When Serena Phillips was working as a patient navigator in New York City, guiding people with cancer through the steps of their treatment, she encountered a woman who was a middle-aged, undocumented immigrant with breast cancer. The patient was seen at a safety net hospital, which provides care to people regardless of their ability to pay or their insurance status. And she was in a precarious situation.
The woman was paying someone she knew 100 dollars a week to sleep on their couch. It was in the middle of winter, and despite being more sensitive to cold due to having damaged nerves—a side effect of her ongoing chemotherapy—she was still working during her treatment, earning seven dollars an hour handing out flyers outside. So she was facing multiple challenges: housing insecurity, poverty, and on top of this, cultural and language barriers, limited health literacy, and limited access to social benefits and programs.
Decades of research has shown how social risk factors like these can adversely impact a person’s health. And a new study has shown that for cancer patients, housing insecurity in particular may make their cancer worse. “Social risks affect how we interact with the health care system and other social systems,” says Matthew Banegas, lead author on the study and a researcher at the Kaiser Permanente Center for Health Research in Portland, Oregon. “Slowly and surely, we have been able to show that these risks are important.”
This study builds on other work that has shown the negative effects of housing insecurity, from worsening people’s mental health to disrupting treatment for HIV/AIDS. Insecure living is, it seems, a health risk.
The study looked at the social risks experienced by more than 1,200 US cancer patients at the time of their diagnosis to see whether being exposed to risk factors—housing insecurity, food insecurity, financial hardship, transport difficulties—appeared to raise their risk of dying from their cancer. The researchers found there was a two-fold greater risk of death for patients experiencing unstable housing—which can refer to a range of housing-related challenges, including homelessness, difficulty paying rent, overcrowding, moving frequently, or spending the majority of income on housing—compared to people who were not.
Notably, the study didn’t assess how insecure housing might influence cancer mortality. “There are a lot of different ways that social risk can impact cancer care,” says Craig Pollack, professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health, who was not involved in the study. The stress of insecure living, for instance, might raise the risk of cancer developing. Or disruption caused by housing insecurity might impact a person getting screening, or affect someone’s chances of receiving high-quality treatment. Housing acts as a hub for a person to access health care, and so instability can disrupt access to services.
But while it remains unclear how a lack of secure, affordable housing might impact cancer outcomes, the study adds to a growing body of evidence that there’s a link between the issue and the disease.
Whenever social risk factors arise, “there’s an opportunity for someone to fall through the cracks or experience a delay,” says Phillips, who is now a data scientist at Georgia State University (she was not involved in the research). That delay could take many forms, “whether it’s cancer not diagnosed as early as it should have, receiving treatment, missing appointments, and not getting treatment in the way they should have,” she says.
But whether housing insecurity specifically is responsible for increasing cancer mortality isn’t yet proven. The issue of housing might simply be “mimicking other factors,” argues Stuart Butler, a senior fellow in economic studies at the Brookings Institution. An insecure living situation could just be another indicator of financial insecurity, which itself has negative health impacts. Social risks “rarely stand alone,” says Banegas, the study lead. “It’s rare that someone only has housing instability. The picture is more complex.”
Even if the exact nature of the link isn’t clear, the connection between housing and health suggests that improving people’s living security would have compound benefits. But it’s a big issue to address. In the US, some programs exist for supporting people with housing, but they are limited in the amount of support they can provide and who qualifies for benefits, leaving enormous gaps in affordable housing for many people.
The question then is: “Who is best available to invest?” says Butler. Whether it’s a manager in a housing agency or the leadership of a hospital, investing in housing—or measures to address social deprivation more generally—often won’t be seen as an integral part of their business’s model. The US health system—including people who provide cancer care—does what it can, but social risks are broad problems that require policy and funding to remedy them. There’s no “magic bullet” for getting the scale of investment needed to tackle something like housing insecurity, Butler says.
A further dimension is that some groups are more likely to suffer from housing insecurity—potentially putting them at greater risk from cancer. Research published in 2019 showed that in parts of the US where Black populations suffer mortgage discrimination—that is, where lenders discriminate against customers based on race—the disparity in cancer mortality between Black and white people is also larger. Groups that disproportionately experience housing insecurity are more likely to be those “that have historically been marginalized and have less financial resources to weather their cancer and receive treatment,” says Pollack.
So it’s not one factor alone that likely contributes to cancer disparities, but rather the joint impact of race, ethnicity, housing, and other different factors acting together, argues Biplab Datta, assistant professor at the Institute of Public and Preventive Health at Augusta University. A potential solution is identifying populations that are at greater risk from cancer, he says, and if housing insecurity is higher among a population or location, then critical improvements—such as improving cancer screening and quality of care, and reducing stress—should be pursued in those places, through policy.
In New York City, the patient that Phillips saw was fortunate to receive timely cancer care, despite her obstacles and social risks. But this isn’t the case with every patient—and that will remain the case while housing insecurity remains widespread.
