As we know, lung cancer is the second most common cancer diagnosed and the leading cause of cancer deaths in the US. Housing security is an important social determinant of health, which can influence and be influenced by cancer diagnosis and care across the continuum. There are multiple pathways that housing security can affect the cancer patient, and one of them is housing discrimination. In this study, we looked at area level mortgage denial rates as a marker for sustained lending discrimination and the neighborhood disinvestment. Within exam, the association between residing areas with high mortgage denial rates and receipt of quality cancer care and outcomes for individuals diagnosed with non-small cell lung cancer. Our hypothesis is that housing discrimination leads to reduced access to equitable cancer care and outcomes.
To investigate that, we selected individuals diagnosed with non-small cell lung cancer between 2014 to 2019 from the National Cancer Database, which is a nationwide hospital based cancer registry, captures about 70% of newly diagnosed cases in the US. It is co-sponsored by the American College of Surgeons and American Cancer Society, and it collects detailed and standardized information on patients tumor treatment and outcomes in all states.
The mortgage data were collected from the Home Mortgage Disclosure Act Database, and we estimated the mortgage denial rate as the proportion of denied home loans to the total of completed home loans. In the study, we have multiple outcomes of interest. First, the receipt of guideline concordant care, including surgery or radiation, lymph node evaluation, neoadjuvant chemo radiation, and adjuvant chemotherapy, and the treatment eligibility and the receipt of guideline concordant care were defined based on the National Comprehensive Cancer Network guidelines.
The results show that patients residing in areas with high mortgage denial rates were less likely to receive guideline concordant care for non-small cell lung cancer. This association was consistent across all treatment subgroups, with an exception for neoadjuvant chemo radiation. Our results also show that patients residing in areas with high mortgage denial rates had worse access to timely chemotherapy and had worse overall survival.
Our findings highlight the critical needs to understand the pathways through which institutional practices are leading barriers in access to resources, such as mortgage denials, can negatively affect access to quality cancer care and outcomes. The results also highlight the needs for comprehensive social risk screening within oncology care settings, connecting patient with community resources, potentially with the assistance of social workers, patient navigators, medical legal partnerships, and ultimately identifying and addressing housing security to ensure equitable access to cancer care and decrease the health disparity would require ongoing investment in practice systems and broader policy levels.
