In a study of National Health Interview Survey (NHIS) data reported in JACC: CardioOncology, Javier Valero-Elizondo, MD, MPH, of Houston Methodist DeBakey Heart and Vascular Center, and colleagues, found that U.S. adult patients aged 18 to < 65 years with atherosclerotic cardiovascular disease were at greater risk of financial toxicity than those with cancer alone, with risk being greatest among patients with both atherosclerotic cardiovascular disease and cancer.1 Patterns were similar but of lesser magnitude among patients older than age 65.

Javier Valero-Elizondo, MD, MPH

As stated by the investigators: “Financial toxicity is a well-established side effect of the high costs associated with cancer care. In recent years, studies have suggested that a significant proportion of those with … [ atherosclerotic cardiovascular disease] experience [financial toxicity] and its consequences.”

Study Details

The study involved data from the NHIS between 2013 and 2018 on adults without and with self-reported atherosclerotic cardiovascular disease (coronary heart disease, angina, myocardial infarction, stroke) or cancer. Financial toxicity was defined as any of the following: any difficulty paying medical bills, inability to pay bills at all, high financial distress, cost-related medication nonadherence, food insecurity, and foregone/delayed care due to cost. 

Multivariate models were adjusted for age, sex, race/ethnicity, family income, education, insurance type, geographic region, cardiovascular risk factor profile, comorbidities, and, where appropriate, high financial distress, cost-related medication nonadherence, food insecurity, and foregone/delayed care due to cost, and burden from medical bills. Results were analyzed among individuals aged 18 to < 65 years (nonelderly cohort) and those aged ≥ 65 years (elderly cohort).

Financial Toxicity by Disease Status: Nonelderly Cohort

Among 141,826 persons aged 18 to < 65 years in the NHIS cohort, 6,887 (weighted prevalence = 4.5%) had cancer, 6,093 (weighted prevalence = 3.8%) had atherosclerotic cardiovascular disease, and 971 (weighted prevalence = 0.6%) had both.

Any financial toxicity was reported by 38.3% of those with neither atherosclerotic cardiovascular disease nor cancer vs 41.0% with cancer, 54.1% with atherosclerotic cardiovascular disease, and 54.5% with both (P < .001 for trend). On multivariate analysis, odds ratios (all significant unless otherwise noted) vs no atherosclerotic cardiovascular disease or cancer were 1.12, 1.35, and 1.39, respectively.

Any difficulty paying medical bills was reported by 28% of those with no atherosclerotic cardiovascular disease or cancer vs 35% with cancer, 45% with atherosclerotic cardiovascular disease, and 47% with both (P < .001 for trend). Odds ratios vs those with neither disease were 1.29, 1.53, and 1.54, respectively. Inability to pay bills at all was reported by 8% of those with no atherosclerotic cardiovascular disease or cancer vs 10%, 18%, and 23% (P < .001 for trend). Odds ratios were 1.29, 1.54, and 2.02.

High financial distress was reported by 26% vs 29%, 42%, and 45% (P < .001 for trend). Odds ratios were 1.03 (not significant), 1.13, and 1.26. Food insecurity was reported by 10% vs 10%, 23%, and 26% (P < .001 for trend). Odds ratios were 0.95 (not significant), 1.27, and 1.34.

Cost-related medication nonadherence was reported by 11% vs 13%, 20%, and 25% (P < .001 for trend). Odds ratios were 1.17, 1.48, and 1.63. Foregone/delayed care due to cost was reported by 11% vs 14%, 21%, and 24% (P < .001 for trend). Odds ratios were 1.14, 1.32, and 1.61.

The presence of at least three financial toxicity factors was significantly higher among patients with atherosclerotic cardiovascular disease (23%) and those with both atherosclerotic cardiovascular disease and cancer (30%) vs those with cancer alone (13%; P < .001).

Financial Toxicity by Disease Status: Elderly Cohort

Among 48,287 persons aged ≥ 65 years in the NHIS cohort, 8,457 (weighted prevalence = 18.1%), 8,167 (weighted prevalence = 16.9%), and 3,211 (weighted prevalence = 6.8%) had cancer, atherosclerotic cardiovascular disease, and both.

The P value for trends in all financial toxicity items was < .001. Any financial toxicity was reported by 21% of those without atherosclerotic cardiovascular disease or cancer vs 18% with cancer, 27% with atherosclerotic cardiovascular disease, and 25% with both. Odds ratios vs neither atherosclerotic cardiovascular disease nor cancer (all significant unless otherwise noted) were 0.98 (not significant), 1.17, and 1.28.

Any difficulty paying medical bills was reported by 14% vs 14%, 21%, and 19%. Odds ratios were 1.11 (not significant), 1.28, and 1.37. Inability to pay bills at all was reported by 3% vs 3%, 7%, and 5%. Odds ratios were 1.14 (not significant), 1.75, and 1.63.

High financial distress was reported by 13% vs 10%, 16%, and 14%. Odds ratios were 0.88, 1.03, and 1.09 (none significant). Food insecurity was reported by 5% vs 4%, 9%, and 5%. Odds ratios were 1.00 (not significant), 1.45, and 1.03 (not significant).

Cost-related medication nonadherence was reported by 4% vs 4%, 6%, and 6%. Odds ratios were 0.98, 1.12, and 1.21 (none significant). Forgone or delayed care due to cost was reported by 4% vs 4%, 6%, and 5%. Odds ratios were 1.01, 1.14, and 0.93 (none significant).

As related by the investigators, overall patterns of financial toxicity remained similar in magnitude and direction in the younger and older cohorts in sensitivity analyses: excluding nonmelanoma skin cancer; including only breast, lung, and colorectal cancers; including only patients with an active cancer diagnosis (diagnosis within the past year); and according to the time since cancer diagnosis.

The investigators concluded: “In a nationally representative study using data from 2013 to 2018, we found that, among non-elderly adults, [atherosclerotic cardiovascular disease] was associated with higher proportions of overall [financial toxicity] than patients with cancer, and patients with both illnesses concurrently had the worst outcomes across different measures of [financial toxicity]. These results were observed among elderly adults as well, although at significantly lower proportions.” 

DISCLOSURE: Dr. Valero-Elizondo reported no conflicts of interest. Dr. Nasir is on the advisory board of Amgen and Novartis; and his research is partly supported by the Jerold B. Katz Academy of Translational Research. 

REFERENCE

1. 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.