Chirag Shah, MD

Heather Hurwitz


Cleveland Clinic Taussig Cancer Institute

Breast Cancer

Pilot Grant

Sexual and Gender Minorities HOPE

Breast cancer is the most common non-skin cancer and affects persons of all genders and sexualities. While cancer outcomes have improved in the past few decades, persons experiencing homelessness (PEH) have higher rates of cancer mortality with a potential cause of a lack of regular cancer screenings. While a lack of access to screenings and barriers such as health insurance, housing, and transportation inhibit all PEH, we identified a need to also provide culturally tailored and inclusive breast/chest screening onsite at shelters for sexual and gender minority persons (SGM), who experience homelessness twice as often as the general population across their lifetimes. In addition, SGM persons require specialized preventative cancer care that attends to their lived and embodied experiences, and addresses additional barriers such as minority stress and discrimination, and higher incidences of substance abuse and HIV+/AIDS.

This project expands our previous onsite mammography and education program initially developed for women experiencing homelessness and addresses SGM PEH by achieving the following aims: 1) collecting sexual orientation and gender identity data about participants to better describe the population; 2) identifying best practices to deliver inclusive preventative cancer screenings, education, and patient navigation specifically to SGM PEH by creating culturally appropriate breast/chest screenings; and 3) tailoring mammography for trans-men and trans-women PEH, depending on breast/chest presentations, utilization of hormone therapy, and healthcare experiences. We will continue the original program by 4) researching additional barriers to preventative care and 5) demonstrating the cost-effectiveness of the program. Initial outcomes have shown that most participants believe in preventative screening, indicating that novel services, such as onsite mammography coupled with education and wrap around services may address barriers to screening among PEH.

As we develop a program to serve PEH, and specifically include SGM persons, we will also be developing clinical recommendations for serving SGM patients. Few studies have evaluated screening behaviors and beliefs among unhoused women and SGM. This study will, for the first time, illuminate factors associated with screening practices within this highly vulnerable population. We do this by collecting data among PEH. Going onsite to shelters, we meet with and develop relationships with PEH. The research coordinator attends events and after PEH receive a mammogram, they are invited to fill out a questionnaire. In addition, the patient navigator collects patient information in the electronic health record (EHR). We use the

EHR to collect patient level data about barriers, the mammogram services received, diagnosis, and to follow up with patients. Results will be stratified by race, which will provide data to examine the unique barriers potentially contributing to any screening inequities among Black and white persons and persons of other races/ethnicities within the larger unhoused population.

Although the amount of change expected from this study cannot be explicitly quantified, the outcomes from this work will, ideally, inform future interventions that aim to address barriers to early detection of cancer among PEH. Ultimately our goal is to develop a program specifically designed to improve precancerous breast/chest screening rates among racial and sexual minorities. We intend to disseminate our findings in peer-reviewed journals. We hope our published work will generate a national health policy dialogue regarding the design and implementation of screening interventions for women and SGM PEH.

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