Homelessness and Cancer: A Multi-Site, Mixed Methods Study of Delayed or No Cancer Therapy

Background: Patients who experience homelessness manifest poor cancer outcomes, often because of treatment delays. Few studies have used mixed methods to learn what happens at the patient and health care staff level to explain these delays. Methods: This single-institution, multi-site study interrogated the entire medical record system (thousands of patients annually) for homelessness and cancer diagnoses from January 1, 2019, through October 10, 2023. Records were abstracted for relevant quantitative and qualitative data; rigorous methods were used to analyze, integrate, and report findings. Results: Forty-three patients with a median age of 58 years (range: 32, 73 years) and 34 (79%) assigned male sex at birth are the focus of this report. The most common cancers include hematologic (n = 8), gastrointestinal (n = 8), and genitourinary (n = 8). Thirty-five patients (81%) initiated cancer therapy, and 27 (63%) manifested treatment delay (>4 weeks post-diagnosis). The median time to cancer therapy was 9 weeks (95% confidence interval: 4.6, 12 weeks). Qualitative themes that explain delays are as follows: (1) logistical challenges in communication between the patient and health care team ("lack of a cell phone"); (2) patient reluctance to receive care ("patient elected to leave Against Medical Advice"); and (3) medical challenges in providing care ("he was hospitalized after being found down and hypotensive"). Conclusions: This study confirms that initiation of cancer therapy is often delayed in patients who experience homelessness. It sheds light on reasons for delay - for example, lack of phone access, an observation which suggests that perhaps provision of a burner phone might help some patients.