Anxiety and Emergency Department Visits in Cancer Patients Show a Complicated Link

Every year, millions of people living with cancer find themselves in the sterile, fluorescent-lit waiting rooms of hospital emergency departments. Some arrive with fevers during chemotherapy, others with uncontrolled pain, bleeding, or breathlessness. But a growing body of research suggests that not all of these visits are driven by physical symptoms alone. A new systematic review published in Supportive Care in Cancer has examined one of the most overlooked factors in this equation: anxiety. The findings, drawn from seven separate studies, reveal a picture that is both nuanced and quietly troubling, and they may reshape how oncologists and emergency physicians think about the psychological dimensions of acute care in cancer populations.

The review, led by Hong-Ying Chung of Griffith University together with colleagues at the University of Toronto and Sinai Health, set out to answer a deceptively simple question: do adults with cancer who experience anxiety end up using the emergency department more often than those who do not? The motivation is clear. Anxiety is astonishingly common in cancer care, with up to thirty percent of patients experiencing clinically significant symptoms at some point after their diagnosis. At the same time, patients with cancer are frequent users of emergency services, and understanding what drives those visits has become a priority for health systems trying to deliver better supportive care while avoiding unnecessary acute care use.

To build their evidence base, the researchers conducted a rigorous systematic search across six major databases: CINAHL, the Cochrane Library, Medline, PsycINFO, PubMed, and Web of Science. Two reviewers independently screened titles and abstracts, then carried out full-text review, data extraction, and quality assessment using the Newcastle-Ottawa Scale for cohort studies. The screening process ultimately identified seven studies that met the inclusion criteria, spanning single-center investigations, multicenter analyses, and population-based retrospective designs. Each of these studies compared emergency department use among adult cancer patients with and without anxiety, but the ways in which they defined and measured both anxiety and emergency use varied considerably, a point that would prove central to interpreting the results.

One of the most striking methodological findings of the review is just how differently the included studies operationalized anxiety. Some relied on diagnostic codes extracted from administrative health data, essentially capturing patients whose anxiety had risen to the level of a formal clinical encounter. Others used patient-reported measures, which can detect subclinical worry and distress that never triggers a psychiatric diagnosis. The timing of anxiety assessment also varied, as did the definitions of an emergency department visit and the degree to which studies adjusted for other factors such as cancer stage, treatment intensity, age, and comorbid conditions. These differences were substantial enough that the authors decided a meta-analysis, the statistical pooling of results into a single summary estimate, would be inappropriate. Instead, they synthesized the findings narratively, a decision that reflects both scientific honesty and the messiness of real-world health services data.

So what did the pooled body of evidence actually show? The results split almost evenly. Four of the seven studies found no statistically significant association between anxiety and emergency department use in multivariable analyses, meaning that after accounting for other variables, anxious and non-anxious patients used emergency services at statistically similar rates. Notably, however, three of those four null studies reported small effect sizes with odds ratios or hazard ratios hovering near 1.0, hinting at a faint positive signal that simply failed to reach the threshold of statistical significance, possibly because of limited sample sizes or measurement imprecision.

In contrast, three studies did report a statistically significant positive association between anxiety and increased emergency department use, and the magnitude of that association varied dramatically, with effect estimates ranging from an odds or hazard ratio of 1.23 to a striking 3.87. In plain terms, the study at the upper end of that range found that anxious cancer patients were nearly four times more likely to use the emergency department than their non-anxious counterparts. Even the most conservative of the positive findings represented a meaningful twenty-three percent increase in the likelihood of an emergency visit. The consistency of direction is important here: whenever a significant difference was observed, it always pointed the same way, with anxiety linked to more emergency care, never less.

Why might anxiety drive cancer patients toward the emergency department? The review does not settle the causal question, but several plausible mechanisms deserve consideration. Anxious patients may interpret physical sensations, such as fatigue, nausea, or chest discomfort, as signs of disease progression, prompting urgent evaluation that a calmer patient might schedule with an outpatient oncology team. Anxiety may also amplify the subjective intensity of symptoms, lowering the threshold at which distress becomes unbearable. There is a broader literature supporting this pattern: systematic reviews in general populations, in patients with diabetes, and in older adults have all linked anxiety disorders to higher health care utilization and costs. Cancer adds its own unique pressures, including fear of recurrence, treatment-related uncertainty, and the emotional weight of a life-threatening diagnosis, any of which could tip a patient toward seeking immediate reassurance in an emergency setting.

The clinical and policy implications of this work are considerable. Unplanned emergency department visits among patients with cancer are associated with hospitalizations, disrupted treatment schedules, and substantial costs, and a significant fraction of these visits are considered potentially preventable. If anxiety contributes meaningfully to acute care use, then interventions such as routine psychosocial screening, integrated mental health services within oncology clinics, and same-day access to urgent advice lines could divert some patients away from the emergency department and toward more appropriate, less costly forms of care. Prior randomized trials of psychosocial screening and intervention in radiotherapy and routine oncology care have shown mixed results on hard outcomes, but the new review suggests that the emergency department is an outcome worth tracking directly in future studies of anxiety management.

The authors are careful not to overstate their conclusions. The evidence base is heterogeneous, and the mixed findings may well be artifacts of how anxiety was measured, when outcomes were assessed, and which covariates were adjusted for in each analysis. Studies using diagnostic codes may miss the many patients whose anxiety is real but never formally documented, while patient-reported measures may capture transient distress rather than enduring pathology. The retrospective designs common to all seven included studies also limit causal inference, since it is impossible to know whether anxiety preceded the emergency visits, followed them, or arose from the same underlying severity of illness that drove the visits in the first place.

The path forward, the researchers argue, lies in prospective longitudinal research that uses standardized anxiety measures applied consistently across the cancer continuum, from diagnosis through treatment, survivorship, and, where relevant, end-of-life care. Such studies would allow researchers to track how fluctuations in anxiety relate to subsequent acute care use over time, and to determine whether treating anxiety reduces emergency visits, hospitalizations, and costs. Until that evidence arrives, the review offers clinicians a practical takeaway: when a patient with cancer arrives in the emergency department, the physical complaint that brought them there may be only part of the story. The silent companion of anxiety, present in as many as one in three patients, deserves a place in the assessment, not as an afterthought, but as a legitimate clinical variable that may shape who seeks emergency care, when, and how often. In a health system straining under the weight of avoidable acute care, understanding that connection could prove to be one of the most consequential findings in supportive cancer care this decade.

Subject of Research: The association between anxiety and emergency department use in adults with cancer

Article Title: Anxiety in patients with cancer and emergency department use: a systematic review

Article References: Anxiety in patients with cancer and emergency department use: a systematic review. (n.d.). https://doi.org/10.1007/s00520-026-11325-2

Image Credits: AI Generated

DOI: 10.1007/s00520-026-11325-2

Keywords: anxiety, cancer, emergency department, systematic review, supportive care, health care utilization, psycho-oncology, mental health, oncology, acute care, patient-reported outcomes, epidemiology