Cancer Diagnoses and Use of Radiation Therapy Among Patients Experiencing Homelessness

Purpose: Patients experiencing homelessness have low rates of cancer screening and a high prevalence of cancer risk factors. However, data are scarce regarding cancer diagnosis and treatment in this high-risk population. We aimed to investigate the prevalence of cancer and utilization of radiation therapy (RT) in patients experiencing homelessness.

Methodology: This study was performed at a large tertiary referral hospital system in an economically disadvantaged urban area. All patients that presented with a homeless shelter address or who presented for care at the hospital system’s emergency departments and screened positive for homelessness were included. These data were cross-referenced with the institution’s state cancer surveillance system database to generate a list of patients experiencing homelessness and at least once cancer diagnosis. Demographic, clinical, and treatment variables were abstracted for each patient. This study was approved by the hospital system’s Institutional Review Board.

Results: Of a total of 9,654 patients experiencing homelessness, 81 patients (0.84%) had at least one cancer diagnosis and 5 patients had multiple cancer diagnoses, for a total of 87 diagnoses. The median age at the time of diagnosis was 60 years (range: 2-84 years). Fifty-eight percent of patients were male, 51% were Black, and 74% had public insurance. Sixty-eight percent of patients were current or former smokers and 51% were current or former alcohol users. Lung (16%), prostate (15%), colorectal (7%), and breast (7%) were the most common primary site diagnoses. Forty-seven percent of patients received surgery, 40% received chemotherapy, 36% received RT, and 17% received hormone therapy; 16% received no treatment at all. Only 36% of patients had no evidence of disease after treatment. Of patients treated with RT, 90% received external beam RT (EBRT). For patients treated with EBRT, the vast majority of patients (85%) were treated with hypofractionated regimens; 25% of patients were treated with single fraction regimens. The treatment completion rate was 88%.

Conclusions: In a large cohort of patients experiencing homelessness in an urban tertiary care setting, cancer diagnoses were uncommon, suggesting severe underutilization of screening in this population. Substance use was high, and the prevalence of substance-related cancers was high. RT was overwhelmingly hypofractionated, likely reflecting physician preference for short on-treatment time in this population. The treatment completion rate was low, likely the result of complex structural and socioeconomic barriers this population faces. Further studies and interventions to optimize treatment regimens and increase completion rates in this population are needed.

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