Financial Impact of Cardiovascular Disease and Cancer Care: Overlapping Toxicities

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The leading causes of mortality in the United States are cardiovascular disease (23%) and cancer (21%), accounting for more than 40% of total deaths reported.1,2 The increasing rise in health-care expenditures over the past several decades has driven the need for metrics to further evaluate the financial burden associated with health care.

With the high costs of novel cancer therapeutics and increasing cancer survivorship, several studies have previously investigated financial hardship and its impact on cancer care outcomes and health-related quality of life.3 More recently, the significant financial toxicity of health-care spending on atherosclerotic cardiovascular disease has also been recognized and reported, demonstrating a substantial economic impact with estimated national expenditures of $126 billion in 2015.4-6 Patients with cancer and those with atherosclerotic cardiovascular disease share the significant economic burden posed by the rapid increase in direct health-care–related expenditures as well as the indirect costs of lost productivity, with consequences for payers, health-care providers, and patients. As survivorship continues to increase, these groups will also increasingly overlap, with a growing population of patients with concurrent cancer and atherosclerotic cardiovascular disease.

Betty K. Hamilton, MD

Betty K. Hamilton, MD

Study Explores Financial Toxicity

In a recent study published in JACC: CardioOncology—and summarized in this issue of The ASCO Post—Valero-Elizondo et al describe the financial toxicity in adults with atherosclerotic cardiovascular disease and/or cancer, using National Health Interview Survey (NHIS) data from 2013 to 2018.7 The diagnosis of cancer included any history of cancer, and atherosclerotic cardiovascular disease included coronary or cerebrovascular disease and were self-reported by patients. Financial toxicity was defined as any of the following: difficulty paying medical bills, high financial distress, cost-related medication nonadherence, food insecurity, or delayed/deferred care due to cost.

Other data collected included sociodemographic information such as age, sex, race/ethnicity, family income, education, insurance status, and region; as well as a cardiovascular risk profile (self-reported hypertension, diabetes mellitus, high cholesterol, obesity, current smoker, physical activity), chronic comorbidities (eg, emphysema, chronic obstructive pulmonary disease, asthma, gastrointestinal ulcer, arthritis, liver conditions or kidney conditions), and years since cancer diagnosis. The authors evaluated nonelderly (≥ 18 to < 65 years) and elderly (≥ 65 years) populations; they found that in both groups, financial toxicity was higher among those with atherosclerotic cardiovascular disease compared with cancer alone, with the highest burden of financial toxicity found among those with both conditions.

Cancer and Cardiovascular Disease: More Similarities Than Differences

With an aging population and continued improvements in detection and novel therapeutics, the need for both cancer survivorship and cardiovascular disease care is expected to continue to grow and overlap. Although the bulk of data and analyses investigating financial toxicity has been within the cancer population, the study by Valero-Elizondo et al highlights the significant burden of atherosclerotic cardiovascular disease and its associated financial toxicity.

Differences in the drivers of financial toxicity between the two groups are described. For example, patients with cancer tended to have more short-term expenditures related to chemotherapy and other treatment vs a more chronic course in atherosclerotic cardiovascular disease, with the costs of lifelong drugs, clinic visits, and hospitalization. However, these two groups actually share many more similarities than differences. The results of this study are thus highly significant to both investigators and clinicians in oncology and cardiology.

It is therefore important to further highlight the relationship between cardiovascular disease and cancer, recognizing that as we continue to understand these similarities, we may provide better care, improve patient education, and develop support structures and interventions (preventive and therapeutic) for patients experiencing these diseases and the resulting financial toxicity associated with care. The cardiovascular toxicities of both old and new cancer therapies initially raised awareness of the importance of heart disease in cancer care among oncologists and cardiologists; however, growing evidence also demonstrates several shared risk factors between the two diseases, suggesting a shared biology.8

Cardio-oncology: Shared Risk Factors

Treatment of cardiovascular disease has also improved substantially over the past decades, with more patients surviving heart disease to live long enough to develop other diseases such as cancer. In fact, besides an increased risk of new cardiovascular events, patients with established cardiovascular disease have a higher risk of cancer compared with the general population (standardized incidence ratio = 1.19, 95% confidence interval = 1.1–1.20), thought to be secondary to such shared risk factors as obesity, smoking, and inflammation.

Prediction models in patients with established cardiovascular disease have been developed to predict the subsequent risk of cancer.9 Chronic health conditions (eg, obesity, hyperglycemia, hypertension, hyperlipidemia, autoimmune disorders) as well as environmental exposures (eg, microbial infections, radiation, chemicals, alcohol and tobacco use) have been identified as potential risk factors, suggesting that these seemingly diverse diseases share some common basic molecular pathways. Thus, efforts in the field of cardio-oncology have recently focused on raising awareness about shared risk factors for cancer and cardiovascular disease in advocacy to promote prevention and healthy lifestyle change, which may have a role in reducing the financial burden of these diseases in the long term.10

Patients with cancer and those with atherosclerotic cardiovascular disease share the significant economic burden posed by the rapid increase in direct health-care–related expenditures….
— Betty K. Hamilton, MD

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A number of studies in cancer survivors have described the greater out-of-pocket costs, limitations in the ability to work, and reduced resources to pay for medical care, demonstrating the significant financial impact and economic burden of cancer on patients.11,12 Cancer survivors are also at increased risk for anxiety and stress regarding finances, and those patients reporting financial hardships are more likely to delay and forgo treatment, have poor adherence to care, and ultimately have inferior outcomes.13,14 Similarly, more recent investigations in cardiovascular disease also demonstrate significant out-of-pocket health-care expenditures, loss of income compounded by the need for informal caregiving by family members, and significant financial distress, as well as psychological distress, poorer mental health, poorer quality of life, nonadherence to medications, and ­poorer outcomes.15

Next Steps

Thus, it is increasingly clear that there is a significant overlap between both cancer and cardiovascular disease in disease course and long-term financial burden. Consequently, there is a need for both fields to align and develop standard measures to investigate and further understand the common determinants of financial toxicity, as well as the social determinants of health (age, race, socioeconomic status, health behaviors) at play. As health-care costs continue to rise, there is a clear need to develop interventions to mitigate the costs of medical care and financial distress experienced by patients.

Novel and aligned approaches to screen, educate, and address financial toxicities in both patients with cancer and those with cardiovascular disease are needed.16 More rigorous investigations in both populations, policy-level initiatives, collaboration between health-care institutions and insurers to ensure value-based care, and patient-level interventions (such as education, financial advocacy services, and communication between providers and patients) are critical to ensure that our scientific advances in the care of patients with cancer and those with cardiovascular disease are not limited by the inability to pay for treatment or to access care. 

Dr. Hamilton is a hematologist-oncologist practicing in the Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, Ohio.

DISCLOSURE: Dr. Hamilton has served in a consulting or advisory role for ­Equilium and Syndax.


1. Kochanek KD, Xu J, Arias E: Mortality in the United States, 2019. NCHS Data Brief 395:1-8, 2020.

2. Johnson NB, Hayes LD, Brown K, et al: CDC National Health Report: Leading causes of morbidity and mortality and associated behavioral risk and protective factors—United States, 2005–2013. MMWR Suppl 63:3-27, 2014.

3. Altice CK, Banegas MP, Tucker-Seeley RD, et al: Financial hardships experienced by cancer survivors: A systematic review. J Natl Cancer Inst 109:djw205, 2016.

4. Valero-Elizondo J, Khera R, Saxena A, et al: Financial hardship from medical bills among nonelderly U.S. adults with atherosclerotic cardiovascular disease. J Am Coll Cardiol 73:727-732, 2019.

5. Khera R, Valero-Elizondo J, Okunrintemi V, et al: Association of out-of-pocket annual health expenditures with financial hardship in low-income adults with atherosclerotic cardiovascular disease in the United States. JAMA Cardiol 3:729-738, 2018.

6. Khera R, Hong JC, Saxena A, et al: Burden of catastrophic health expenditures for acute myocardial infarction and stroke among uninsured in the United States. Circulation 137:408-410, 2018.

7. Valero-Elizondo J, Chouairi F, Khera R, et al: Atherosclerotic cardiovascular disease, cancer, and financial toxicity among adults in the United States. JACC CardioOncol 3:236-246, 2021.

8. Koene RJ, Prizment AE, Blaes A, et al: Shared risk factors in cardiovascular disease and cancer. Circulation 133:1104-1114, 2016.

9. van ‘t Klooster CC, Ridker PM, Cook NR, et al: Prediction of lifetime and 10-year risk of cancer in individual patients with established cardiovascular disease. JACC CardioOncol 2:400-410, 2020.

10. Johnson CB, Davis MK, Law A, et al: Shared risk factors for cardiovascular disease and cancer: Implications for preventive health and clinical care in oncology patients. Can J Cardiol 32:900-907, 2016.

11. Longo CJ, Fitch MI: Unequal distribution of financial toxicity among people with cancer and its impact on access to care: A rapid review. Curr Opin Support Palliat Care 15:157-161, 2021.

12. Mols F, Tomalin B, Pearce A, et al: Financial toxicity and employment status in cancer survivors: A systematic literature review. Support Care Cancer 28:5693-5708, 2020.

13. Ver Hoeve ES, Ali-Akbarian L, Price SN, et al: Patient-reported financial toxicity, quality of life, and health behaviors in insured US cancer survivors. Support Care Cancer 29:349-358, 2021.

14. Ramsey SD, Bansal A, Fedorenko CR, et al: Financial insolvency as a risk factor for early mortality among patients with cancer. J Clin Oncol 34:980-986, 2016.

15. Slavin SD, Khera R, Zafar SY, et al: Financial burden, distress, and toxicity in cardiovascular disease. Am Heart J 238:75-84, 2021.

16. Khera N, Kumbamu A, Langer SL, et al: Developing an educational intervention to address financial hardship in cancer patients. Mayo Clin Proc Innov Qual Outcomes 4:424-433, 2020.

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