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

Abstract

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 < .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.

Housing Status and Acute Care Use After Cancer Diagnosis

“…Homelessness is associated with poor outcomes following cancer diagnosis due, in part, to later-stage diagnoses and inadequate access to guideline-concordant therapy, which requires coordinated, multidisciplinary communication among clinicians and patients. 1 , 2 Acute care use following cancer diagnosis may signal challenges associated with accessing scheduled oncologic treatment, symptom management, or care for comorbidities. 3 , 4 We hypothesized that individuals who were unhoused would have greater increases in acute care use after cancer diagnosis compared with individuals who were housed.…”

Unaffordable housing and cancer: novel insights into a complex question

“…Although identification of localized increases in cancer risk may degrade housing value ( 7 ), improvements in the built environment that in turn improve population health have also been shown to drive up the cost of housing ( 8 ). Further, homelessness is caused by severe cost housing burden and associated with poor cancer outcomes, but the population affected is transient and can move to lower–cost burden counties before the associated cancer outcomes are realized ( 9 , 10 ). Development of conceptual models that incorporate a fuller taxonomy of housing situations may be relevant for cancer.…”