Homelessness Associated with Increased Rates of All-Cause Mortality among Veterans with Lung and Colorectal Cancer

BACKGROUND:
Currently, almost half of single homeless adults are older than 50 years, which is the age when the incidence of cancer increases. Prior studies have highlighted cancer as a leading cause of death in unhoused patients older than age 50. However, cancer outcomes, including stage at diagnosis, surgical outcomes, and mortality rates following cancer diagnosis in homeless patients are understudied. Therefore, this retrospective, national cohort study sought to characterize the diagnosis, treatment, surgical outcomes, and mortality of unhoused compared to housed patients who received care in VA for lung, colorectal cancer (CRC), and breast cancer. Using VA data, investigators identified all Veterans diagnosed with these cancers who received VA care from October 2011 through September 2020 (n = 109,485). The major outcomes, by cancer type (lung, 68%; CRC, 26%; and breast, 6%), were: 1) treatment course (e.g., stage at diagnosis, time to treatment initiation); 2) surgical outcomes (e.g., 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.

FINDINGS:

• Homelessness was associated with increased rates of mortality for lung and colorectal cancer, as well as later stage at diagnosis for colorectal cancer.
• Veterans experiencing homelessness had longer postoperative lengths of stay for all cancer types, but no differences in other treatment or surgical outcomes were observed.
• For all three cancers, unhoused Veterans were more commonly Black compared to housed Veterans (35% vs 16% in lung cancer, 41% vs 20% in CRC, and 45% vs 30% in breast cancer) and younger, with the average age at diagnosis 64 years (vs 69) for lung cancer, 61 years (vs 68) for CRC, and 54 years (vs 58) for breast cancer.
• Of the 109,485 Veterans in this cohort, 104,129 were housed (95%) and 5,356 were unhoused (5%) at the time of diagnosis. Of the unhoused cohort, 19% gained housing within the first year after diagnosis and were censored from the survival analysis at the time of gaining housing.

IMPLICATIONS:

• Differences in oncologic outcomes in breast, CRC, and lung cancer between housed and unhoused patients in VA were present but smaller than observed in other settings. Thus, there may be important systems in VA that could inform policy to improve outcomes for unhoused patients.

LIMITATIONS:

• Depending on the volume and expertise of individual VAMCs, Veterans may seek community care for certain cancers (particularly breast cancer).

AUTHOR/FUNDING INFORMATION:
Dr. Graham is part of HSR&D’s Health Economics Resource Center (HERC) in Palo Alto, CA.

Decker H, Graham L, Titan A, et al. Housing Status, Cancer Care, and Associated Outcomes Among US Veterans. JAMA Network Open. December 21, 2023; 6(12):e2349143.