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OPEN Disparities in outcomes

among patients diagnosed
with cancer in proximity
to an emergency department visit
Nicholas Pettit1*, Elisa Sarmiento1 & Jeffrey Kline1,2*
A suspected diagnosis of cancer in the emergency department (ED) may be associated with poor
outcomes, related to health disparities, however data are limited. This is a retrospective observational
cohort of the Indiana State Department of Health Cancer Registry, and the Indiana Network for
Patient Care. First time cancer diagnoses appearing in the registry between January 2013 and
December 2017 were included. Cases identified as patients who had an ED visit in the 6 months before
their cancer diagnosis; controls had no preceding ED visits. The primary outcome was mortality,
comparing ED-associated mortality to non-ED-associated. 134,761 first-time cancer patients were
identified, including 15,432 (11.5%) cases. The mean age was same at 65, more of the cases were Black
than the controls (12.4% vs 7.4%, P < .0001) and more were low income (36.4%. vs 29.3%). The top
3 ED-associated cancer diagnoses were lung (18.4%), breast (8.9%), and colorectal cancers (8.9%),
whereas the controls were breast (17%), lung (14.9%), and prostate cancers (10.1%). Cases observed
an over three-fold higher mortality, with cumulative death rate of 32.9% for cases vs 9.0% for controls
(P < .0001). Regression analysis predicting mortality, controlling for many confounders produced an
odds ratio of 4.12 (95% CI 3.72–4.56 for cases). This study found that an ED visit within 6 months prior
to the first time of ICD-coded cancer is associated with Black race, low income and an overall three-
fold increased adjusted risk of death. The mortality rates for ED-associated cancers are uniformly
worse for all cancer types. These data suggest that additional work is needed to reduce disparities
among ED-associated cancer diagnoses.

Abbreviations
ED Emergency department
CCI Charlson Comorbidity Index

Cancer is a leading cause of death ­worldwide1. The number of cancer survivors continues to grow in the face
of improving therapies and earlier detection, as well as declining age-standardized incidence rates in men and
­ omen2. Improved detection modalities is one reason for these improvements. Longitudinal outcome
stable in w
studies have suggested that each week added to the time to initial cancer treatment is associated with a 1–3%
absolute increased risk of mortality with breast, lung, renal, and pancreatic c­ ancers3. National guidelines exist for
cancer screening that are relevant to emergency care. For example, the U.S. Preventive Task Force recommends
yearly lung cancer screening with low-dose CT for chronic, heavy smokers, between the ages of 50–80 years
old. However, only a minority of patients are appropriately screened as outpatients (4% in the setting of lung
cancer), which may contribute to the burden of emergently presenting c­ ancer4. Thus, there is an unmet need to
define the burden of emergency department associated cancer diagnoses as to create future interventions, such
as ED SBIRTs (screening, brief intervention, referral to treatment) as to either modify the risk factors for cancer
(tobacco use) or referral for cancer s­ creening5.
Although poorly quantified, preliminary data suggest that many patients are diagnosed with cancer during
an ED v­ isit6. Because patients who have cancer diagnosed during ED presentations may have multiple inequities
in care (lack of insurance, no primary care, and possibly higher smoking rates), their outcomes may be worse.

1
Department of Emergency Medicine, Indiana University, Indianapolis, IN, USA. 2Department of Emergency
Medicine, Wayne State University, 4201 St. Antoine, University Health Center – 6G, Detroit, MI 48201,
USA. *email: [email protected]; [email protected]

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However, since the literature is sparse, and mostly retrospective, little is absolutely known about the outcomes
of patients with emergently diagnosed cancer.
In this work, we use data linkage and in a retrospective observational cohort methodology to characterize the
demographics, phenotypes, and outcomes of patients that have ED-associated cancer diagnoses. We used a state-
wide database to examine the rate of recent visit–defined arbitrarily as within six months–to an ED in patients
with newly diagnosed cancer with the inference that the recent visit was the touchpoint where the initial clinical
information suggested a possible new cancer diagnosis. We hypothesized that ED-associated cancer diagnoses
will suffer higher mortality as compared to non-ED-associated cancer diagnoses.

Methods
Patients. This is a retrospective observational cohort study from patients with cancer in the state of Indiana,
located in the USA. Data was obtained from Indiana State Department of Health (ISDH) Cancer Registry, the
Indiana Network for Patient Care (INPC), supplemented with data from the electronic health records (EHR) of
two major hospitals in the greater Indianapolis area. Data was curated and provided by The Regenstrief Institute
which includes 47 hospitals and 3 insurance ­institutions7.
Patients with their first cancer diagnosis between January 2013 and December 2017 were identified using the
ISDH Cancer Registry. To determine presence or absence of a recent ED visit, clinical features and outcomes,
patients in the ISDH Cancer registry were co-identified in the INPC research database, which represents one of
the largest health information exchanges in the country. Cases were defined as patients with any ED visits in the
6 months before their cancer diagnosis were and controls were all others (irrespective of reason for visit). Six
months was chosen as the studied time frame, in comparison to the previously published 30-day definition of
an emergency presentation from UK-based data, as many patients in the USA wait upwards of 90 days or more
from first presentation to ­treatment8,9.
The index date for all patients was set as the date of initial cancer diagnosis according to the first posted
cancer-defining ICD code. The ICD Oncology Topography codes, the cancer primary site, as well as patient zip
code and insurance used at the time of diagnosis were extracted from the ISDH Cancer Registry.
Using unique identifiers for data linkage, demographics and clinical data, comorbid ICD codes were down-
loaded from the INPC and supplemented with ISDH Cancer Registry data. The Charlson Comorbidity Index
(CCI) at time of index was then calculated using diagnoses within the year prior to ­index10. Social history
(tobacco use, drug use, and alcohol use) was also identified using ICD codes. Tobacco use was extracted from
local hospital electronic health records. Vital status and patient mortality was extracted using Social Security
Administration (SSA) death data linked to the INPC and calculated in days from the index ED visit. Where SSA
data was missing, death data was extracted from the INPC and the ISDH Cancer Registry.

Statistics. Patient demographics and characteristics were compared between those patients who did not
have an ED visit within six months prior to cancer diagnosis (controls) and those patients who did (cases).
Missing data were excluded from analysis. Categorical variables were presented as frequencies, and continuous
variables were presented as medians (with interquartile ranges). To test for differences between groups, the Chi-
square test or 95% confidence interval for differences in proportions were used for bivariate variables, and the
Wilcoxon test for continuous variables. Adjusted odds ratios from logistic regression containing the following
dependent variables (age, gender, race, SES, drug use, alcohol use, tobacco use, and the Charlson comorbidity
index)was used to determine the association of ED diagnosis (cases) with minority status, low SES status and
death compared with non-ED diagnosis (controls). A generalized estimating equation using the GENMOD
procedure was used to adjust for clustering at the city level via zip code which was the estimate of SES. We per-
formed statistical analyses using SAS version 9.4 (SAS Institute, Cary, NC).

Ethics approval. This work was approved under exempt status by the Indiana University Institutional
Review Board (IRB #1,808,879,348). De-identified data was used for this study, and informed consent to partici-
pate was waived by the IRB. All methods were carried out in accordance with relevant guidelines and regulations.

Results
Comparing the two populations. Table 1 gives the demographics and characteristics of the patients
involved in this study, separating patients into controls, those with no-associated ED visits in prior 6 months
and compares those to case patients with an associated ED visit within 6 months from the time of cancer diag-
nosis. In total, 134,761 patients were identified to be diagnosed with cancer within the Indiana Cancer Registry,
with 15,432 (11.5%) cases. First time cancer diagnoses were identified during the 2013–2017 study period, but
mortality was included up to 2019.
Pertinent differences included the finding that African Americans comprised a significantly greater propor-
tion of cases (12.4% versus 7.4, 95% CI for difference of 5.0% = 2.3 to 6.4%). Furthermore, cases had higher rates
of drug, alcohol, and tobacco use than controls at 3.3% vs 0.8% (95% CI for 2.5% = 0.20–0.25) for drug use,
6.3% vs 2.3% for alcohol use (95% CI for 4.0% = 0.14–0.16), and 40.3% vs 25.2% for tobacco use (95% CI for
15.1% = 0.07–0.08). In terms of primary outcome, cases had a significantly higher mortality rate of 32.8% versus
9.0% (95% CI for 23.8% = 0.23–0.24) within a median 116 days for cases and 268 days for controls.

Top cancers per cohort. Table 2 lists the top 10 malignancies for both cohorts in order of decreasing
frequency. The values within each column for frequencies gives two percentages, with the first percentage the
overall percentage and the second being the percentage just within controls or cases. For controls, the top 3

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Controls (No ED visit within six months prior) Cases (ED visit within six months prior)
N = 119,329 N (total cohort percent*, column N = 15,432 N (total cohort percent, column
Total N = 134,761 N (percent) ­percent#) percent)
Gender
Female 70,590 (52.4) 62,614 (46.5, 52.5) 7,976 (5.9, 51.7)
Male 64,165 (47.6) 56,709 (42.1, 47.5) 7,456 (5.5, 48.3)
Unknown 6 (0.0) 6 (0.0, 0.0) 0 (0.0, 0.0)
Age at diagnosis, Median (IQR) 65.0 (55.0–74.0) 65.0 (56.0–73.0) 65.0 (54.0–75.0)
Race
American Indian or Alaska Native 89 (0.1) 74 (0.1, 0.1) 15 (0.0, 0.1)
Asian 953 (0.7) 874 (0.7, 0.7) 79 (0.1, 0.5)
Black 10,770 (7.9) 8,858 (6.6, 7.4) 1,912 (1.4, 12.4)
Native Hawaiian or Other Pacific Islander 31 (0.0) 28 (0.0, 0.0) 3 (0.0, 0.0)
Other 79 (0.1) 77 (0.1, 0.1) 2 (0.0, 0.0)
Unknown 1,185 (0.9) 1,098 (0.8, 0.9) 87 (0.1, 0.6)
White 121,654 (90.2) 108,320 (80.4, 90.8) 13,334 (9.9, 86.4)
Drug use
No 133,242 (98.9) 118,324 (87.8, 99.2) 14,918 (11.1, 96.7)
Yes 1,519 (1.1) 1,005 (0.8, 0.8) 514 (0.4, 3.3)
Alcohol use
No 131,046 (97.24) 116,579 (86.51, 97.70) 14,467 (10.7, 93.8)
Yes 3,715 (2.76) 2,750 (2.04, 2.30) 965 (0.7, 6.3)
tobacco use
No 98,521 (73.1) 89,309 (66.3, 74.8) 9,212 (6.84, 59.69)
Yes 36,240 (26.9) 30,020 (22.2, 25.2) 6,220 (4.62, 40.31)
Vital status
Alive 118,910 (88.2) 108,548 (80.6, 90.9) 10,362 (7.7, 67.2)
Deceased 15,851 (11.8) 10,781 (8.0, 9.0) 5,070 (11.8, 32.9)
CCI, Median (IQR, Range) 2.0 (1.0–3.0) 2.0 (1.0–3.0, 1.0–19.0) 2.0 (1.0–4.0, 1.0–17.0)

Table 1.  Characteristics of the study population. Abbreviations: ED-emergency department, CCI-Charlson

comorbidity index.

Controls (No ED visit within

six months prior) N = 119,329 N Cases (ED visit within six months
(total cohort ­percent&, column prior) N = 15,432 N (total cohort
Cancer type* Total N = 134,761 N (percent) ­percent#) Cancer type* percent, column percent)
Breast 22,978 (17.05) 21,606 (16.03, 18.11) Bronchus/Lung 2,838 (2.11, 18.39)
Bronchus/lung 20,023 (14.86) 17,185 (12.75, 14.40) Breast 1,372 (1.02, 8.89)
Prostate gland 13,593 (10.09) 12,677 (9.41, 10.62) Colon/Rectum 1,369 (1.0, 8.87)
Hematopoietic and Reticuloen-
Colon/rectum 11,887 (8.82) 10,518 (7.80, 8.81) 1,066 (0.79, 6.91)
dothelial Systems
Hematopoietic and Reticuloen-
7,360 (5.46) 6,294 (4.67, 5.27) Prostate Gland 916 (0.68, 5.94)
dothelial Systems
Bladder 5,887 (4.37) 5,068 (3.76, 4.25) Bladder 819 (0.61, 5.31)
Kidney 5,015 (3.72) 4,211 (3.12, 3.53) Kidney 804 (0.60, 5.21)
Corpus uteri 4,668 (3.46) 4,197 (3.11, 3.52) Pancreas 664 (0.48, 4.17)
Lymph nodes 4,264 (3.16) 3,662 (2.72, 3.07) Lymph Nodes 602 (0.45, 3.90)
Pancreas 3,914 (2.90) 3,270 (2.43, 2.74) Liver And Intrahepatic Bile Ducts 475 (0.35, 3.1)

Table 2.  Frequency of cancers among controls and cases. *Displaying top 10. &total cohort percent is the
column value divided by the N total (137,761), #column percent is the column value divided by the column’s
total N.

cancers in decreasing frequency are breast (18.1%), lung (14.4%), and prostate (10.1%). Comparatively the most
frequently ED-associated cancers were lung (18.4%), breast (8.9%), and colon/rectal (8.9%).

Comparing mortality between cancers. Figure 1 (S1 Table) compares the cumulative mortality rates
for 9 cancer diagnoses during the 5-year study period, (since the 10th cancer in each was different between the
two). The percentage of mortality for all nine cancer types were consistently higher in cases compared with

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Figure 1.  Bar graph comparing mortality among nine cancers. Bar graph comparing mortality percentages
from cases compared to controls for the top 9 most common cancers, over 5-year study period, error bars
representing 95% CI.

Figure 2.  Survival curve for cases vs. controls. Kaplan Meier survival curve comparing days lived from cases
(blue line) to controls (red line).

controls. A concerning 45% relative difference exists between cases and controls for pancreatic cancer. Figure 2
shows Kaplan Meier survival curves for these nine cancers and demonstrates a consistently worse survival for
cases versus controls up until 5 years of follow-up (P < 0.001 log-rank statistic).

Socioeconomic status and racial outcomes. Table 3 compares SES data between cases and controls,
and was assigned by zip code into 5 different categories, namely below/near poverty, low income, middle class,
upper middle class, and highest tax ­bracket11,12. Among cases, 36.9% were low income or below poverty level,
compared with 29.5% in the controls (95% CI for difference of 7.4% = 0.03–0.04). Supplemental Table 3 breaks
down the mortality among cases and controls based upon SES. Similar to the data presented in Figs. 1 and 2,
mortality among cases consistently worse; overall, 36.3% of low-income cases having died in the study period,
whereas only 11% low-income controls died.
Black race consistently worsened cancer prognosis among cases (S2 Table). For breast cancer, mortality rate
was 12.1% for Black patients who were ED cases, versus a mortality rate of 5.5% for Black patients who were in

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Controls (No ED visit within six months prior) N = 118,599 N (total Cases (ED visit within six months prior) N = 15,344 N (total cohort
Total N = 134,761 cohort ­percent&, column p
­ ercent#) percent, column percent)
Socioeconomic status*
Below or near poverty level 214 (0.16, 0.18) 31 (0.02, 0.20)
Low income 34,794 (25.98, 29.34) 5,583 (4.17, 36.39)
Middle class 83,568 (62.39, 70.46) 9,729 (7.26, 63.41)
Upper middle class 10 (0.01, 0.01) 0 (0, 0)
Highest tax brackets 13 (0.01, 0.01) 1 (0, 0.01)

Table 3.  Socioeconomic status for controls vs. cases. *See text for description of socioeconomic class,
**P < 0.001 estimated by Chi-square, &total cohort percent is the column value divided by the N total (137,761),
#
column percent is the column value divided by the column’s total N.

Recent ED visit Odds ratio (95% CI)*

Seen 6 months prior (unadjusted) 4.93 (4.40–5.51)
Seen 6 months prior (adjusted**) 4.12 (3.72–4.56)
Minority status (non-whites) Odds Ratio (95% CI)*
Seen 6 months prior (unadjusted) 1.55 (1.24–1.94)
Seen 6 months prior (adjusted**) 0.97 (0.96–0.99)
Low socioeconomic status Odds Ratio (95% CI)*
Seen 6 months prior (unadjusted) 1.37 (1.01–1.87)
Seen 6 months prior (adjusted**) 1.19 (0.94–1.50)

Table 4.  Mortality risk based upon recent emergency department (ED) visit, minority and socioeconomic
status. *Odds of death comparing cases with controls using logistic regression. **Adjusted for age, gender, race,
SES, drug use, alcohol use, tobacco use, & Charlson Score.

the control group (95% CI for 6.6% difference = 0.01–0.04). Black patients comprised 18.2% of the breast cancer
patients among cases versus 8.0% of controls (95% CI for 10.1% difference = 0.06–0.09). These trends continued
for lung cancer, with a mortality rate of 58.7% among Black patients in case group, compared with a mortality
rate of 22.4% among the control group.

Controlling for confounders. Table 4 shows the result of logistic regression to examine the effect of case
or control status on mortality while controlling for confounding variables. The equation was designed to control
for clustering by city (via zip code) and also for seven other potential independent predictor variables (age, gen-
der, race, SES, drug use, alcohol use, tobacco use, and the CCI) and found cases had an increased risk of death
over controls with an adjusted odds ratio of 4.12 (95% CI 3.72–4.56). After these corrections, the lower limit of
the 95% CI for mortality consistently remained above 1.0 for case versus control status for all cancer.

Discussion
Our findings show uniformly worsened outcomes of all patients during a period of five years, especially in minor-
ity and low-income patients, diagnosed with new cancer diagnosed in temporal proximity to an ED visit. These
data infer that patients with undiagnosed cancer who rely on the ED as a source of primary medical care will
have a worsened outcome compared with patients who have organized medical ­care6. Prior work from the United
Kingdom’s “Routes-to-Diagnosis” conducted by the Public Health England, suggested 23% of newly diagnosed
cancer patients presented emergently and survival rates were much lower for those emergent presenters, which
is similar to what we discovered in this ­work13. For example, in a recent cross-sectional population-based study
from 14 jurisdictions in six countries demonstrated that 24.0–42.5% of patients were defined as emergency
presentations of ­cancer8. Emergency presentation, which is associated with various cancer types, older age, and
advanced stage at diagnosis, strongly predicts worse prognosis and probably contributes to international differ-
ences in cancer ­survival8. Notably absent from this recent meta-analysis of 857,068 patients across 6 countries
are patients from the USA.
In the US, a study from Michigan, lung and colorectal cancer patients with ED-associated cancer diagnosis
had more advanced staged cancer and were more likely to be Black than those diagnosed without a recent ED
visit, but no data on mortality were p ­ resented14. In this study, the authors chose a conservative approach by
defining an ED-diagnosed cancer as one that had an ED visit in the month of or month before the diagnosis of
cancer, however, prior to this publication there is no precedent for defining an ED-associated cancer. Instead, we
chose 6 months as our conservative time point as to define ED-associated cancer, as there is substantial evidence
that ambulatory follow-up compliance after ED discharge is poor, and has been estimated to be between 26 and
56% depending on the ED p ­ opulation15. Additionally, there is some evidence that suggests almost one third of
patients with new onset cancer experience delays of over 90 days, and thus there is no precedent for establishing

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the optimal time from ED visit to cancer ­diagnosis9. Among 9,470,626 ED visits among Medicare beneficiaries
aged 65 and older, nearly 30% lacked ambulatory follow-up at 30 days, with lower rates of ambulatory follow-up
observed among those of Black race and seen in rural E ­ Ds16. Further, a study from Western Australia demon-
strated that of 1358 people with incident breast, prostate, colorectal, and lung cancers the diagnostic interval
from symptom to diagnosis ranged from 92–108 days, further suggesting the time to cancer diagnosis can exceed
several ­months17. Rural health disparities exacerbate the time to cancer treatment and ultimately mortality, due to
long travel times, low availability of clinical trials, and additional health burdens, an issue that is well observed in
the state of ­Indiana18. Thus, additional research is clearly needed among US populations to delineate and improve
the time to cancer diagnosis and treatment for ED-suspected cancer patients.
It has been demonstrated that emergent presentations of cancer are associated with lower curative rates and
treatments, even when compared to cancers diagnosed “electively” (even at the same stage)19. The present data in
Fig. 2, together with prior findings support the inference that patients who have a diagnosis of cancer temporally
connected with an ED visit, suffer from a disparity in their odds of survival. From a health services standpoint,
potentially modifiable causes for this disparity include lack of access to primary medical care and cancer screen-
ing before diagnosis, increased rate of tobacco and alcohol use, worsened uncontrolled comorbidities at the
time of diagnosis, and lack of access to specialty cancer care after diagnosis. Thus, additional work should focus
on reducing the time to cancer diagnosis as expedited diagnosis of symptomatic cancer likely benefits patients’
survival and improved quality of life as demonstrated in a systematic review of over 200 s­ tudies20.
This work employed a state-wide assessment of cancer diagnoses in the state of Indiana. From this, numerous
patient factors appear to contribute to the observed mortality and worse outcomes, namely race and socioeco-
nomic status. Meanwhile, factors such as age and sex appear to have little relationship between the association
of diagnosis and mortality. This is compared to other works where older age (≥ 85 years old) are 2.5 times more
likely to present with an emergent diagnosis of cancer, when compared to a 65–74-year-old ­cohort21. Those
authors conclude that cancer and age are likely to reflect disease specific factors. Further, our work we excluded
pediatric patients (< 18 years old), and it is well known that more than half of patients that present with de novo
cancer diagnoses in the ED are emergently d ­ iagnosed22.
What limited evidence exists from data obtained in the United States, has demonstrated associations between
socioeconomic status and the diagnosis of cancer as an emergency. African Americans in one study had increased
odds of emergently diagnosed colorectal cancer (AOR 1.5, 95% CI 1.38–1.63) as compared to a similar white
­cohort23. This disparity not only exists among the diagnosis of cancer but in the primary and secondary preven-
tions among lower SES populations. Colorectal screening, despite its efficacy and recommendations, has been
shown to be low among African Americans and those with low SES, demonstrating an opportunity or intervening
on this high risk population in the ­ED24. Furthermore, the low SES population have inequities that result in poor
lifestyle choices, some of which (smoking status, diet, physical activity) are preventable and modifiable if this
population had access to equitable opportunities. Cancer mortality among this population has an association
between mortality and modifiable risk factors, again at current date are not routinely performed in the E ­ D25.
Blacks are diagnosed with breast and lung cancer in the cases versus controls and their outcomes appear to be
worse. We speculate that blacks are more dependent upon EDs than whites for unscheduled, emergent care, and
thus are more likely to present to an ED emergently for their undiagnosed m ­ alignancy26. Similar phenomenon
can be applied to whites with low SES, where patients of low SES are more reliant on the ED for their care and
are more likely to present emergently with their undiagnosed c­ ancer27,28. These data suggest race and socioeco-
nomic status are more important than other factors, such as comorbidities, since the CCI was equal. While not
examined in this large data analyses, there is growing evidence that African Americans have more aggressive
tumor biology, such as in several breast cancer studies, which can be speculated that this also contributes to these
patients presenting more emergently for their undiagnosed c­ ancer29.
Of the cancers that have proven screenings that demonstrate success, lung and colorectal cancers do markedly
worse when associated with an ED-visit, 54% vs 18% mortality for lung cancer (P < 0.0001), and 26.4% vs 9%
for colorectal cancer (P < 0.0001). Breast cancer also has a successful screening modality, namely mammogra-
phy, and suffers from similar poor outcomes when associated with an ED visit, 11.9% mortality vs 3.4%, ED to
non-ED ­associated30. Prostate cancer screening is controversial and recommendations vary by organization and
country, regardless, a screening modality is available and those diagnosed with prostate cancer associated with an
ED visit have higher mortality than those that don’t (13.2% vs 3.5%)31. Lastly, cervical cancer also is frequently
screened for as outpatients and 22% of those seen in the ED were dead, versus 7.4% of those not seen in the
ED. This evidence is supported by known disparities in cancer screening, with minority patients experiencing
greater delays in evaluation and screening for cancer, leading to suboptimal treatment among those patients
subsequently diagnosed with ­cancer32.
Previous research has called for both improving the outcomes of patients that are diagnosed with cancer
through an emergent presentation, as well as helping to reduce the burden of emergent diagnoses by improving
cancer ­screening6,33. This is likely a systems issue, but plausible future steps is utilizing the ED space for more
than just emergent care. Average length of stays in ED has multiple variables that impact exact time frame which
patients sit in the ED, but in one paper an average a patient can expect a wait of 4 ­h34. As the trend of increasing
length of stay continues to increase nationwide, EDs are experiencing the unfortunate phenomena of ED crowd-
ing which has been well demonstrated to be associated with increased hospital ­death35. We propose future work
in developing interventions for this at risk population while in the ED, similar to what has been performed for
rapid hepatitis screening and cervical cancer screening in urban EDs, demonstrating proof of concept and utiliz-
ing the ED space for more than emergent ­care36,37. Similar revolutionary changes in ED workflow for improving
the overall health of ED patients has been adopted with universal HIV screening in the ED, as well as universal
suicide screening in E ­ Ds38,39. Intervening on this population is challenging but supported by a Cochrane Review,
guaiac fecal immunochemical test (FIT) can reduce colorectal mortality by 15%, and providing appropriately

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chosen patients with home use FIT tests through primary care has improved screening rates, sustaining a screen-
ing rate of 75%40,41. Currently screening routinely for cancer does not occur in the emergency setting, but for
many vulnerable patients (uninsured, lower SES, racial minorities), the emergency room serves as the only
opportunity for routine care and we should begin to explore alternative strategies to maximally improve the care
of these ­patients42. Removing the barriers to cancer screening, such as providing patients with FIT cards prior
to discharge may represent an opportunity to increase adherence to CRC screening and reduce the burden of
emergently diagnosed CRC​43. Novel approaches need be undertaken at the systems and health policy level to
address the disparities that are well demonstrated among ED-associated cancer diagnoses.

Limitations. There are limitations to this study, namely the retrospective methodology to obtaining the
administrative data. A diagnosis of cancer, while suspected in the ED, usually occurs weeks to months after the
actual ED encounter, and thus confirming linkage from a suspected ED visit and a diagnosis is challenging. Fur-
ther, patient stage and tumor specific biology are not included on the ICD-coded diagnosis and thus knowing
the stage and extent of disease is not available without retrospective chart review. Additionally, survivor bias is
present, because in order to be included in this study, one must have an ICD-coded cancer diagnosis. Regardless,
we made an inference that being diagnosed with cancer within 6 months of a recorded ED visit, meant those ED
physicians had an opportunity to diagnose asymptomatic cancer, if that ED visit wasn’t directly related to the
presentation of emergent cancer diagnosis. The relationship between the ED visit and the diagnosis of cancer
are unclear, due to lack of detailed ED visit information as well as most patients that are discharged from the ED
have symptom-based discharge diagnoses as opposed to a definitive discharge ­diagnosis44. No detailed ED visit
was curated from this study and thus linking the ED-diagnosis to the ultimate cancer diagnosis is not feasible
in this study.
No knowledge is known about previous screenings and primary care follow up was available in this study,
thus no inference can be made to know whether or not screening may have reduced the likelihood of the found
associations. The lack of follow-up knowledge means we can’t examine the relationship between mortality and
inadequate access to expert care, but the correction for clustering on logistic analyses suggests this is not just
a result of location. Ultimately, it is difficult to determine if the observed outcome differences primarily reflect
lead-time bias, health care disparities, or other factors, but comparing to the limited available data primarily
from Europe, these data clearly present a concerning trend for patients with a new diagnosis of cancer. Unlike
Europe which relies on the general practitioner to help coordinate cancer workups, cancer care-pathways are
ill-defined and understudied. Thus, the outcomes of this present study may be very different in Europe and in
other health care settings.
Further limitations include those cancers that are so advanced that tissue biopsy is not obtained, or patients
prefer to not seek treatment. Lastly, pediatric cancers and their association with being emergently diagnosed in
the ED were not explored in this study. No pediatric cancers have preventable or modifiable risk factors, and as
such the goal of this work is to find interventions on cancers that can be prevented with lifestyle modification
(smoking cessation, weight loss), or caught earlier with age-appropriate screening.

Conclusions
Patients diagnosed with cancer with an associated ED visit within 6 months prior to their ICD-code cancer
diagnosis are associated with poor outcomes, specifically increased mortality, as compared to a cohort that did
not have an ED visit within 6 months prior to their diagnosis. Lung, breast, and colorectal are the most frequently
ED-associated cancer diagnoses, with upwards of 50% mortality as compared to non-ED associated cancers.
Further, there are associated racial and socioeconomic disparities among those diagnosed, both in cancer type
and frequency, and mortality. These data are among the first to our knowledge that describe patients in the United
States, among a statewide database. They further suggest that ED-associated cancer diagnoses offers an oppor-
tunity for additional research to understand the associations between diagnoses and socioeconomic and racial
disparities. Given existing literature is limited to retrospective, database analyses, future work should be aimed
at prospective studies as to guide future interventions to help reduce the disparities and reduce the mortality
among ED-associated cancer diagnoses.

Data availability
All data generated or analyzed during this study are included in this published article (and its Supplementary
information files).

Received: 22 December 2021; Accepted: 24 May 2022

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Acknowledgements
We would like to thank the research database managers at The Regenstrief Institute for helping cultivate the
data for these analyses.

Author contributions
N.P. and J.K. designed and collected the data. E.S. analyzed the data. N.P., E.S., and J.K. wrote the manuscript.

Competing interests
The authors declare no competing interests.

Additional information
Correspondence and requests for materials should be addressed to N.P. or J.K.
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