1
|
Decker H, Graham L, Titan A, Hawn M, Kushel M, Kanzaria HK, Wick E. Housing Status and Cancer Screening in US Veterans. J Gen Intern Med 2025; 40:1297-1305. [PMID: 40011415 PMCID: PMC12045890 DOI: 10.1007/s11606-024-09098-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 09/27/2024] [Indexed: 02/28/2025]
Abstract
BACKGROUND Cancer is a leading cause of death in people experiencing homelessness, who are more commonly diagnosed with late-stage disease and have poorer survival after diagnosis than housed. OBJECTIVE To characterize the incidence and timeliness of colorectal and breast cancer screening in a national sample of Veterans. DESIGN Retrospective, matched cohort study from 2011 to 2021 in a national sample of Veterans receiving care from the Veterans Health Administration (VA). PARTICIPANTS Each Veteran experiencing homelessness was matched to three housed Veterans with the same age, gender, clinic location, and month and year of outpatient clinic appointment. EXPOSURE We classified Veterans as homeless if they had any homeless indicator at the matched clinic visit or in the 12 months prior and all others as housed. MAIN MEASURES Our primary outcomes were being up to date on screening, receiving a biopsy following a positive screen and timeliness of biopsy. We assessed the association between housing status and our outcomes using conditional Poisson regression models with generalized estimating equations, adjusting for race, ethnicity, marital status, Charlson Comorbidity Index, smoking status, and mental health comorbidities. KEY RESULTS Our sample included 2,580,640 Veterans, with 1,935,480 housed and 645,160 experiencing homelessness. Patients experiencing homelessness had a 16% lower adjusted incidence rate ratio (aIRR) of being up to date with colorectal cancer screening when compared to housed (aIRR 0.84, 95%CI 0.83-0.84; p<0.001) and a 13% lower aIRR for breast cancer (aIRR 0.87, 95%CI 0.86-0.88; p<0.001). Following a positive stool-based test, patients experiencing homelessness had a 12% lower aIRR of undergoing diagnostic colonoscopy compared to housed (aIRR 0.88, 95%CI 0.84-0.92; p<0.001). Time to biopsy was similar between groups for both cancer types. CONCLUSIONS Veterans experiencing homelessness were less commonly screened for cancer than a matched housed cohort. However, screening rates in this group were higher than in non-Veteran homeless populations. The VA system may offer insights into providing preventative care for this population.
Collapse
Affiliation(s)
- Hannah Decker
- Department of Surgery, UCSF, San Francisco, USA.
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, USA.
| | | | | | - Mary Hawn
- Department of Surgery, Stanford, USA
| | - Margot Kushel
- Department of Medicine, UCSF, San Francisco, USA
- Benioff Homelessness and Housing Initiative, Zuckerburg San Francisco General Hospital, San Francisco, USA
| | - Hemal K Kanzaria
- Benioff Homelessness and Housing Initiative, Zuckerburg San Francisco General Hospital, San Francisco, USA
- Department of Emergency Medicine, UCSF, San Francisco, USA
| | | |
Collapse
|
2
|
Kwon Y, Roberts ET, Degenholtz HB, Jacobs BL, Sabik LM, Cole ES. Housing-Related Disparities in Receipt of Breast Cancer Screening Among Women Medicaid Beneficiaries. JCO Oncol Pract 2025:OP2401094. [PMID: 40117533 DOI: 10.1200/op-24-01094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2024] [Revised: 01/30/2025] [Accepted: 02/19/2025] [Indexed: 03/23/2025] Open
Abstract
PURPOSE People experiencing housing insecurity (PEHI) may face barriers to preventive cancer screening, but the extent to which PEHI receive screening at the population level is understudied. Therefore, this study examined disparities in utilization of breast cancer screening associated with housing insecurity (HI) among women beneficiaries enrolled in a large Medicaid program. METHODS We assessed receipt of biennial mammography among women Medicaid beneficiaries, age 50-64 years, in administrative Medicaid data linked to encounter-level records on housing-related services in Pennsylvania (PA; Homelessness Management Information System [HMIS]) from 2011 to 2019. We characterized disparities in screening between beneficiaries with an encounter for housing-related services in HMIS (indicating experience or history of HI) compared with beneficiaries without any such encounters. RESULTS We included 73,456 women Medicaid beneficiaries in PA, including 1,792 HMIS service recipients and 71,664 comparison beneficiaries. The mammography rate was 44.8% among HMIS service recipients and 50.1% among comparison beneficiaries, representing a disparity of 5.3 percentage-points (pp; P < .001). This disparity was pronounced between HMIS service recipients with chronic experience of homelessness and comparison beneficiaries (-9.4 pp; P = .036). In stratified analyses, beneficiaries without any primary care visits had the lowest rate of mammography, although realized access to primary care did not eliminate the disparity in screening associated with HI. CONCLUSION HI was associated with a significant disparity in mammography among women Medicaid beneficiaries, underscoring the need for efforts to improve preventive care among housing-insecure populations.
Collapse
Affiliation(s)
- Youngmin Kwon
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN
| | - Eric T Roberts
- Department of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Howard B Degenholtz
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, PA
| | - Bruce L Jacobs
- Department of Urology, Division of Health Services Research, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Lindsay M Sabik
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, PA
| | - Evan S Cole
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, PA
| |
Collapse
|
3
|
Al-Assil T, Kalina C, Laird MC, Olivier RC, Dawood N, Kumar NS, Riordan R, Shebrain S, Dickson C, Munene G. Sheltered yet unscreened: Exploring cancer screening rates and barriers in the unhoused (homeless) population. Am J Surg 2025; 248:116289. [PMID: 40101343 DOI: 10.1016/j.amjsurg.2025.116289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2024] [Revised: 02/23/2025] [Accepted: 03/03/2025] [Indexed: 03/20/2025]
Abstract
INTRODUCTION Cancer related mortality amongst the homeless and unhoused has been reported to be significantly higher than the housed population. This study explores cancer screening uptake and barriers in a homeless community in Michigan. METHODS Questionnaires were administered at two homeless shelters focusing on Hepatitis C (HCV), lung, breast, colon, and cervical cancer screenings. RESULTS Amongst 143 participants, rates of screening uptake were lowest for breast cancer (44 %), followed by colorectal cancer (45 %), HCV (55 %), and cervical cancer (79 %). The three most common barriers to receiving screenings were lack of transportation (21.8 %), lack of access to or awareness of screenings (20.5 %), and low prioritization of health compared to other insecurities faced while being homeless (17.9 %). CONCLUSIONS Enhancing the unhoused/homeless community's access to cancer screenings is crucial. High willingness to undergo screenings suggests potential targeted interventions, such as providing transportation tokens and comprehensive educational resources, onsite screenings, and potentially employing social work navigators at shelters.
Collapse
Affiliation(s)
- Talal Al-Assil
- Western Michigan University Homer Stryker M.D. School of Medicine, 300 Portage St., Kalamazoo, MI, 49007, USA
| | - Claire Kalina
- Western Michigan University Homer Stryker M.D. School of Medicine, 300 Portage St., Kalamazoo, MI, 49007, USA
| | - Madison C Laird
- Western Michigan University Homer Stryker M.D. School of Medicine, 300 Portage St., Kalamazoo, MI, 49007, USA
| | - Ryan C Olivier
- Western Michigan University Homer Stryker M.D. School of Medicine, 300 Portage St., Kalamazoo, MI, 49007, USA
| | - Nataly Dawood
- Western Michigan University Homer Stryker M.D. School of Medicine, 300 Portage St., Kalamazoo, MI, 49007, USA
| | - Neya Suresh Kumar
- Western Michigan University Homer Stryker M.D. School of Medicine, 300 Portage St., Kalamazoo, MI, 49007, USA
| | - Raven Riordan
- Western Michigan University Homer Stryker M.D. School of Medicine, 300 Portage St., Kalamazoo, MI, 49007, USA
| | - Saad Shebrain
- Department of Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, 1000 Oakland Dr, Kalamazoo, MI, 49008, USA
| | - Cheryl Dickson
- Department of Health Equity & Community Affairs, Western Michigan University Homer Stryker M.D. School of Medicine, 300 Portage St., Kalamazoo, MI, 49007, USA
| | - Gitonga Munene
- Department of Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, 1000 Oakland Dr, Kalamazoo, MI, 49008, USA; West Michigan Cancer Center, 200 N Park St, Kalamazoo, MI, 49007, USA.
| |
Collapse
|
4
|
Horrill TC, Beck SM, Wiens A. Toward an Understanding of Cancer as an Issue of Social Justice: Perspectives and Implications for Oncology Nursing. Curr Oncol 2025; 32:104. [PMID: 39996903 PMCID: PMC11854311 DOI: 10.3390/curroncol32020104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2024] [Revised: 02/08/2025] [Accepted: 02/08/2025] [Indexed: 02/26/2025] Open
Abstract
Within the fields of oncology practice and research, cancer has historically been and continues to be understood as primarily biologically produced and physiologically driven. This understanding is rooted in biomedicine, the dominant model of health and illness in the Western world. Yet, there is increasing evidence of inequities in cancer that are influenced by social and structural inequities. In this article, we propose that cancer-related inequities ought to be seen as issues of social justice, and, given nursing's longstanding commitments to social justice, they ought to be a priority for oncology nurses. Using a social justice lens, we highlight potential social injustices in the form of inequities in cancer outcomes and access to cancer care across the cancer continuum. Our intention is not to provide an exhaustive review of evidence, but to provide our perspective, adding to the dialogue surrounding health equity and cancer while shifting the narrative away from an understanding of cancer inequities as stemming from "lifestyle" and "behavioural" choices. We conclude by exploring the implications of considering cancer inequities as social injustices for nursing practice.
Collapse
Affiliation(s)
- Tara C. Horrill
- College of Nursing, Rady Faculty of Health Sciences, University of Manitoba, 89 Curry Place, Winnipeg, MB R3T 2N2, Canada
| | - Scott M. Beck
- BC Cancer Agency, University of British Columbia, 601 W Broadway, Vancouver, BC V5Z 4C2, Canada
| | - Allison Wiens
- CancerCare Manitoba, 675 McDermot Avenue, Winnipeg, MB R3E 0V9, Canada
| |
Collapse
|
5
|
Valderrama M, Nebreda E, López‐Ejeda N, Linares M. When Teaching and Learning Microbiology Engage Societal Needs. Microb Biotechnol 2025; 18:e70098. [PMID: 39918055 PMCID: PMC11803454 DOI: 10.1111/1751-7915.70098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2024] [Revised: 01/14/2025] [Accepted: 01/20/2025] [Indexed: 02/11/2025] Open
Abstract
This article explores the integration of community-based learning into microbiology education, using as an example the Service-Learning (S-L) programme 'Movies in company for preventing diseases' implemented at the Complutense University of Madrid. The programme exemplifies how academic knowledge can be effectively applied to address societal issues focused on disadvantaged populations. The issue describes the basis and quality criteria for designing a S-L in clinical microbiology: real needs identification, student's curricular connection, social engagement and learning link, assessment of active participation of students, commitment outside university campus and recognition and assessment. The impact on university participants and community partners and the contribution to university social responsibility is also presented. The S-L programme fosters social engagement in all participants, both students and university tutors, and positively impacts community underserved members by providing crucial health information and support. The success of this programme highlights its potential as a model for integrating academic learning in microbiology with societal needs and emphasises the role of universities in addressing global challenges.
Collapse
Affiliation(s)
- María‐José Valderrama
- Department of Genetics, Physiology and Microbiology, Biological Sciences FacultyComplutense de Madrid UniversityMadridSpain
| | - Etna Nebreda
- Department of Genetics, Physiology and Microbiology, Biological Sciences FacultyComplutense de Madrid UniversityMadridSpain
| | - Noemí López‐Ejeda
- Department of Biodiversity, Ecology and Evolution, Biological Sciences FacultyComplutense de Madrid UniversityMadridSpain
| | - María Linares
- Department of Biochemistry and Molecular Biology, Pharmacy FacultyComplutense de Madrid UniversityMadridSpain
| |
Collapse
|
6
|
Decker H, Mabeza RM, Liu R, Kushel M, Wick E. Reimagining Cancer Care for Patients Experiencing Homelessness by Expanding the Traditional Oncology Team. JCO Oncol Pract 2025:OP2400684. [PMID: 39805064 DOI: 10.1200/op-24-00684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2024] [Revised: 10/31/2024] [Accepted: 12/09/2024] [Indexed: 01/16/2025] Open
Affiliation(s)
| | | | - Raymond Liu
- Department of Hematology Oncology, The Permanente Medical Group, San Francisco, CA
| | | | | |
Collapse
|
7
|
Decker H, Erickson C, Wick E. Addressing Colorectal Cancer Disparities in Unhoused Populations: A Call for Equitable Access and Compassionate Care. Clin Colon Rectal Surg 2025; 38:5-10. [PMID: 39734723 PMCID: PMC11679202 DOI: 10.1055/s-0044-1786531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2024]
Abstract
Housing is essential for health. Unhoused individuals have markedly worse health status than the general population culminating in higher rates of premature mortality. Cancer is a leading cause of death in older unhoused adults. Caring for unhoused patients at risk for or with colorectal cancer poses challenges at every stage of oncologic care: prevention, screening, diagnosis, treatment, and follow-up. These challenges result in later stages at diagnosis and worse overall survival. Health systems can work to advance health equity in colorectal cancer in unhoused patients by improving access to care, transitions of care, health care quality, and focusing on socioeconomic/environmental impact.
Collapse
Affiliation(s)
- Hannah Decker
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Caroline Erickson
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Elizabeth Wick
- Department of Surgery, University of California San Francisco, San Francisco, California
| |
Collapse
|
8
|
Decker H, Wick EC. Invited Commentary: Promoting Transparency in Cancer Outcomes in the National Cancer Database. J Am Coll Surg 2025; 240:111-112. [PMID: 39625167 DOI: 10.1097/xcs.0000000000001215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2024]
|
9
|
Ewing AP, Tounkara F, Marshall D, Henry AV, Abdel-Rasoul M, McElwain S, Clark J, Hefner JL, Zaire PJ, Nolan TS, Tarver WL, Doubeni CA. Examining Racial Disparities in Colorectal Cancer Screening and the Role of Online Medical Record Use: Findings From a Cross-Sectional Study of a National Survey. JMIR Cancer 2024; 10:e53229. [PMID: 39631060 PMCID: PMC11634048 DOI: 10.2196/53229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 09/04/2024] [Accepted: 09/25/2024] [Indexed: 12/07/2024] Open
Abstract
Background Colorectal cancer (CRC) is the second leading cause of cancer-related deaths in the United States. Early detection via routine CRC screening can significantly lower risks for CRC-specific morbidity and mortality. Public health initiatives between 2000 and 2015 nearly doubled CRC screening rates for some US adults. However, screening rates remain lowest for adults aged 45-49 years (20%), patients of safety net health care facilities (42%), adults without insurance (44%), and other subgroups compared with national averages (72%). Given the evolving landscape of digital health care and trends in web-based health information-seeking behaviors, leveraging online medical record (OMR) systems may be an underutilized resource to promote CRC screening utilization. Recognizing trends in OMR usage and patient demographics may enhance digital inclusion-a key social determinant of health-and support equitable web-based interventions aimed at boosting CRC screening across diverse populations. Objective This study examined the association of accessing an OMR with CRC screening utilization and corresponding sociodemographic characteristics of US adults. Methods In 2023, we conducted a secondary data analysis using a pooled, weighted sample from Health Information National Trends Survey (HINTS) 5 cycles, 2, 3, and 4 (2018-2020), a nationally representative survey assessing how US adults access and use health-related information. We analyzed the association between sociodemographic characteristics, medical conditions, OMR access, and CRC screening behaviors via logistic regression. Results The sample included adults aged 45-75 years (N=5143). The mean age was 59 (SD 8) years for those who reported CRC screening and 52 (SD 6) years for those never screened. Nearly 70% (4029/5143) of participants reported CRC screening and 52% (2707/5143) reported OMR access in the past year. Adjusted odds of CRC screening were higher among non-Hispanic African American or Black adults than among non-Hispanic White adults (odds ratio [OR] 1.76, 95% CI 1.22-2.53), adults who accessed an OMR (OR 1.89, 95% CI 1.45-2.46), older individuals (OR 1.18, 95% CI 1.16-1.21), the insured (OR 3.69, 95% CI 2.34-5.82), and those with a professional or graduate degree versus those with a high school diploma or less (OR 2.65, 95% CI 1.28-5.47). Individuals aged 65-75 years were significantly more likely (P<.001) to be screened (1687/1831, 91%) than those aged 45-49 years (190/610, 29%). Conclusions Promoting OMR access, especially among the most disadvantaged Americans, may assist in reaching national screening goals. Emphasis should be placed on the mutability of OMR use compared with most other statistically significant associations with CRC screening behaviors. OMR access provides an intervenable means of promoting CRC education and screening, especially among those facing structural barriers to cancer diagnoses and care. Future research should focus on tailored and accessible interventions that expand OMR access, particularly for younger populations.
Collapse
Affiliation(s)
- Aldenise P Ewing
- College of Public Health, The Ohio State University, 1841 Neil Ave, 249 Cunz Hall, Columbus, OH, 43210, United States, 1 6146880748
| | - Fode Tounkara
- College of Medicine, The Ohio State University, Columbus, OH, United States
| | - Daniel Marshall
- College of Public Health, The Ohio State University, 1841 Neil Ave, 249 Cunz Hall, Columbus, OH, 43210, United States, 1 6146880748
| | - Abhishek V Henry
- College of Public Health, The Ohio State University, 1841 Neil Ave, 249 Cunz Hall, Columbus, OH, 43210, United States, 1 6146880748
| | | | - Skylar McElwain
- College of Public Health, The Ohio State University, 1841 Neil Ave, 249 Cunz Hall, Columbus, OH, 43210, United States, 1 6146880748
| | - Justice Clark
- Ohio Wesleyan University, Delaware, OH, United States
| | - Jennifer L Hefner
- College of Public Health, The Ohio State University, 1841 Neil Ave, 249 Cunz Hall, Columbus, OH, 43210, United States, 1 6146880748
| | - Portia J Zaire
- College of Nursing, The Ohio State University, Columbus, OH, United States
| | - Timiya S Nolan
- The University of Alabama at Birmingham, Birmingham, AL, United States
| | - Willi L Tarver
- College of Medicine, The Ohio State University, Columbus, OH, United States
| | - Chyke A Doubeni
- College of Medicine, The Ohio State University, Columbus, OH, United States
| |
Collapse
|
10
|
Shah K, Santos PMG, Boe LA, Barnes JM, Tao A, Tsai CJ, Chino F. Inpatient Care and Outcomes Among People With Cancer Experiencing Homelessness. JAMA Oncol 2024; 10:1503-1510. [PMID: 39235774 PMCID: PMC11378068 DOI: 10.1001/jamaoncol.2024.3645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 05/29/2024] [Indexed: 09/06/2024]
Abstract
Importance Cancer is a leading cause of death among people experiencing homelessness (PEH) in the US. Acute care settings are important sources of care for PEH; however, the association of housing status with inpatient care remains understudied, particularly in the context of cancer. Objective To assess whether housing status is associated with differences in the inpatient care of hospitalized adults with cancer. Design, Setting, and Participants This cross-sectional study included hospitalized inpatient adults aged 18 years or older diagnosed with cancer who were identified using data from the 2016 to 2020 National Inpatient Sample. Propensity score matching was used to create a cohort of PEH and housed individuals matched according to age, sex, race and ethnicity, insurance type, cancer diagnosis, number of comorbidities, substance use disorder, severity of illness, year of admission, hospital location, hospital ownership, region, and hospital bed size. Matched pairs were identified using a 1:1 nearest neighbor matching algorithm without replacement, accounting for survey weights. Data were analyzed from August 1, 2022, to April 30, 2024. Exposure Housing status. Main Outcomes and Measures The associations of receipt of invasive procedures, systemic therapy, or radiotherapy during hospitalization (primary outcomes) as well as inpatient death, high cost of stay, and discharge against medical advice (AMA) (secondary outcomes) with housing status. Odds ratios and 95% CIs were estimated with multivariable logistic regression, with adjustment for patient, disease, and hospital characteristics of the matched cohort. Results The unmatched cohort comprised 13 838 612 individuals (median [IQR] age, 67 [57-76] years; 7 329 473 males [53.0%]) and included 13 793 462 housed individuals (median [IQR] age, 68 [58-77] years) and 45 150 (median [IQR] age, 58 [52-64] years) individuals who were experiencing homelessness after accounting for survey weights. The PEH cohort had a higher prevalence of lung (17.3% vs 14.5%) and upper gastrointestinal (15.2% vs 10.5%) cancers, comorbid substance use disorder (70.2% vs 15.3%), and HIV (5.3% vs 0.5%). Despite having higher rates of moderate or major illness severity (80.1% vs 74.0%) and longer length of stay (≥5 days: 62.2% vs 49.1%), PEH were less likely to receive invasive procedures (adjusted odds ratio [AOR], 0.53; 95% CI, 0.49-0.56), receive systemic therapy (AOR, 0.73; 95% CI, 0.63-0.85), or have a higher-than-median cost of stay (AOR, 0.71; 95% CI, 0.65-0.77). Although PEH had lower rates of inpatient death (AOR, 0.79; 95% CI, 0.68-0.92), they were 4 times more likely to be discharged AMA (AOR, 4.29; 95% CI, 3.63-5.06). Conclusions and Relevance In this nationally representative cross-sectional study of hospitalized adults with cancer, disparities in inpatient care of PEH highlight opportunities to promote equitable cancer care in this socioeconomically vulnerable population.
Collapse
Affiliation(s)
- Kanan Shah
- Department of Internal Medicine, New York University Langone Hospitals, New York
| | - Patricia Mae G. Santos
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Lillian A. Boe
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Justin M. Barnes
- Department of Radiation Oncology, Washington University in St Louis, St Louis, Missouri
| | - Anna Tao
- Department of General Surgery, San Joaquin General Hospital, French Camp, California
| | - C. Jillian Tsai
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
- Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, New York
| |
Collapse
|
11
|
Decker H, Colom S, Evans JL, Graham-Squire D, Perez K, Kushel M, Wick E, Raven MC, Kanzaria HK. Association of housing status and cancer diagnosis, care coordination and outcomes in a public hospital: a retrospective cohort study. BMJ Open 2024; 14:e088303. [PMID: 39266319 PMCID: PMC11404260 DOI: 10.1136/bmjopen-2024-088303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Accepted: 07/18/2024] [Indexed: 09/14/2024] Open
Abstract
OBJECTIVES Cancer is a leading cause of death in unhoused adults. We sought to examine the association between housing status, stage at diagnosis and all-cause survival following cancer diagnosis at a public hospital. DESIGN Retrospective cohort study examining new cancer diagnoses between 1 July 2011 and 30 June 2021. SETTING A public hospital in San Francisco. EXPOSURE Housing status (housed, formerly unhoused, unhoused) was ascertained via a county-wide integrated dataset that tracks both observed and reported homelessness. METHODS We reported univariate analyses to investigate differences in demographic and clinical characteristics by housing group. We then constructed Kaplan-Meier curves stratified by housing group to examine unadjusted all-cause mortality. Finally, we used multivariable Cox proportional hazards models to compare the hazard rate of mortality for each housing status group, adjusting for demographic and clinical factors. RESULTS Our cohort included 5123 patients with new cancer diagnoses, with 4062 (79%) in housed patients, 623 (12%) in formerly unhoused patients and 438 (9%) in unhoused patients. Unhoused and formerly unhoused patients were more commonly diagnosed with stage 4 disease (28% and 27% of the time, respectively, vs 22% of housed patients). After adjusting for demographic and clinical characteristics, unhoused patients with stage 0-3 disease had a 50% increased hazard of death (adjusted HR (aHR) 1.5, 95% CI 1.1 to 1.9; p<0.004) as did formerly unhoused patients (aHR 1.5, 95% CI 1.2 to 1.9; p=0.001) compared with housed individuals 3 months after diagnosis. CONCLUSIONS Unhoused and formerly unhoused patients diagnosed with non-metastatic cancer had substantially increased hazards of death compared with housed patients cared for in a public hospital setting. Current or former lack of housing could contribute to poor outcomes following cancer diagnoses via multiple mechanisms.
Collapse
Affiliation(s)
- Hannah Decker
- Department of Surgery, UCSF, San Francisco, California, USA
| | - Sara Colom
- Benioff Homelessness and Housing Initiative, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - Jennifer L Evans
- Benioff Homelessness and Housing Initiative, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - Dave Graham-Squire
- Benioff Homelessness and Housing Initiative, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - Kenneth Perez
- Benioff Homelessness and Housing Initiative, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - Margot Kushel
- Benioff Homelessness and Housing Initiative, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
- Department of Internal Medicine, UCSF, San Francisco, California, USA
| | - Elizabeth Wick
- Department of Surgery, UCSF, San Francisco, California, USA
| | - Maria C Raven
- Benioff Homelessness and Housing Initiative, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
- Department of Emergency Medicine, University of California San Francisco, San Francisco, California, USA
| | - Hemal K Kanzaria
- Benioff Homelessness and Housing Initiative, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
- Department of Emergency Medicine, University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
12
|
Fragner T, Belogianni K, Grabovac I. Cancer care in people experiencing homelessness: identifying key issues, challenges, and facilitators. Br J Gen Pract 2024; 74:342-343. [PMID: 39054087 PMCID: PMC11299681 DOI: 10.3399/bjgp24x738801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024] Open
Affiliation(s)
- Tobias Fragner
- Research assistant, Centre for Public Health, Department of Social and Preventive Medicine, Medical University of Vienna, Vienna, Austria
| | - Katerina Belogianni
- Research associate in nutritional sciences, Civil Law Non-Profit Organization of Preventive Environmental and Occupational Medicine PROLEPSIS, Athens, Greece. Faculty of Life Sciences and Medicine, Department of Nutritional Sciences, King's College London, London, UK
| | - Igor Grabovac
- Specialist in public health, Centre for Public Health, Department of Social and Preventive Medicine, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
13
|
Baggett TP, Sporn N, Barbosa Teixeira J, Rodriguez EC, Anandakugan N, Critchley N, Kennedy E, Hart K, Joyce A, Chang Y, Percac-Lima S, Park ER, Rigotti NA. Patient Navigation for Lung Cancer Screening at a Health Care for the Homeless Program: A Randomized Clinical Trial. JAMA Intern Med 2024; 184:892-902. [PMID: 38856994 PMCID: PMC11165412 DOI: 10.1001/jamainternmed.2024.1662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 03/21/2024] [Indexed: 06/11/2024]
Abstract
Importance People experiencing homelessness die of lung cancer at rates more than double those in the general population. Lung cancer screening (LCS) with low-dose computed tomography (LDCT) reduces lung cancer mortality, but the circumstances of homelessness create barriers to LCS participation. Objective To determine whether patient navigation, added to usual care, improved LCS LDCT receipt at a large Health Care for the Homeless (HCH) program. Design, Setting, and Participants This parallel group, pragmatic, mixed-methods randomized clinical trial was conducted at Boston Health Care for the Homeless Program (BHCHP), a federally qualified HCH program that provides tailored, multidisciplinary care to nearly 10 000 homeless-experienced patients annually. Eligible individuals had a lifetime history of homelessness, had a BHCHP primary care practitioner (PCP), were proficient in English, and met the pre-2022 Medicare coverage criteria for LCS (aged 55-77 years, ≥30 pack-year history of smoking, and smoking within the past 15 years). The study was conducted between November 20, 2020, and March 29, 2023. Intervention Participants were randomized 2:1 to usual BHCHP care either with or without patient navigation. Following a theory-based, patient-centered protocol, the navigator provided lung cancer education, facilitated LCS shared decision-making visits with PCPs, assisted participants in making and attending LCS LDCT appointments, arranged follow-up when needed, and offered tobacco cessation support for current smokers. Main Outcomes and Measures The primary outcome was receipt of a 1-time LCS LDCT within 6 months after randomization, with between-group differences assessed by χ2 analysis. Qualitative interviews assessed the perceptions of participants and PCPs about the navigation intervention. Results In all, 260 participants (mean [SD] age, 60.5 [4.7] years; 184 males [70.8%]; 96 non-Hispanic Black participants [36.9%] and 96 non-Hispanic White participants [36.9%]) were randomly assigned to usual care with (n = 173) or without (n = 87) patient navigation. At 6 months after randomization, 75 participants in the patient navigation arm (43.4%) and 8 of those in the usual care-only arm (9.2%) had completed LCS LDCT (P < .001), representing a 4.7-fold difference. Interviews with participants in the patient navigation arm and PCPs identified key elements of the intervention: multidimensional social support provision, care coordination activities, and interpersonal skills of the navigator. Conclusions and Relevance In this randomized clinical trial, patient navigation support produced a 4.7-fold increase in 1-time LCS LDCT completion among HCH patients in Boston. Future work should focus on longer-term screening participation and outcomes. Trial Registration ClinicalTrials.gov Identifier: NCT04308226.
Collapse
Affiliation(s)
- Travis P. Baggett
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
- Mongan Institute, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
- Institute for Research, Quality & Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, Massachusetts
| | - Nora Sporn
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
| | - Joana Barbosa Teixeira
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
| | | | | | - Natalia Critchley
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
| | - Evangeline Kennedy
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
| | - Katherine Hart
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
| | - Andrea Joyce
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
| | - Yuchiao Chang
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
- Mongan Institute, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Sanja Percac-Lima
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
- Mongan Institute, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Elyse R. Park
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
- Mongan Institute, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Nancy A. Rigotti
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
- Mongan Institute, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
14
|
Coronado-Vázquez MDV, Gómez-Trenado R, Benito-Sánchez B, Barrio-Cortes J, Gil-Salmerón A, Amengual-Pliego M, Grabovac I. Cancer prevention in people experiencing homelessness: ethical considerations and experiences from the CANCERLESS project. Front Public Health 2024; 12:1371505. [PMID: 38655508 PMCID: PMC11036339 DOI: 10.3389/fpubh.2024.1371505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 03/25/2024] [Indexed: 04/26/2024] Open
Abstract
The incidence of cancer in Europe has been increasing in recent years. Despite this, cancer prevention has remained a low priority in health policies. Cancer is one of the main causes of mortality among people experiencing homelessness, who continue to have difficulties accessing prevention programs. A strategy that has been tested to favor cancer prevention is the health navigator figure. The objective of CANCERLESS project is to implement this model among populations experiencing homelessness in four European countries to foster the prevention and early detection of cancer. In this perspective, a presentation of CANCERLESS project is made, and its ethical aspects are discussed according to the ethics of public health, the ethics of care, solidarity, relational autonomy, and the social recognition of the virtue of just generosity. The ethical foundations of CANCERLESS project are rooted in social justice and in equity in access to health systems in general and cancer screening programs in particular. The ethics of public health guided by utilitarianism are insufficient in serving the interests of the most disadvantaged groups of the population. Hence, it is necessary to resort to relational bioethics that includes the ethics of care and solidarity and that recognizes the moral identity of socially excluded persons, reaffirming their position of equality in society. Relational autonomy therefore provides a broader conception by including the influence of living conditions in decisions. For this reason, the CANCERLESS project opts for a dialogue with those affected to incorporate their preferences and values into decisions about cancer prevention.
Collapse
Affiliation(s)
- María del Valle Coronado-Vázquez
- Healthcare Center Las Cortes, Gerencia 1 Healthcare Center Las Cortes, Gerencia Asistencial de Atención Primaria, Madrid, Spain
- Facultad de Medicina, Francisco de Vitoria University, Madrid, Spain
- B21-20R Group, Instituto Aragonés de Investigaciones Sanitarias, Universidad de Zaragoza, Zaragoza, Spain
| | - Rosa Gómez-Trenado
- Foundation for Biosanitary Research and Innovation in Primary Care (FIIBAP), Madrid, Spain
- Health Work Department, Complutense University of Madrid, Madrid, Spain
| | - Beatriz Benito-Sánchez
- Foundation for Biosanitary Research and Innovation in Primary Care (FIIBAP), Madrid, Spain
| | - Jaime Barrio-Cortes
- Foundation for Biosanitary Research and Innovation in Primary Care (FIIBAP), Madrid, Spain
- Faculty of Health, Camilo José Cela University, Madrid, Spain
- Gregorio Marañón Health Research Institute, Madrid, Spain
- Research Network on Chronicity, Primary Care and Prevention and Health Promotion, Carlos III Health Institute, Madrid, Spain
| | - Alejandro Gil-Salmerón
- International Foundation for Integrated Care, Oxford, United Kingdom
- International University of Valencia, Valencia, Spain
- Complutense University of Madrid, Madrid, Spain
| | - Miguel Amengual-Pliego
- B21-20R Group, Instituto Aragonés de Investigaciones Sanitarias, Universidad de Zaragoza, Zaragoza, Spain
| | - Igor Grabovac
- Department of Social and Preventive Medicine, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
15
|
Silver CM, Janczewski LM, Royan R, Chung JW, Bentrem DJ, Kanzaria HK, Stey AM, Bilimoria KY, Merkow RP. Access, Outcomes, and Costs Associated with Surgery for Malignancy Among People Experiencing Homelessness. Ann Surg Oncol 2024; 31:1468-1476. [PMID: 38071712 DOI: 10.1245/s10434-023-14713-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 11/21/2023] [Indexed: 02/08/2024]
Abstract
BACKGROUND Little is known about surgery for malignancy among people experiencing homelessness (PEH). Poor healthcare access may lead to delayed diagnosis and need for unplanned surgery. This study aimed to (1) characterize access to care among PEH, (2) evaluate postoperative outcomes, and (3) assess costs associated with surgery for malignancy among PEH. METHODS This was a retrospective cohort study of patients in the Healthcare Cost and Utilization Project (HCUP) who underwent surgery in Florida, New York, or Massachusetts for gastrointestinal or lung cancer from 2016 to 2017. PEH were identified using HCUP's "Homeless" variable and ICD-10 code Z59. Multivariable regression models controlling patient and hospital variables evaluated associations between homelessness and postoperative morbidity, length of stay (LOS), 30-day readmission, and hospitalization costs. RESULTS Of 67,034 patients at 566 hospitals, 98 (0.2%) were PEH. Most PEH (44.9%) underwent surgery for colorectal cancer. PEH more frequently underwent unplanned surgery than housed patients (65.3% vs 23.7%, odds ratio (OR) 5.17, 95% confidence interval (CI) 3.00-8.92) and less often were treated at cancer centers (66.0% vs 76.2%, p=0.02). Morbidity rates were similar between groups (20.4% vs 14.5%, p=0.10). However, PEH demonstrated higher odds of facility discharge (OR 5.89, 95% CI 3.50-9.78) and readmission (OR 1.81, 95% CI 1.07-3.05) as well as 67.7% longer adjusted LOS (95% CI 42.0-98.2%). Adjusted costs were 32.7% higher (95% CI 14.5-53.9%) among PEH. CONCLUSIONS PEH demonstrated increased odds of unplanned surgery, longer LOS, and increased costs. These results underscore a need for improved access to oncologic care for PEH.
Collapse
Affiliation(s)
- Casey M Silver
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Lauren M Janczewski
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Regina Royan
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Emergency Medicine, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Jeannette W Chung
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - David J Bentrem
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Hemal K Kanzaria
- Department of Emergency Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Anne M Stey
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Karl Y Bilimoria
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ryan P Merkow
- Department of Surgery, University of Chicago, Chicago, IL, USA.
| |
Collapse
|
16
|
Asgary R. Cancer care and treatment during homelessness. Lancet Oncol 2024; 25:e84-e90. [PMID: 38301706 DOI: 10.1016/s1470-2045(23)00567-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 09/24/2023] [Accepted: 10/27/2023] [Indexed: 02/03/2024]
Abstract
People experiencing homelessness have not yet benefited from the substantial progress made in managing cancers, including advances in chemotherapy and radiotherapy, surgical interventions, multidisciplinary team approaches, and integrated cancer care models. People experiencing homelessness are at higher risks of developing cancers and their mortality due to cancer is twice that of the general population. Potential interventions to improve access to cancer treatment include alliances and active engagement with community organisations and shelters, cancer case management and peer-to-peer support, mHealth and navigation strategies, tailored hospital discharge to adult group homes, well equipped subacute rehabilitation centres, and specialised shelters and respite housing to assure appropriate follow-up care. Other interventions include improving preventive care, expanding data, targeted policy efforts, and broader housing advocacy. In this Personal View, I discuss challenges and opportunities in cancer treatment, with a review of the current evidence on potential interventions, and highlight strategies to improve access to cancer care for homeless populations.
Collapse
Affiliation(s)
- Ramin Asgary
- Department of Global Health, Milken Institute School of Public Health, George Washington University, Washington, DC, USA; Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| |
Collapse
|
17
|
Jeleff M, Haider S, Schiffler T, Gil-Salmerón A, Yang L, Barreto Schuch F, Grabovac I. Cancer risk factors and access to cancer prevention services for people experiencing homelessness. Lancet Public Health 2024; 9:e128-e146. [PMID: 38307679 DOI: 10.1016/s2468-2667(23)00298-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 11/13/2023] [Accepted: 11/20/2023] [Indexed: 02/04/2024]
Abstract
Cancer is one of the most pressing global health issues, and populations with complex needs, such as people experiencing homelessness, have higher cancer incidence and mortality rates compared with the housed population. We mapped the evidence on cancer risk factors as well as barriers and facilitators to cancer prevention services among people experiencing homelessness, which is key to localising research gaps and identifying strategies for tailored interventions adapted to people experiencing homelessness. The results of 40 studies contribute to an understanding of the dynamic, interactive factors at different levels that determine access to cancer prevention services: socioeconomic, psychological, and physical factors (individual level); practical support and relational loops between health-care providers and people experiencing homelessness (interpersonal level); housing and regular medical care (system level); and interventions to facilitate access to cancer prevention (policy level). Furthermore, studies reported higher prevalence of various cancer-associated risk factors among people experiencing homelessness with the most common being tobacco use, ranging from 26% to 73%. The results show the importance of interventions to facilitate cancer prevention services through social support and low-threshold interventions (eg, navigation programmes), and training health-care staff in creating supportive and trusting environments that increase the likelihood of the continuity of care among people experiencing homelessness.
Collapse
Affiliation(s)
- Maren Jeleff
- Department of Social and Preventive Medicine, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - Sandra Haider
- Department of Social and Preventive Medicine, Center for Public Health, Medical University of Vienna, Vienna, Austria.
| | - Tobias Schiffler
- Department of Social and Preventive Medicine, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - Alejandro Gil-Salmerón
- International Foundation for Integrated Care, Oxford, UK; International University of Valencia, Valencia, Spain; Complutense University of Madrid, Madrid, Spain
| | - Lin Yang
- Department of Cancer Epidemiology and Prevention Research, Cancer Care Alberta, Alberta Health Services, Calgary, Canada; Department of Oncology and Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Felipe Barreto Schuch
- Department of Sports Methods and Techniques, Federal University of Santa Maria, Santa Maria, Brazil; Faculty of Health Sciences, Universidad Autónoma de Chile, Providencia, Chile
| | - Igor Grabovac
- Department of Social and Preventive Medicine, Center for Public Health, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
18
|
Decker HC, Graham LA, Titan A, Hawn MT, Kanzaria HK, Wick E, Kushel MB. Housing Status Changes Are Associated With Cancer Outcomes Among US Veterans. Health Aff (Millwood) 2024; 43:234-241. [PMID: 38315919 DOI: 10.1377/hlthaff.2023.01003] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
Cancer is a leading cause of death in older unhoused adults. We assessed whether being unhoused, gaining housing, or losing housing in the year after cancer diagnosis is associated with poorer survival compared with being continuously housed. We examined all-cause survival in more than 100,000 veterans diagnosed with lung, colorectal, and breast cancer during the period 2011-20. Five percent were unhoused at the time of diagnosis, of whom 21 percent gained housing over the next year; 1 percent of veterans housed at the time of diagnosis lost housing. Continuously unhoused veterans and veterans who lost their housing had poorer survival after lung and colorectal cancer diagnosis compared with those who were continuously housed. There was no survival difference between veterans who gained housing after diagnosis and veterans who were continuously housed. These findings support policies to prevent and end homelessness in people after cancer diagnosis, to improve health outcomes.
Collapse
Affiliation(s)
- Hannah C Decker
- Hannah C. Decker , University of California San Francisco, San Francisco, California
| | - Laura A Graham
- Laura A. Graham, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
| | - Ashley Titan
- Ashley Titan, Stanford University, Stanford, California
| | | | | | | | | |
Collapse
|
19
|
Ozcan BB, Dogan BE, Mootz AR, Hayes JC, Seiler SJ, Schopp J, Kitchen DL, Porembka JH. Breast Cancer Disparity and Outcomes in Underserved Women. Radiographics 2024; 44:e230090. [PMID: 38127658 DOI: 10.1148/rg.230090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
Women in the United States who continue to face obstacles accessing health care are frequently termed an underserved population. Safety-net health care systems play a crucial role in mitigating health disparities and reducing burdens of disease, such as breast cancer, for underserved women. Disparities in health care are driven by various factors, including race and ethnicity, as well as socioeconomic factors that affect education, employment, housing, insurance status, and access to health care. Underserved women are more likely to be uninsured or underinsured throughout their lifetimes. Hence they have greater difficulty gaining access to breast cancer screening and are less likely to undergo supplemental imaging when needed. Therefore, underserved women often experience significant delays in the diagnosis and treatment of breast cancer, leading to higher mortality rates. Addressing disparities requires a multifaceted approach, with formal care coordination to help at-risk women navigate through screening, diagnosis, and treatment. Mobile mammography units and community outreach programs can be leveraged to increase community access and engagement, as well as improve health literacy with educational initiatives. Radiology-community partnerships, comprised of imaging practices partnered with local businesses, faith-based organizations, homeless shelters, and public service departments, are essential to establish culturally competent breast imaging care, with the goal of equitable access to early diagnosis and contemporary treatment. Published under a CC BY 4.0 license. Test Your Knowledge questions are available in the Online Learning Center. See the invited commentary by Leung in this issue.
Collapse
Affiliation(s)
- B Bersu Ozcan
- From the Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, MC 8896, Dallas, TX 75390-8896
| | - Başak E Dogan
- From the Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, MC 8896, Dallas, TX 75390-8896
| | - Ann R Mootz
- From the Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, MC 8896, Dallas, TX 75390-8896
| | - Jody C Hayes
- From the Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, MC 8896, Dallas, TX 75390-8896
| | - Stephen J Seiler
- From the Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, MC 8896, Dallas, TX 75390-8896
| | - Jennifer Schopp
- From the Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, MC 8896, Dallas, TX 75390-8896
| | - Deanna L Kitchen
- From the Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, MC 8896, Dallas, TX 75390-8896
| | - Jessica H Porembka
- From the Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, MC 8896, Dallas, TX 75390-8896
| |
Collapse
|
20
|
Decker HC, Graham LA, Titan A, Kanzaria HK, Hawn MT, Kushel M, Wick E. Housing Status, Cancer Care, and Associated Outcomes Among US Veterans. JAMA Netw Open 2023; 6:e2349143. [PMID: 38127343 PMCID: PMC10739065 DOI: 10.1001/jamanetworkopen.2023.49143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 11/09/2023] [Indexed: 12/23/2023] Open
Abstract
Importance Cancer is a leading cause of death among older people experiencing homelessness. However, the association of housing status with cancer outcomes is not well described. Objective To characterize the diagnosis, treatment, surgical outcomes, and mortality by housing status of patients who receive care from the US Department of Veterans Affairs (VA) health system for colorectal, breast, or lung cancer. Design, Setting, and Participants This retrospective cohort study identified all US veterans diagnosed with lung, colorectal, or breast cancer who received VA care between October 1, 2011, and September 30, 2020. Data analysis was performed from February 13 to May 9, 2023. Exposures Veterans were classified as experiencing homelessness if they had any indicators of homelessness in outpatient visits, clinic reminders, diagnosis codes, or the Homeless Operations Management Evaluation System in the 12 months preceding diagnosis, with no subsequent evidence of stable housing. Main Outcomes and Measures The major outcomes, by cancer type, were as follows: (1) treatment course (eg, stage at diagnosis, time to treatment initiation), (2) surgical outcomes (eg, length of stay, major complications), (3) overall survival by cancer type, and (4) hazard ratios for overall survival in a model adjusted for age at diagnosis, sex, stage at diagnosis, race, ethnicity, marital status, facility location, and comorbidities. Results This study included 109 485 veterans, with a mean (SD) age of 68.5 (9.7) years. Men comprised 92% of the cohort. In terms of race and ethnicity, 18% of veterans were Black, 4% were Hispanic, and 79% were White. A total of 68% of participants had lung cancer, 26% had colorectal cancer, and 6% had breast cancer. There were 5356 veterans (5%) experiencing homelessness, and these individuals more commonly presented with stage IV colorectal cancer than veterans with housing (22% vs 19%; P = .02). Patients experiencing homelessness had longer postoperative lengths of stay for all cancer types, but no differences in other treatment or surgical outcomes were observed. These patients also demonstrated higher rates of all-cause mortality 3 months after diagnosis for lung and colorectal cancers, with adjusted hazard ratios of 1.1 (95% CI, 1.1-1.2) and 1.3 (95% CI, 1.2-1.4) (both P < .001), respectively. Conclusions and Relevance In this large retrospective study of US veterans with cancer, homelessness was associated with later stages at diagnosis for colorectal cancer. Differences in lung and colorectal cancer survival between patients with housing and those experiencing homelessness were present but smaller than observed in other settings. These findings suggest that there may be important systems in the VA that could inform policy to improve oncologic outcomes for patients experiencing homelessness.
Collapse
Affiliation(s)
| | - Laura A. Graham
- Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
- S-SPIRE, Stanford University, Stanford, California
| | - Ashley Titan
- Department of Surgery, Stanford University, Stanford, California
| | - Hemal K. Kanzaria
- Department of Emergency Medicine, University of California, San Francisco
- Benioff Homelessness and Housing Initiative, University of California, San Francisco
| | - Mary T. Hawn
- Department of Surgery, Stanford University, Stanford, California
| | - Margot Kushel
- Benioff Homelessness and Housing Initiative, University of California, San Francisco
- Division of General Internal Medicine, Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
| | - Elizabeth Wick
- Department of Surgery, University of California, San Francisco
| |
Collapse
|
21
|
Raven MC. Improving Cancer Outcomes Among Unhoused Patients-Lessons From the Veterans Health Administration. JAMA Netw Open 2023; 6:e2349096. [PMID: 38127354 DOI: 10.1001/jamanetworkopen.2023.49096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Affiliation(s)
- Maria C Raven
- UCSF Department of Emergency Medicine, University of California, San Francisco Benioff Housing and Homelessness Initiative, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
| |
Collapse
|
22
|
Schiffler T, Jeleff M, Gil-Salmerón A, Yang L, Haider S, Schuch FB, Grabovac I. Cancer risk factors and access to cancer prevention services for people experiencing homelessness: a scoping review protocol. BMJ Open 2023; 13:e074710. [PMID: 37597871 PMCID: PMC10441056 DOI: 10.1136/bmjopen-2023-074710] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 07/18/2023] [Indexed: 08/21/2023] Open
Abstract
INTRODUCTION Homelessness is a complex social issue that significantly impairs the health of those affected. People experiencing homelessness (PEH) have a higher prevalence of adverse health outcomes, including premature mortality, compared with the general population, with cancer being the second-leading cause of death. The objective of this scoping review is to map the evidence to assess the exposure of PEH to known cancer risk factors and identify barriers and facilitators PEH experience in accessing cancer prevention services. METHODS AND ANALYSIS This scoping review will be conducted in line with the Joanna Briggs Institute guidelines for scoping reviews. For a time window from the date of database establishment until 20 February 2023, the research team will create a detailed search strategy and apply it to the following databases: CINAHL, Embase, Global Index Medicus, PubMed, Scopus and Web of Science. In addition, we will search OpenGrey and Google for grey literature and contact non-governmental organisations to request relevant reports. In the first stage, eligibility criteria will be assessed through a blinded title/abstract assessment, and following this assessment, a full-text screening will be performed. Subsequently, the research team will perform the data extraction and synthesise all relevant information in relation to the scoping review question. ETHICS AND DISSEMINATION As this protocol does not involve gathering primary data, ethical approval is not necessary. The results of this review will be published in a peer-reviewed journal and on institutional websites.
Collapse
Affiliation(s)
- Tobias Schiffler
- Department of Social and Preventive Medicine, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - Maren Jeleff
- Department of Social and Preventive Medicine, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - Alejandro Gil-Salmerón
- International Foundation for Integrated Care, Oxford, UK
- International University of Valencia, Valencia, Spain
| | - Lin Yang
- Department of Cancer Epidemiology and Prevention Research, Cancer Care Alberta, Alberta Health Services, Calgary, Alberta, Canada
- Departments of Oncology and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Sandra Haider
- Department of Social and Preventive Medicine, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - Felipe B Schuch
- Department of Sports Methods and Techniques, Federal University of Santa Maria, Santa Maria, Brazil
- Faculty of Health Sciences, Universidad Autonoma de Chile, Providencia, Chile
| | - Igor Grabovac
- Department of Social and Preventive Medicine, Center for Public Health, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
23
|
Schiffler T, Carmichael C, Smith L, Doñate-Martínez A, Alhambra-Borrás T, Varadé MR, Barrio Cortes J, Kouvari M, Karnaki P, Moudatsou M, Tabaki I, Gil-Salmeron A, Grabovac I. Access to cancer preventive care and program considerations for people experiencing homelessness across four European countries: an exploratory qualitative study. EClinicalMedicine 2023; 62:102095. [PMID: 37533422 PMCID: PMC10393536 DOI: 10.1016/j.eclinm.2023.102095] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 06/23/2023] [Accepted: 06/27/2023] [Indexed: 08/04/2023] Open
Abstract
Background People experiencing homelessness (PEH) have a higher prevalence of adverse health outcomes and premature mortality compared to the non-homeless population. These include a higher burden of cancer and cancer-specific morbidity and mortality-outcomes that may be a consequence of significant barriers to accessing primary and secondary prevention and community health services. This study aimed to better comprehend the health needs and barriers to accessing preventive cancer care for PEH across four European countries as well as necessary considerations for developing interventions around cancer prevention for this population. Methods In this exploratory qualitative study, 69 semi-structured interviews were conducted across Austria, Greece, Spain, and the UK, with a sample comprising 15 professionals working in homelessness support services, 19 health professionals, and 35 PEH. Interviews took place between August 1 and October 31, 2021, and data were analysed inductively and iteratively following a thematic approach. Findings Findings were organised into two overarching themes: (1) Experiences and understanding of cancer prevention and treatment and (2) Considerations for program interventions. While cancer was a significant worry among PEH across all settings, they generally had minimal knowledge and understanding of cancer symptoms and prevention. Specific programs for cancer prevention for PEH were described as almost non-existent. Health professionals in some settings indicated that cancer in PEH was often missed in the early stages and instead diagnosed when the severity of symptoms intensified. Interpretation Overall, our findings indicate many commonalities in the health needs of PEH and the barriers they face when they seek access to cancer-specific healthcare services in the European context. Funding This study received funding from the European Union's Horizon 2020 Research and Innovation Programme under GA 965351.
Collapse
Affiliation(s)
- Tobias Schiffler
- Centre for Public Health, Department of Social and Preventive Medicine, Medical University of Vienna, Vienna, Austria
| | - Christina Carmichael
- Centre for Health, Performance and Wellbeing, Anglia Ruskin University, Cambridge, UK
| | - Lee Smith
- Centre for Health, Performance and Wellbeing, Anglia Ruskin University, Cambridge, UK
| | | | | | - Miguel Rico Varadé
- General Directorate of Social Services, Council of Family, Youth and Social Policy, Community of Madrid, Madrid, Spain
| | - Jaime Barrio Cortes
- Foundation for Biosanitary Research and Innovation in Primary Care, Madrid, Spain
| | - Matina Kouvari
- Institute of Preventive Medicine, Environmental and Occupational Health Prolepsis, Athens, Greece
| | - Pania Karnaki
- Institute of Preventive Medicine, Environmental and Occupational Health Prolepsis, Athens, Greece
| | - Maria Moudatsou
- PRAKSIS – Programs of Development, Social Support and Medical Cooperation, Athens, Greece
| | - Ioanna Tabaki
- PRAKSIS – Programs of Development, Social Support and Medical Cooperation, Athens, Greece
| | | | - Igor Grabovac
- Centre for Public Health, Department of Social and Preventive Medicine, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
24
|
Bourgeois A, Horrill TC, Mollison A, Lambert LK, Stajduhar KI. Barriers to cancer treatment and care for people experiencing structural vulnerability: a secondary analysis of ethnographic data. Int J Equity Health 2023; 22:58. [PMID: 36998035 PMCID: PMC10064679 DOI: 10.1186/s12939-023-01860-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 03/13/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND A key pillar of Canada's healthcare system is universal access, yet significant barriers to cancer services remain for people impacted by structural vulnerability (e.g., poverty, homelessness, racism). For this reason, cancer is diagnosed at a later stage, resulting in worse patient outcomes, a reduced quality of life, and at a higher cost to the healthcare system. Those who face significant barriers to access are under-represented in cancer control services Consequently, these inequities result in people dying from cancers that are highly treatable and preventable, however; little is known about their treatment and care course. The aim of this study was to explore barriers to accessing cancer treatment among people experiencing structural vulnerability within a Canadian context. METHODS We conducted a secondary analysis of ethnographic data informed by critical theoretical perspectives of equity and social justice. The original research draws from 30 months of repeated interviews (n = 147) and 300 h of observational fieldwork with people experiencing health and social inequities at the end-of-life, their support persons, and service providers. RESULTS Our analysis identified four themes presenting as 'modifiable' barriers to inequitable access to cancer treatment: (1) housing as a key determinant for cancer treatment (2) impact of lower health literacy (3) addressing social care needs is a pre-requisite for treatment (4) intersecting and compounding barriers reinforce exclusion from cancer care. These inter-related themes point to how people impacted by health and social inequities are at times 'dropped' out of the cancer system and therefore unable to access cancer treatment. CONCLUSION Findings make visible the contextual and structural factors contributing to inequitable access to cancer treatment within a publically funded healthcare system. Identifying people who experience structural vulnerability, and approaches to delivering cancer services that are explicitly equity-oriented are urgently needed.
Collapse
Affiliation(s)
- Amber Bourgeois
- School of Nursing, University of Victoria, Institute on Aging & Lifelong Health, Stn. CSC Victoria, PO Box 1700, V8W 2Y2, Victoria, BC, Canada.
| | - Tara C Horrill
- College of Nursing, University of Manitoba, 89 Curry Place Winnipeg, R3T 2N2, Victoria, MB, Canada
| | - Ashley Mollison
- Social Dimensions of Health, University of Victoria Institute on Aging and Lifelong Health, Stn. CSC Victoria, PO Box 1700, V8W 2Y2, Victoria, BC, Canada
| | - Leah K Lambert
- School of Nursing, University of British Columbia, BC Cancer Suite 500, 686 West Broadway, V5Z 1G1, Vancouver, BC, Canada
| | - Kelli I Stajduhar
- School of Nursing, University of Victoria, Institute on Aging & Lifelong Health, Stn. CSC Victoria, PO Box 1700, V8W 2Y2, Victoria, BC, Canada
| |
Collapse
|
25
|
Drescher NR, Oladeru OT. Cancer Screening, Treatment, and Outcomes in Persons Experiencing Homelessness: Shifting the Lens to an Understudied Population. JCO Oncol Pract 2023; 19:103-105. [PMID: 36548925 DOI: 10.1200/op.22.00720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Nicolette R Drescher
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL
| | - Oluwadamilola T Oladeru
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL
| |
Collapse
|
26
|
Sayani A, Ali MA, Dey P, Corrado AM, Ziegler C, Nicholson E, Lofters A. Interventions Designed to Increase the Uptake of Lung Cancer Screening: An Equity-Oriented Scoping Review. JTO Clin Res Rep 2023; 4:100469. [PMID: 36938372 PMCID: PMC10015251 DOI: 10.1016/j.jtocrr.2023.100469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 01/17/2023] [Accepted: 01/23/2023] [Indexed: 02/05/2023] Open
Abstract
Introduction Participation in lung cancer screening (LCS) is lower in populations with the highest burden of lung cancer risk (through the social patterning of smoking behavior) and lowest levels of health care utilization (through structurally inaccessible care) leading to a widening of health inequities. Methods We conducted a scoping review using the Arksey and O'Malley methodological framework to inform equitable access to LCS by illuminating knowledge and implementation gaps in interventions designed to increase the uptake of LCS. We comprehensively searched for LCS interventions (Ovid Medline, Excerpta Medica database, the Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, and Scopus from 2000 to June 22, 2021) and included peer-reviewed articles and gray literature published in the English language that describe an intervention designed to increase the uptake of LCS, charted data using our previously published tool and conduced a health equity analysis to determine the intended-unintended and positive-negative outcomes of the interventions for populations experiencing the greatest inequities. Results Our search yielded 3572 peer-reviewed articles and 54,292 pieces of gray literature. Ultimately, we included 35 peer-reviewed articles and one gray literature. The interventions occurred in the United States, United Kingdom, Japan, and Italy, focusing on shared decision-making, the use of electronic health records as reminders, patient navigation, community-based campaigns, and mobile computed tomography scanners. We developed an equity-oriented LCS framework and mapped the dimensions and outcomes of the interventions on access to LCS on the basis of approachability, acceptability, availability, affordability, and appropriateness of the intervention. No intervention was mapped across all five dimensions. Most notably, knowledge and implementation gaps were identified in dimensions of acceptability, availability, and affordability. Conclusions Interventions that were most effective in improving access to LCS targeted priority populations, raised community-level awareness, tailored materials for sociocultural acceptability, did not depend on prior patient engagement/registration with the health care system, proactively considered costs related to participation, and enhanced utilization through informed decision-making.
Collapse
Affiliation(s)
- Ambreen Sayani
- Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario, Canada
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Muhanad Ahmed Ali
- Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario, Canada
| | - Pooja Dey
- Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario, Canada
| | - Ann Marie Corrado
- Peter Gilgan Centre for Women’s Cancers, Women’s College Hospital, Toronto, Ontario, Canada
| | - Carolyn Ziegler
- Library Services, Unity Health Toronto, Toronto, Ontario, Canada
| | | | - Aisha Lofters
- Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario, Canada
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
- Peter Gilgan Centre for Women’s Cancers, Women’s College Hospital, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Family Medicine, Women’s College Hospital, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Ontario, Canada
| |
Collapse
|
27
|
Mayo ZS, Campbell SR, Shah CS, Weleff J, Kilic SS. Improving Treatment Interventions and Cancer Outcomes in Persons Experiencing Homelessness: A Population Underrepresented in Equity Initiatives. Int J Radiat Oncol Biol Phys 2023; 115:302-304. [PMID: 36621233 DOI: 10.1016/j.ijrobp.2022.09.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/30/2022] [Accepted: 09/04/2022] [Indexed: 01/09/2023]
Affiliation(s)
- Zachary S Mayo
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH.
| | | | - Chirag S Shah
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH
| | - Jeremy Weleff
- Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, OH; Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut
| | - Sarah S Kilic
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH
| |
Collapse
|
28
|
Kilic SS, Mayo ZS, Weleff J, Parker S, Strzalka C, Phelan MP, Suh JH, Campbell SR, Shah CS. Cancer Diagnoses and Use of Radiation Therapy Among Persons Experiencing Homelessness. Int J Radiat Oncol Biol Phys 2023; 116:79-86. [PMID: 36731679 DOI: 10.1016/j.ijrobp.2023.01.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 01/19/2023] [Accepted: 01/23/2023] [Indexed: 02/01/2023]
Abstract
PURPOSE Persons experiencing homelessness (PEH) have low rates of cancer screening and worse cancer mortality compared with persons not experiencing homelessness. Data regarding cancer diagnosis and treatment in PEH are limited. We investigated cancer prevalence and use of radiation therapy (RT) in PEH. METHODS AND MATERIALS Patients presenting between January 1, 2014, and September 27, 2021, at a large metropolitan hospital system were assessed for homelessness via intake screening or chart search. PEH data were cross-referenced with the institution's cancer database to identify PEH with cancer diagnoses. Demographic, clinical, and treatment variables were abstracted. RESULTS Of a total of 9654 (9250 evaluable) PEH with a median age of 42 years, 81 patients (0.88%) had at least 1 cancer diagnosis and 5 had multiple diagnoses, for a total of 87 PEH with at least 1 cancer diagnosis. The median age at diagnosis was 60 years. In total, 43% were female and 51% were Black, and 43% presented with advanced or metastatic disease. Lung (17%), prostate (15%), leukemia/lymphoma (13%), and head/neck (9%) were the most common diagnoses. In total, 17% of patients underwent surgery alone, 13% received chemotherapy alone, 14% received RT alone, and 6% received hormone therapy alone. A total of 8% of patients underwent no treatment, and 43% underwent multimodality therapy. In total, 58% of treated patients never achieved disease-free status. Of the 31 patients who received RT, 87% received external beam RT. Most patients (70%) received hypofractionated regimens. For patients who had multifraction treatment, the treatment completion rate was 85%, significantly lower than the departmental completion rate of 98% (P < .00001). CONCLUSIONS In a large cohort of PEH in a metropolitan setting, cancer diagnoses were uncommon and were frequently in advanced stages. Most patients underwent single-modality treatment or no treatment at all. Despite the use of hypofractionation, the RT completion rate was low, likely reflecting complex barriers to care. Further interventions to optimize cancer diagnosis and treatment in PEH are urgently needed.
Collapse
Affiliation(s)
- Sarah S Kilic
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Zachary S Mayo
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jeremy Weleff
- Department of Psychiatry and Psychology, Center for Behavioral Health, Neurological Institute, Cleveland Clinic, Cleveland, Ohio; Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut
| | - Sean Parker
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | | | | | - John H Suh
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Shauna R Campbell
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Chirag S Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
29
|
Lambert LK, Horrill TC, Beck SM, Bourgeois A, Browne AJ, Cheng S, Howard AF, Kaur J, McKenzie M, Stajduhar KI, Thorne S. Health and healthcare equity within the Canadian cancer care sector: a rapid scoping review. Int J Equity Health 2023; 22:20. [PMID: 36709295 PMCID: PMC9883825 DOI: 10.1186/s12939-023-01829-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 01/11/2023] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Despite a publicly-funded healthcare system, alarming cancer-related health and healthcare inequities persist in Canada. However, it remains unclear how equity is being understood and taken up within the Canadian cancer context. Our objective was to identify how health and healthcare equity are being discussed as goals or aims within the cancer care sector in Canada. METHODS A rapid scoping review was conducted; five biomedical databases, 30 multidisciplinary websites, and Google were searched. We included English-language documents published between 2008 and 2021 that discussed health or healthcare equity in the Canadian cancer context. RESULTS Of 3860 identified documents, 83 were included for full-text analysis. The prevalence of published and grey equity-oriented literature has increased over time (2008-2014 [n = 20]; 2015-2021 [n = 62]). Only 25% of documents (n = 21) included a definition of health equity. Concepts such as inequity, inequality and disparity were frequently used interchangeably, resulting in conceptual muddling. Only 43% of documents (n = 36) included an explicit health equity goal. Although a suite of actions were described across the cancer control continuum to address equity goals, most were framed as recommendations rather than direct interventions. CONCLUSION Health and healthcare equity is a growing priority in the cancer care sector; however, conceptual clarity is needed to guide the development of robust equity goals, and the development of sustainable, measurable actions that redress inequities across the cancer control continuum. If we are to advance health and healthcare equity in the cancer care sector, a coordinated and integrated approach will be required to enact transformative and meaningful change.
Collapse
Affiliation(s)
- Leah K Lambert
- Nursing and Allied Health Research and Knowledge Translation, BC Cancer, Suite 500, 686 West Broadway, Vancouver, BC, V5Z 1G1, Canada.
- School of Nursing, University of British Columbia, Vancouver, Canada.
| | - Tara C Horrill
- College of Nursing, University of Manitoba, Winnipeg, Canada
| | - Scott M Beck
- Nursing and Allied Health Research and Knowledge Translation, BC Cancer, Suite 500, 686 West Broadway, Vancouver, BC, V5Z 1G1, Canada
| | - Amber Bourgeois
- Nursing and Allied Health Research and Knowledge Translation, BC Cancer, Suite 500, 686 West Broadway, Vancouver, BC, V5Z 1G1, Canada
- School of Nursing, University of Victoria, Victoria, Canada
| | - Annette J Browne
- School of Nursing, University of British Columbia, Vancouver, Canada
| | | | - A Fuchsia Howard
- School of Nursing, University of British Columbia, Vancouver, Canada
| | - Jagbir Kaur
- Nursing and Allied Health Research and Knowledge Translation, BC Cancer, Suite 500, 686 West Broadway, Vancouver, BC, V5Z 1G1, Canada
- School of Nursing, University of British Columbia, Vancouver, Canada
| | - Michael McKenzie
- Radiation Therapy Program, BC Cancer, Vancouver, Canada
- Division of Radiation Oncology and Developmental Radiotherapeutics, University of British Columbia, Vancouver, Canada
| | | | - Sally Thorne
- School of Nursing, University of British Columbia, Vancouver, Canada
| |
Collapse
|
30
|
Mayo ZS, Kilic SS, Weleff J, Parker SM, Strzalka C, Phelan M, Mian OY, Stephans KL, Suh JH, Tendulkar RD. Prostate Cancer Screening Disparities in Persons Experiencing Homelessness. JCO Oncol Pract 2022; 18:e1866-e1873. [PMID: 36206501 DOI: 10.1200/op.22.00412] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE The purpose of this study was to assess prostate-specific antigen (PSA) testing rates in persons experiencing homelessness (PEH), identify factors associated with screening, and compare PSA screening rates in PEH with a matched cohort of persons not experiencing homelessness (non-PEH). MATERIALS AND METHODS We identified 9,249 potentially eligible PEH cared for at a large metropolitan hospital system from an institutional registry of all patients who presented to the health care system as homeless from 2014 to 2021. Homelessness was defined by the presence of the Z-code for homelessness (Z59), the listed address matching to the address of a homeless shelter or other transitional housing or a positive screen for homelessness. A matched cohort of 10,000 non-PEH was generated for comparison. Univariate chi-square analysis and multivariate logistic regression were performed to evaluate variables associated with PSA testing. RESULTS A total of 1,605 PEH and 3,413 non-PEH were eligible for PSA screening within the study timeframe. Half of PEH were Black (50%). Medicaid was the most common insurance (51%), followed by Medicare (18%). PEH were less likely to have a PCP (58% v 81%, P < .001) and had a significantly lower PSA testing rate (13% v 34%, P < .001) compared with non-PEH. Univariate analysis revealed that PSA testing was more common in PEH who were employed (P < .001), had private insurance or Medicare (P < .001), or had an established primary care provider (PCP; P < .001). Multivariate analysis confirmed that having a PCP (OR, 2.54; 95% CI, 1.62 to 4.00; P < .001) significantly increased the likelihood of PSA testing in PEH. CONCLUSION PEH experience low rates of prostate cancer screening. Interventions to increase screening in this population, including increased PCP access, are needed.
Collapse
Affiliation(s)
- Zachary S Mayo
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Sarah S Kilic
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Jeremy Weleff
- Department of Psychiatry and Psychology, Center for Behavioral Health, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Sean M Parker
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | | | - Michael Phelan
- Department of Emergency Medicine, Emergency Services Institute, Cleveland Clinic, Cleveland, OH
| | - Omar Y Mian
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Kevin L Stephans
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - John H Suh
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Rahul D Tendulkar
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| |
Collapse
|
31
|
Phillips S, Raskin SE, Harrington CB, Bishop D, Gany FM. "Like pouring salt in a wound": A qualitative exploration of the consequences of unmet housing needs for cancer patients and survivors in New York City. J Psychosoc Oncol 2022; 41:411-433. [PMID: 36271879 PMCID: PMC10322638 DOI: 10.1080/07347332.2022.2136025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To identify consequences of unmet housing needs in the period following cancer diagnosis. DESIGN Qualitative descriptive design. PARTICIPANTS New York City-based cancer patients and survivors (n = 21) who reported experience of unmet housing needs while receiving cancer treatment. Key informants (n = 9) with relevant expertise (e.g. oncology social workers). METHODS One-time semi-structured telephone or in-person interviews were conducted with all participants. Inductive thematic coding was conducted using a pragmatic paradigm. FINDINGS Four categories of consequences emerged: 1) cancer management and health (rest and recovery, illness/injury risk, medical care); 2) psychological (stress and anxiety, lack of control and independence, self-esteem/pride, sadness/depression, cancer coping); 3) social (relationships, consequences for others, isolation); and 4) standard of functional living. CONCLUSION The simultaneous experience of cancer and unmet housing needs is broadly burdensome. IMPLICATIONS FOR PSYCHOSOCIAL PROVIDERS Screening and resources for addressing unmet housing needs must be prioritized to holistically care for patients.
Collapse
Affiliation(s)
- Serena Phillips
- Andrew Young School of Policy Studies, Georgia State University, Atlanta, GA, USA
| | - Sarah E. Raskin
- L. Douglas Wilder School of Government and Public Affairs, Virginia Commonwealth University, Richmond, VA, USA
| | | | - Darla Bishop
- Milken Institute School of Public Health, The George Washington University, Washington, DC, USA
| | - Francesca M. Gany
- Immigrant Health and Cancer Disparities Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| |
Collapse
|
32
|
Role of Occupation in Shaping Cancer Disparities. Cancers (Basel) 2022; 14:cancers14174259. [PMID: 36077790 PMCID: PMC9454748 DOI: 10.3390/cancers14174259] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 08/24/2022] [Accepted: 08/29/2022] [Indexed: 11/25/2022] Open
Abstract
Simple Summary The investigation of cancer disparities is of major importance. In this paper, we address this issue through the occupational point of view, trying to capture how work and its related factors impact on cancer inequalities. The data we provide may increase awareness relevant to cancer control, and stimulate further studies aimed at the identification of the occupational determinants of cancer disparities and the quantification of their role. Abstract Cancer occurrence is characterized globally by profound socioeconomic differences. Occupation is a fundamental component of socioeconomic status. In this review, we discuss the role of occupation as a determinant of cancer disparities. First, we address the issue of participation in cancer screening programs based on income, health insurance, occupational status and job title. Second, we review the role of occupation in contributing to disparities by acting as a mediator between cancer and (i) education and (ii) race/ethnicity. Lastly, we analyze data from a multicenter case−control study of lung cancer to calculate the mediating role of occupational exposure to diesel exhaust, silica and welding fumes in the association between education and lung cancer. By addressing the complex paths from occupation to cancer inequalities from multiple points of view, we provide evidence that occupational-related characteristics, such as income, health insurance, unemployment and hazardous exposures impinge on cancer control and outcomes. The increasing awareness of these aspects is fundamental and should lead to public health interventions to avoid inequalities rising from occupational factors.
Collapse
|
33
|
Social Determinants of Health in Oncology: Towards a More Personalized and Equitable Delivery of Cancer Care. Am J Clin Oncol 2022; 45:273-278. [PMID: 35532746 DOI: 10.1097/coc.0000000000000914] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Social determinants of health (SDOH) are defined as the set of modifiable social and physical risk factors that affect health. It is known that SDOH directly influence the population's overall health, but their effects on patients with cancer are considerably less elucidated. Here, we review the literature describing the effects of SDOH outlined by the Healthy People 2020 framework on patients diagnosed with cancer. We have found that while some SDOH are well-defined in cancer patients, evidence surrounding several variables is scarce. In addition, we have found that many SDOH are associated with disparities at the screening stage, indicating that upstream interventions are necessary before addressing the clinical outcomes themselves. Further investigation is warranted to understand how SDOH affect screenings and outcomes in multiple disciplines of oncology and types of cancers as well as explore how SDOH affect the treatments sought by these vulnerable patients.
Collapse
|
34
|
Horrill TC, Browne AJ, Stajduhar KI. Equity-Oriented Healthcare: What It Is and Why We Need It in Oncology. Curr Oncol 2022; 29:186-192. [PMID: 35049692 PMCID: PMC8774995 DOI: 10.3390/curroncol29010018] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 12/21/2021] [Accepted: 12/29/2021] [Indexed: 11/24/2022] Open
Abstract
Alarming differences exist in cancer outcomes for people most impacted by persistent and widening health and social inequities. People who are socially disadvantaged often have higher cancer-related mortality and are diagnosed with advanced cancers more often than other people. Such outcomes are linked to the compounding effects of stigma, discrimination, and other barriers, which create persistent inequities in access to care at all points in the cancer trajectory, preventing timely diagnosis and treatment, and further widening the health equity gap. In this commentary, we discuss how growing evidence suggests that people who are considered marginalized are not well-served by the cancer care sector and how the design and structure of services can often impose profound barriers to populations considered socially disadvantaged. We highlight equity-oriented healthcare as one strategy that can begin to address inequities in health outcomes and access to care by taking action to transform organizational cultures and approaches to the design and delivery of cancer services.
Collapse
Affiliation(s)
- Tara C. Horrill
- School of Nursing, University of British Columbia, Vancouver, BC V6T 2B5, Canada;
- Correspondence:
| | - Annette J. Browne
- School of Nursing, University of British Columbia, Vancouver, BC V6T 2B5, Canada;
| | - Kelli I. Stajduhar
- School of Nursing, University of Victoria, Victoria, BC V8P 5C2, Canada;
| |
Collapse
|
35
|
Ralli M, Marinelli A, De-Giorgio F, Crescenzi D, Vincentiis MD, Greco A, Arcangeli A, Ercoli L. Prevalence of Otolaryngology Diseases in an Urban Homeless Population. Otolaryngol Head Neck Surg 2021; 166:1022-1027. [PMID: 34813392 DOI: 10.1177/01945998211060699] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Otolaryngology diseases are common among people experiencing homelessness; however, they are seldom evaluated in a specialist setting, and investigations on their prevalence have rarely been conducted. The aim of this retrospective study was to evaluate the prevalence of otolaryngology conditions in an urban homeless population. STUDY DESIGN Retrospective study. SETTING Primary health care facility. METHODS The clinical records of patients referred to the medical facilities of the Primary Care Services of the Eleemosynaria Apostolica, Vatican City, between October 1, 2019, and July 31, 2021, were retrospectively reviewed; those reporting at least 1 otolaryngology disease were included in the study. RESULTS A total of 2516 records were retrospectively reviewed, and 484 (19.24%) were included in the study. The most common otolaryngology disease was pharyngotonsillitis (n = 118, 24.13%), followed by rhinitis with nasal obstruction (n = 107, 21.88%), hearing loss (n = 93, 19.01%), otitis (n = 81, 16.56%), abscess (n = 46, 9.40%), and sinusitis (n = 33, 6.74%). Head and neck cancer or precancerous lesions were reported in 34 subjects (7.02%). More than 1 simultaneous otolaryngology disorder was found in nearly 50% of our sample. A wide range of comorbidities was also reported. CONCLUSIONS Our results confirm an elevated otolaryngology demand in the homeless population and encourage the development of more efficient and effective strategies for a population-tailored diagnosis and treatment of these conditions.
Collapse
Affiliation(s)
- Massimo Ralli
- Department of Sense Organs, Sapienza University of Rome, Rome, Italy.,Primary Care Services, Eleemosynaria Apostolica, Vatican City State
| | - Alessia Marinelli
- Department of Sense Organs, Sapienza University of Rome, Rome, Italy
| | - Fabio De-Giorgio
- Department of Health Care Surveillance and Bioethics, Section of Legal Medicine, Università Cattolica del Sacro Cuore, Rome, Italy.,Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | | | - Antonio Greco
- Department of Sense Organs, Sapienza University of Rome, Rome, Italy
| | - Andrea Arcangeli
- Department of Anesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Lucia Ercoli
- Primary Care Services, Eleemosynaria Apostolica, Vatican City State.,Istituto di Medicina Solidale Onlus, Rome, Italy.,Department of Biomedicine and Prevention, Tor Vergata University, Rome, Italy
| |
Collapse
|
36
|
Louie AD, Nwaiwu CA, Rozenberg J, Banerjee D, Lee GJ, Senthoor D, Miner TJ. Providing Appropriate Pancreatic Cancer Care for People Experiencing Homelessness: A Surgical Perspective. Am Soc Clin Oncol Educ Book 2021; 41:1-9. [PMID: 33929879 DOI: 10.1200/edbk_100027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
People experiencing homelessness are particularly vulnerable when diagnosed with pancreatic cancer. Patients with lower socioeconomic status have worse outcomes from pancreatic cancer as the result of disparities in access to treatment and barriers to navigation of the health care system. Patients with lower socioeconomic status, or who are vulnerably housed, are less likely to receive surgical treatment even when it is recommended by National Comprehensive Cancer Network guidelines. This disparity in access to surgical care explains much of the gap in pancreatic cancer outcomes. There are many factors that contribute to this disparity in surgical management of pancreatic cancer in people experiencing homelessness. These include a lack of reliable transportation, feeling unwelcome in the medical setting, a lack of primary care and health insurance, and implicit biases of health care providers, including racial bias. Solutions that focus on rectifying these problems include utilizing patient navigators, addressing implicit biases of all health care providers and staff, creating an environment that caters to the needs of patients experiencing homelessness, and improving their access to insurance and regional support networks. Implementing these potential solutions all the way from the individual provider to national safety nets could improve outcomes for patients with pancreatic cancer who are experiencing homelessness.
Collapse
Affiliation(s)
- Anna D Louie
- Department of Surgery, Lifespan Health System, and Warren Alpert Medical School of Brown University, Providence, RI.,Cancer Center at Brown University, Warren Alpert Medical School of Brown University, Providence, RI
| | - Chibueze A Nwaiwu
- Department of Surgery, Lifespan Health System, and Warren Alpert Medical School of Brown University, Providence, RI.,Supporting Underrepresented Research to Generate Equity (SURGE) Lab Collaborators, Warren Alpert Medical School of Brown University, Providence, RI
| | - Julia Rozenberg
- Department of Surgery, Lifespan Health System, and Warren Alpert Medical School of Brown University, Providence, RI
| | - Debolina Banerjee
- Department of Surgery, Lifespan Health System, and Warren Alpert Medical School of Brown University, Providence, RI
| | - Gillian J Lee
- Department of Surgery, Lifespan Health System, and Warren Alpert Medical School of Brown University, Providence, RI
| | - Dewahar Senthoor
- Department of Surgery, Lifespan Health System, and Warren Alpert Medical School of Brown University, Providence, RI
| | - Thomas J Miner
- Department of Surgery, Lifespan Health System, and Warren Alpert Medical School of Brown University, Providence, RI.,Cancer Center at Brown University, Warren Alpert Medical School of Brown University, Providence, RI
| |
Collapse
|
37
|
Facer BD, Bingham B, Fleisch SB, Walker JN, Ahmad M, Osmundson EC. Radiation Therapy Adherence Among Patients Experiencing Homelessness. Int J Radiat Oncol Biol Phys 2021; 109:1019-1027. [PMID: 33127492 DOI: 10.1016/j.ijrobp.2020.10.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 10/20/2020] [Accepted: 10/23/2020] [Indexed: 11/18/2022]
Abstract
PURPOSE Radiation therapy is a valuable, yet time- and resource-intense therapy. Patients experiencing homelessness (PEH) face many barriers related to the timely receipt of radiation therapy. Owing to a paucity of data regarding cancer treatment and homelessness, clinicians have a limited evidence base when recommending therapy to PEH. This study was performed to evaluate adherence to radiation therapy treatment regimens in PEH with cancer. METHODS AND MATERIALS The study cohort was primarily derived from the Vanderbilt University Medical Center Homeless Health Services program. Patients in the Homeless Health Services program with radiation oncology visits were identified by query of the electronic medical record. Manual chart review was performed to gather standard treatment parameters and data describing missed appointments. A comparison group of patients not experiencing homelessness (non-PEH) was generated by aggregating appointment data for all other patients receiving similar treatments at Vanderbilt University Medical Center during multiple, consecutive years. RESULTS In the study, 3408 PEH were identified, of whom 48 underwent radiation oncology consultation. Thirty-two were prescribed at least 1 course of radiation therapy, for a total of 54 unique courses. Out of these courses, 34 (62.9%) were completed as prescribed without delay, 12 (22.2%) were completed with delay(s), and 8 (14.8%) were not fully completed. Although the PEH cohort had significantly higher rates of delayed and undelivered fractions, the proportion of delayed or incomplete courses was not significantly different from the comparison group of non-PEH, particularly for courses with 10 or fewer fractions. Reasons for missed appointments for PEH were variable. CONCLUSIONS This is the first publication describing adherence to radiation therapy in PEH. Our data suggest that PEH are as likely as non-PEH to complete a course of radiation therapy, albeit with more treatment interruptions. When treatment courses of >10 fractions are expected, PEH may benefit from more hypofractionated regimens, provided they have equivalent clinical efficacy to longer regimens. Documenting reasons for missed appointments will be essential to further understanding the needs of PEH. This study serves as a foundation for further analysis regarding homelessness and radiation therapy.
Collapse
Affiliation(s)
- Benjin D Facer
- Vanderbilt University School of Medicine, Nashville, Tennessee; University of Texas Rio Grande Valley, Edinburg, Texas.
| | - Brian Bingham
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sheryl B Fleisch
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jessica N Walker
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mahmoud Ahmad
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Evan C Osmundson
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| |
Collapse
|
38
|
Kohler RE, Roncarati JS, Aguiar A, Chatterjee P, Gaeta J, Viswanath K, Henry C. Trauma and cervical cancer screening among women experiencing homelessness: A call for trauma-informed care. WOMEN'S HEALTH (LONDON, ENGLAND) 2021; 17:17455065211029238. [PMID: 34225506 PMCID: PMC8264729 DOI: 10.1177/17455065211029238] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 05/28/2021] [Accepted: 06/08/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Women experiencing homelessness are at increased risk of cervical cancer and have disproportionately low Pap screening behaviors compared to the general population. Prevalence of Pap refusals and multiple kinds of trauma, specifically sexual trauma, are high among homeless women. This qualitative study explored how trauma affects Pap screening experiences, behaviors, and provider practices in the context of homelessness. METHODS We conducted 29 in-depth interviews with patients and providers from multiple sites of a Federally Qualified Health Center as part of a study on barriers and facilitators to cervical cancer screening among urban women experiencing homelessness. The Health Belief Model and trauma-informed frameworks guided the analysis. RESULTS Trauma histories were common among the 18 patients we interviewed. Many women also had strong physical and psychological reactions to screening, which influenced current behaviors and future intentions. Although most women had screened at least once in their lifetime, many patients experienced anticipated anxiety and retraumatization which pushed them to delay or refuse Paps. We recruited 11 providers who identified strategies they used to encourage screening, including emphasizing safety and shared decision-making before and during the exam, building strong patient-provider trust and communication, and individually tailoring education and counseling to patients' needs. We outlined suggestions and implications from these findings as trauma-informed cervical cancer screening. CONCLUSION Discomfort with Pap screening was common among women experiencing homelessness, especially those with histories of sexual trauma. Applying a trauma-informed approach to cervical cancer screening may help address complex barriers among women experiencing homelessness, with histories of sexual trauma, or others who avoid, delay, or refuse the exam.
Collapse
Affiliation(s)
- Racquel E Kohler
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Boston Health Care for the Homeless Program, Boston, MA, USA
| | - Jill S Roncarati
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Boston Health Care for the Homeless Program, Boston, MA, USA
| | | | - Pritha Chatterjee
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Dana-Farber Cancer Institute, Boston, MA, USA
| | - Jessie Gaeta
- Boston Health Care for the Homeless Program, Boston, MA, USA
| | - Kasisomayajula Viswanath
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Boston Health Care for the Homeless Program, Boston, MA, USA
| | - Cassis Henry
- Boston Health Care for the Homeless Program, Boston, MA, USA
| |
Collapse
|
39
|
Dickins KA, Philpotts LL, Flanagan J, Bartels SJ, Baggett TP, Looby SE. Physical and Behavioral Health Characteristics of Aging Homeless Women in the United States: An Integrative Review. J Womens Health (Larchmt) 2020; 30:1493-1507. [PMID: 33290147 DOI: 10.1089/jwh.2020.8557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: The average age of the homeless population is and will continue to rise. Although women comprise a significant and growing percentage of this vulnerable population, their age- and sex-specific health characteristics are poorly understood. Materials and Methods: This integrative review appraises published research addressing the physical and behavioral health characteristics of aging homeless women (≥50 years) in the United States (2000-2019). The authors searched six electronic databases to identify eligible studies. Studies were screened for methodological quality by using the Johns Hopkins Nursing Evidence-Based Practice model. The review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Results: Ten primary studies met the review eligibility criteria. All were level III (non-experimental); nine appraised as "good" quality (level B), and one as "lower" quality (level C). Aging homeless women demonstrate elevated rates of physical health conditions, related to suboptimal nutrition, lower than expected preventive health screening uptake, and geriatric concerns. Disproportionate rates of mental health conditions are compounded by substance use and interpersonal trauma. Familial and social dynamics and socioeconomic disadvantage contribute to social health concerns. Spiritual health is a critically important yet underexplored protective factor. Conclusions: Studies are limited, though collective findings suggest that aging homeless women endure a disproportionate physical, behavioral, and social health burden compared with aging non-homeless women and aging homeless men. Implications for research on early aging, preventative health strategies, and homelessness among women, and clinical practice in the context of geriatric and women's health are described.
Collapse
Affiliation(s)
- Kirsten A Dickins
- Yvonne L. Munn Center for Nursing Research, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lisa L Philpotts
- Treadwell Library, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jane Flanagan
- Yvonne L. Munn Center for Nursing Research, Massachusetts General Hospital, Boston, Massachusetts, USA
- William F. Connell School of Nursing, Boston College, Boston, Massachusetts, USA
| | - Stephen J Bartels
- Mongan Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Travis P Baggett
- Mongan Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Boston Health Care for the Homeless Program, Boston, Massachusetts, USA
| | - Sara E Looby
- Yvonne L. Munn Center for Nursing Research, Massachusetts General Hospital, Boston, Massachusetts, USA
- Metabolism Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
40
|
Understanding the Associations between Smoking-Related Risk Perception, Interest in Quitting Smoking, and Interest in Lung Cancer Screening among Homeless Adult Smokers. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17238817. [PMID: 33260975 PMCID: PMC7729438 DOI: 10.3390/ijerph17238817] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 11/17/2020] [Accepted: 11/25/2020] [Indexed: 12/19/2022]
Abstract
Individuals experiencing homelessness smoke cigarettes at high rates, suffer a disproportionate incidence of lung cancer, but are unlikely to be screened to enhance early detection. Understanding correlates of lung cancer screening (LCS) interest within this vulnerable group may lend insight into prevention and treatment efforts and reduce their smoking-related morbidity and mortality. This study sought to understand how risk perception and interest in quitting smoking relate to LCS interest among homeless adults. Participants comprised a convenience sample of CO-verified current smokers (N = 310; 72.6% men, Mage = 43 + 11.7) from a homeless shelter in Dallas, TX. Participants self-reported risk perception, interest in quitting smoking, and interest in LCS. The average risk perception was 6.7 + 3.2 (range 0-10), 74.8% (n = 232) agreed or strongly agreed with interest in LCS, and 65.8% (n = 204) were interested in quitting smoking. Greater interest in quitting smoking, but not greater risk perception, was associated with greater interest in LCS (adjusted OR: 1.968, (95% CI: 1.213, 3.191), p = 0.006). Risk perception and interest in quitting smoking did not interact in their association with interest in LCS. Results suggest that homeless smokers with an interest in quitting may be receptive to LCS: a diagnostic tool by which cancers can be caught at earlier stages and prior to metastasis. However, few in the current sample would be eligible for LCS based on current guidelines; results have implications for altered screening practices among chronic smokers experiencing homelessness.
Collapse
|
41
|
Alcaraz KI, Wiedt TL, Daniels EC, Yabroff KR, Guerra CE, Wender RC. Understanding and addressing social determinants to advance cancer health equity in the United States: A blueprint for practice, research, and policy. CA Cancer J Clin 2020; 70:31-46. [PMID: 31661164 DOI: 10.3322/caac.21586] [Citation(s) in RCA: 325] [Impact Index Per Article: 65.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 09/12/2019] [Accepted: 09/25/2019] [Indexed: 12/21/2022] Open
Abstract
Although cancer mortality rates declined in the United States in recent decades, some populations experienced little benefit from advances in cancer prevention, early detection, treatment, and survivorship care. In fact, some cancer disparities between populations of low and high socioeconomic status widened during this period. Many potentially preventable cancer deaths continue to occur, and disadvantaged populations bear a disproportionate burden. Reducing the burden of cancer and eliminating cancer-related disparities will require more focused and coordinated action across multiple sectors and in partnership with communities. This article, part of the American Cancer Society's Cancer Control Blueprint series, introduces a framework for understanding and addressing social determinants to advance cancer health equity and presents actionable recommendations for practice, research, and policy. The article aims to accelerate progress toward eliminating disparities in cancer and achieving health equity.
Collapse
Affiliation(s)
- Kassandra I Alcaraz
- Behavioral and Epidemiology Research Group, American Cancer Society, Atlanta, Georgia
| | - Tracy L Wiedt
- Cancer Control Department, American Cancer Society, Atlanta, Georgia
| | - Elvan C Daniels
- Extramural Research, American Cancer Society, Atlanta, Georgia
| | - K Robin Yabroff
- Surveillance and Health Services Research, American Cancer Society, Atlanta, Georgia
| | - Carmen E Guerra
- Perelman School of Medicine and Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Richard C Wender
- Cancer Control Department, American Cancer Society, Atlanta, Georgia
| |
Collapse
|
42
|
Holowatyj AN, Heath EI, Pappas LM, Ruterbusch JJ, Gorski DH, Triest JA, Park HK, Beebe-Dimmer JL, Schwartz AG, Cote ML, Schwartz KL. The Epidemiology of Cancer Among Homeless Adults in Metropolitan Detroit. JNCI Cancer Spectr 2019; 3:pkz006. [PMID: 30944890 PMCID: PMC6433093 DOI: 10.1093/jncics/pkz006] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 02/01/2019] [Accepted: 02/14/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Homeless individuals suffer and die disproportionately from chronic diseases and disorders. We describe the epidemiology of cancer among homeless persons in metropolitan Detroit. METHODS A retrospective cohort study was performed using 1973-2014 data from the Metropolitan Detroit Cancer Surveillance System, a population-based cancer registry and member of the National Institutes of Health-National Cancer Institute's Surveillance, Epidemiology, and End Results program. Homeless adults were identified through address at diagnosis listed as a homeless shelter, hospital, or supplemental field indicating homelessness. Age-adjusted, sex-specific proportional incidence ratios (PIR) compared cancer incidence proportions by primary tumor site of homeless patients to the nonhomeless referent population. Kaplan-Meier curves depicted unadjusted survival differences in a propensity score matched sample. Differences in 10-year survival were assessed using the score test with a sandwich estimator accounting for matched cluster effects. Statistical tests were two-sided. RESULTS A total of 388 individuals experienced homelessness at first primary invasive cancer diagnosis. Statistically significantly higher proportions of respiratory system (PIR = 1.51; 95% confidence interval = 1.28 to 1.79) and female genital system (PIR = 1.83; 95% confidence interval = 1.31 to 2.55) cancers were observed among homeless men and women, respectively. Homeless persons had poorer overall and cancer-reported survival compared with a propensity score matched referent population (median: overall survival, 20.0 vs 38.0 months, respectively, P < .001; cancer-reported survival, 38.0 vs 64.0 months, respectively, P < .001). CONCLUSION Disparities in disease burden exist between adults who are experiencing homelessness compared with the nonhomeless population at cancer diagnosis. These findings provide clinically relevant information to understand the cancer burden in this medically underserved population and suggest an urgent need to develop cancer prevention and intervention programs to reduce disparities and improve the health of homeless persons.
Collapse
Affiliation(s)
- Andreana N Holowatyj
- Correspondence to: Andreana N. Holowatyj, PhD, MS, Department of Population Health Sciences, Huntsman Cancer Institute, University of Utah, 2000 Circle of Hope, Room 4746, Salt Lake City, UT 84112 (e-mail: )
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|