age < 65 years was protective (OR = 0.72 [0.59–0.89]; IRR = 0.78 [0.68–0.90]). Other preferred languages and cancer treatment experience were also risk factors in the sub-cohort with melanoma.

Conclusions

This study reports the prevalence and frequency of ED presentations following a skin cancer diagnosis and their association with socioeconomic and linguistic factors in Australia. Increased awareness of these factors could help address health inequities and potentially reduce the need for ED presentations.

Keywords

Emergency service, hospital, Emergency medical services, Skin neoplasms, Melanoma, Information storage and retrieval, Data linkage, Social determinants of health

Introduction

Malignant skin cancers are the most commonly diagnosed cancer type; regardless of whether melanoma or non-melanoma skin cancer (NMSC), they are among the top 30 cancer types, contributing to the highest cancer burden globally and in Australia.1,2 By 2040, global projections suggest that new cases and deaths from melanoma will increase by 50% and 68%, respectively, with 510,000 new cases and 96,000 melanoma-related deaths.3 In Australia, the five-year survival rate for melanoma is 93.6%, compared to 70.8% for NMSC. However, a significant survival gap exists between localized and advanced stages of melanoma (stage I: 99.2%; stage IV: 26.2%).2

Internationally, emergency department (ED) presentations are associated with higher mortality compared to non-ED presentations among cancer patients.4–8 Specifically, among patients with unplanned hospitalizations in the year after a melanoma diagnosis, 57% were admitted through the emergency department.6 An important contributor to this is toxicity from anti-cancer treatments, especially immunotherapy, which is a primary systemic treatment for melanoma. Immune-mediated toxicity accounts for 39% of ED presentations, as reported in a large single-center study.9 Regarding the prevalence of ED presentations in malignant skin cancers, a Canadian study found that 30% of 67 patients presented to the ED within three months of receiving ipilimumab (an immunotherapy) for metastatic melanoma.10 Another Canadian study, however, reported that 11% of 618 melanoma patients utilized emergency services within 12 months after cancer treatment.11

In Australia, we identified evidence gaps regarding the prevalence, frequency, and relevant risk factors (Table S1). Given the differences in healthcare systems and universal health coverage across countries or regions,12 it is essential to assess ED presentations and related factors individually for each country. This approach will guide local policy development and administration while allowing for international comparative analysis. This study aimed to fill the gap and provide evidence for potential interventions to reduce ED presentations in the future. Specifically, we measured the prevalence and frequency of ED presentations within one year after diagnosis of malignant skin cancers, and analyzed demographic factors associated with higher ED prevalence and frequency.

Materials and methods

Study design

This is a data-linkage, retrospective cohort study. The study conduct and reporting followed the STrengthening the Reporting of OBservational studies in Epidemiology statement.13

Data source and sample

Relying on the Victorian Comprehensive Cancer Centre Data Connect platform,14 this study utilized the Victorian Admitted Episodes Dataset (VAED) and the Victorian Emergency Minimum Dataset (VEMD). The data were derived from the Royal Melbourne Hospital (both the City and Royal Park Campuses) and Western Health (including the Footscray, Sunshine, Williamstown, and Sunbury Day Hospitals). In total, the study recorded 477,304 episodes among 44,142 adult cancer patients in VAED, as well as 139,313 episodes among 29,945 adult cancer patients in VEMD, with the latest diagnosis year being 2020.

The data access, linkage, and related ethical approval processes were obtained through collaborations between the Victorian Comprehensive Cancer Centre Alliance, BioGrid Australia, and the University of Melbourne. Data extraction was conducted by BioGrid using a cryptographic mechanism that ensures deidentification and privacy-protected data linkage.14 The protocol for this project was approved by the Melbourne Health Human Research Ethics Committee (protocol number: BG-202201_1).

For this study, the data linkage mechanism involved identifying all eligible patients via VAED and those who had ED presentation(s) via VEMD and then calculating the outcomes—post-diagnosis prevalence and frequency. To calculate these outcomes, we captured the date of cancer diagnosis via VAED based on the admission or discharge date of the corresponding hospitalization episode and the arrival date of the ED visit via VEMD. In this manner, we ensured that the ED presentation for both outcomes occurred after the episode of cancer diagnosis (Fig. 1).

Data sources and key variables for the study outcomes.
Fig. 1  Data sources and key variables for the study outcomes.

VAED, Victorian Admitted Episodes Dataset; VEMD, Victorian Emergency Minimum Dataset.

For this study, eligible patients were those aged 18 years or older, primarily diagnosed between 2010 and 2018, with melanoma (ICD-10-AM/ACHI/ACS C43) and NMSC (ICD-10-AM/ACHI/ACS C44). The start year (2010) represents the year the recording of ED presentations began in the VEMD. The end year (2018) was selected to ensure a sufficient post-diagnosis follow-up period (maximum of 12 months) for the outcomes, as 2020 was the final year in both datasets.

Variables

Outcomes include the prevalence and frequency of all-cause ED presentations within 12 months after diagnosis for malignant skin cancers. Prevalence was defined as the number of unique patients who presented for emergency care during their post-diagnosis period, divided by the total number of patients. Frequency was defined as the total number of episodes of emergency care during the post-diagnosis period.

Exposure variables include patient characteristics, such as year of diagnosis, age at diagnosis, sex, socioeconomic status (SES), preferred language (English or other), and cancer treatment experience with any systemic therapy (chemotherapy, targeted therapy, or immunotherapy) or radiotherapy. These variables were selected based on their reported impact on skin cancer mortality in previous studies.15–19 In this study, SES was classified according to the 2016 Australian Bureau of Statistics Index of Relative Socio-economic Advantage and Disadvantage. The time of cancer treatment was defined as within one year after cancer diagnosis.

Statistical analysis

A descriptive analysis was conducted to determine the prevalence of ED presentations within 12 months after the diagnosis of malignant skin cancers. Multivariable logistic and Poisson regression analyses were performed to investigate the association between the exposures and the two outcomes, with the measures being the odds ratio (OR) and the incidence risk ratio (IRR), respectively. The models included: (Model 1) no adjustment; (Model 2) adjustment for year of diagnosis, age at diagnosis, and sex; and (Model 3) adjustment for the aforementioned variables, SES, preferred language, and experience with systemic therapy or radiotherapy. These variables were selected for adjustment due to their potential roles as confounders or covariates in the associations between exposures and ED presentation. To increase statistical power in the adjustment, the year of diagnosis and age at diagnosis were treated as continuous variables; SES was treated as a decile. Given the nature of independent analyses with the three models on multiple exposures, which might introduce Type I errors, only results with consistent significance (p < 0.05) across the three models will be interpreted and discussed. Regarding missing data, we did not apply imputation techniques as the proportion of missing data in the entire study sample was no more than 5%. The above analyses were conducted for both the overall cohort with malignant skin cancers and the sub-cohort with melanoma only.

Results

We included 3,873 patients diagnosed with malignant skin cancers between 2010 and 2018 (Table 1). Among them, 631 were diagnosed with melanoma. The prevalence of ED presentation within 12 months after cancer diagnosis was 29% across all patients with malignant skin cancers and 26% in the melanoma subset (Fig. 2). The frequency of post-diagnosis ED presentations was 2,119 episodes (median: 0; range: 0–14) in patients with malignant skin cancers, and 287 episodes in those with melanoma. In patients with post-diagnosis ED presentations, the frequency was a median of 1 (range: 1–14) in those with malignant skin cancers and a median of 1 (range: 1–10) in those with melanoma only.

Table 1

Patient characteristics

CharacteristicsPrevalence of post-diagnosis ED presentation (%)
Malignant skin cancers (N = 3,873)Melanoma sub-cohort (N = 631)
Overall29% (1,129/3,873)26% (161/631)
Year of diagnosis
  2010–201229% (292/1,023)20% (34/169)
  2013–201531% (442/1,408)30% (62/209)
  2016–201827% (395/1,442)26% (65/253)
Age
  <6520% (264/1,338)20% (63/308)
  65–7526% (235/903)25% (38/151)
  >=7539% (630/1,632)35% (60/172)
Sex
  Female27% (411/1,504)25% (63/252)
  Male30% (718/2,369)26% (98/379)
Socioeconomic status
  71–100%30% (725/2,418)29% (93/325)
  31–70%23% (190/830)18% (33/188)
  0–30%35% (212/613)30% (34/113)
  Missing125
Preferred language
  English27% (891/3,325)25% (147/598)
  Non-English41% (153/377)52% (12/23)
  Missing17110
Systemic therapy or radiotherapy
  Yes58% (30/52)72% (13/18)
  No/unknown29% (1,099/3,821)24% (148/613)
Prevalence of emergency department presentation by year of cancer diagnosis.
Fig. 2  Prevalence of emergency department presentation by year of cancer diagnosis.

The results of the associations between patient characteristics and the prevalence of post-diagnosis ED presentations are shown in Table 2. In patients with malignant skin cancers, factors associated with a higher prevalence included the years 2013–2015 (OR = 1.21 [95% confidence interval 1.02–1.44]) versus 2016–2018, age ≥75 years (OR = 1.78 [1.47–2.15]) versus ages 65–75, male (OR = 1.17 [1.01–1.36]), SES levels 0–30% (OR = 1.59 [1.24–2.03]) and 71–100% (OR = 1.30 [1.07–1.58]), preferred language other than English (OR = 1.47 [1.17–1.84]), and experience with systemic therapy or radiotherapy within one year after cancer diagnosis (OR = 3.77 [2.12–6.71]). The factor associated with fewer ED presentations was being younger than 65 years (OR = 0.72 [0.59–0.89]). In patients with melanoma, consistent risk factors included both lower (OR = 1.79 [1.00–3.20]) and higher (OR = 1.83 [1.15–2.90]) SES levels, preferred language other than English (OR = 2.73 [1.11–6.71]), and cancer treatment experience (OR = 7.63 [2.64–22.06]).

Table 2

Associations between patient characteristics and prevalence of emergency department presentation within 12 months after cancer diagnosis

Patient characteristicsPatients with malignant skin cancers
Patients with melanoma
OR (95% CI) (Model 1)OR (95% CI) (Model 2)OR (95% CI) (Model 3)OR (95% CI) (Model 1)OR (95% CI) (Model 2)OR (95% CI) (Model 3)
Year of diagnosis
  2010–20121.06 (0.89–1.27)1.10 (0.92–1.32)1.04 (0.86–1.25)0.73 (0.46–1.17)0.76 (0.47–1.22)0.77 (0.48–1.26)
  2013–20151.21 (1.03–1.43)*1.27 (1.08–1.50)*1.21 (1.02–1.44)*1.22 (0.81–1.84)1.24 (0.82–1.88)1.17 (0.76–1.80)
  2016–20181.001.001.001.001.001.00
Age
  <650.70 (0.57–0.85)*0.70 (0.57–0.86)*0.72 (0.59–0.89)*0.76 (0.48–1.21)0.77 (0.49–1.22)0.74 (0.46–1.19)
  65–751.001.001.001.001.001.00
  >=751.79 (1.49–2.14)*1.80 (1.51–2.15)*1.78 (1.47–2.15)*1.59 (0.98–2.58)1.59 (0.98–2.58)1.41 (0.85–2.33)
  Sex: Male vs. Female1.16 (1.00–1.33)*1.19 (1.02–1.37)*1.17 (1.01–1.36)*1.05 (0.73–1.51)0.97 (0.67–1.41)0.93 (0.63–1.36)
Socioeconomic status
  71–100%1.44 (1.20–1.73)*1.33 (1.10–1.60)*1.30 (1.07–1.58)*1.88 (1.21–2.94)*1.87 (1.19–2.93)*1.83 (1.15–2.90)*
  31–70%1.001.001.001.001.001.00
  0–30%1.78 (1.41–2.25)*1.66 (1.31–2.10)*1.59 (1.24–2.03)*2.02 (1.17–3.50)*1.97 (1.12–3.44)*1.79 (1.00–3.20)*
Preferred language: Non-English vs. English1.87 (1.50–2.32)*1.47 (1.17–1.84)*1.47 (1.17–1.84)*3.35 (1.45–7.75)*3.01 (1.29–7.04)*2.73 (1.11–6.71)*
  Systemic therapy or   radiotherapy: Yes vs. No/unknown3.38 (1.94–5.88)*3.63 (2.06–6.40)*3.77 (2.12–6.71)*8.17 (2.86–23.29)*7.87 (2.74–22.66)*7.63 (2.64–22.06)*

*Statistically significant (p < 0.05). Adjustment: (Model 1) no adjustment; (Model 2) year of diagnosis, age at diagnosis, and sex; (Model 3) year of diagnosis, age at diagnosis, sex, SES, preferred language, and cancer treatment of systemic therapy or radiotherapy. To increase statistical power, the year of diagnosis and age at diagnosis were treated as continuous variables, and socioeconomic status was categorized into deciles. CI, confidence interval; OR, odds ratio; SES, sex, socioeconomic status.

The association results for the frequency of post-diagnosis ED presentations are presented in Table 3. In patients with malignant skin cancers, factors associated with more frequent ED presentations included age ≥75 years (IRR = 1.52 [1.35–1.70]), both lower (IRR = 1.69 [1.45–1.96]) and higher (IRR = 1.27 [1.12–1.45]) SES levels, preferred language other than English (IRR = 1.49 [1.32–1.69]), and experience with systemic therapy or radiotherapy (IRR = 2.36 [1.82–3.05]). The factor associated with fewer ED presentations was age < 65 years (IRR = 0.78 [0.68–0.90]). In patients with melanoma, the same risk factors were found for preferred language other than English and cancer treatment experience; younger age (<65 years) was the protective factor.

Table 3

Associations between patient characteristics and the frequency of emergency department presentation within 12 months after diagnosis

Patient characteristicsPatients with malignant skin cancers
Patients with melanoma
IRR (Model 1)IRR (Model 2)IRR (Model 3)IRR (Model 1)IRR (Model 2)IRR (Model 3)
Year of diagnosis
  2010–20121.04 (0.93–1.16)1.07 (0.96–1.19)1.02 (0.91–1.15)0.79 (0.58–1.08)0.82 (0.60–1.11)0.84 (0.62–1.14)
  2013–20151.07 (0.97–1.18)1.18 (1.00–1.22)1.10 (0.99–1.22)1.12 (0.86–1.45)1.14 (0.87–1.48)1.07 (0.82–1.39)
  2016–20181.001.001.001.001.001.00
Age
  <650.72 (0.63–0.82)*0.72 (0.63–0.82)*0.78 (0.68–0.90)*0.75 (0.55–1.01)0.76 (0.56–1.02)0.74 (0.54–1.00)*
  65–751.001.001.001.001.001.00
  >=751.49 (1.34–1.66)*1.50 (1.35–1.67)*1.52 (1.35–1.70)*1.34 (0.99–1.80)1.33 (0.99–1.79)1.14 (0.83–1.55)
  Sex: Male vs. Female1.20 (1.09–1.31)*1.22 (1.11–1.33)*1.23 (1.12–1.35)*1.14 (0.89–1.44)1.09 (0.86–1.39)1.05 (0.82–1.34)
Socioeconomic status
  71–100%1.44 (1.27–1.62)*1.35 (1.19–1.52)*1.27 (1.12–1.45)*1.31 (0.98–1.74)1.31 (0.98–1.75)1.24 (0.93–1.66)
  31–70%1.001.001.001.001.001.00
  0–30%2.00 (1.73–2.30)*1.88 (1.63–2.17)*1.69 (1.45–1.96)*1.57 (1.11–2.20)*1.57 (1.11–2.21)*1.38 (0.97–1.97)
Preferred language: Non-English vs. English1.76 (1.56–1.99)*1.50 (1.32–1.70)*1.49 (1.32–1.69)*2.43 (1.60–3.69)*2.29 (1.50–3.49)*2.15 (1.39–3.34)*
  Systemic therapy or   radiotherapy: Yes vs. No/unknown2.21 (1.72–2.85)*2.27 (1.76–2.92)*2.36 (1.82–3.05)*3.11 (2.05–4.72)*2.95 (1.94–4.48)*2.81 (1.84–4.29)*

*Statistically significant (p < 0.05). Adjustment: (Model 1) no adjustment; (Model 2) year of diagnosis, age at diagnosis, and sex; (Model 3) year of diagnosis, age at diagnosis, sex, SES, preferred language, and cancer treatment of systemic therapy or radiotherapy. To increase statistical power, the year of diagnosis and age at diagnosis were treated as continuous variables, and socioeconomic status was categorized into deciles. CI, confidence interval; IRR, incidence risk ratio.

Discussion

This data-linkage cohort study provides the prevalence and frequency of post-diagnosis ED presentations, including the risk factors, among patients with malignant skin cancers at two metropolitan centers in Victoria, Australia. Within one year of a skin cancer diagnosis, the prevalence of ED presentation was 29% (26% in melanoma), with a median of one presentation for those who had presented to the ED. For both prevalence and frequency, risk factors such as having a preferred language other than English and cancer treatment, including systemic therapy or radiotherapy, were consistently found in both the malignant skin cancer cohort and the sub-cohort with melanoma. For the larger cohort, risk factors also included older age (≥75 years) and both lower and higher SES; conversely, the protective factor was younger age (<65 years).

The prevalence of post-diagnosis ED presentation seems lower than reported in other developed countries.9–11 Notably, the outcome in our study was based on all-cause ED presentations, captured regardless of the reason for presentation. We assume that the main reason for the differences in the prevalences reported above could be due to differences in sample selection, particularly the disease stage at diagnosis (stages III-IV or not) and corresponding treatments. It is assumed that toxicity driven by systemic therapies, especially from combined therapies, is the main reason for emergency presentations, in addition to age-related comorbidities.9,20–22 The difference in our association results between patients who received cancer treatment (either systemic therapy or radiotherapy) and those who did not may support this assumption.

Regarding the frequency of post-diagnosis ED presentations, few studies have specifically reported it. One study in France found an average of 2.2 emergency presentations among those who used healthcare services after receiving treatment for advanced melanoma for at least two months.22 Compared to the overall estimate of ED presentations in Australia (334 per 1,000 population in 2022–2023),23 our results appear higher when roughly translated into a population-level estimate (malignant skin cancers: 547 per 1,000; melanoma: 561 per 1,000). We look forward to more studies for comparative assessment within and across countries.

Regarding the risk factors for ED presentation, we found consistency in the results suggesting social determinants of health, including lower and higher SES levels and preferred languages other than English. Although a similar association between a lower SES level and emergency presentation has been found in previous studies,11,24 our study suggests a potential U-shaped association, as higher prevalence and frequency were also observed in patients with a higher level of SES. For patients with a lower SES level, one reason explaining higher emergency presentations could be the lack of access to primary care physicians and specialists, especially among those living in remote or very remote areas.25 Additionally, patients with low SES levels are often older, have more comorbidities, and are in later disease stages, often with poor health literacy.5,26,27 For patients with a higher SES level, we assume they may have better access to healthcare, including emergency care. To explain these results, further research is needed.

The results related to linguistic disparities highlight the public health challenges faced by culturally and linguistically diverse patients. Many studies have reported patient-side barriers to healthcare,28 including lower likelihood to seek help, report symptoms, and receive recommended treatments.28–30 At the same time, institutional and system-level barriers must not be ignored, including lack of access to and knowledge of cancer information in their languages on Australian cancer-related websites,31 less likelihood of being provided with next steps to access cancer care,32 and less likelihood of experiencing culturally sensitive care from internationally educated practitioners,33 and receiving the latest cancer treatments in clinical trials, which could potentially improve efficacy and reduce treatment-related toxicity.34 Ultimately, some of these patients may delay seeking help, often only doing so with ED physicians when their conditions have worsened due to comorbidities, toxicity, or other reasons, which explains the higher ED presentations in this study and unplanned admissions in another study.29 For these patients, cancer care delivery should tailor cancer information to their backgrounds and enhance communication with practitioners.35

The association between older age and a higher prevalence and frequency of post-diagnosis ED presentations highlights the need for care specific to this vulnerable group. As is well documented, older patients have fewer opportunities to complete treatment and may be in a poorer position to tolerate toxicities; at the same time, they live with more comorbidities.20,28,36 All of these factors can explain the higher ED presentations found in our study. Given the benefits of comprehensive geriatric assessment in treatment completion, toxicity management, and improved patient outcomes,37 efforts should also focus on models of care, particularly through primary care involvement and multidisciplinary care, to improve quality of life, functional outcomes, and management of comorbidities.38–40 Ultimately, this may reduce emergency department utilization and excess costs for patients and payers. Current evidence supports the involvement of primary care in improving cancer survivorship, particularly in reducing both short-term and long-term mortality, including for older patients.41,42 Additionally, a study in Australia found that a nurse practitioner-led model of care based on a telephone helpline can improve symptom management and reduce ED presentations in cancer survivors.43

Risk factors also include the earlier years of diagnosis. In the overall cohort with malignant skin cancers, the prevalence of ED presentations in 2013–2015 was significantly higher than in 2016–2018, the latest years analyzed in our study. Similar patterns can be observed in patients with melanoma only, including the frequency of ED presentations, but without statistical significance. Notably, the first advanced treatment for melanoma, ipilimumab (an immunotherapy that blocks CTLA-4), became available around 2013 on the Pharmaceutical Benefits Scheme, followed by pembrolizumab and nivolumab, another immunotherapies that target programmed cell death protein 1, allowing people with advanced melanoma to receive Australian taxpayer subsidies for prolonged survivorship.44 The lower risks of ED presentations in the later years could be explained by revolutionized skin cancer control, particularly earlier diagnosis, better treatment options, and improved toxicity management.45–50

The risk factors defined in this study may help identify at-risk populations and provide an opportunity for preemptive support to minimize unnecessary ED presentations. These factors echo the recently released, ambitious national framework—the Australian Cancer Plan—aimed at accelerating world-class cancer outcomes and improving the lives of those affected by cancer. Particularly, the results are relevant to some of its ten priority population groups, including older Australians and individuals from lower SES and culturally and linguistically diverse backgrounds. From an implementation perspective, efforts should be made to ensure that patients at risk of ED presentations can be identified, educated, and supported with a more individualized approach to follow-up care after cancer diagnosis and treatment.

Future research is needed to continue tracking the progress of interventions on these vulnerable populations. ED prevalence and frequency are easily accessible and trackable metrics. At the same time, they can provide insights into health service utilization and resource allocation. They may also serve as a potential surrogate marker for predicting health outcomes in patients undergoing anti-cancer treatment and identifying cohorts that could benefit from additional support to reduce emergency presentations.20 Therefore, we call for more research using these data points. With the increasing use of combination therapies (e.g., ipilimumab plus nivolumab),9 longer durations of cancer treatment (e.g., ICIs),43 and the extended indications of immunotherapy or targeted therapy as adjuvant or neoadjuvant treatments for earlier-stage and surgical patients,44,50 such investigations using these metrics should be even more needed—particularly for ED presentations due to treatment toxicity.

Limitations of the study should be acknowledged. First, given that we aimed to provide a broad overview of post-diagnosis ED presentations among the skin cancer population in Australia, the study design was made in an epidemiological manner. Therefore, we used all-cause ED presentations, with a landmark of 12 months post-diagnosis, and did not explore further the reasons behind the ED presentations. To understand the reasons, especially how much they contribute to further healthcare utilization (e.g., critical care) and a higher mortality risk, additional research may be warranted. Second, potential biases in risk factor analysis may not have been adequately addressed, given the retrospective study design and the use of administrative hospital datasets that lack records of relevant clinical variables. Particularly, the disease stage at diagnosis, details of other treatment options, and patient survival. Of note, many skin cancer surgeries in Australia are performed in primary care or outpatient services rather than in hospitals; a similar condition applies to advanced oral treatments, which are usually taken as outpatient treatments. As an epidemiological study, however, the current design, without these variables, may still be sufficient to understand the general prevalence and frequency of ED presentations. Building upon this study, we look forward to conducting a similar study with enriched variables in the future; data linkage with other sources will be a possible option. Given the limited number of hospitals in Victoria involved in the study, our results may not be generalizable to the entire state or country. Even though healthcare in Australia is highly centralized, with many patients visiting metropolitan hospitals, we assume that our prevalence and frequency results might be underestimated, as patients from lower SES backgrounds and those living in regional or rural areas may present to EDs at nearby hospitals. Finally, although examining the results with consistent significance across statistical models can reduce Type I errors, this approach might introduce Type II errors. For associations with statistical significance (p < 0.05) in at least one, but not all of the three models, an independent study with a more specific adjustment design will be needed to confirm the association.

Conclusions

This study provides the first prevalence and frequency data on post-diagnosis ED presentations in patients with skin malignancies, including melanoma. Notably, male patients, those of older age, individuals with both lower and higher SES levels, those primarily speaking a language other than English, and those undergoing systemic therapy or radiotherapy, had a higher risk of ED presentation within 12 months after their skin cancer diagnosis.

Supporting information

Supplementary material for this article is available at https://doi.org/10.14218/OnA.2025.00006 .

Table S1

Search formula in PubMed.

(DOCX)

Click here for additional data file.

Declarations

Acknowledgement

The authors sincerely thank Data Connect and the BioGrid colleagues for providing the data platform and linkage service. This work was presented at the VCCC Alliance Research Conference 2023, held on 12–13 September 2023 in Melbourne, Australia.

Ethical statement

This study was carried out in accordance with the recommendations of the Committee on Publication Ethics, the Declaration of Helsinki, and the guidelines for the conduct, reporting, editing, and publication of scholarly work from the International Committee of Medical Journal Editors. The data access, linkage, and related ethical approval processed were obtained through collaborations between the Victorian Comprehensive Cancer Centre Alliance, BioGrid Australia, and the University of Melbourne. The protocol for this project was approved by the Melbourne Health Human Research Ethics Committee (protocol number: BG-202201_1). The individual consent for this analysis was waived due to the requirements outlined by the Australian National Health and Medical Research Council National Statement on Ethical Conduct in Human Research (2023).

Data sharing statement

The Victorian Admitted Episodes Dataset and the Victorian Emergency Minimum Dataset used in this study are not publicly available, as they are managed by the Victorian Government and require an application for access.

Funding

None.

Conflict of interest

One of the authors, JZ, has been an editorial board member of the Oncology Advances journal since August 2023. The authors have no other conflicts of interest to disclose.

Authors’ contributions

Conceptualisation (DI, JZ), methodology (OW, JZ), resources (OW, DM, SP, CK), project administration (SP, CK), data curation (OW, DM), investigation (DI, JZ), formal analysis (DI, JZ), writing - original draft (DI), writing - review & editing (JS, ZX, JZ), and supervision (JZ). All authors approved the final version of the manuscript for submission.

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Izon D, Wawryk O, McCarthy D, Soon J, Philip S, Kearney C, et al. Post-diagnosis Emergency Department Presentation and Demographic Factors in Malignant Skin Cancers: A Data-linkage Cohort Study. Oncol Adv. 2025;3(1):3-11. doi: 10.14218/OnA.2025.00006.
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Received Revised Accepted Published
February 21, 2025 March 26, 2025 March 26, 2025 March 30, 2025
DOI http://dx.doi.org/10.14218/OnA.2025.00006
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Post-diagnosis Emergency Department Presentation and Demographic Factors in Malignant Skin Cancers: A Data-linkage Cohort Study

David Izon, Olivia Wawryk, Damien McCarthy, Jennifer Soon, Sally Philip, Chris Kearney, Zhiheng Xu, Jianrong Zhang
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