Housing Insecurity Ups Risk of Dying From Any Cause After Cancer Diagnosis

Tara Haelle

September 28, 2022

Housing insecurity is linked to an increased risk for death from any cause among patients with cancer, even after accounting for other social risks and determinants of health, according to a recent research letter published in JAMA Network Open.

"Despite national efforts to integrate social risk screening and referral programs within the oncology setting to advance cancer health equity, many community oncology practices have limited social risk screening and referral programs," write Matthew P. Banegas, PhD, of the University of California San Diego, and colleagues. "Our findings underscore the importance of screening for social risks at the time of cancer diagnosis and connecting patients with relevant social services."

Andrea L. Merrill, MD, a surgical oncologist, said the results were not surprising given her clinical experience at a safety-net hospital that treats many patients with limited resources.

"Patients with housing instability may have trouble keeping their phone charged to get calls or reminders for visits, getting to visits, and managing the side effects of treatment," Merrill, assistant professor of surgery at Boston Medical Center, told Medscape Medical News. "This all leads to treatment interruptions and delays, which we know worsens oncologic outcomes."

Merrill said these patients also often lack any sort of support system and may sometimes struggle with coexistent substance abuse that, when combined with financial hardship, "create huge barriers for patients to get care, especially the frequent visits required for cancer treatment," she said.

Like the authors, Merrill emphasized the importance of asking patients about their current social and housing situation, though she acknowledged how easily that's forgotten in a busy clinic where physicians are focused on treating the cancer.

And although social determinants are important for treatment success, there is limited research exploring an association between social risks at the time of cancer diagnosis and mortality.

The researchers analyzed data from 1277 adults enrolled in Kaiser Permanente Northwest who were diagnosed with cancer between June 2017 and December 2019. Within 90 days before or after their diagnosis, all the participants completed a social risk survey that assessed their financial hardship, food insecurity, housing instability, and transportation difficulties. After accounting for race and ethnicity, the researchers calculated the relationship between each of the four social determinants of health with a patient's time from diagnosis to death from any cause.

Other statistical adjustments included baseline associations between mortality and each social determinant, and the likelihood of having one of the social determinants based on demographics, socioeconomic status, and clinical characteristics.

The patients' average age was 63, and the vast majority were White, with only 5.1% identifying as Asian American, 4.9% as Hispanic, and 3.3% as African American.

Overall, most patients (84%) reported no social risks, and 16% reported at least one social risk, with financial hardship being the most common (11.5%). Those with at least one risk were more likely to be women and from a racial or ethnic minority group. These patients were also more likely to have Medicaid, have had breast or lung cancer, or have advanced-stage tumors.

The authors' analysis of the 275 deaths in the study revealed housing stability to increase the risk for death from any cause by more than 50% (adjusted hazard ratio [aHR], 1.54; P = .04). After considering all other social risks, the likelihood of death among those with housing insecurity doubled (aHR, 2.05; P = .002).

Housing is regarded as the "most foundational determinant" among the social determinants of health, "affecting households' ability to earn an income, buy healthy food, and access transportation and healthcare," Kathryn Leifheit, PhD, MSPH, an assistant professor of pediatrics at UCLA David Geffen School of Medicine in Los Angeles, told Medscape Medical News.

Like Merrill, Leifheit was not surprised that housing instability had a stronger association with all-cause mortality than other social risk factors in the study.

"However, the authors' finding that the other three social risk factors were not significantly associated with all-cause mortality was surprising to me," Leifheit said.

"We know that financial well-being, food security, and transportation are important determinants of health," she said. "I would caution against interpreting the data to mean that these factors are unimportant when it comes to cancer patients' survival."

In fact, Merrill noted, "it's possible we might see an even stronger association with social factors if a more diverse patient population were studied."

In addition to a lack of racial and ethnic diversity among study participants, another notable study limitation is that the analysis only included patients from a single health system.

Both Merrill and Leifheit highlighted that physicians can help patients who may be facing housing insecurity or other related social risk factors by enlisting social workers to connect patients with housing support services.

It’s helpful to know if any "medical respite care" facilities, such as the Barbara McInnis House in Boston near her facility, exist in the area and to be familiar with processes to connect patients to Section 8 low-cost housing.

"Often, local governments and advocacy organizations maintain a centralized website with links to local resources such as emergency rental assistance, housing vouchers, and legal support," said Leifheit, pointing to Stay Housed L.A. as an example in her area.

But, Merrill acknowledged, "we can only do so much to help patients get housing, unfortunately."

A systemic issue like this will require the kind of systemic change that can only come from policy, such as an initiative to build more medical respite houses or the creation of specialized Section 8 housing specifically for people with serious medical conditions, Merrill said.

Other policy options include making it easier to build more housing by, for instance, changing zoning regulations, helping people pay rent by expanding emergency rental assistance and housing voucher programs, and making it easier for tenants to stay in their current rental homes by enacting rent stabilization or reforming landlord-tenant laws, Leifheit explained.

"There are a number of viable policy options to make housing more affordable so that people don't end up homeless or doubled up with friends while they're trying to survive a cancer diagnosis," Leifheit said.

The research was funded by the National Cancer Institute. Several co-authors reported disclosures, including AstraZeneca grant support, personal fees from Freenome and from Boston Consulting Group, serving on the Flatiron Health Equity Advisory Board, and employment at the National Cancer Society. The full list of disclosures can be found with the original article.

JAMA Network Open. Published September 16, 2022. Research letter

Tara Haelle is a health/science journalist based in Dallas. Follow her at @tarahaelle .

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