Study Examines Barriers to Survivorship Care

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Even among a large group of cancer survivors who were mostly insured, college-educated, and had annual incomes above the national average, up to 10% delayed care in the previous 12 months because they simply could not afford out-of-pocket expenses like copays and deductibles. These findings were reported by Coughlin et al in Cancer Medicine.

Other frequently cited reasons for delayed care were “had to pay out of pocket for some or all of the procedures,” “deductible was too high/or could not afford the deductible,” “couldn't afford the copay,” “couldn't get time off work,” and “were nervous about seeing a health-care provider.”

"It is likely that these percentages are much higher among cancer survivors in the general population, and particularly among minorities and other populations suffering significant health disparities in general," said first study author Steven S. Coughlin, PhD, MPH, Interim Chief of the Division of Epidemiology in the Medical College of Georgia, Department of Population Health Sciences.

Survivorship care may need to continue throughout a patient's lifetime, and populations at particular risk for being unable to afford the care include racial minorities, as well as women, younger individuals, and those with lower incomes.

"There are subgroups of the population who are at higher risk for poor access, for financial hardship, and for cancer in the first place," said Dr. Coughlin. "Those are the individuals we are particularly worried about."

"You can imagine that if you go to these populations that are still grossly underrepresented in many of these types of surveys, such as [Blacks], Hispanics, and individuals who live in more rural communities, these problems are probably magnified tenfold, if not more," said coauthor Jorge E. Cortes, MD, Director of the Georgia Cancer Center. "Some people have lifelong commitments because of the investment they had to make to pay for their treatment, so now they are cured, but they are in debt, they may have lost their job, there may be strains that developed in their personal and family relationships. Assessment and management of all these aspects of the patient as a whole have been incorporated into this science of survivorship, which is an integral part of cancer care nowadays.”

All of Us Research Program

Investigators analyzed data from 5,426 cancer survivors who volunteered to share their information with the National Institutes of Health's All of Us Research Program, a historic effort to collect and study health data over many years from at least 1 million people living in the United States. The cancer survivors had a mean age of 67, were mostly female and White, and had a history of a variety of cancers.

The investigators looked at demographic factors, and other personal characteristics like insurance and employment status, personal medical history of cancer, and health-care use and access in the national database. The most common cancers included in the analysis were breast, prostate, and colorectal cancers. Patients with skin cancer were excluded from their study because their follow-up care needs are more often comparatively minor.

About half those studied had an annual income of $75,000 or more, while the median household income was $68,703 in 2019, according to the U.S. Census Bureau. About 47% had private health insurance, 41% had Medicare, 6% had Medicaid, and the rest were insured through the military or the Department of Veterans Affairs, other insurers, or were uninsured.

At least in the current data set, minorities were not significantly more likely to report delaying care in the past 12 months, and just a small percentage were uninsured. The investigators noted again there was likely an underrepresentation of individuals most at risk for these problems in the database, which patients opt to participate in.

The study authors concluded, “In summary, a minority of cancer survivors who participated in the NIH All of Us Research Program had difficulty paying for health care in the past 12 months. However, these issues are magnified among minorities … and those with lower income.”

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