Addressing housing instability as a quality-of-care determinant in cancer: A meta-analysis across national and Veterans Affairs cohorts.

Abstract

11045 Background: Housing instability is an under-recognized determinant of cancer outcomes that directly affects screening adherence, treatment delivery, and survival. Over 650,000 Americans experience homelessness nightly, yet its impact on oncologic quality-of-care metrics remains poorly quantified. We conducted a meta-analysis to evaluate disparities in cancer screening, treatment, and survival among persons experiencing homelessness (PEH) versus housed individuals, and to assess whether housing status functions as a system-level quality indicator. Methods: Real-world evidence from the Veterans Health Administration (VHA), National Inpatient Sample (NIS), and community cohorts (2011–2024) was pooled using random-effects DerSimonian–Laird models. Eligible studies reported odds ratios (ORs) or hazard ratios (HRs) comparing PEH with housed counterparts. Heterogeneity was summarized using I² statistics, and all analyses were performed in Stata. Results: Six cohorts contributed sixteen effect estimates encompassing >200,000 cancer cases. PEH were less likely to be up to date for colorectal cancer screening (pooled OR 0.56, 95% CI 0.23–1.31; I² = 93.9%). Homelessness was associated with markedly lower odds of surgery or other invasive procedures (pooled OR 0.42, 95% CI 0.26–0.66; I² = 98.4%) and substantially higher odds of discharge against medical advice (pooled OR 5.37, 95% CI 3.39–8.50; I² = 92.9%). In gastrointestinal cancer admissions, PEH also had longer hospital stays and higher costs. Within VHA datasets, homelessness independently predicted higher all-cause mortality after lung (HR 1.09–1.29) and colorectal cancer (HR 1.18–1.22). Veterans who gained housing after diagnosis achieved survival comparable to continuously housed peers (HR ≈ 1.0). Conclusions: Across diverse U.S. datasets, homelessness is consistently associated with lower screening uptake, reduced treatment receipt, and higher mortality—outcomes that represent measurable quality-of-care failures. Stable housing acts as a protective, modifiable factor influencing survival independent of access or insurance. Incorporating housing status screening into oncology intake workflows can close equity gaps, improve safety, and advance value-based cancer care. Housing stability should be recognized as a core quality metric in oncology. Cohorts included in the meta-analysis of homelessness and cancer outcomes. Study Cancer Type(s) Main Outcomes Effect (95% CI) Asgary 2014 Colorectal Screening OR 0.35 (0.23–0.53) VA Cohort 2011–21 CRC, Breast Screening / Colonoscopy aIRR 0.84 (0.83–0.84); 0.88 (0.84–0.92) Shah 2024 All cancers Procedure / Therapy / AMA AOR 0.53; 0.73; 4.29 Mevawalla 2019 GI Surgery / AMA OR 0.33; AOR 6.86 VA Mortality 2011–20 Lung Mortality HR 1.21 (0.93–1.57) Health Affairs 2024 Lung, CRC, Breast Mortality by housing HR 1.09–1.29 (lung); 1.22 (CRC)