{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,11,11]],"date-time":"2026-11-11T06:54:18Z","timestamp":1794380058403,"version":"4.9.0"},"reference-count":47,"publisher":"BMJ","issue":"9","license":[{"start":{"date-parts":[[2024,9,12]],"date-time":"2024-09-12T00:00:00Z","timestamp":1726099200000},"content-version":"unspecified","delay-in-days":11,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"name":"Benioff Homelessness and Housing Initiative","award":["N\/A"],"award-info":[{"award-number":["N\/A"]}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2024,7,18]]},"published-print":{"date-parts":[[2024,9]]},"abstract":"<jats:sec>\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>Cancer is a leading cause of death in unhoused adults. We sought to examine the association between housing status, stage at diagnosis and all-cause survival following cancer diagnosis at a public hospital.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>Retrospective cohort study examining new cancer diagnoses between 1 July 2011 and 30 June 2021.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Setting<\/jats:title>\n                    <jats:p>A public hospital in San Francisco.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Exposure<\/jats:title>\n                    <jats:p>Housing status (housed, formerly unhoused, unhoused) was ascertained via a county-wide integrated dataset that tracks both observed and reported homelessness.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We reported univariate analyses to investigate differences in demographic and clinical characteristics by housing group. We then constructed Kaplan-Meier curves stratified by housing group to examine unadjusted all-cause mortality. Finally, we used multivariable Cox proportional hazards models to compare the hazard rate of mortality for each housing status group, adjusting for demographic and clinical factors.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Our cohort included 5123 patients with new cancer diagnoses, with 4062 (79%) in housed patients, 623 (12%) in formerly unhoused patients and 438 (9%) in unhoused patients. Unhoused and formerly unhoused patients were more commonly diagnosed with stage 4 disease (28% and 27% of the time, respectively, vs 22% of housed patients). After adjusting for demographic and clinical characteristics, unhoused patients with stage 0\u20133 disease had a 50% increased hazard of death (adjusted HR (aHR) 1.5, 95% CI 1.1 to 1.9; p&lt;0.004) as did formerly unhoused patients (aHR 1.5, 95% CI 1.2 to 1.9; p=0.001) compared with housed individuals 3\u2009months after diagnosis.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Unhoused and formerly unhoused patients diagnosed with non-metastatic cancer had substantially increased hazards of death compared with housed patients cared for in a public hospital setting. Current or former lack of housing could contribute to poor outcomes following cancer diagnoses via multiple mechanisms.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2024-088303","type":"journal-article","created":{"date-parts":[[2024,9,12]],"date-time":"2024-09-12T14:46:54Z","timestamp":1726152414000},"page":"e088303","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":11,"title":["Association of housing status and cancer diagnosis, care coordination and outcomes in a public hospital: a retrospective cohort study"],"prefix":"10.1136","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0850-4134","authenticated-orcid":false,"given":"Hannah","family":"Decker","sequence":"first","affiliation":[{"name":"Department of Surgery, UCSF, San Francisco, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sara","family":"Colom","sequence":"additional","affiliation":[{"name":"Benioff Homelessness and Housing Initiative, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jennifer L","family":"Evans","sequence":"additional","affiliation":[{"name":"Benioff Homelessness and Housing Initiative, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dave","family":"Graham-Squire","sequence":"additional","affiliation":[{"name":"Benioff Homelessness and Housing Initiative, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kenneth","family":"Perez","sequence":"additional","affiliation":[{"name":"Benioff Homelessness and Housing Initiative, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Margot","family":"Kushel","sequence":"additional","affiliation":[{"name":"Benioff Homelessness and Housing Initiative, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA"},{"name":"Department of Internal Medicine, UCSF, San Francisco, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elizabeth","family":"Wick","sequence":"additional","affiliation":[{"name":"Department of Surgery, UCSF, San Francisco, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maria C","family":"Raven","sequence":"additional","affiliation":[{"name":"Benioff Homelessness and Housing Initiative, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA"},{"name":"Department of Emergency Medicine, University of California San Francisco, San Francisco, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hemal K","family":"Kanzaria","sequence":"additional","affiliation":[{"name":"Benioff Homelessness and Housing Initiative, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA"},{"name":"Department of Emergency Medicine, University of California San Francisco, San Francisco, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2024,9,12]]},"reference":[{"key":"2025121601011528000_14.9.e088303.1","doi-asserted-by":"crossref","first-page":"1529","DOI":"10.1016\/S0140-6736(14)61132-6","article-title":"The health of homeless people in high-income countries: descriptive epidemiology, health consequences, and clinical and policy recommendations","volume":"384","author":"Fazel","year":"2014","journal-title":"The Lancet"},{"key":"2025121601011528000_14.9.e088303.2","doi-asserted-by":"publisher","DOI":"10.3122\/jabfm.2019.04.180374"},{"key":"2025121601011528000_14.9.e088303.3","doi-asserted-by":"crossref","first-page":"e128","DOI":"10.1016\/S2468-2667(23)00298-0","article-title":"Cancer risk factors and access to cancer prevention services for people experiencing homelessness","volume":"9","author":"Jeleff","year":"2024","journal-title":"Lancet Public Health"},{"key":"2025121601011528000_14.9.e088303.4","doi-asserted-by":"crossref","first-page":"289","DOI":"10.1080\/17457300.2013.825631","article-title":"Homeless in America: injuries treated in US emergency departments, 2007-2011","volume":"21","author":"Mackelprang","year":"2014","journal-title":"Int J Inj Contr Saf Promot"},{"key":"2025121601011528000_14.9.e088303.5","unstructured":"The California statewide study of people experiencing homelessness toward a new understanding, 2023."},{"key":"2025121601011528000_14.9.e088303.6","doi-asserted-by":"crossref","first-page":"413","DOI":"10.1016\/j.annemergmed.2022.01.003","article-title":"Beyond homelessness: expounding on housing inequality and racism","volume":"79","author":"Winfield","year":"2022","journal-title":"Ann Emerg Med"},{"key":"2025121601011528000_14.9.e088303.7","doi-asserted-by":"publisher","DOI":"10.1001\/archpedi.1991.02160100041021"},{"key":"2025121601011528000_14.9.e088303.8","doi-asserted-by":"crossref","first-page":"1052","DOI":"10.1001\/jamainternmed.2022.3697","article-title":"Factors associated with mortality among homeless older adults in California: the HOPE hOME study","volume":"182","author":"Brown","year":"2022","journal-title":"JAMA Intern Med"},{"key":"2025121601011528000_14.9.e088303.9","first-page":"66","article-title":"Aging trends in homeless populations","volume":"12","author":"Culhane","year":"2013","journal-title":"Contexts (Berkeley Calif)"},{"key":"2025121601011528000_14.9.e088303.10","doi-asserted-by":"publisher","DOI":"10.1093\/geront\/gnw011"},{"key":"2025121601011528000_14.9.e088303.11","doi-asserted-by":"crossref","first-page":"e84","DOI":"10.1016\/S1470-2045(23)00567-3","article-title":"Cancer care and treatment during homelessness","volume":"25","author":"Asgary","year":"2024","journal-title":"Lancet Oncol"},{"key":"2025121601011528000_14.9.e088303.12","doi-asserted-by":"publisher","DOI":"10.1016\/j.amepre.2015.03.038"},{"key":"2025121601011528000_14.9.e088303.13","doi-asserted-by":"crossref","DOI":"10.1001\/jamanetworkopen.2023.49143","article-title":"Housing status, cancer care, and associated outcomes among US veterans","volume":"6","author":"Decker","year":"2023","journal-title":"JAMA Netw Open"},{"key":"2025121601011528000_14.9.e088303.14","unstructured":"Secretary Shinseki details plan to end homelessness for veterans, 2023. Available: https:\/\/www.va.gov\/opa\/pressrel\/pressrelease.cfm?id=1807"},{"key":"2025121601011528000_14.9.e088303.15","unstructured":"Mcconville S , Kanzaria H , Hsia R , et al . n.d. How hospital discharge data can inform state homelessness policy."},{"key":"2025121601011528000_14.9.e088303.16","unstructured":"The 2023 annual homelessness assessment report. 2023."},{"key":"2025121601011528000_14.9.e088303.17","unstructured":"ZSFG fiscal year 2022-2023 annual report, 2023. Available: https:\/\/live-zsfgcare.pantheonsite.io\/wp-content\/uploads\/2023\/11\/Health-Commission-Final-ZSFG-FY-Annual-Report-2022-2023.pdf"},{"key":"2025121601011528000_14.9.e088303.18","unstructured":"San Francisco general hospital fiscal year report 2011-2012. 2012."},{"key":"2025121601011528000_14.9.e088303.19","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(07)61602-X"},{"key":"2025121601011528000_14.9.e088303.20","doi-asserted-by":"crossref","first-page":"1866","DOI":"10.1377\/hlthaff.2019.00082","article-title":"Frequent emergency department users: focusing solely on medical utilization misses the whole person","volume":"38","author":"Kanzaria","year":"2019","journal-title":"Health Aff (Millwood)"},{"key":"2025121601011528000_14.9.e088303.21","unstructured":"N.d. Death clearance manual minimum requirements and best practices for conducting death clearance."},{"key":"2025121601011528000_14.9.e088303.22","unstructured":"NAACCR Data Dictionary . Version 24 - data item #605: inpatient status, Available: https:\/\/apps.naaccr.org\/data-dictionary\/data-dictionary\/version=24\/data-item-view\/item-number=605\/"},{"key":"2025121601011528000_14.9.e088303.23","doi-asserted-by":"crossref","first-page":"1143","DOI":"10.1007\/s11606-022-07873-y","article-title":"Cluster analysis of the highest users of medical, behavioral health, and social services in San Francisco","volume":"38","author":"Hewlett","year":"2023","journal-title":"J Gen Intern Med"},{"key":"2025121601011528000_14.9.e088303.24","doi-asserted-by":"publisher","DOI":"10.1007\/s11999-014-3686-7"},{"key":"2025121601011528000_14.9.e088303.25","doi-asserted-by":"crossref","DOI":"10.1186\/s12889-022-13499-w","article-title":"Unmet health needs and barriers to health care among people experiencing homelessness in San Francisco\u2019s Mission District: a qualitative study","volume":"22","author":"Thorndike","year":"2022","journal-title":"BMC Public Health"},{"key":"2025121601011528000_14.9.e088303.26","doi-asserted-by":"crossref","DOI":"10.2196\/10049","article-title":"Mobile phone, computer, and internet use among older homeless adults: results from the HOPE HOME cohort study","volume":"6","author":"Raven","year":"2018","journal-title":"JMIR Mhealth Uhealth"},{"key":"2025121601011528000_14.9.e088303.27","doi-asserted-by":"crossref","first-page":"3707","DOI":"10.1007\/s11606-022-07471-y","article-title":"Health impact of street sweeps from the perspective of healthcare providers","volume":"37","author":"Qi","year":"2022","journal-title":"J Gen Intern Med"},{"key":"2025121601011528000_14.9.e088303.28","doi-asserted-by":"crossref","unstructured":"Decker H , Raguram M , Kanzaria HK , et al . Provider perceptions of challenges and facilitators to surgical care in unhoused patients: a qualitative analysis, 2023.","DOI":"10.1016\/j.surg.2023.11.009"},{"key":"2025121601011528000_14.9.e088303.29","doi-asserted-by":"publisher","DOI":"10.1093\/jncimonographs\/lgs005"},{"key":"2025121601011528000_14.9.e088303.30","doi-asserted-by":"crossref","first-page":"1095","DOI":"10.1016\/j.surg.2023.11.009","article-title":"Provider perceptions of challenges and facilitators to surgical care in unhoused patients: A qualitative analysis","volume":"175","author":"Decker","year":"2024","journal-title":"Surgery"},{"key":"2025121601011528000_14.9.e088303.31","doi-asserted-by":"crossref","first-page":"357","DOI":"10.1001\/jamainternmed.2019.6010","article-title":"Disparities in care and mortality among homeless adults hospitalized for cardiovascular conditions","volume":"180","author":"Wadhera","year":"2020","journal-title":"JAMA Intern Med"},{"key":"2025121601011528000_14.9.e088303.32","doi-asserted-by":"crossref","first-page":"774","DOI":"10.1016\/j.amepre.2020.12.012","article-title":"The problem of veteran homelessness: an update for the new decade","volume":"60","author":"Tsai","year":"2021","journal-title":"Am J Prev Med"},{"key":"2025121601011528000_14.9.e088303.33","doi-asserted-by":"crossref","first-page":"234","DOI":"10.1377\/hlthaff.2023.01003","article-title":"Housing status changes are associated with cancer outcomes among US veterans","volume":"43","author":"Decker","year":"2024","journal-title":"Health Aff (Millwood)"},{"key":"2025121601011528000_14.9.e088303.34","doi-asserted-by":"crossref","first-page":"e344","DOI":"10.1016\/S1470-2045(18)30200-6","article-title":"Cancer screening in the homeless population","volume":"19","author":"Asgary","year":"2018","journal-title":"Lancet Oncol"},{"key":"2025121601011528000_14.9.e088303.35","doi-asserted-by":"crossref","first-page":"276","DOI":"10.1353\/hpu.2010.0070","article-title":"Cancer screening in homeless women: attitudes and behaviors","volume":"9","author":"Long","year":"1998","journal-title":"J Health Care Poor Underserved"},{"key":"2025121601011528000_14.9.e088303.36","unstructured":"Chau S , Chin M , Chang J , et al . Cancer risk behaviors and screening rates among homeless adults in Los Angeles County. Cancer Epidemiol Prev Biomarkers 2002;11."},{"key":"2025121601011528000_14.9.e088303.37","doi-asserted-by":"crossref","first-page":"529","DOI":"10.1016\/j.whi.2014.06.002","article-title":"Breast cancer screening among homeless women of New York City shelter-based clinics","volume":"24","author":"Asgary","year":"2014","journal-title":"Womens Health Issues"},{"key":"2025121601011528000_14.9.e088303.38","doi-asserted-by":"crossref","DOI":"10.1186\/s12939-023-01920-8","article-title":"Water, Sanitation, and Hygiene (WaSH) insecurity in unhoused communities of Los Angeles, California","volume":"22","author":"Avelar Portillo","year":"2023","journal-title":"Int J Equity Health"},{"key":"2025121601011528000_14.9.e088303.39","doi-asserted-by":"crossref","first-page":"883","DOI":"10.1097\/SLA.0000000000005917","article-title":"Association of Housing Status With Types of Operations and Postoperative Health Care Utilization","volume":"278","author":"Decker","year":"2023","journal-title":"Ann Surg"},{"key":"2025121601011528000_14.9.e088303.40","unstructured":"A Rule by the Centers for Medicare & Medicaid Services on . Medicare program; Hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system and policy changes and fiscal year 2023 rates; quality programs and medicare promoting interoperability Pr.2023. Available: https:\/\/www.federalregister.gov\/documents\/2022\/08\/10\/2022-16472\/medicare-program-hospital-inpatient-prospective-payment-systems-for-acute-care-hospitals-and-the"},{"key":"2025121601011528000_14.9.e088303.41","doi-asserted-by":"crossref","first-page":"995","DOI":"10.1097\/SLA.0000000000005455","article-title":"The persistence of poverty and its impact on cancer diagnosis, treatment and survival","volume":"277","author":"Papageorge","year":"2023","journal-title":"Ann Surg"},{"key":"2025121601011528000_14.9.e088303.42","doi-asserted-by":"publisher","DOI":"10.1377\/hlthaff.2019.01246"},{"key":"2025121601011528000_14.9.e088303.43","doi-asserted-by":"crossref","first-page":"291","DOI":"10.1001\/jamaoncol.2023.6814","article-title":"Examining medicaid waivers-an opportunity to promote equity in cancer care","volume":"10","author":"Greene","year":"2024","journal-title":"JAMA Oncol"},{"key":"2025121601011528000_14.9.e088303.44","unstructured":"Home. n.d. Available: https:\/\/www.dhcs.ca.gov\/CalAIM\/ECM\/Pages\/Home.aspx"},{"key":"2025121601011528000_14.9.e088303.45","doi-asserted-by":"crossref","first-page":"164","DOI":"10.1377\/hlthaff.2023.01049","article-title":"Homelessness and health: factors, evidence, innovations that work","volume":"43","author":"Garcia","year":"2024","journal-title":"Health Aff (Millwood)"},{"key":"2025121601011528000_14.9.e088303.46","doi-asserted-by":"crossref","first-page":"499","DOI":"10.1353\/hpu.2013.0053","article-title":"Medical respite programs for homeless patients: a systematic review","volume":"24","author":"Doran","year":"2013","journal-title":"J Health Care Poor Underserved"},{"key":"2025121601011528000_14.9.e088303.47","doi-asserted-by":"crossref","first-page":"226","DOI":"10.1377\/hlthaff.2023.01039","article-title":"Mortal systemic exclusion yielded steep mortality-rate increases in people experiencing homelessness, 2011\u201320","volume":"43","author":"Fowle","year":"2024","journal-title":"Health Aff (Millwood)"}],"container-title":["BMJ Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjopen-2024-088303","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,12,16]],"date-time":"2025-12-16T09:01:32Z","timestamp":1765875692000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmjopen.bmj.com\/lookup\/doi\/10.1136\/bmjopen-2024-088303"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,9]]},"references-count":47,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2024,9,12]]},"published-print":{"date-parts":[[2024,9]]}},"alternative-id":["10.1136\/bmjopen-2024-088303"],"URL":"https:\/\/doi.org\/10.1136\/bmjopen-2024-088303","relation":{"has-part":[{"id-type":"doi","id":"https:\/\/doi.org\/10.1136\/bmjopen-2024-088303.supp1","asserted-by":"subject"}]},"ISSN":["2044-6055","2044-6055"],"issn-type":[{"value":"2044-6055","type":"print"},{"value":"2044-6055","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,9]]}}}