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Financial Hardship Can Affect Long-Term Outcomes in Patients with Cancer

TON - December 2020, Vol 13, No 6 - Quality Care Symposium
Charlie Dawson

Protecting patients with cancer from financial hardship can save more than money. According to data presented at the 2020 ASCO Quality Care Symposium, mitigating the financial burden of cancer treatment on patients may save lives as well.

Analysis of a large, diverse, nationally representative sample has shown that financial hardship is associated with increased mortality risk in adults, regardless of whether they have had cancer. Although adjustment for health insurance coverage reduced the magnitude of this association in adults aged 18 to 64 years, it had little effect among adults aged 65 to 79 years. The investigators noted that this reflects, in part, the protective effects of Medicare coverage.

“Our findings highlight a number of additional needs for routine screening, as well as efforts to address financial hardship in the United States,” said lead investigator, K. Robin Yabroff, PhD, MBA, Senior Scientific Director, Health Services Research, American Cancer Society.

In the United States today, approximately 17 million people are cancer survivors, many of whom have lasting adverse effects of their disease and its treatment. Compared with individuals without a history of cancer, cancer survivors are at greater risk for new cancers, chronic conditions, healthcare expenditures (including out-of-pocket spending), and work limitations, according to Dr Yabroff.

“Limitations in work are especially important, because they can limit income and access to health insurance coverage for the working-age population,” Dr Yabroff added.

Although cancer survivors often have financial hardship, few studies have evaluated the association of financial hardship and long-term health outcomes. For this study, Dr Yabroff and colleagues examined the associations of a history of cancer and medical financial hardship with mortality, using data from the National Health Interview Survey (NHIS) from 1997 to 2014 and the NHIS Linked Mortality Files, which provided data on between 1 and 18 years of follow-up.

Based on available surveys, medical financial hardship was measured as an inability to afford healthcare services or delaying or forgoing any medical care because of cost during the previous 12 months. Mortality risk was estimated with weighted Cox proportional hazards models. The researchers used age as the time scale and controlled for the effects of sex, race and/or ethnicity, educational attainment, marital status, comorbid conditions, region, and survey year.

30% of Cancer Survivors Report Financial Hardship

Nearly 500,000 adults were included in the analysis. Among the population aged 18 to 64 years, approximately 30% of cancer survivors reported financial hardship compared with 21% of patients without a history of cancer.

Dr Yabroff also highlighted “striking differences” in health insurance coverage for cancer survivors, as well as for those without a cancer history. Adults aged 18 to 64 years with financial hardship were much more likely to have public insurance alone, or to be uninsured, than those without financial hardship, regardless of whether they had a history of cancer.

The researchers observed a similar pattern for patients aged 65 to 79 years. Those with Medicare or other public insurance (eg, Medicaid) were more likely to report financial hardship than younger patients, regardless of a diagnosis of cancer.

Financial Toxicity and Mortality Risk

Dr Yabroff and colleagues then analyzed the associations between cancer history, financial hardship, and mortality.

“Compared to adults without a cancer history and no financial hardship, adults with a cancer history and hardship had a strikingly large hazard ratio [for mortality],” said Dr Yabroff. “When we added health insurance coverage to the adjusted model, we saw a reduction on the magnitude of the association between cancer history and financial hardship and mortality.”

Conversely, older individuals with a history of cancer and financial hardship had the highest hazard ratio for mortality, adding health insurance coverage had less of an effect on mortality.

One limitation of the study, Dr Yabroff noted, is that health insurance coverage and financial hardship were measured only at a single point in time.

“In the future, longitudinal studies with measures of both insurance coverage and hardship at multiple time points will help to disaggregate the effects of these 2 factors,” Dr Yabroff concluded. “We also need a better understanding of the trade-offs between receipt of healthcare, financial hardship, and daily needs, such as food and housing, and how this is related to health outcomes.”

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Last modified: December 28, 2020