LOS ANGELES — Sharon Horton stepped through the door of a sky-blue mobile clinic and onto a Skid Row sidewalk. She wore a yellow knit beanie, gold hoop earrings and the relieved grin of a woman who has finally checked a mammogram off her to-do list.

It had been years since her last breast cancer screening procedure. This one, which took place in City of Hope's Cancer Prevention and Screening mobile clinic, was faster and easier. The staff was kind. The machine that X-rayed her breast was more comfortable than the cold hard contraption she remembered.

Relatively speaking, of course — it was still a mammogram.

"It's like, OK, let me go already!" Horton, 68, said with a laugh.

The clinic was parked on South San Pedro Street in front of Union Rescue Mission, the nonprofit shelter where Horton resides. Within a week, City of Hope, a cancer research hospital, would share the results with Horton and Dr. Mary Marfisee, the mission's family medical services director. If the mammogram detected anything of concern, they'd map out a treatment plan from there.

"It's very important to take care of your health, and you need to get involved in everything that you can to make your life a better life," said Horton, who is looking forward to a forthcoming move into Section 8 housing.

Horton was one of the first patients of a new women's health initiative from UCLA's Homeless Healthcare Collaborative at Union Rescue Mission. Staffed by third-year UCLA Medical School students and led by Marfisee, a UCLA assistant clinical professor of family medicine, the clinic treats mission residents as well as unhoused people living in the surrounding neighborhood.

The new cancer screening project arrives at a time of dire financial pressures on county public health services.

Citing rising costs and a $50-million reduction in federal, state and local grant and contract income, the Los Angeles County Department of Public Health on Feb. 27 ended services at seven of 13 public clinics that provide vaccines, tests and treatment for sexually transmitted diseases and other services to housed and unhoused county residents.

Although Union Rescue Mission's own funding comes mainly from private sources and is less imperiled by public cuts, the 135-year-old shelter expects the need for its services to rise, Chief Executive Mark Hood said.

Even as unsheltered homelessness declined for the last two years across Los Angeles County, the unsheltered population on Skid Row — long seen as the epicenter of the region's homelessness crisis — grew 9% in 2024, the most recent year for which census data are available.

For many local women navigating daily concerns over housing, food and personal safety, "their own health is not a priority," Marfisee said.

Those whose problems have become too serious to ignore face daunting obstacles to care. Marfisee recalled one patient who came to her with a lump in her breast and no identification.

In order to get a mammogram, Marfisee explained, the woman first needed to obtain a birth certificate, and then a state-issued identification card. Then she needed to enroll in Medi-Cal. After that, clinic staff helped her find a primary care physician who could order the imaging test.

Given the barriers to preventative care, homeless women die from breast cancer at nearly twice the rate of securely housed women, a 2019 study found. Marfisee's own survey of the mission's female residents found that nearly 90% were not up to date on recommended cancer screenings like mammograms and pap smears, which detect early cervical cancer.

To address this gap, Marfisee — a dogged patient advocate — reached out to City of Hope. The Duarte-based research and treatment center unveiled in March 2024 its first mobile cancer screening clinic, a moving van-sized clinic on wheels that it deploys to food banks and health centers, as well as to companies offering free mammograms as an employee benefit.

"In true Dr. Mary fashion, she saw the vision," said Jessica Thies, the mobile screening program's regional nursing director. After working through some logistical hurdles, the mission and City of Hope secured a date for the van's first visit.

The next challenge was getting the word out to patients. Marfisee and her students walked through the surrounding neighborhood, went cot to cot in the women's dorm and held two informational sessions in December and January to answer patients' questions.

At the sessions, the team walked through the basics of who should get a mammogram (women age 40 or older, those with a family history of breast cancer) and the procedure itself. ("Like a tortilla maker?" one woman asked skeptically after hearing a description of the mammography unit.)

The medical students were able to dispel rumors some women had heard: The test doesn't damage breast tissue, nor do the X-rays increase cancer risk. Others questioned a mammogram's value: What good was it knowing they had cancer if they couldn't get follow-up care?

On this latter point, Marfisee is determined not to let patients fall through the cracks.

Thirteen patients received mammograms at the van's first visit on Wednesday. Within a week, City of Hope will contact patients with their results and send them to Marfisee and her team. She is already mentally mapping the next steps should any patient have a situation that requires a biopsy or further imaging: working with their case manager at the mission, calling in favors, wrangling with any insurance the patient might have.

"It'll be a good fight," Marfisee said, as residents in the adjacent cafeteria carried trays of sloppy joes and burgers to their lunch tables. "But we'll just keep asking for help and get it done."

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