Mortality among homeless veterans with cancer implies ‘lessons to learn’ from VA approach
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Key takeaways:
- Homeless veterans received cancer diagnosis at a younger age than veterans with housing.
- Survival outcome disparities appear less severe among homeless veterans with cancer vs. overall homeless population.
Homeless veterans with lung or colorectal cancers had higher mortality rates than housed veterans, study data published in JAMA Network Open showed.
Nevertheless, the findings run contrary to the results of previous research investigating the impact of homelessness on individuals with cancer that showed larger outcome disparities compared with those who had housing. The analysis suggests that the United States Department of Veterans Affairs may have systems in place that could benefit nonveteran homeless patients, according to the study’s investigators.
“Many factors contribute to the likelihood of survival after a cancer diagnosis, including biological, environmental, behavioral, health care, economic, political and social determinants,” Hannah C. Decker, MD, a surgery resident at University of California, San Francisco, told Healio.
“Lack of housing is a critical factor that interacts across multiple domains to impact health outcomes — from poor access to ambulatory care, to bias and stigma, to difficulty navigating complex health care systems, to vulnerability to external forces such as law enforcement or shelter requirements,” she added. “However, these disparities are smaller at the VA than observed in other settings, which suggests that there may be lessons to learn from the VA about caring for this population.”
Background and methods
Homeless individuals are in worse health and at greater risk for injury and death compared with those who have housing, according to background information provided by the researchers.
Roughly 50% of homeless individuals are at least 50 years old, and that is the age cancer diagnoses begin increasing. Previous studies reported cancer as a leading cause of death for individuals without housing.
“Our team believed that evaluating if there are disparities between housed and unhoused populations was a critical first step in providing the best care possible for this vulnerable group,” Decker said. “We also thought it was important to study this issue at the VA because the VA system robustly documents housing status in a way that many other health care systems do not. This enabled us to conduct a national study that identifies a larger number of patients as experiencing homelessness.”
Decker and colleagues used the VA Corporate Data Warehouse Oncology Domain to find all veterans diagnosed with lung, colorectal or breast cancer who received VA care from Oct. 1, 2011, through Sept. 30, 2020 — a group of 109,485 individuals (mean age, 68.5 ± 9.7 years; 92% men).
They classified homeless veterans as those who had any indicators of homelessness in the year prior to diagnosis through outpatient visits, clinic reminders, diagnostic codes or the Homeless Operations Management Evaluation System.
OS by cancer type and multivariate-adjusted risk for death — expressed as hazard ratios — served as the study’s primary outcome measurements.
Results and what’s next
Homeless veterans made up 5% of the study cohort, although 19% of those acquired housing after their diagnosis.
Black veterans represented 37% of the homeless group but only 18% of the cohort studied.
“This difference is consistent with the overall demographics of unhoused individuals in the United States, with Black people overrepresented due to structural racism,” Decker said. “There are well-documented racial disparities in cancer outcomes, so there may be an interaction between race and housing status that impacted overall outcomes, which should be further explored.”
Veterans with lung cancer made up the majority (68%), followed by colorectal (26%) and breast cancer (6%).
Researchers observed that homeless veterans received cancer diagnoses at younger ages than housed veterans for each cancer studied: lung (mean, 64.4 vs. 69.8 years), colorectal (mean, 61.8 vs. 68.1 years) and breast (mean, 54.6 vs. 58.8 years).
Homeless veterans with lung cancer had higher mortality rates after 3 months than housed veterans (HR = 1.1; 95% CI, 1.1-1.2) and so did those with colorectal cancer (HR = 1.3; 95% CI, 1.2-1.4).
Homeless veterans received diagnoses of stage IV colorectal cancer at higher rates than housed veterans (22% vs. 19%; P = .02), but the two cohorts had statistically insignificant differences in stage of diagnosis for the other two cancers.
For veterans with breast cancer, homeless patients received no treatment 7% of the time vs. 4% for those who had housing. That disparity did not emerge in the other cancers evaluated.
“These differences were smaller than what was previously reported in other settings, [including] a study in Boston and one in Canada,” Decker said of the results. “This made us think that there may be important lessons in how the VA cares for veterans experiencing homelessness.
“The VA reduces financial barriers to care by providing health care to all members regardless of insurance status, which may result in improved access to primary and preventive care, cancer screening and cancer-directed treatment,” she added. “The VA also has prioritized addressing veteran homelessness since 2009 by investing in dedicated housing resources — homelessness prevention, rapid rehousing, rental subsidies and permanent supportive housing.”
As evidence of the VA’s focus on its homeless members, Decker noted the 20% of homeless veterans in the study who acquired housing after their cancer diagnosis.
“Our future work explores if gaining housing after cancer diagnosis helps improve outcomes among veterans experiencing homelessness,” she said.
For more information:
Hannah C. Decker, MD, can be reached at hannah.decker@ucsf.edu.
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