Homelessness and cancer care: a missing priority in the Australian Cancer Plan

The 2023 Australian Cancer Plan (ACP) is a ten‐year national strategy that aims to achieve equity in cancer outcomes for all Australians.1 The ACP identifies ten priority groups requiring targeted action, including Aboriginal and Torres Strait Islander people, people with disability, and people from culturally and linguistically diverse backgrounds. These groups were identified as having worse cancer outcomes than other Australians. Research consistently shows that social determinants, including socio‐economic status, income, education, employment, housing, and social support, considerably influence health outcomes.2 It is therefore paramount to address factors that hinder equitable access to these social determinants, while considering nuanced vulnerabilities experienced by specific groups.

Homelessness is a socially determined circumstance, often arising from intersecting economic, housing, structural and interpersonal factors.3 It is experienced by more people than those who are visibly “sleeping rough”. It also includes people who live in emergency and temporary accommodation, people who reside in vehicles, those who rely on “couch surfing”, or those who live in substandard housing (eg, with poor sanitation).4 The number of Australians living in these circumstances is rising due to a variety of factors, such as unaffordable housing, limited housing availability, and rising cost of living.5,6 The most common primary reasons for seeking specialist homelessness services in 2023–24 were family and domestic violence and the current housing crisis.7

Australia has made substantial gains in cancer survival, with population five‐year survival rates rising from 50% to 72% over the past two decades.8 However, these improvements are not equally shared. It is critical that the ACP directs focused attention to groups whose survival rates remain low. People experiencing homelessness are absent from the ACP, despite facing profound health inequities.3 This is particularly relevant in the context of Australia’s worsening housing crisis5 because housing insecurity is adversely associated with cancer care and outcomes.9

Homelessness in Australia

In the 2021 census, it was estimated that more than 122 000 Australians were experiencing homelessness.10 Despite concerted efforts to capture the number of people experiencing homelessness in the 2021 census, the Australian Bureau of Statistics acknowledged it likely underestimated the true number.11 Analysing multiple data sources is required to obtain a more complete picture.12

People experiencing homelessness are a heterogenous group whose identities often intersect with multiple priority populations identified in the ACP.4 There is a risk of further marginalising individuals whose needs fall outside those in the priority populations specified in the ACP. The profound health vulnerabilities among this population coupled with the rising homelessness crisis warrants their recognition as a standalone population.

Cancer and homelessness

There are limited data on the number of people who experience homelessness and cancer concurrently in Australia. One scoping review examining cancer care and treatment during homelessness found 19 studies, of which only nine were primary data studies and none were conducted in Australia.13 As noted by the author, people experiencing homelessness have a cancer incidence up to four times higher and a mortality rate twice as large as the general population.13 A systematic review of studies from the United States found that housing insecurity was associated with worse cancer care or outcomes.9 Further research is needed to understand the extent of cancer‐related health inequities for people experiencing homelessness in Australia and to inform targeted interventions.

Cancer screening

Cancer screening programs are necessary to ensure early detection and improve survival rates. International evidence suggests that people experiencing homelessness face multiple barriers to screening, including limited access to primary care, low health literacy, stigma, trauma, and logistical challenges such as having no fixed address.14

Australian research has identified trauma, limited access to a regular or female general practitioner, time constraints, previous negative experiences, fear of results, and past sexual assault as key barriers to cervical screening.15 These authors trained specialist homelessness service providers to discuss screening and support clients’ access to cervical screening, although they reported no changes to actual screening behaviours were seen because of this intervention.15 Regardless, this approach is akin to a recent Australian study, which found that people experiencing homelessness engaged with health assessments when offered through trusted specialist homelessness services and staff.16 Collectively, these highlight possible pathways for increasing screening among people experiencing homelessness. These opportunities can also be informed by recent national and international calls for greater support and flexible, trauma‐informed health care for people experiencing homelessness.17,18 Further research should explore screening program‐specific considerations for increasing access for people experiencing homelessness.

Treatment and aftercare

Besides providing acceptable cancer screening programs for people experiencing homelessness, Australian health systems must ensure effective post‐diagnosis treatment pathways. International evidence shows that homelessness is linked to both later‐stage diagnoses and treatment delays.13,19

Clinical management of cancer often requires complicated treatment regimens and multidisciplinary specialists.20,21 Even with early diagnosis, cancer treatment typically requires navigating complex health systems, attending multiple appointments, ongoing communication, and high health literacy.13 These demands can be especially challenging for people experiencing homelessness who may have limited access to transport, mail and phone communication, and appropriate educational materials and resources.

Cancer treatments can cause many serious side effects. Nausea and vomiting affect about 80% of patients undergoing chemotherapy and, if left untreated, can lead to metabolic disorders, dehydration, and oesophageal tears.22

Tumour‐ and treatment‐induced immunosuppression increases susceptibility to infection, which is associated with increased mortality and morbidity.23 Typical advice includes maintaining good hygiene and avoiding cuts and abrasions, all of which are difficult for people experiencing homelessness.

Nutritional deficits are associated with increased risk of post‐treatment complications and poorer cancer‐related outcomes.24 Accessing nutritious food is challenging for people experiencing homelessness and many have poor nutrition when diagnosed due to a reliance on food donations or cheap, nutrient‐poor foods.25

Barriers to cancer care

People experiencing homelessness face a range of barriers when accessing cancer care, and general health care more broadly. The social circumstances (eg, economic, housing, interpersonal, individual and structural factors)2 that can lead to homelessness can also influence a person’s response to and engagement with health care.

For example, many people experiencing homelessness have also experienced considerable trauma, including childhood adversity and violence, which can affect trust in health care services and adherence to recommended medical treatment.26 Therefore, cancer services need to adopt trauma‐informed approaches.

A systematic review examining homelessness stigma and its relationship to health found that perceptions of stigma were related with poorer general health and service avoidance.27 This is particularly problematic for conditions such as cancer, as management often requires sustained engagement across multiple appointments and providers.

Evidence from one US study highlighted additional barriers when people experiencing homelessness underwent cancer treatment as hospital inpatients.28 Despite longer lengths of stay, they were less likely to receive invasive procedures (eg, surgery), or systemic therapies (eg, chemotherapy) compared with people in stable housing who were diagnosed with the same type and stage of cancer. It is possible these differences in treatments were related to bias and discrimination.

People experiencing homelessness also face practical barriers, such as medication insecurity (eg, theft of pain relief)29 and transport costs, as well as structural barriers, including substantial health care expenses and difficulties navigating the health care and social systems.30 For example, the Australian Patient Assisted Travel Schemes are only available to those with a fixed address,31 excluding some people experiencing homelessness who need to travel for treatment.

Previous negative experiences of the health care system and distrust of government organisations compound barriers to appropriate and timely health care access.32 Therefore, people experiencing homelessness likely face multifaceted barriers at every point in their cancer journey.

Pathways to equity

Development of a Housing First policy is a priority for people experiencing homelessness and is supported by the Royal Australian College of General Practitioners.33 Housing First policies provide immediate housing to people experiencing homelessness without pre‐conditions, prioritising stability as a foundation for building wellbeing.34 In the context of cancer care, this would require coordination between health and social systems to provide immediate temporary accommodation during cancer treatment and recovery, followed by prioritisation for long term housing.

In addition, prioritising people experiencing homelessness as needing urgent and targeted action might reduce cancer‐related inequities. Examples of targeted solutions include defining the cancer care team at diagnosis (including community‐based outreach teams), standardising record keeping of preferences and reasons for care deviations, and ensuring communication between patients and their team.30

Tailored navigation strategies may improve cancer screening participation, shorten the time from screening to diagnosis and treatment, improve treatment adherence, and enhance quality of life and patient satisfaction.35 It is recommended that development of patient navigation strategies consider the needs of people experiencing homelessness. Further recommended health system responses are listed in the Box.

Conclusion

Without concerted efforts, cancer‐related health inequities faced by people experiencing homelessness in Australia are unlikely to be resolved. Further research is needed to understand cancer experiences of people experiencing homelessness and ways in which cancer screening and treatment can be tailored to needs. Delivering cancer care services that are acceptable and accessible to people experiencing homelessness may foster better engagement with the health care system more broadly. This may benefit other priority populations in the ACP that share intersecting identities with people experiencing homelessness. The changes we recommend would be a powerful catalyst to enable Australia to meet the ACP’s objective to “improve cancer outcomes for all Australians, and particularly for those groups whose health outcomes are poorest”.1