Increasing Breast Cancer Screening in Women Experiencing Homelessness

People experiencing homelessness have an extremely high rate of late-stage cancer diagnosis and associated mortality. Studies estimate that up to 30% of these deaths are due to preventable causes or barriers to timely treatment.

Early screening can reduce deaths from breast cancer by up to 40%. However, in this population, access to screening is hindered by issues such as trouble finding adequate food and shelter, medical care, transportation, reliable phone access and/or social support.

As part of its outreach to medically insecure individuals in Northeast Ohio, Cleveland Clinic Cancer Institute began a mobile mammography program. The Homeless Women Receiving Onsite Patient Education (HOPE) program combines onsite mammography with patient navigation and education for women experiencing homelessness.

Community Outreach staff meet people at local social service agencies, women’s shelters and drug rehab centers, educating them about mammography and helping to address obstacles to getting a regular mammogram. The team began by using two mobile mammography vans on a contract basis to offer mammography screenings at community events in metropolitan Cleveland as well as in the Mansfield and Sandusky areas. Beginning in 2024, they augmented their capabilities with the addition of a 32-foot mobile mammography van of their own, which gives patients access to 3D mammography.

Between 2022-2024, the HOPE program screened more than 150 women. “Considering that there are nearly 10,000 housing-insecure individuals in Cleveland, these numbers are moderate, but these are some of the highest risk and most difficult to reach individuals,” says Heather McKee Hurwitz, PhD, Project Staff with Cleveland Clinic’s Department of Hematology & Medical Oncology.

“Meeting patients face to face where they are really helps to cultivate and build relationships,” says Community Outreach APP Coordinator Stacy Mathews, MSN, CNP. “People often have lots of questions, and we want them to know we’re here for them.”

Supporting vulnerable populations

Through this work, the Community Outreach team discovered key elements to program success, including:

• Fostering partnerships. Cleveland Clinic has longstanding alliances with federally qualified health centers and other social service agencies. These partnerships open doors to the underserved populations the clinic is looking to help. “People generally trust the agency that’s supporting them,” says Ron Lloyd, Director of the Community Outreach program. “By introducing us to these individuals, the agencies help solidify our relationship. If people see that we're there working together, that changes the dynamic and can help build trust in healthcare systems.”

• Understanding barriers to care. The Community Outreach team works with case managers at each agency to reach screening-eligible patients and learn what obstacles may stand in the way of screening. Through a partnership with May Dugan Center, for example, the team publicized onsite mammography events and provided mammograms for people who already visit May Dugan for food assistance. “Sometimes people have pressing issues that prevent them from completing screenings,” explains Lloyd. “When we meet them where they are and support their priority needs, it's easier to bridge that gap.”

The team recognized that language is a common barrier to care. They welcome individuals who speak any language, and provide translation using Cleveland Clinic’s Global Patient Services. Also, the research team translated the survey instruments into Spanish and Arabic to ensure that the study was inclusive of the diverse housing insecure population in Northeast Ohio.

• Educating patients. Education is a core component of the HOPE program. The team empowers women to make informed decisions about their health. They distribute materials to educate women about the importance of mammograms. During outreach events, they also invite people to ask questions about mammograms and other health screenings.

• Offering patient navigation. As part of the HOPE program, patient navigators build relationships with participants at onsite events and then help with coordinating mammograms and any necessary diagnostic follow-up appointments. They support patients and work to make the process as easy as possible, overcoming barriers such as lack of insurance or transportation.

If the patient has abnormal mammogram results, the patient navigator will walk them through setting up a diagnostic mammogram. In addition to the navigator, the team’s designated Advanced Practice Provider (APP) makes sure they understand their test results, and addresses any concerns, from screening fears to barriers to starting the cancer treatment journey if needed.

As part of the navigation team’s “concierge” services, patients can also receive Uber Health Rides to/from their follow-up appointments. This support helps overcome transportation concerns, which are one of the most common barriers to screening.

• Offering psychosocial support. Patient navigators recognize that cancer screening comes with associated fears. They provide an extra layer of support to guide people through the continuum of care, which can be difficult to navigate without assistance. This support is beneficial not only for an initial mammogram, but also to help ensure patients receive regular screenings.

“Data shows that having a comprehensive approach to providing all these elements is necessary [for a successful screening program],” says Hurwitz. “Strong partnerships are central to this work."

Hearing from under-represented patients

Building on this program, the Community Outreach team secured grant funding for a research study to better understand barriers that people in under-resourced communities face in getting cancer screenings. For the study, researchers asked women getting mobile mammography to share their views about breast cancer screenings as well as what obstacles they faced in getting timely screenings.

In the first year of the program, 41 women participated in the survey, with 124 more participating in the subsequent two years. Survey participants were women ages 40 and older who were eligible for a mammography screening and who were experiencing homelessness.

The survey results helped to dispel some common misconceptions about this population. For example, beliefs that people were skeptical of preventative screenings or worried that a mammogram would be painful turned out to be false among these survey respondents. Nearly all survey respondents (90%) agreed with the statement that they saw value in preventative care screenings. Of the respondents, 12% reported barriers to screening such as fear, anxiety, location, addiction, lack of transportation, under-prioritizing health and the costs of health care.

“There are many myths that people experiencing homelessness don’t consider screening a priority,” says Lloyd. “They do, but it doesn’t rank as high at the moment in time. What we’re trying to do is establish a presence out in the community, make sure their needs are being met and ensure we’re available to help them when the time is right.”

What’s next

The Community Outreach team has been enacting the Harold Freeman model of patient navigation and community outreach for cancer prevention since 2005 in seven medically under-resourced “zones” across Northeast Ohio. They continue to examine the HOPE study findings to improve their support to under-represented patients. “Our focus is on building trusting relationships as a key to excellent patient care and addressing cancer disparities,” says Hurwitz. The HOPE program will remain one of the important projects for the Community Outreach team.