Epidemiology and Psychiatric Correlates of Cancer among Homeless and Unstably Housed Veterans in the VA Health Care System

Tsai, Jack; Szymkowiak, Dorota; Zullig, Leah L.

doi:10.1158/1055-9965.epi-22-1154

Cited by 2 publications

(1 citation statement)

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“…Housing Status, Cancer Care, and Associated Outcomes Among US Veterans metastatic colorectal cancer than patients with housing (22% vs 19%), but they were diagnosed at similar lung and breast cancer stages. Although this finding is consistent with other VA studies, 20 it differs from other settings. For example, a study from the Boston Health Care for the Homeless Program reported that greater than 40% of colorectal cancers in patients experiencing homelessness were metastatic on presentation (compared with <20% of patients with housing) and almost 70% of breast cancers in these patients were locally advanced on presentation.…”

Section: Jama Network Open | Equity Diversity and Inclusionsupporting

confidence: 91%

Housing Status, Cancer Care, and Associated Outcomes Among US Veterans

Decker,

Graham,

Titan

et al. 2023

JAMA Netw Open

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ImportanceCancer is a leading cause of death among older people experiencing homelessness. However, the association of housing status with cancer outcomes is not well described.ObjectiveTo 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 ParticipantsThis 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.ExposuresVeterans 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 MeasuresThe 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.ResultsThis 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 &lt; .001), respectively.Conclusions and RelevanceIn 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.

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Section: Jama Network Open | Equity Diversity and Inclusionsupporting

confidence: 91%

Housing Status, Cancer Care, and Associated Outcomes Among US Veterans

Decker,

Graham,

Titan

et al. 2023

JAMA Netw Open

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Screening rates for hepatitis B and C among low‐income US veterans: Data from the National Veteran Homeless and Other Poverty Experiences Study

Beydoun,

Tsai

2024

Journal of Viral Hepatitis

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Screening for viral hepatitis is considered a high‐priority area in the Veterans Health Administration (VHA). Yet, few studies have examined viral hepatitis screening test use among low‐income veterans who are considered high‐risk with limited healthcare access. Using cross‐sectional data from 933 participants in the 2021–2022 National Veteran Homeless and Other Poverty Experiences (NV‐HOPE) study, we examined rates and correlates of lifetime screening for hepatitis B (HBV) and hepatitis C (HCV) infections. Multivariable logistic regression models evaluated characteristics associated with HBV/HCV screening. Nearly 16% and 21% reported lifetime HBV and HCV screening, respectively. These rates are considerably lower than HBV (47.3%) and HCV (92.9%) screening rates documented among contemporaneous veterans in VHA electronic health records. In the NV‐HOPE data, veterans 50–79 years were more likely than those ≥80 years of age to ever‐screen for HBV/HCV. Whereas, household income was inversely related to lifetime screening behaviours, veterans reporting ‘other’ employment types (vs. full‐time/part‐time employment) were more likely to ever‐screen for HBV/HCV. Ever‐screening for HBV was more likely among veterans reporting non‐Hispanic ‘other’ (vs. non‐Hispanic ‘white’) race, housing instability, Medicaid insurance, as well as drug use and cognitive disorder histories. Living with ≥5 members (vs. alone), histories of alcohol use, cancer, and liver disorders were also correlated with ever‐screening for HCV. HIV/AIDS history correlated with ever‐screening for HBV/HCV. In conclusion, fewer than one‐third of low‐income US veterans ever‐screened for HBV/HCV, with lower screening rates among those less likely to be exposed to viral hepatitis, thereby informing interventions aimed at promoting available screening, treatment and vaccinations for HBV/HCV.

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Epidemiology and Psychiatric Correlates of Cancer among Homeless and Unstably Housed Veterans in the VA Health Care System

Cited by 2 publications

References 28 publications

Housing Status, Cancer Care, and Associated Outcomes Among US Veterans

Housing Status, Cancer Care, and Associated Outcomes Among US Veterans

Screening rates for hepatitis B and C among low‐income US veterans: Data from the National Veteran Homeless and Other Poverty Experiences Study

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