Bridging the Gap: How Housing Status and Race Shape Cancer Screening Disparities

Cancer screening disparities remain a persistent challenge, particularly among underserved populations facing barriers related to housing instability, race, and ethnicity. Leveraging a partnership with a large federally qualified health center (FQHC) in Los Angeles, researchers implemented a multi-component strategy—including targeted outreach, patient navigation, workflow enhancements, and culturally tailored public health campaigns—to improve screening rates for breast, cervical, and colorectal cancers.

Pharmacy Times spoke with Kimlin Ashing, PhD, and Narissa Nonzee, PhD, of City of Hope, about the motivation behind the study, key findings across racial and housing subgroups, and how community partnerships and tailored interventions can help address persistent gaps in cancer prevention and screening.

Pharmacy Times: What initially motivated your team to examine cancer screening disparities specifically through the lens of housing status, and how did you decide to combine that with race and ethnicity as co-variables?
Kimlin Ashing, PhD: So both Dr Nonzee and myself are very committed and dedicated to addressing health disparities, and so we believe we have the cure for certain cancers, and those are the screen detectable cancers. And so given that in our catchment community, we're seeing disparities in stage of diagnosis later stage for those vulnerable populations, we saw that as a high need issue and a high burden community to address disparities and screening for those communities right.

Narissa Nonzee, PhD: And to add on to that, we've had the wonderful privilege of partnering with a very not only a very large federally qualified health center within Los Angeles County, but one of the largest providers of homeless health care as well. And so really understanding that intersection of social determinants of health, whether they manifest itself within housing status or race and ethnicity, really drove the research question behind this.

Pharmacy Times: Can you walk us through the components of the multi-component implementation strategy—and were different components more effective for patients experiencing housing instability compared to those who were stably housed?

Nonzee: There are about 4 main components, a lot of things going on at the same time, but four main components for a multi component strategy. One was really all about community outreach. And this really manifested in the form of text outreach to individuals who are overdue for cancer screenings of the breast, cervix, as well as clone and rectal also manifested in the form of mailed newsletters.

Additionally, there was a component of peer navigation to address social determinants of health that was integrated into our strategy. Third one is point of care workflow enhancements. This could have been in form of, for example, introducing color guard as a modality for colorectal cancer screening, linking with our mobile cancer prevention and screening program to deliver point of care services, for example, for breast and cervical cancer screening, and appointment assistance scheduling from a patient navigator.

And then finally, really taking this broad look at a multi ethnic public health campaign. And of course, Dr. Ashing brings a lot of her expertise to this area, being able to, you know, partner with City of Hope to on print and video education materials and as well, as you know, training for their their staff that's been delivered by City of Hope, see care team and COE.

Ashing: In terms of kind of looking holistically At the organization, what are their strengths and what are their challenges, and really providing, as Dr. Nonzee said, that additional training in the oncology space for their teams, and that included, you know, the medical professional team, as well as the front desk team, because we know that all components of a healthcare system and organization are vital to getting patients to agree and to adhere to best health practices, including cancer screening. We really looked at the whole system and how we can support them in doing the good work that they do.

Pharmacy Times: Housing status is often underreported in clinical settings. How did you operationalize and capture this variable within the Federally Qualified Health Centers’ (FQHC) existing data infrastructure, and what were the limitations of that approach?

Ashing: The clinic that we partner with that's one of their main property populations to serve. So given that they have clinics and infrastructures set up in spaces where those who are unhoused gather for services. So there are clinics, and what you know, in downtown LA, where there's a high proportion of unhoused. So those infrastructure already existed in terms of where people go and know where to go to get care, and so we just harness that and leverage that resource that already exist. And given that that population is primarily highly burden and have later stage diagnosis, it became an important component for us to address in terms of looking at cancer disparities. And you're right, it is a population that's that's underserved and often ignored in the oncology arena, so we were really honored to be able to serve that community.

Nonzee: Right and our community partner, FQHC, is really that that trusted provider right in the community, as Dr Ashley mentioned, and they care for approximately 70,000 you know, patients within LA County, 21% who are unhoused. That's over 14,000 individuals. And to be able to establish that trust over time. I think, yeah, as she mentioned, was really harnessing their strengths in terms of data capture. This is often captured through, you know, initial intake forms with patients, with a patient reported, ideally it's to be updated every year. Implementation wise. Certainly there are challenges with that, but you bring up a good point that measurement could be a little bit of an issue here, but I think again, because of that trusted relationship and close follow up care, whether it's in the primary care setting or in a transitional housing setting, is really what would help improve the validity of that data.

Ashing: So it brings up sort of the importance of cancer centers and academic institutions really partnering with trusted community organizations and advocacy groups to bring cancer care, including preventive care and screening, to those most vulnerable. And so it's incumbent upon us, and so City of Hope is really dedicated to working with those community partners to bring the best of what we know in terms of cancer can prevention to those who could benefit the most.

Pharmacy Times: Which racial or ethnic subgroup showed the most significant change in screening rates, and to what degree do you attribute that shift to the implementation strategy versus broader contextual factors at the FQHC?

Ashing: I'll start off with sort of you know, the big picture summary. So overall, we found, regardless of housing status, but certainly the unhoused had lower rates of screening, as expected. Unfortunately, that African Americans tend to have lower rates of screening, but then also that very high cancer site. So for cervical cancer, we see also the Asian American, Pacific Islander community having lower rates of screening for colorectal in addition to African Americans, indigenous community and Native American community had lower rates of screening.

So we really need to look at sort of community level ethnicity and the type of cancer and the type of screening that's available. So given that for cervical and colon that there are at home screening tests making that more acceptable within those communities. To reduce some of the barriers in terms of transportation and access and convenience would be important, but also language and culturally responsive. Approaches are highly recommended to improve screening for vulnerable populations and communities.

Pharmacy Times: Did the strategy close any pre-existing screening disparities, or did it improve rates broadly while leaving equity gaps intact? How does your team plan to address any gaps that remain?

Ashing: Well, screening, although, you know, sit for a long time and so and we know that that they are life saving. It's challenging addressing all of the cultural context, the fear of cancer, as well as the system level, you know, challenges and barriers in terms of convenience. So it takes dedicated work. Part of the lessons learned from this is that we do need to look at, you know, cancer site and the intersection of cancer site, housing, status, ethnicity, to have more tailored interventions for each of the cancers that we intend to improve screening on.

Also for gender and sex. For cervical cancer, it's women. We did also look at prostate cancer, even though didn't highlight that, because that's not reportable to you know, to HRSA as as as an outcome, but really needing to look at again the intersection of Kansas site, gender, housing status, to have again a multi level, but have it also tailored by the specific cancer side.

Nonzee: Yes and just, you know, continuing the work outside of traditional four walls of a primary care clinic, right? And really, I do believe that the primary care services are also co located with some of their temporary housing, recuperative housing. So how do we expand the delivery and addressing of needs beyond an actual clinic site, and where I think we will continue to take this.

Nonzee: I'll share more, even though you led the initial initiative to be able to secure additional HRSA funds for a mobile cancer prevention in the Screening Unit. Our community partner was really the first to help launch this initiative, and we partnered with them specifically within the Antelope Valley area, where, as you are probably familiar has more role characteristics, and patients were able to receive multiple cancer screenings in a single visit adjacent to a trusted healthcare provider. So that was really a great source of facilitating care.

Pharmacy Times: Given that this work was conducted at a single urban FQHC, what would need to be adapted or tested before this implementation strategy could be replicated at other safety-net settings with different patient populations?

Ashing: Well, actually, one of the reasons we chose this FQHC, federal qualified health clinic. Well, they chose us actually, but the partnership really serve not only multi ethnic but multi and diverse regions. So they do have clinics within our unhoused communities. They do have clinics within urban regions. They do have clinics in rural regions as well. So this allowed us to reach, you know, a wide range of California, Southern California, so we were able to work with community partners to do some tailoring by region. But I think that's one of the gaps that we need to do further, is the tailoring for specific regions.

So, for example, the the rural community. So even though we did have partners providing some influence, some of the the infographics because we also created infographics with very brief and and and messages to improve their awareness of cancer screening and where to get screening, then that could be tailored, maybe even further, to the rural community. So further tailoring of this intervention would clearly, hopefully bring the kinds of, you know, wonderful outcomes that we need where we're seeing increases, you know, in the, you know, 50% increases in screening that we would hope to find.

Nonzee: yeah, I agree, in terms of specifically concrete like, for example, the the outreach strategy may need to be adapted right in terms of the text messages that go out to individuals who are due for cancer screening. And that could be anywhere from content to frequency to the source of the communicator to the modality. And all of these can be tested further to see how we can best provide that precision for the patient populations they're serving.

Ashing: I mean, just want to add, but I think Dr Nonzee said that we're really grateful for the community partner. We couldn't have done it without them, and I think it really exemplifies that cancer centers and academic centers ought to work with community partners and community clinics to bring the best of what we know of cancer care. It should be part of our obligation and sort of our commitment to addressing cancer disparities.

Nonzee: They are the frontline providers who have the deepest knowledge of the community and are the best experts and leaders about how to deliver these services. I would agree with that. And just additional context of this project too, it was funded through the, you know, a HRSA specific HRSA initiative, the access program to be able to accelerate cancer screening and navigation to underserved populations. And this is going on nationwide, where multiple cancer centers and FQHCs are developing these partnerships. So more support for that, I think would be good in the future.