Housing assistance, Outcomes, Medicare, and SEER (HOMES): using a novel data linkage to understand cancer inequities

Project Summary Socioeconomic and racial disparities in cancer care and outcomes among older adults have been persisted and even widened in recent years. At the same time, the lack of safe and affordable housing has become a national crisis. Despite the strong potential for housing insecurity to impact cancer inequities, there is a paucity of evidence connecting these two areas. The Housing assistance, Outcomes, MEdicare, and SEER (HOMES) Study is a highly innovative investigation of the association between housing insecurity and cancer inequities. It focuses on the role of federal housing assistance which, through a variety of programs, including Housing Choice Vouchers, public housing, and multifamily housing, limit household spending on rent and utilities. By increasing housing affordability and stability, improving housing quality, changing neighborhood context, and connecting residents with health and social services, federal housing assistance has the potential to improve the quality of care that patients with cancer receive and, more broadly, shed light on the intersection of cancer and housing. The study focuses on older adults diagnosed with breast, colorectal, prostate, and non- small cell lung cancers given their high incidence and well-documented inequities. The study makes use of a novel dataset being constructed by the National Cancer Institute that merges linked SEER-Medicare data on patients diagnosed (2006-2019) with U.S. Department of Housing and Urban Development data on the receipt of federal housing assistance. Because individuals who receive housing assistance may be fundamentally different from those who do not, the study makes use of an innovative pseudo-waitlist control design that leverages the limited supply of housing assistance relative to demand and the random timing of the receipt of housing assistance. The first aim examines the overall relationship between receipt of federal housing assistance and cancer care (time to treatment, receipt of guideline concordant care, emergency department visits) and outcomes (stage at diagnosis). The second aim investigates whether these relationships vary by cancer site and, given experiences of systemic racism that intersect with cancer disparities and housing policy, by race/ethnicity. The final aim studies whether the association between housing assistance and cancer care and outcomes varies by the form of housing assistance and across different neighborhood contexts. Informed by a policy advisory committee in conjunction with representatives from the American Cancer Society Cancer Action Network and National Cancer Roundtables, the HOMES Study has the strong potential to provide actionable housing and cancer policy recommendations and inform changes to practice designed to improve cancer equity.