Reducing the financial impact of cancer diagnosis and treatment may save not only bank accounts but lives as well, according to recent data. Two separate survey studies presented during the 2020 ASCO Quality Care Symposium have highlighted the pervasiveness and deadliness of financial toxicity, underscoring the need for clinical and policy solutions.
In the first study, a survey of patients with metastatic colorectal cancer, nearly three out of four patients were found to experience major financial hardship within 12 months of diagnosis, despite having access to health insurance coverage.1 The second study, an analysis of National Health Interview Survey (NHIS) and NHIS Linked Mortality Files, showed that medical financial hardship was associated with an increased risk of mortality among adults with and without a cancer history.2
“We believe that clinical and policy interventions are critically important and needed to protect patients with cancer and their families from financial devastation during and after cancer treatment,” said Veena Shankaran, MD, of the University of Washington School of Medicine and Fred Hutchinson Cancer Research Center, Seattle.
“Clinical and policy interventions are needed to protect patients with cancer and their families from financial devastation during and after cancer treatment.”— Veena Shankaran, MD
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Background and Study Design
As Dr. Shankaran explained, financial hardship or toxicity is now a well-recognized complication of cancer diagnosis and treatment. It results from the high direct medical costs, nonmedical costs, and indirect costs that uniquely affect patients with cancer. However, no studies have longitudinally assessed the financial impact of cancer diagnosis using a combination of self-reported and objective financial measures. Furthermore, few studies concurrently enroll and measure financial impacts in both patients and caregivers.
Led by the SWOG Cancer Research Network and conducted in the NCI Community Oncology Research Program, S1417CD is the first national prospective cohort study to measure the financial impact of cancer diagnosis and treatment on patients and caregivers. The primary objective of the study was to estimate the cumulative incidence of self-reported major financial hardship 12 months into patients’ diagnosis and treatment course. Major financial hardship was defined as one or more of the following: new debt accumulation, selling or refinancing one’s home due to cost issues, experiencing a 20% or greater decline in income, or borrowing money and taking loans to pay for cancer treatment.
Major Financial Hardship for More Than Two-Thirds
As Dr. Shankaran reported, of the 380 patients enrolled, 368 had baseline survey data and were considered eligible. At 12 months, 73% of these patients were still alive, she noted, which speaks to the improvement in survival for patients with metastatic colorectal cancer over the past decade.
The median age of the patient population was 60 years, and the majority of patients were male, White, married, and had private or Medicare insurance. Nearly 60% had annual household incomes of $50,000 or less annually, said Dr. Shankaran, and 40% had a high school education or less. Most patients reported being employed prior to their diagnosis, and at least one credit report was successfully obtained for more than 90% of enrolled subjects.
The cumulative incidence of major financial hardship reached approximately 71% by 12 months. Findings showed that the largest component of major financial hardship was accrual of debt, followed by loans, and at least a 20% decline in income. Although selling or refinancing one’s home as a result of cancer costs was uncommon in this population, said Dr. Shankaran, 41% of patients reported two or more components of financial hardship.
When debt was excluded, the cumulative incidence of major financial hardship dropped to 43% at 12 months, commented Dr. Shankaran, but it still accumulated consistently and progressively over time. A trend toward an increased risk of financial hardship was observed for patients younger than age 65, those who were not White, patients who were not married, and those with a household income of less than $50,000 annually.
Conversely, a trend toward decreased financial hardship was observed among unemployed individuals, said Dr. Shankaran, although this observation was likely confounded by age. In any event, the investigators found no statistically significant evidence that these prespecified factors were associated with major financial hardship. A post-hoc analysis showed that income less than $100,000 and total assets less than $100,000 were both adversely associated with major financial hardship.
Dr. Shankaran and colleagues are currently conducting several analyses, including of credit report data and the association between financial hardship and health-related quality of life. The investigators also plan to assess the financial distress of enrolled caregivers and to develop a prediction model to identify patients at highest risk for major financial hardships to enable more targeted interventions.
“Importantly, our study results showed that patients are very willing to participate in research that aims to address the problem of financial toxicity in oncology,” Dr. Shankaran concluded.
Cancer History and Medical Financial Hardship Linked to Mortality
Robin Yabroff, PhD, MPH, Senior Scientific Director of Health Services Research at the American Cancer Society, outlined the lasting effects of disease and treatment for the approximately 17 million cancer survivors in the United States.
“Compared to individuals without a cancer history, cancer survivors have a greater risk for new cancers and chronic conditions, health-care expenditures, and limitations in the amount or type of work,” said Dr. Yabroff. “Cancer survivors are also more likely to report worrying about daily financial needs, including food and housing, and are at increased risk of filing for bankruptcy protection.”
Dr. Yabroff continued: “Financial hardship among cancer survivors is also associated with worse health-related quality of life and greater symptom burden.”
For their study, Dr. Yabroff and colleagues examined the associations of cancer history and medical financial hardship with mortality using a large, diverse, nationally representative cohort. The researchers identified a cohort of adults aged 18 to 64 years (n = 415,114) and 65 to 79 years (n = 73,571) from the NHIS (1997–2014) and NHIS Linked Mortality Files (2015). Patients were stratified to reflect differences in employment as well as health insurance coverage (eg, Medicare beneficiaries are age-eligible starting at 65).
“Our findings showed that financial hardship is associated with greater mortality risk in adults with and without a history of cancer.”— Robin Yabroff, PhD, MPH
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According to Dr. Yabroff, approximately 30% of cancer survivors reported financial hardship, as compared with 21% of those without a cancer history. Dr. Yabroff also highlighted the “striking differences” in health insurance coverage for both cancer survivors and those without a cancer history.
“Individuals with financial hardship are much more likely to report having public insurance alone or being uninsured than those without a financial hardship, regardless of a cancer history,” said Dr. Yabroff, who noted a similar pattern in terms of health insurance coverage for older patients. “Patients with Medicare and/or public insurance coverage were also more likely to report financial hardship both with and without a cancer history.”
Findings also showed that financial hardship is associated with greater mortality risk in adults with and without a history of cancer. Although adjustment for health insurance coverage reduced the magnitude of the association among adults aged 18 to 64, said Dr. Yabroff, it had little effect among adults between age 65 and 79. “This reflects, in part, the protective effects of Medicare coverage,” she observed.
According to Dr. Yabroff, these findings also highlight additional needs for routine screening as well as efforts to address financial hardship. “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 two factors,” she concluded. “We also need better understanding of the trade-offs between receipt of health care, financial hardship, and daily needs, such as food and housing, and how this is related to health outcomes.”
DISCLOSURE: Dr. Shankaran reported financial relationships with Amgen, AstraZeneca, Bayer, Bristol Myers Squibb, Merck, Proteus Digital Health, and Taiho Pharmaceutical. Dr. Yabroff reported no conflicts of interest.
1. Shankaran V, Unger JM, Darke A, et al: Cumulative incidence of financial hardship in metastatic colorectal cancer patients: Primary endpoint results for SWOG S1417CD. 2020 ASCO Quality Care Symposium. Abstract 137.
2. Yabroff KR, Han X, Song W, et al: Association of cancer history and medical financial hardship with mortality in the United States. 2020 ASCO Quality Care Symposium. Abstract 86.
Formal discussant of these abstracts on financial toxicity, Reginald Tucker-Seeley, ScD, of USC Leonard Davis School of Gerontology, said the studies by Drs. Shankaran and Yabroff highlight how far the field has come in understanding the pathway from cancer diagnosis to financial hardship for...