Medication Nonadherence Among Cancer Survivors: Are Indirect Health-Care Costs to Blame?

Get Permission

Approximately 1 in 10 long-term survivors of cancer fails to take medications as prescribed due to financial hardship, according to research presented at the 2021 ASCO Quality Care Symposium.1 However, indirect health-care costs—not drug copays—may be responsible, the study investigators suggested.

The retrospective analysis of Medicare recipients found that survivors who reported cost-related prescription nonadherence in the previous 6 months had more than $600 higher out-of-pocket health-care costs than did those reporting adherence. Results also showed similar adherence when comparing rural- and urban-dwelling survivors. However, decisions on prescription adherence may be more cost-sensitive for patients living in rural compared with urban areas, the study authors noted.

Courtney P. Williams, DrPH

Courtney P. Williams, DrPH

“These findings suggest that adherence decisions may not depend fully on direct health-care costs,” lead study author ­Courtney P. Williams, DrPH, Cancer Prevention Postdoctoral Fellow at the National Cancer Institute. “Instead, these decisions may be linked to indirect health-care costs associated with health-care access issues, such as personal transportation to receive care or limited accessibility to pharmacies, specialists, or survivorship care in rural areas.”

As Dr. Williams explained, more than half of cancer survivors in the United States are estimated to experience at least one domain of financial hardship due to their cancer treatment and survivorship care. A common coping behavior attributed to cancer-related financial hardship is medication nonadherence, in which patients skip recommended doses of medications, split their pills, or do not fill their prescribed medications.

“Medication nonadherence often leads to unmet therapeutic goals and potential emergency department use, which further increases health-care spending and exacerbates potentially existing financial hardship,” said Dr. Williams. Previous research has shown that rural cancer survivors more often report financial problems due to cancer than those in urban areas, she noted.

According to Dr. Williams, however, little is known about the direct patient costs leading to prescription nonadherence among older cancer survivors and whether there are differences between those survivors living in rural and urban areas.

Adherence decisions may not depend fully on direct health-care costs. Instead, these decisions may be linked to indirect health-care costs associated with health-care access issues.
— Courtney P. Williams, DrPH

Tweet this quote

Study Methods

For this retrospective cohort study, Dr. Williams and colleagues used data from the Surveillance, Epidemiology, and End Results (SEER) Program, Medicare claims, and the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey-linked data resource to compare patient health-care costs for older cancer survivors who did and did not report cost-related prescription nonadherence. Patients included in the cohort were Medicare Fee-for-Service beneficiaries with a diagnosis of prostate, breast, colorectal, gynecologic, or lung cancer between 2008 and 2015.

The researchers captured cost-related prescription nonadherence in the prior 6 months with CAHPS survey data. Patient-cost responsibility (deductibles, coinsurance, copayments) was summed for all medical care received in the year prior to the survey using the Medicare administrative claims data. Finally, cancer diagnosis was captured at any time before this using SEER data. Survivors were stratified into urban or rural settings based on rural-urban continuum codes in the SEER data.

Survey Findings

As Dr. Williams reported, the cohort included 9,137 survivors of cancer, with a median age of 76 years. Prostate cancer survivors were the most prevalent in the sample (40%), and most cancer survivors had a localized, or regional, cancer diagnosis.

Dr. Williams also noted that these individuals are long-term cancer survivors, with a median of 7 years from the time of cancer diagnosis to taking the CAHPS survey.

Data analysis showed that approximately 1 of every 10 cancer survivors reported cost-related prescription nonadherence in the previous 6 months, regardless of geographic setting. After adjusting for demographic and clinical characteristics, survivors reporting cost-related prescription nonadherence had a $628 higher cost responsibility in the year prior when compared with those reporting adherence.

Comparing Rural and Urban Cancer Survivors

Although similar adherence was found between rural- and urban-dwelling survivors, after the investigators adjusted for demographic and clinical characteristics, urban-dwelling survivors had higher cost responsibility compared with rural-dwelling survivors, regardless of adherence status.


  • Compared with those reporting adherence, cost-related prescription nonadherence was associated with higher health-care cost responsibility in cancer survivors, according to survey findings.
  • Prescription adherence decisions may be more cost-sensitive for patients living in rural compared with urban areas.

Analysis within residence group showed that rural-dwelling survivors had similar cost responsibilities when comparing those reporting prescription nonadherence and adherence. Conversely, urban-dwelling survivors reporting nonadherence had nearly a $700 higher cost responsibility in the year prior when compared with those reporting adherence.

According to Dr. Williams, interventions to address out-of-pocket health-care costs, particularly for rural cancer survivors, may aid in increased prescription adherence. “Understanding how to address direct health-care costs and potential cost-related barriers to care for urban- and rural-dwelling cancer survivors could ultimately lead to better long-term outcomes,” she concluded. 

DISCLOSURE: Dr. Williams reported no conflicts of interest.


1. Williams C, Davidoff AJ, Halpern MT, et al: Medication nonadherence and patient cost responsibility for rural and urban cancer survivors. 2021 ASCO Quality Care Symposium. Abstract 4. Presented September 25, 2021.


Related Articles

Expert Point of View: Michaela A. Dinan, PhD

Invited discussant of the study on medication nonadherence, Michaela A. Dinan, PhD, Co-Leader of Cancer Prevention and Control at Yale Cancer Center and Associate Professor of Chronic Disease Epidemiology at the Yale School of Public Health, in Connecticut, noted that the CAHPS survey data provide...