The following article is part of a series highlighting the effects of social determinants of health on cancer care. The other articles in this series address transportation insecurity and food insecurity.
Experts have noted that housing insecurity can influence — and be influenced by — cancer care.1 The term “housing insecurity” encompasses many housing-related issues, including high housing costs, unstable housing circumstances, and poor or unsafe living conditions.
Research has shown that cancer survivors are more likely than patients without a cancer history to experience medical financial hardship, including problems paying medical bills and forgoing care because of costs.2
Medical and nonmedical financial hardships negatively affect housing circumstances via eviction, foreclosure, the need to refinance homes because of medical bills, and moving in with family or friends to save money.1 Frequent moves, evictions, and, homelessness can impede patients’ access to cancer screening, treatment, and survivorship care.
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Assessing Housing Insecurity in Cancer Patients
Systematic screening for housing insecurity has not been uniformly implemented at care sites, and existing efforts are typically not comprehensive.1
A survey of 17 National Comprehensive Cancer Network (NCCN) institutions showed that most of them screen for financial hardship, commonly with tools measuring overall distress, such as the NCCN Distress Thermometer.3 However, the centers did not assess housing insecurity specifically.
A survey of 221 National Cancer Institute (NCI) Community Oncology Research Program-affiliated practices showed that 72% had a financial screening process, and 50% had cancer-specific financial navigators.4 However, housing insecurity was not specifically assessed.
Researchers did assess the impact of housing insecurity in a study of 1277 patients with newly diagnosed cancer.5 Housing insecurity was associated with an increased risk of death in an adjusted analysis in which housing insecurity was assessed independently (hazard ratio [HR], 1.54; 95% CI, 1.02-2.31; P =.04) and in analysis adjusted for other social risk factors as well (HR, 2.05; 95% CI, 1.29-3.27; P =.002).
Addressing Housing Needs and Adjusting Treatment Plans
Research has suggested that medical-legal partnerships can reduce housing insecurity for patients.6 These partnerships can address patients’ legal needs related to housing, such as rectifying substandard housing conditions, negotiating payments with landlords to avoid eviction, and helping patients retain housing subsidies.
A literature review by The Commonwealth Fund indicated that interventions focused on housing security improved clinical outcomes and were associated with reduced overall health care costs.7 However, this analysis was not focused only on patients with cancer.
Social needs may be mitigated by changes in care delivery in addition to resolving the underlying social risk itself.1 For example, patients experiencing homelessness could be offered medications that do not require refrigeration. Treatments requiring electricity, such as infusion pumps, could be avoided.
Placement in short-term residential care for medical and supportive services for homeless or temporarily displaced patients may help them adhere to treatment as well.1 However, there is limited evidence about the effectiveness of adjustments like these for cancer patients with housing insecurity.
A Call for Research and Investment
Experts suggest that identifying and addressing housing insecurity and other financial hardships in cancer patients requires investment at the practice, systems, and broader policy levels.8
Data infrastructure and interoperability may be particularly important, since housing-focused community organizations often use different platforms to document and report their services.1 In addition, many electronic health records systems do not allow providers to document and track the delivery of social services or outcomes of social services referrals.
Additional research could provide quantifiable information about the scope of housing insecurity and its impact on access, quality, and cost of cancer care.1 Similarly, there is a need to evaluate the effectiveness, costs, and sustainability of health system, payer, and policy initiatives and identify best practices for screening patients for social needs and connecting them to relevant resources.
References
1. Fan Q, Keene DE, Banegas MP, et al. Housing insecurity among patients with cancer. J Natl Cancer Inst. 2022;114(12):1584-1592. doi:10.1093/jnci/djac1363
2. Zheng Z, Jemal A, Han X, et al. Medical financial hardship among cancer survivors in the United States. Cancer. 2019;125(10):1737-47.
3. Khera N, Sugalski J, Krause D, et al. Current practices for screening and management of financial distress at NCCN member institutions. J Natl Compr Canc Netw. 2020;18(7):825-831. doi:10.6004/jnccn.2020.7538
4. McLouth LE, Nightingale CL, Dressler EV, et al. Current practices for screening and addressing financial hardship within the NCI Community Oncology Research Program. Cancer Epidemiol Biomarkers Prev. 2021;30(4):669-675. doi:10.1158/1055-9965.EPI-20-1157
5. Banegas MP, Dickerson, JF, Zheng Z, et al. Association of social risk factors with mortality among US adults with a new cancer diagnosis. JAMA Netw Open. 2022;5(9):e2233009. doi:10.1001/jamanetworkopen.2022.33009
6. Hernández D. ‘Extra oomph:’ Addressing housing disparities through medical legal partnership interventions. Housing Studies. 2016;31(7):871-890. doi:10.1080/02673037.2016.115043112
7. McCarthy D, Lewis C, Horstman C, et al. Guide to evidence for health-related social needs interventions: 2022 update. The Commonwealth Fund. Published September 2022. Accessed July 31, 2023.
8. Yabroff KR, Bradley CJ, Shih Y-CT. Improving the process of screening for medical financial hardship in oncology practice. Cancer Epidemiol Biomarkers Prev. 2021;30(4):593-596. doi:10.1158/1055-9965.EPI-21-0111
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