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PQI: Social Determinants of Health in Cancer

Background: This PQI identifies social determinants of health (SDOH) as they relate to cancer patients and incorporates strategies to address patients’ social needs.

Description: Social determinants of health (SDOH) are the conditions in the environment where people are born, live, learn, work, play, worship, and age which have an impact on various healthcare matters. Economic stability; education; health and health care; neighborhood and built environment; and social and community context are the five domains of SDOH1. The domains are interconnected, as patients with low economic stability (LES) may reside in environments with high air pollutants, food deserts and unsuitable housing. Patients with LES have increased odds of lacking health insurance, formal education and transportation to appointments which can exacerbate oncology outcomes from adherence or health literacy issues2. Having a lack of access to education and/or receiving a poor quality of education may prevent cancer patients from achieving optimal health outcomes due to potential adherence issues secondary to a lack of understanding of their care plan.

To promote more equitable care for cancer patients, it is pivotal to understand different aspects of SDOH so that healthcare workers are better equipped to facilitate quality care. In a cross-sectional survey of 165 physicians in oncology and hematology, 93% agreed that SDOH had a significant impact on their patient’s health outcomes. Additionally, 81% of physicians indicated that they and their staff had limited time to spend assisting patients with social needs and 76% reported that assistance programs (to help patients with social needs) were not readily accessible3. This PQI provides a social need screening assessment kit derived from the Health Leads Social Needs Screening Toolkit to assist all healthcare workers identify social needs for cancer patients and provide recommendations to address those needs.4

PQI Process:4,5,6 Table 1 below lists key questions for nurses/medical assistance to ask patients during the pre-screening stage of their appointment, in order to identify social needs and provides recommendations/resources to address those needs during their care with the clinician. Refer patients to social work, counseling services, case management, and patient navigation as appropriate.



1. In the last 12 months, did you ever eat less than you felt you should because there wasn't enough money for food?
Yes
No

2. Are you worried that in the next 2 months, you may not have stable housing?
Yes
No

3. In the last 12 months, has the electric, gas, oil, or water company threatened to shut off your services in your home?
Yes
No

4. In the last 12 months, have you ever had to go without health care because you didn't have a way to get there?
Yes
No

5. Do you ever need help reading hospital materials?
Yes
No

6. Do problems getting child care make it difficult for you to work or study?
Yes
No
Not applicable

7. Do you feel that you lack companionship?
Yes
No

8. Over the past 2 weeks, how often have you been bothered by any of the following problems?
A. Little Interest or pleasure in doing things?
Not at all
Several days
More than half the days
Nearly every day

B. Feeling down, depressed, or hopeless?
Not at all
Several days
More than half the days
Nearly every day

9. Do you experience physical violence or emotional trauma in or outside of home?
Yes
No

10. As of today, do you have a job?
Yes
No

11. In the last 12 months, have you needed to see a doctor, but could not because of cost?
Yes
No

Patient Centered Activities:
1. Refer patients to the following resources:
2. For local housing assistance, refer patients to the Department of Housing and Urban Development's (HUD) Resource Locator. HUD also provides numerous housing assistance resources on their Housing Assistance Exchange.
3. Those who may need assistance paying their home energy bills may be eligible to participate in the Low-Income Home Energy Assistance Program (LIHEAP). Providers can help their patients assess general eligibility, or put them in contact with their local LIHEAP office.
4. Consider utilizing telehealth services if and when appropriate, especially for patients with barriers to transportation.

To assist Medicaid patients with transportation concerns, utilize CMS' Medicaid Non-Emergency Medical Transportation Booklet for Providers.

For elderly patients or those with a disability affecting transportation, visit the Eldercare Locator, provided by the U.S. Administration on Aging, to locate local transportation services.

For local transportation services, the following resources offers transportation to patients traveling to cancer-related medical appointments
5. Provide patients with an NCODA OCE/IVE sheet specific to their cancer regimen
Providers can assess a patient's health literacy using the Agency for Healthcare Research and Quality's short assessment of health literacy.

For patients with low health literacy, consider using USP pictograms to convey medication instructions, precautions, or warning to patients.
6. To help patients locate child care resources in their resources, refer them to ChildCare.gov's resource locator.
7. Recommend patients taking this three minute assessment that assess social isolation risk level and provides information and local recommendations based upon results: Are You Affected by Social Isolation? - Connect2Affect
8. Based on the patient's response, they may have a mental health need6. Utilize NCCN's Distress Thermometer and refer patients to the appropriate mental health team for evaluation.
9. Assess patients for post-traumatic stress disorders, adjustment disorders, and acute stress disorders.
  • Initiate psychotherapy with or without antidepressants and/or an anxiolytic.
  • If there is a response: follow up and maintain communication with the oncology and primary care team as well as family/caregivers.
  • If no response: re-evaluate psychotherapy, support, education, and consider adding on an antipsychotic (if appropriate).5
10. Utilize the NCODA Financial Assistance Tool to search for the availability of copay cards as well as patient assistance and trial programs for prescribed drug(s).
11. Utilize the NCODA Financial Assistance Tool to search for the availability of copay cards as well as patient assistance and trial programs for prescribed drug(s).

  1. Social Determinants of Health - Healthy People 2030 | health.gov [Internet]. Health.gov. 2022 [cited 2022 Jul 1]. Available from: https://health.gov/healthypeople/priority-areas/social-determinants-health
  2. Williams PA, Zaidi SK, Sengupta R. AACR Cancer Disparities Progress Report 2022. Cancer Epidemiol Biomarkers Prev. 2022 Jul 1;31(7):1249-1250.
  3. Zettler ME, Feinberg BA, Jeune-Smith Y, Gajra A. Impact of social determinants of health on cancer care: a survey of community oncologists. BMJ Open. 2021 Oct 6;11(10):e049259.
  4. Health Leads. Social Needs Screen Toolkit 2017. Available at: https://healthleadsusa.org/resources/the-health-leads-screening-toolkit/. Accessed July 8, 2022.
  5. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Distress Management V.2.2022
  6. Kroenke, K., Spitzer, R. L., & Williams, J. B. (2003). The Patient Health Questionnaire-2: validity of a two-item depression screener. Medical Care, 41(11), 1284-1292.