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Barriers To Cancer Care For Elder Homeless Men

Homelessness is a universal issue that continues to affect hundreds of nations worldwide. The UN estimates that, globally, at least 100 million individuals are homeless at any given time.

In Canada, at least 200,000 Canadians experience homelessness in any given year, 30,000+ Canadians are homeless on any given night, and 50,000+ Canadians per night are part of the "hidden homeless" — staying with friends or relatives on a temporary basis as they have nowhere else to go.

In the USA, about 3.5 million people experience homelessness annually, of whom 15 percent are chronically homeless (ie, have experienced home­lessness for at least a year or repeatedly), and 630,000 individuals experience homelessness each night.

The highest risk of homelessness

is among men aged 45–54 years.

Most homeless individuals in the USA were born between the 40s and 60s, and 20 percent are older than 50 years, an age at which most adults would need age­ appropriate cancer screening.

Homeless populations often have poor health, largely due to having inadequate or no access to health care, and are commonly overlooked in cancer research. This issue is further compounded by the fact that homeless people often have a history of chronic illness and high rates of mental illness and substance abuse, coupled with infrequent access to primary care.

Cancer is among the most common causes of mortality in homeless adults. However, information regarding appropriate cancer screening measures in homeless people is scarce.

Cancer-­related death rates are twice as high in

homeless adults as in the general population.

Few studies have reported on the specific barriers to cancer screening among homeless people. The available data indicates that barriers at the systems level include little or no access to a primary care physician; or not having been able to visit a clinic in the past year; and inadequate access to health care in general.

One study out of in Los Angeles reported that 23 percent of homeless people had ever had a colonoscopy compared with 47 percent of the general population.

Overall there is a higher incidence of cancer, a more advanced cancer stage at diagnosis, and higher mortality rates among homeless people compared with the general population.

Although barriers to health care are generic in nature, certain other factors specific to homeless people have been identified; these factors relate to their housing status and the social conditions that contribute to homelessness, including difficulty in securing a companion to accompany them to screening procedures, various social conditions (eg, no permanent address or phone access) that prevent them from attending medical appointments, and low prioritization of preventive care.

In a qualitative study published in 2015, homeless people thought that their risk of cancer was more than that of the average population, were worried about cancer, and viewed cancer screening as a priority in managing their health care.

On the other hand, providers often have misconceptions, biases, or implicit prejudices against homeless people, their priorities, and their medical needs (eg, believing that they do not care about their health, or are likely to engage in risky behaviour such as substance abuse).

The focus of the health­care system has often been on responding to the urgent issues of homeless people, while overlooking preventive care, especially cancer screening. This practice might be partly due to the perception that homeless people have more important priorities to deal with than preventive care.

There is no framework for routine and efficient screening strategies in shelter­-based clinics where homeless people might attempt to access health care. Therefore, specific barriers to cancer screening are often not addressed and homeless people do not receive help in navigating the process and making informed choices about their health.

A growing body of evidence indicates that health navigator programmes can produce significant and sustained increases in cancer screening. Services offered to homeless people via drop-in centre and shelter­-based clinics offer a unique opportunity to collect appropriate data and address the most important barriers to cancer screening of homeless individuals who have limited access to preventive care.

Adapted from Study:

Cancer screening in the homeless population

Ramin Asgary MD

The Lancet Oncology




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