Radiation Therapy Adherence Among Patients Experiencing Homelessness

Cancer Prevention for Women Experiencing Homelessness: Onsite Mammography, Navigation, and Education

PURPOSE

Persons experiencing homelessness (PEHs) represent a medically underserved population with a disproportionately high rate of late-stage cancer diagnoses and cancer mortality. During mobile onsite mammography and breast health education events, we studied PEH's barriers to and uptake of cancer screenings.

METHODS

This study used patient surveys and review of the electronic health record. The main outcome measures included mammogram and diagnostic imaging (as needed) results. A questionnaire assessed patient's views and barriers related to social determinants of health. The study included women accessing community organization resources who were 40 years or older or who met criteria for screening mammography.

RESULTS

Forty-six individuals completed mammograms and 41 individuals participated in the survey, for a response rate of 89%. Thirty-five participants (85%) held health insurance provided by a Medicaid managed plan. Thirty-six participants (87%) received a negative mammogram result, and five participants (12%) required follow-up for abnormal results. Of these five, two participants completed diagnostic follow-up with negative results, and three did not complete diagnostic follow-up. In addition to barriers related to housing insecurity, five patients (12%) reported transportation barriers. A majority (n = 28, 68%) disagreed or strongly disagreed with the statement, "I'm afraid the mammogram will be painful." A majority (n = 31, 76%) disagreed or strongly disagreed with the statement, "I'm busy and do not have time." Nearly all participants (n = 37, 90%) responded yes to the statement, "I believe in preventative care screenings." Eight participants (20%) completed at least one additional cancer screening.

CONCLUSION

By creating enduring programs offering screening, navigation, and education, academic-community partnerships may begin to address the increased cancer mortality among PEHs by improving screening adherence.

Cancer care and treatment during homelessness

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.

Access to cancer preventive care and program considerations for people experiencing homelessness across four European countries: an exploratory qualitative study

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.

Cancer Diagnoses and Use of Radiation Therapy Among Persons Experiencing Homelessness

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.