Financial Impact of Breast Cancer in Black Versus White Women

Mapping research strands of ethics of artificial intelligence in healthcare: A bibliometric and content analysis

The growth of artificial intelligence in promoting healthcare is rapidly progressing. Notwithstanding its promising nature, however, AI in healthcare embodies certain ethical challenges as well. This research aims to delineate the most influential elements of scientific research on AI ethics in healthcare by conducting bibliometric, social network analysis, and cluster-based content analysis of scientific articles. Not only did the bibliometric analysis identify the most influential authors, countries, institutions, sources, and documents, but it also recognized four ethical concerns associated with 12 medical issues. These ethical categories are composed of normative, meta-ethics, epistemological and medical practice. The content analysis complemented this list of ethical categories and distinguished seven more ethical categories: ethics of relationships, medico-legal concerns, ethics of robots, ethics of ambient intelligence, patients' rights, physicians' rights, and ethics of predictive analytics. This analysis likewise identified 40 general research gaps in the literature and plausible future research strands. This analysis furthers conversations on the ethics of AI and associated emerging technologies such as nanotech and biotech in healthcare, hence, advances convergence research on the ethics of AI in healthcare. Practically, this research will provide a map for policymakers and AI engineers and scientists on what dimensions of AI-based medical interventions require stricter policies and guidelines and robust ethical design and development.

The cost of cure: Examining objective and subjective financial toxicity in head and neck cancer survivors

BACKGROUND

Little is documented regarding objective financial metrics and their impact on subjective financial toxicity in head and neck cancer (HNC) survivors.

METHODS

In a cross-sectional analysis, 71 survivors with available claims data for HNC-specific out-of-pocket expenses (OOPE) completed a survey including patient-reported, subjective financial toxicity outcome tools: the Comprehensive Score for financial Toxicity (COST) and the Financial Distress Questionnaire (FDQ).

RESULTS

Worse COST scores were significantly associated with lower earnings at survey administration (coefficient = 3.79; 95% CI 2.63-4.95; p < 0.001); loss of earnings after diagnosis (coefficient = 6.03; 95% CI 0.53-11.52; p = 0.032); and greater annual OOPE as a proportion of earnings [log10(Annual OOPE:Earnings at survey): coefficient = -5.66; 95% CI -10.28 to -1.04; p = 0.017]. Similar results were found with FDQ.

CONCLUSION

Financial toxicity is associated with particular socioeconomic characteristics which, if understood, would assist the development of pre-treatment screening tools to detect at-risk individuals and intervene early in the HNC cancer survivorship trajectory.

Evaluation of overall survival and barriers to surgery for patients with breast cancer treated without surgery: a National Cancer Database analysis

Surgery remains the foundation of curative therapy for non-metastatic breast cancer, but many patients do not undergo surgery. Evidence is limited regarding this population. We sought to assess factors associated with lack of surgery and overall survival (OS) in patients not receiving breast cancer surgery. Retrospective cohort study of patients in the US National Cancer Database treated in 2004-2016. The dataset comprised 2,696,734 patients; excluding patients with unknown surgical status or stage IV, cT0, cTx, or pIS, metastatic or recurrent disease resulted in 1,192,294 patients for analysis. Chi-square and Wilcoxon rank-sum tests were used to assess differences between groups. OS was analyzed using the Kaplan-Meier method with a Cox proportional hazards model performed to assess associated factors. In total 50,626 (4.3%) did not undergo surgery. Black race, age >50 years, lower income, uninsured or public insurance, and lower education were more prevalent in the non-surgical cohort; this group was also more likely to have more comorbidities, higher disease stage, and more aggressive disease biology. Only 3,689 non-surgical patients (7.3%) received radiation therapy (RT). Median OS time for the non-surgical patients was 58 months (3-year and 5-year OS rates 63% and 49%). Median OS times were longer for patients who received chemotherapy (80 vs 50 (no-chemo) months) and RT (85 vs 56 (no-RT) months). On multivariate analysis, age, race, income, insurance status, comorbidity score, disease stage, tumor subtype, treatment facility type and location, and receipt of RT were associated with OS. On subgroup analysis, receipt of chemotherapy improved OS for patients with triple negative (HR 0.66, 95% CI 0.59-0.75, P < 0.001) and HER2+ (HR 0.74, 95% CI 0.65-0.84, P < 0.001) subgroups while RT improved OS for ER+ (HR 0.72, 95% CI 0.64-0.82, P < 0.001) and favorable-disease (ER+, early-stage, age >60) (HR 0.61, 95% CI 0.45-0.83, P = 0.002) subgroups. Approximately 4% of women with breast cancer do not undergo surgery, particularly those with more aggressive disease and lower socioeconomic status. Despite its benefits, RT was underutilized. This study provides a benchmark of survival outcomes for patients who do not undergo surgery and highlights a potential role for use of RT.

Evaluation of Racial/Ethnic Differences in Treatment and Mortality Among Women With Triple-Negative Breast Cancer

Importance

To our knowledge, there is no consensus regarding differences in treatment and mortality between non-Hispanic African American and non-Hispanic White women with triple-negative breast cancer (TNBC). Little is known about whether racial disparities vary by sociodemographic, clinical, and neighborhood factors.

Objective

To examine the differences in clinical treatment and outcomes between African American and White women in a nationally representative cohort of patients with TNBC and further examine the contributions of sociodemographic, clinical, and neighborhood factors to TNBC outcome disparities.

Design, Setting, and Participants

This population-based, retrospective cohort study included 23 123 women who received a diagnosis of nonmetastatic TNBC between January 1, 2010, and December 31, 2015, followed up through December 31, 2016, and identified from the Surveillance, Epidemiology, and End Results data set. The study was conducted from July 2019 to November 2020. The analyses were performed from July 2019 to June 2020.

Exposures

Race and ethnicity, including non-Hispanic African American and non-Hispanic White race.

Main Outcomes and Measures

Using logistic regression analysis and competing risk regression analysis, we estimated odds ratios (ORs) of receipt of treatment and hazard ratios (HRs) of breast cancer mortality in African American patients compared with White patients.

Results

Of 23 213 participants, 5881 (25.3%) were African American women and 17 332 (74.7%) were White women. Compared with White patients, African American patients had lower odds of receiving surgery (OR, 0.69; 95% CI, 0.60-0.79) and chemotherapy (OR, 0.89; 95% CI, 0.81-0.99) after adjustment for sociodemographic, clinicopathologic, and county-level factors. During a 43-month follow-up, 3276 patients (14.2%) died of breast cancer. The HR of breast cancer mortality was 1.28 (95% CI, 1.18-1.38) for African American individuals after adjustment for sociodemographic and county-level factors. Further adjustment for clinicopathological and treatment factors reduced the HR to 1.16 (95% CI, 1.06-1.25). This association was observed in patients living in socioeconomically less deprived counties (HR, 1.26; 95% CI, 1.14-1.39), urban patients (HR, 1.21; 95% CI, 1.11-1.32), patients having stage II (HR, 1.19; 95% CI, 1.02-1.39) or III (HR, 1.15; 95% CI, 1.01-1.31) tumors that were treated with chemotherapy, and patients younger than 65 years (HR, 1.24; 95% CI, 1.12-1.37).

Conclusions and Relevance

In this retrospective cohort study, African American women with nonmetastatic TNBC had a significantly higher risk of breast cancer mortality compared with their White counterparts, which was partially explained by their disparities in receipt of surgery and chemotherapy.

Understanding the Relationship between Breast Reconstruction Subtype and Risk of Financial Toxicity: A Single-Institution Pilot Study

BACKGROUND

The impact of breast reconstruction on financial toxicity remains poorly understood despite growing awareness. The authors sought to illustrate the relationship between breast reconstruction subtypes and the risk of financial toxicity.

METHODS

The authors conducted a single-institution cross-sectional survey of all female breast cancer patients undergoing any form of breast reconstruction between January of 2018 and June of 2019. Financial toxicity was measured by means of the validated Comprehensive Score for Financial Toxicity instrument. Demographics, clinical course, and coping strategies were abstracted from a purpose-built survey and electronic medical records. Multivariable linear regression was performed to identify associations with financial toxicity.

RESULTS

The authors' analytical sample was 350 patients. One hundred eighty-four (52.6 percent) underwent oncoplastic reconstruction, 126 (36 percent) underwent implant-based reconstruction, and 40 (11.4 percent) underwent autologous reconstruction. Oncoplastic reconstruction recipients were older, had a higher body mass index, and were more likely to have supplemental insurance and receive adjuvant hormonal therapy. No significant differences in the risk of financial toxicity were uncovered across breast reconstruction subtypes (p = 0.53). Protective factors against financial toxicity were use of supplemental insurance (p = 0.0003) and escalating annual household income greater than $40,000 (p < 0.0001). Receipt of radiation therapy was positively associated with worsening financial toxicity (-2.69; 95 CI percent, -5.22 to -0.15). Financial coping strategies were prevalent across breast reconstruction subtypes.

CONCLUSIONS

Breast reconstruction subtype does not differentially impact the risk of financial toxicity. Increasing income and supplemental insurance were found to be protective, whereas receipt of radiation therapy was positively associated with financial toxicity. Prospective, multicenter studies are needed to identify the main drivers of out-of-pocket costs and financial toxicity in breast cancer care.

Relationship Between Financial Toxicity and Surgical Treatment for Early-Stage Breast Cancer: A Propensity Score-Matched Comparison of Breast-Conserving Therapy and Mastectomy

BACKGROUND

Financial toxicity (FT) can lead to decreased quality of life and poor treatment outcomes. However, there is limited published data on the extent to which the various surgical treatment approaches for early-stage breast cancer are determinants for FT.

STUDY DESIGN

We performed a single-institution cross-sectional survey of adult female patients with stage 0 to II breast cancer undergoing unilateral breast-conserving therapy or unilateral mastectomy. FT was measured using the Comprehensive Score for Financial Toxicity (COST) survey. Propensity matching was performed to optimize comparability of study groups. A multivariate regression model was used to identify factors associated with worsening FT as a robustness check. Our secondary end point was prevalence of coping strategies associated with cost of cancer care.

RESULTS

Among 294 patients who met inclusion criteria, 203 underwent breast-conserving therapy and 91 received mastectomy. We generated 72 total matched pairs and noted no differences in demographic and socioeconomic characteristics. Of these, 55 pairs had complete COST information, which was comparable on adjusted analysis (26.6 vs 24.7; p = 0.481). High annual income (β = 4.83; p < 0.001) and supplemental insurance (β = 5.37; p < 0.001) were significantly associated with higher COST scores, while change in employment status (β = -4.81; p < 0.001) correlated significantly with lower COST scores. No significant differences were observed in coping strategies.

CONCLUSIONS

Choice of BCT or mastectomy was not associated with a differential risk for FT in early-stage cancer. Decisions on ablative approach should be made based on patient preferences and disease-specific criteria. Transparent counseling on FT for high-risk populations promotes patient-centricity.

Financial hardship among cancer survivors in Southern New Jersey

PURPOSE

To identify predictors of financial hardship, operationalized as foregoing health care, making financial sacrifices, and being concerned about having inadequate financial and insurance information.

METHODS

Cancer survivors (n = 346) identified through the New Jersey State Cancer Registry were surveyed from August 2018 to September 2019. Multivariable logistic regression analyses were performed.

RESULTS

Cancer survivors with household incomes less than $50,000 annually were more likely than those earning $50,0000-$90,000 to report foregoing health care (15.8 percentage points, p < 0.05). Compared to retirees, survivors who were currently unemployed, disabled, or were homemakers were more likely to forego doctor's visits (11.4 percentage points, p < 0.05), more likely to report borrowing money (16.1 percentage points, p < 0.01), and more likely to report wanting health insurance information (25.7 percentage points, p < 0.01). Employed survivors were more likely than retirees to forego health care (16.8 percentage points, p < 0.05) and make financial sacrifices (20.0 percentage points, p < 0.01). Survivors who never went to college were 9.8 percentage points (p < 0.05) more likely to borrow money compared to college graduates. Black survivors were more likely to want information about dealing with financial and insurance issues (p < 0.01); men were more likely to forego health care (p < 0.05).

CONCLUSION

Findings highlight the role of employment status and suggest that education, income, race, and gender also shape cancer survivors' experience of financial hardship. There is a need to refine and extend financial navigation programs. For employed survivors, strengthening family leave policies would be desirable.

What mediates the racial/ethnic disparity in psychosocial stress among breast cancer patients?

BACKGROUND

Prior studies have observed greater levels of psychosocial stress (PSS) among non-Hispanic (nH) African American and Hispanic women when compared to nH White patients after a breast cancer diagnosis. We aimed to determine the independent and interdependent roles of socioeconomic position (SEP) and unmet support in the racial disparity in PSS among breast cancer patients.

METHODS

Participants were recruited from the Breast Cancer Care in Chicago study (n = 989). For all recently diagnosed breast cancer patients, aged 25-79, income, education, and tract-level disadvantage and affluence were summed to create a standardized socioeconomic position (SEP) score. Three measures of PSS related to loneliness, perceived stress, and psychological consequences of a breast cancer diagnosis were defined based on previously validated scales. Five domains of unmet social support needs (emotional, spiritual, informational, financial, and practical) were defined from interviews. We conducted path models in MPlus to estimate the extent to which PSS disparities were mediated by SEP and unmet social support needs.

RESULTS

Black and Hispanic patients reported greater PSS compared to white patients and greater unmet social support needs (p = 0.001 for all domains). Virtually all of the disparity in PSS could be explained by SEP. A substantial portion of the mediating influence of SEP was further transmitted by unmet financial and practical needs among Black patients and by unmet emotional needs for Hispanic patients.

CONCLUSIONS

SEP appeared to be a root cause of the racial/ethnic disparities in PSS within our sample. Our findings further suggest that different interventions may be necessary to alleviate the burden of SEP for nH AA (i.e., more financial support) and Hispanic patients (i.e., more emotional support).

Call to action: breast cancer screening recommendations for Black women

African-American/Black women have more aggressive breast cancer subtypes, are diagnosed at younger ages, and have an increasing incidence rate. These disparities have resulted in Black women continuing to experience the highest mortality rate from breast cancer of any US racial or ethnic group. However, national screening mammography guidelines do not reflect the high-risk status of Black women. Here we review breast cancer screening guidelines and address the lack of inclusion of the specific needs of Black women. In order to equitably care for the health needs of Black women, high-risk designation would improve access to earlier screening and supplemental imaging including breast MRI.

Breast Cancer-Related Employment Disruption and Financial Hardship in the Sister Study

Background

More than one-half of breast cancer cases are diagnosed among women aged younger than 62 years, which may result in employment challenges. This study examined whether cancer-related employment disruption was associated with increased financial hardship in a national US study of women with breast cancer.

Methods

Women with breast cancer who were enrolled in the Sister or Two Sister Studies completed a survivorship survey in 2012. Employment disruption was defined as stopping work completely or working fewer hours after diagnosis. Financial hardship was defined as: 1) experiencing financial problems paying for cancer care, 2) borrowing money or incurring debt, or 3) filing for bankruptcy because of cancer. Prevalence ratios and 95% confidence intervals for the association between employment disruption and financial hardship were estimated using multivariable Poisson regression with robust variance.

Results

We analyzed data from women employed at diagnosis (n = 1628). Women were a median age of 48 years at diagnosis and 5.6 years from diagnosis at survey completion. Overall, 27.3% of women reported employment disruption (15.4% stopped working; 11.9% reduced hours), and 21.0% experienced financial hardship (16.0% had difficulty paying for care; 12.6% borrowed money or incurred debt; 1.8% filed for bankruptcy). In adjusted analysis, employment disruption was associated with nearly twice the prevalence of financial hardship (prevalence ratio = 1.93, 95% confidence interval = 1.58 to 2.35).

Conclusions

Women experiencing employment disruptions after breast cancer may be more vulnerable to financial hardship. Findings highlight the need to target risk factors for employment disruption, facilitate return to work or ongoing employment, and mitigate financial consequences after cancer.

Current Practices for Screening and Addressing Financial Hardship within the NCI Community Oncology Research Program

BACKGROUND

Cancer-related financial hardship is associated with poor care outcomes and reduced quality of life for patients and families. Scalable intervention development to address financial hardship requires knowledge of current screening practices and services within community cancer care.

METHODS

The NCI Community Oncology Research Program (NCORP) 2017 Landscape Assessment survey assessed financial screening and financial navigation practices within U.S. community oncology practices. Logistic models evaluated associations between financial hardship screening and availability of a cancer-specific financial navigator and practice group characteristics (e.g., safety-net designation, critical access hospital, proportion of racial and ethnic minority patients served).

RESULTS

Of 221 participating NCORP practice groups, 72% reported a financial screening process and 50% had a cancer-specific financial navigator. Practice groups with more than 10% of new patients with cancer enrolled in Medicaid (_adjOR = 2.81, P = 0.02) and with less than 30% racial/ethnic minority cancer patient composition (_adjOR = 3.91, P < 0.01) were more likely to screen for financial concerns. Practice groups with less than 30% racial/ethnic minority cancer patient composition (_adjOR = 2.37, P < 0.01) were more likely to have a dedicated financial navigator or counselor for patients with cancer.

CONCLUSIONS

Most NCORP practice groups screen for financial concerns and half have a cancer-specific financial navigator. Practices serving more racial or ethnic minority patients are less likely to screen and have a designated financial navigator.

IMPACT

The effectiveness of financial screening and navigation for mitigating financial hardship could be tested within NCORP, along with specific interventions to address cancer care inequities.See related commentary by Yabroff et al., p. 593.

Obesity, comorbidities, and treatment selection in Black and White women with early breast cancer

BACKGROUND

This study investigates obesity and comorbidity in Black and White women with early breast cancer (stages I-III) and their potential impact on treatment decisions for patients with hormone receptor-positive (HR+)/human epidermal growth factor receptor 2-negative (HER2-) tumors.

METHODS

In this retrospective chart review, comparisons of frequencies for Black and White patients were calculated with the Fisher exact test. Log binomial regression was used to estimate prevalence ratios (PRs) with 95% confidence intervals for total and individual comorbidities, and multivariable modeling was used to estimate PRs adjusted for age and body mass index (BMI).

RESULTS

In a sample of 548 patients, 26% were Black, and 74% were White. Sixty-two percent of Black patients and 32% of White patients were obese (BMI ≥ 30 kg/m² ; P < .0001). Seventy-five percent of Black patients and 87% of White patients had HR+ tumors (P = .001). Significant intergroup differences were seen for 2 or more total comorbidities (62% of Blacks vs 47% of Whites; P = .001), 2 or more obesity-related comorbidities (33% vs 10%; P < .0001), hypertension (60% vs 32%; P < .0001), diabetes mellitus (23% vs 6%; P < .0001), hypercholesterolemia or hyperlipidemia (28% vs 18%; P = .02), and hypothyroidism (4% vs 11%; P = .012). In women with HR+/HER2- tumors, there were no intergroup differences in treatment decisions regarding the type of surgery, chemotherapy regimen, radiation, or endocrine treatment despite significant differences in the prevalence of obesity and comorbidities.

CONCLUSIONS

This study documents significant disparities between Black and White women with early breast cancer with regard to high rates of obesity, overall comorbidities, and obesity-related comorbidities, and it highlights the prevalence of competing risks that may complicate outcomes in breast cancer.

Results from a prospective longitudinal survey of employment and work outcomes in newly diagnosed cancer patients during and after curative-intent chemotherapy: A Wisconsin Oncology Network study

BACKGROUND

Postcancer work limitations may affect a substantial proportion of patients and contribute to the "financial toxicity" of cancer treatment. The degree and nature of work limitations and employment outcomes are poorly understood for cancer patients, particularly in the immediate period of transition after active treatment. We prospectively examined employment, work ability, and work limitations during and after treatment.

METHODS

A total of 120 patients receiving curative therapy who were employed prior to their cancer diagnosis and who intended to work during or after end of treatment (EOT) completed surveys at baseline (pretreatment), EOT, and 3, 6, and 12 months after EOT. Surveys included measures of employment, work ability, and work limitations. Descriptive statistics (frequencies, percentages, means with standard deviations) were calculated.

RESULTS

A total of 111 participants completed the baseline survey. On average, participants were 48 years of age and were mostly white (95%) and female (82%) with a diagnosis of breast cancer (69%). Full-time employment decreased during therapy (from 88% to 50%) and returned to near prediagnosis levels by 12-month follow-up (78%). Work-related productivity loss due to health was high during treatment.

CONCLUSIONS

This study is the first to report the effects of curative intent cancer therapy on employment, work ability, and work limitations both during and after treatment. Perceived work ability was generally high overall 12 months after EOT, although a minority reported persistent difficulty. A prospective analysis of factors (eg, job type, education, symptoms) most associated with work limitations is underway to assist in identifying at-risk patients.

Breast cancer treatment delays by socioeconomic and health care access latent classes in Black and White women

BACKGROUND

Breast cancer mortality is higher for Black and younger women. This study evaluated 2 possible contributors to disparities-time to treatment and treatment duration-by race and age.

METHODS

Among 2841 participants with stage I-III disease in the Carolina Breast Cancer Study, we identified groups of women with similar patterns of socioeconomic status (SES), access to care, and tumor characteristics using latent class analysis. We then evaluated latent classes in association with treatment delay (initiation >60 days after diagnosis) and treatment duration (in quartiles by treatment modality).

RESULTS

Thirty-two percent of younger Black women were in the highest quartile of treatment duration (versus 22% of younger White women). Black women experienced a higher frequency of delayed treatment (adjusted relative frequency difference [RFD], 5.5% [95% CI, 3.2%-7.8%]) and prolonged treatment duration (RFD, 8.8% [95% CI, 5.7%-12.0%]). Low SES was significantly associated with treatment delay among White women (RFD, 3.5% [95% CI, 1.1%-5.9%]), but treatment delay was high at all levels of SES in Black women (eg, 11.7% in high SES Black women compared with 10.6% and 6.7% among low and high SES White women, respectively). Neither SES nor access to care classes were significantly associated with delayed initiation among Black women, but both low SES and more barriers were associated with treatment duration across both groups.

CONCLUSIONS

Factors that influence treatment timeliness persist throughout the care continuum, with prolonged treatment duration being a sensitive indicator of differences by race, SES, and care barriers.

Productivity costs associated with metastatic breast cancer in younger, midlife, and older women

BACKGROUND

The objective of the current study was to estimate productivity costs due to metastatic breast cancer (mBC) via productive time lost among survivors and potential life-years lost from premature mortality among 3 age groups: younger (aged 18-44 years), midlife (aged 45-64 years), and older (aged ≥65 years) women.

METHODS

The authors estimated the number of work and home productivity days missed due to mBC by age group using data from the 2000 to 2016 National Health Interview Survey. Years of potential life lost (YPLL) due to mBC were calculated for each age group using 2015 National Vital Statistics System data. The authors valued both sources of lost productivity time using the Current Population Survey and prior studies.

RESULTS

The per-woman value of lost productive days (work and home) due to mBC ranged from $680 for older women to $5169 for younger women. In 2015, the value of lost work and home productivity days associated with mBC nationally was $67 million for younger women, $246 million for midlife women, and $66 million for older women. YPLL were highest among midlife women (403,786 life-years), followed by older women (248,522 life-years) and younger women (95,943 life-years). Midlife women were found to have the highest market value of YPLL ($4.1 billion), followed by younger women ($1.6 billion) and older women ($527 million).

CONCLUSIONS

The results of the current study demonstrated that mBC generates a high economic burden through lost productivity, especially among midlife women.

Distinct financial distress profiles in patients with breast cancer prior to and for 12 months following surgery

BACKGROUND

Study purposes were to identify subgroups of patients with breast cancer with distinct self-reported financial distress (FD) profiles and determine which demographic, clinical and symptom characteristics, as well as quality of life (QOL) outcomes were associated with subgroup membership.

METHODS

Patients (n=391) who were assessed for changes in FD a total of 10 times from prior to through 12 months after breast cancer surgery. Latent profile analysis was used to identify subgroups of patients with distinct FD profiles.

RESULTS

Three distinct FD profiles (ie, None (14.6%), Low (52.7%), High (32.7%)) were identified. Compared with None and/or Low subgroups, patients in the High subgroup were more likely to report a lower annual household income and performance status; had a higher body mass index, axillary lymph node dissection and more advanced stage disease; had a longer time from cancer diagnosis to surgery; and had received neoadjuvant or adjuvant chemotherapy. In addition, patients in the High subgroup reported higher fatigue, sleep disturbance, state/trait anxiety, depressive symptom scores, and lower attentional function and QOL scores.

CONCLUSION

This study provides new insights on risk factors for and evidence of a higher symptom burden associated with FD. Findings from this study provide clinicians with information on how to identify high-risk patients and to recommend appropriate interventions for both symptom management and FD. Additional research on the mechanisms that underlie the relationships among FD and common physical and psychological symptoms may inform future interventions.

Financial toxicity and employment status in cancer survivors. A systematic literature review

Background

Financial toxicity has traditionally been attributed to the rising costs of cancer care. As ability to work impacts one’s financial situation, limited employment and reduced income may also contribute to financial toxicity. We examined evidence of the association between financial toxicity and employment status in cancer survivors.

Methods

A systematic literature review was performed via PubMed, Web of Science, CINAHL, and PsycINFO with search terms including “Cancer,” “Financial toxicity,” and “Employment” on September 25, 2019.

Results

Thirty-one papers met eligibility criteria. Thirteen studies were rated as having high quality, 16 as adequate, and two as low. Being actively treated for cancer had serious negative consequences on employment and medical expenditures. Unemployment, changed or reduced employment, lost days at work, poor work ability, and changes to employment were associated with a higher risk of financial toxicity. Patients who were younger, non-white, unmarried, of low education, living with dependents, residing in non-metropolitan service areas, with lower income, and of low socioeconomic status were more at risk of financial toxicity. Other variables associated with financial toxicity included having a mortgage/personal loan, higher out of pocket costs and household bills, limited health insurance, more severely ill, on active treatment, and lower functioning or quality of life.

Conclusion

Cancer negatively affects employment, and these changes are significant contributors to financial toxicity. Researchers, healthcare professionals, and patients themselves should all cooperate to tackle these complex issues.

Treatment Decision Making and Financial Toxicity in Women With Metastatic Breast Cancer

INTRODUCTION

Oncologists have increasingly been proponents of shared decision making (SDM) to enhance patient outcomes and reduce unnecessary health care spending. However, its effect on patient out-of-pocket costs is unknown. This study investigated the relationship between patient preferences for SDM and financial toxicity (FT) in patients with metastatic breast cancer (MBC).

PATIENTS AND METHODS

This cross-sectional study utilized surveys of women aged ≥ 18 with MBC who received care at two academic hospitals in Alabama from 2017 to 2019. Patients self-reported their SDM preference (Control Preferences Scale) and FT (Comprehensive Score for Financial Toxicity [COST] tool; 11-item scale, with lower scores indicating worse FT). Effect sizes were calculated using the proportion of variance explained (R²) or Cramer's V. Differences in FT by SDM preference were estimated using mixed models clustered by site and treating medical oncologist.

RESULTS

In 95 women with MBC, 44% preferred SDM, 29% preferred provider-driven decision making, and 27% preferred patient-driven decision making. Patients preferring SDM were more often college educated (53% vs. 39%; V = 0.12) with an income greater than $40,000/y (55% vs. 43%; V = 0.18). Overall median COST was 22 (interquartile range, 16-29). After adjusting for patient demographic and clinical characteristics, patients preferring patient-driven decision making trended toward worse FT (COST 17: 95% confidence interval, 12-22) compared to those preferring SDM (COST 19: 95% confidence interval, 15-23) and those preferring provider-driven decision making (COST 22: 95% confidence interval, 17-27).

CONCLUSION

Patients preferring more patient-driven decision making reported worse FT, although differences did not reach statistical significance. Further research is needed to understand this relationship.

Financial distress among breast cancer survivors

Aims:

there has been an increasing awareness of the potential for oncology care to result in long-term financial burdens and financial toxicity. Patients who report cancer-related financial problems or high costs are more likely to forgo or delay prescription medications and medical care.

Materials and Methods:

we examined financial distress using data from a survey of 164 breast cancer survivors who had completed primary therapy for the disease.

Key Findings:

among respondents, 8.6% (13 of 151) reported that “being less able to provide for the financial needs of their family” was as a severe problem; 14.4% (22 of 153) reported “difficulty in meeting medical expenses” was a severe problem; and 8.4% (13 of 154) reported that “no money for cost of or co-payment for medical visits” was a severe problem. About 8.4% (13 of 154) of the respondents reported that “no money for cost of or co-payment for medicine” was a severe problem. In logistic regression analysis, younger age and lower household income were significant predictors of financial distress. In multiple linear regression analysis, younger age and lower household income were significant predictors of financial distress.

Significance:

financial toxicity remains a major issue in breast cancer care. Efforts are needed to ensure patients experiencing high levels of financial toxicity are able to access recommended care. In addition, patients should talk with their providers about the costs of oncology care and about opportunities to reduce costs while maintaining high quality of care.

CVCDAP: an integrated platform for molecular and clinical analysis of cancer virtual cohorts

Recent large-scale multi-omics studies resulted in quick accumulation of an overwhelming amount of cancer-related data, which provides an unprecedented resource to interrogate diverse questions. While certain existing web servers are valuable and widely used, analysis and visualization functions with regard to re-investigation of these data at cohort level are not adequately addressed. Here, we present CVCDAP, a web-based platform to deliver an interactive and customizable toolbox off the shelf for cohort-level analysis of TCGA and CPTAC public datasets, as well as user uploaded datasets. CVCDAP allows flexible selection of patients sharing common molecular and/or clinical characteristics across multiple studies as a virtual cohort, and provides dozens of built-in customizable tools for seamless genomic, transcriptomic, proteomic and clinical analysis of a single virtual cohort, as well as, to compare two virtual cohorts with relevance. The flexibility and analytic competence of CVCDAP empower experimental and clinical researchers to identify new molecular mechanisms and develop potential therapeutic approaches, by building and analyzing virtual cohorts for their subject of interests. We demonstrate that CVCDAP can conveniently reproduce published findings and reveal novel insights by two applications. The CVCDAP web server is freely available at https://omics.bjcancer.org/cvcdap/.

Symptom Experience, Management, and Outcomes According to Race and Social Determinants Including Genomics, Epigenomics, and Metabolomics (SEMOARS + GEM): an Explanatory Model for Breast Cancer Treatment Disparity

Even after controlling for stage, comorbidity, age, and insurance status, black women with breast cancer (BC) in the USA have the lowest 5-year survival as compared with all other races for stage-matched disease. One potential cause of this survival difference is the disparity in cancer treatment, evident in many population clinical trials. Specifically, during BC chemotherapy, black women receive less relative dose intensity with more dose reductions and early chemotherapy cessation compared with white women. Symptom incidence, cancer-related distress, and ineffective communication, including the disparity in patient-centeredness of care surrounding patient symptom reporting and clinician assessment, are important factors contributing to racial disparity in dose reduction and early therapy termination. We present an evidence-based overview and an explanatory model for racial disparity in the symptom experience during BC chemotherapy that may lead to a reduction in dose intensity and a subsequent disparity in outcomes. This explanatory model, the Symptom Experience, Management, Outcomes and Adherence according to Race and Social determinants + Genomics Epigenomics and Metabolomics (SEMOARS + GEM), considers essential factors such as social determinants of health, clinician communication, symptoms and symptom management, genomics, epigenomics, and pharmacologic metabolism as contributory factors.

Employment Changes Following Breast Cancer Diagnosis: The Effects of Race and Place

The financial implications of breast cancer diagnosis may be greater among rural and black women. Women with incident breast cancer were recruited as part of the Carolina Breast Cancer Study. We compared unadjusted and adjusted prevalence of cancer-related job or income loss, and a composite measure of either outcome, by rural residence and stratified by race. We included 2435 women: 11.7% were rural; 48.5% were black; and 38.0% reported employment changes after diagnosis. Rural women more often reported employment effects, including reduced household income (43.6% vs 35.4%, two-sided χ2 test P = .04). Rural white, rural black, and urban black women each more often reported income reduction (statistically significant vs. urban white women), although these groups did not meaningfully differ from each other. In multivariable regression, rural differences were mediated by socioeconomic factors, but racial differences remained. Programs and policies to reduce financial toxicity in vulnerable patients should address indirect costs of cancer, including lost wages and employment.

Racial/Ethnic Disparities and Survival in Pediatrics with Gliomas Based on the Surveillance, Epidemiology, and End Results Database in the United States

BACKGROUND

Gliomas are the most common type of primary central nervous system tumor for both children and adults. However, the influence of racial/ethnic disparities on the survival of children with gliomas has not been fully evaluated yet.

METHODS

Baseline characteristics of patients, including sex, year of diagnosis, surgery, grade, radiation, histology, and races, were collected. Univariate and multivariate analyses for overall survival (OS) were performed using Cox proportional hazards regression model. Survival curves were plotted using Kaplan-Meier methods.

RESULTS

A total of 4400 childhood patients were enrolled, including 2516 non-Hispanic whites (NHWs), 1050 Hispanic whites (HWs), 519 blacks, 282 Asians or Pacific Islanders (APIs), and 33 American Indian/Alaska Natives. NHWs had the longest overall survival (OS), whereas blacks had the shortest OS (P = 0.003). Stratified by histologic type, OS of children with astrocytoma was better among NHWs and HWs than among blacks and APIs (P = 0.004). OS of children with ependymoma was better among NHWs and APIs than among HWs and blacks (P = 0.008). However, no significant difference was observed in OS for children with medulloblastoma (P = 0.854).

CONCLUSIONS

Survival outcomes varied significantly by race/ethnicity among childhood gliomas. Better management of childhood gliomas is warranted to close the survival gap between race/ethnicity.

Integrating biology and access to care in addressing breast cancer disparities: 25 years' research experience in the Carolina Breast Cancer Study

Purpose of Review

To review research on breast cancer mortality disparities, emphasizing research conducted in the Carolina Breast Cancer Study, with a focus on challenges and opportunities for integration of tumor biology and access characteristics across the cancer care continuum.

Recent Findings

Black women experience higher mortality following breast cancer diagnosis, despite lower incidence compared to white women. Biological factors, such as stage at diagnosis and breast cancer subtypes, play a role in these disparities. Simultaneously, social, behavioral, environmental, and access to care factors are important. However, integrated studies of biology and access are challenging and it is uncommon to have both data types available in the same study population. The central emphasis of Phase 3 of the Carolina Breast Cancer Study, initiated in 2008, was to collect rich data on biology (including germline and tumor genomics and pathology) and health care access in a diverse study population, with the long term goal of defining intervention opportunities to reduce disparities across the cancer care continuum.

Summary

Early and ongoing research from CBCS has identified important interactions between biology and access, leading to opportunities to build greater equity. However, sample size, population-specific relationships among variables, and complexities of treatment paths along the care continuum pose important research challenges. Interdisciplinary teams, including experts in novel data integration and causal inference, are needed to address gaps in our understanding of breast cancer disparities.

Factors Associated With Oncologist Discussions of the Costs of Genomic Testing and Related Treatments

BACKGROUND

Use of genomic testing is increasing in the United States. Testing can be expensive, and not all tests and related treatments are covered by health insurance. Little is known about how often oncologists discuss costs of testing and treatment or about the factors associated with those discussions.

METHODS

We identified 1220 oncologists who reported discussing genomic testing with their cancer patients from the 2017 National Survey of Precision Medicine in Cancer Treatment. Multivariable polytomous logistic regression analyses were used to assess associations between oncologist and practice characteristics and the frequency of cost discussions. All statistical tests were two-sided.

RESULTS

Among oncologists who discussed genomic testing with patients, 50.0% reported often discussing the likely costs of testing and related treatments, 26.3% reported sometimes discussing costs, and 23.7% reported never or rarely discussing costs. In adjusted analyses, oncologists with training in genomic testing or working in practices with electronic medical record alerts for genomic tests were more likely to have cost discussions sometimes (odds ratio [OR] = 2.09, 95% confidence interval [CI] = 1.19 to 3.69) or often (OR = 2.22, 95% CI = 1.30 to 3.79), respectively, compared to rarely or never. Other factors statistically significantly associated with more frequent cost discussions included treating solid tumors (rather than only hematological cancers), using next-generation sequencing gene panel tests, having higher patient volume, and working in practices with higher percentages of patients insured by Medicaid, or self-paid or uninsured.

CONCLUSIONS

Interventions targeting modifiable oncologist and practice factors, such as training in genomic testing and use of electronic medical record alerts, may help improve cost discussions about genomic testing and related treatments.

Factors Associated with Endocrine Therapy Non-Adherence in Breast Cancer Survivors

BACKGROUND

For women with hormone receptor positive breast cancer, long-term endocrine therapy (ET) can greatly reduce the risk of recurrence, yet adherence is low- particularly among traditionally underserved populations.

METHODS

The Carolina Breast Cancer Study oversampled Black and young women (<50 years of age). Participants answered an ET-specific medication adherence questionnaire assessing reasons for non-adherence. We used principal factor analysis to identify latent factors describing ET non-adherence. We then performed multivariable regression to determine clinical and demographic characteristics associated with each ET non-adherence factor.

RESULTS

1,231 women were included in analysis, 59% reported at least one barrier to ET adherence. We identified three latent factors which we defined as: habit - challenges developing medication-taking behavior; tradeoffs - high perceived side effect burden and medication safety concerns; and resource barriers - challenges related to cost or accessibility. Older age (50+) was associated with less reporting of habit (Adjusted Risk Ratio (aRR) 0.54[95% CI: 0.43-0.69] and resource barriers (aRR 0.66[0.43-0.997]), but was not associated with tradeoff barriers. Medicaid-insured women were more likely than privately-insured to report tradeoff (aRR:1.53 [1.10-2.13]) or resource barriers (aRR:4.43[2.49-6.57]). Black race was associated with increased reporting of all factors (habit: aRR 1.29[1.09-1.53]; tradeoffs: 1.32[1.09-1.60], resources: 1.65[1.18-2.30]).

CONCLUSION

Barriers to ET adherence were described by three distinct factors, and strongly associated with sociodemographic characteristics. Barriers to ET adherence appear inadequately addressed for younger, Black, and publicly-insured breast cancer survivors. These findings underscore the importance of developing multi-faceted, patient-centered interventions that address a diverse range of barriers to ET adherence.

Integrating access to care and tumor patterns by race and age in the Carolina Breast Cancer Study, 2008-2013

PURPOSE

Understanding breast cancer mortality disparities by race and age is complex due to disease heterogeneity, comorbid disease, and the range of factors influencing access to care. It is important to understand how these factors group together within patients.

METHODS

We compared socioeconomic status (SES) and comorbidity factors in the Carolina Breast Cancer Study Phase 3 (CBCS3, 2008-2013) to those for North Carolina using the 2010 Behavioral Risk Factor Surveillance Study. In addition, we used latent class analysis of CBCS3 data to identify covariate patterns by SES/comorbidities, barriers to care, and tumor characteristics and examined their associations with race and age using multinomial logistic regression.

RESULTS

Major SES and comorbidity patterns in CBCS3 participants were generally similar to patterns in the state. Latent classes were identified for SES/comorbidities, barriers to care, and tumor characteristics that varied by race and age. Compared to white women, black women had lower SES (odds ratio (OR)  6.3, 95% confidence interval (CI) 5.2, 7.8), more barriers to care (OR 5.6, 95% CI 3.9, 8.1) and several aggregated tumor aggressiveness features. Compared to older women, younger women had higher SES (OR 0.5, 95% CI 0.4, 0.6), more barriers to care (OR 2.1, 95% CI 1.6, 2.9) and aggregated tumor aggressiveness features.

CONCLUSIONS

CBCS3 is representative of North Carolina on comparable factors. Patterns of access to care and tumor characteristics are intertwined with race and age, suggesting that interventions to address disparities will need to target both access and biology.

Medical Financial Hardship Intensity and Financial Sacrifice Associated with Cancer in the United States

BACKGROUND

With rising costs of cancer care, this study aims to estimate the prevalence of, and factors associated with, medical financial hardship intensity and financial sacrifices due to cancer in the United States.

METHODS

We identified 963 cancer survivors from the 2016 Medical Expenditures Panel Survey - Experiences with Cancer. Medical financial hardship due to cancer was measured in material (e.g., filed for bankruptcy), psychological (e.g., worry about paying bills and finances), and behavioral (e.g., delaying or forgoing care due to cost) domains. Nonmedical financial sacrifices included changes in spending and use of savings. Multivariable logistic models were used to identify characteristics associated with hardship intensity and sacrifices stratified by age group (18-64 or 65+ years).

RESULTS

Among cancer survivors ages 18 to 64 years, 53.6%, 28.4%, and 11.4% reported at least one, two, or all three domains of hardship, respectively. Among survivors ages 65+ years, corresponding percentages were 42.0%, 12.7%, and 4.0%, respectively. Moreover, financial sacrifices due to cancer were more common in survivors ages 18 to 64 years (54.2%) than in survivors 65+ years (38.4%; P < 0.001). Factors significantly associated with hardship intensity in multivariable analyses included low income and educational attainment, racial/ethnic minority, comorbidity, lack of private insurance coverage, extended employment change, and recent cancer treatment. Most were also significantly associated with financial sacrifices.

CONCLUSIONS

Medical financial hardship and financial sacrifices are substantial among cancer survivors in the United States, particularly for younger survivors.

IMPACT

Efforts to mitigate financial hardship for cancer survivors are warranted, especially for those at high risk.

Understanding breast cancer survivors' financial burden and distress after financial assistance

PURPOSE

Little is known about how breast cancer may impact survivors' financial well-being. This study aims to investigate the financial status, burden, and opinions of breast cancer survivors who received short-term financial assistance, emotional support, and resource navigation from a community organization during treatment.

METHODS

Clients previously served by the community organization were mailed a 16-question survey (n = 751) to elicit their perspective on financial status and burden before, during, and after diagnosis and treatment along with general demographic and opinion items.

RESULTS

136 surveys (18.1%) were returned yielding 118 (15.7%) suitable for analyses. Clients' average age was 54.3 years. Most were female (99.2%), Caucasian (66.1%), and diagnosed with Stage 1 or 2 breast cancer (58.5%). Clients reported significantly worse (p < 0.001) financial status after being diagnosed compared to before diagnosis. Financial distress was highest during cancer treatment (mean = 3.92, SD = 0.85), lowest prior to treatment (mean = 2.48, SD = 1.05), and remained high after treatment (mean = 3.59, SD = 1.05). Those with higher distress after treatment were significantly (p = 0.01) more likely to report lower social support during treatment.

CONCLUSIONS

Breast cancer survivors reported worsening financial status and distress after being diagnosed and during treatment despite receiving short-term financial assistance, emotional support, and resource navigation. Survivors' financial distress after treatment remained higher than before treatment. However, most felt receiving financial assistance improved their quality of life and made them feel more in control of financial decision-making. Breast cancer survivors who feel they have low social support during treatment may feel higher financial distress posttreatment.

Financial hardship among rural cancer survivors: An analysis of the Medical Expenditure Panel Survey

Some cancer survivors report spending 20% of their annual income on medical care. Undue financial burden that patients face related to the cost of care is referred to as financial hardship, which may be more prevalent among rural cancer survivors. This study examined contrasts in financial hardship among 1419 rural and urban cancer survivors using the 2011 Medical Expenditure Panel Survey supplement - The Effects of Cancer and Its Treatment on Finances. We combined four questions, creating a measure of material financial hardship, and examined one question on financial worry. We conducted multivariable logistic regression analyses, which produced odds ratios (OR) for factors associated with financial hardship and worry, and then generated average adjusted predicted probabilities. We focused on rural and urban differences classified by metropolitan statistical area (MSA) designation, controlling for age, education, race, marital status, health insurance, family income, and time since last cancer treatment. More rural cancer survivors reported financial hardship than urban survivors (23.9% versus 17.1%). However, our adjusted models revealed no significant impact of survivors' MSA designation on financial hardship or worry. Average adjusted predicted probabilities of financial hardship were 18.6% for urban survivors (Confidence Interval [CI]: 11.9%-27.5%) and 24.2% for rural survivors (CI: 15.0%-36.2%). For financial worry, average adjusted predicted probabilities were 19.9% for urban survivors (CI: 12.0%-31.0%) and 18.8% for rural survivors (CI: 12.1%-28.0%). Improving patient-provider communication through decision aids and/or patient navigators may be helpful to reduce financial hardship and worry regardless of rural-urban status.

Financial Burdens of Cancer Treatment: A Systematic Review of Risk Factors and Outcomes

BACKGROUND

Patients with cancer experience financial toxicity from the costs of treatment, as well as material and psychologic stress related to this burden. A synthesized understanding of predictors and outcomes of the financial burdens associated with cancer care is needed to underpin strategic responses in oncology care. This study systematically reviewed risk factors and outcomes associated with financial burdens related to cancer treatment.

METHODS

MEDLINE, Embase, PubMed, PsychINFO, and the Cochrane Library were searched from study inception through June 2018, and reference lists were scanned from studies of patient-level predictors and outcomes of financial burdens in US patients with cancer (aged ≥18 years). Two reviewers conducted screening, abstraction, and quality assessment. Variables associated with financial burdens were synthesized. When possible, pooled estimates of associations were calculated using random-effects models.

RESULTS

A total of 74 observational studies of financial burdens in 598,751 patients with cancer were identified, among which 49% of patients reported material or psychologic financial burdens (95% CI, 41%-56%). Socioeconomic predictors of worse financial burdens with treatment were lack of health insurance, lower income, unemployment, and younger age at cancer diagnosis. Compared with patients with health insurance, those who were uninsured demonstrated twice the odds of financial burdens (pooled odds ratio [OR], 2.09; 95% CI, 1.33-3.30). Financial burdens were most severe early in cancer treatment, did not differ by disease site, and were associated with worse health-related quality of life (HRQoL) and nearly twice the odds of cancer medication nonadherence (pooled OR, 1.70; 95% CI, 1.13-2.56). Only a single study demonstrated an association with increased mortality. Studies assessing the comparative effectiveness of interventions to mitigate financial burdens in patients with cancer were lacking.

CONCLUSIONS

Evidence showed that financial burdens are common, disproportionately impacting younger and socioeconomically disadvantaged patients with cancer, across disease sites, and are associated with worse treatment adherence and HRQoL. Available evidence helped identify vulnerable patients needing oncology provider engagement and response, but evidence is critically needed on the effectiveness of interventions designed to mitigate financial burden and impact.

Racial differences in employment and cost-management behaviors in patients with metastatic breast cancer

PURPOSE

Little is known about racial variations in the financial impact of cancer care. Using data from a national survey of racially diverse patients with metastatic breast cancer, we examined racial/ethnic patterns in employment and cost-management (i.e., financial coping) behaviors.

METHODS

We conducted an online survey of patients with metastatic breast cancer. Participants reported on socio-demographic characteristics, employment, and financial coping behaviors. We employed adjusted modified Poisson regressions to evaluate racial/ethnic differences in changes in work for pay and financial coping.

RESULTS

Our analysis included 1052 respondents from 41 states, including Non-Hispanic Blacks (NHB, 9%), Hispanics (7%), Asians/Pacific Islanders/Native Hawaiians (API/NH, 10%), American Indians/Alaskan Natives (AI/AN, 8%), and Non-Hispanic Whites (NHW, 66%). In adjusted analyses comparing NHWs with patients of color, patients of color were more likely to take unpaid leave (NHB Adjusted Risk Ratio [ARR] = 2.27; 95% CI 1.54, 3.34), take paid leave (Hispanic ARR = 2.27; 95% CI 1.54, 1.29), stop work (AI/AN ARR = 1.22; 95% CI 1.05, 1.41), and reduce work hours (AI/AN ARR = 1.33; 95% CI 1.14, 1.57). Patients of color were more likely than NHWs to stop treatment (NHB ARR = 1.22; 95% CI 1.08, 1.39), borrow money from friends/family (Hispanic ARR = 1.75; 95% CI 1.25, 2.44), skip other medical bills (API/NH ARR = 2.02; 95% CI 1.54, 2.63), and skip non-medical bills (AI/AN ARR = 1.67 95% CI 1.06, 2.63). Non-Hispanic Whites more commonly reported using savings or skipping a vacation to help manage costs.

CONCLUSIONS

Racial/ethnic differences exist in employment changes and financial coping among metastatic breast cancer patients, with patients of color experiencing worse consequences. Equity must be a guiding principle in strategies addressing financial burden during cancer care.

Race and delays in breast cancer treatment across the care continuum in the Carolina Breast Cancer Study

BACKGROUND

After controlling for baseline disease factors, researchers have found that black women have worse breast cancer survival, and this suggests that treatment differences may contribute to poorer outcomes. Delays in initiating and completing treatment are one proposed mechanism.

METHODS

Phase 3 of the Carolina Breast Cancer Study involved a large, population-based cohort of women with incident breast cancer. For this analysis, we included black women (n = 1328) and white women (n = 1331) with stage I to III disease whose treatment included surgery with or without adjuvant therapies. A novel treatment pathway grouping was used to benchmark the treatment duration (surgery only, surgery plus chemotherapy, surgery plus radiation, or all 3). Models controlled for the treatment pathway, age, and tumor characteristics and for demographic factors related to health care access. Exploratory analyses of the association between delays and cancer recurrence were performed.

RESULTS

In fully adjusted analyses, blacks had 1.73 times higher odds of treatment initiation more than 60 days after their diagnosis in comparison with whites (odds ratio [OR], 1.73; 95% confidence interval [CI], 1.04-2.90). Black race was also associated with a longer treatment duration. Blacks were also more likely to be in the highest quartile of treatment duration (OR, 1.69; 95% CI, 1.41-2.02), even after adjustments for demographic and tumor characteristics (OR, 1.31; 95% CI, 1.04-1.64). A nonsignificant trend toward a higher recurrence risk was observed for patients with delayed initiation (hazard ratio, 1.44; 95% CI, 0.89-2.33) or the longest duration (hazard ratio, 1.17; 95% CI, 0.87-1.59).

CONCLUSIONS

Black women more often had delayed treatment initiation and a longer duration than whites receiving similar treatment. Interventions that target access barriers may be needed to improve timely delivery of care.

Financial Costs and Burden Related to Decisions for Breast Cancer Surgery

PURPOSE

Financial toxicity is a well-recognized adverse effect of cancer care, yet little is known about how women consider treatment costs when facing preference-sensitive decisions for breast cancer surgery or how surgical treatment choice affects financial harm. We sought to determine how financial costs and burden relate to decisions for breast cancer surgery.

METHODS

Women (≥ 18 years old) with a history of breast cancer were recruited from the Army of Women and Sisters Network to complete an 88-item electronic survey. Descriptive statistics and regression analysis were used to evaluate the impact of costs on surgical decisions and financial harm after breast cancer surgery.

RESULTS

A total of 607 women with stage 0 to III breast cancer were included. Most were white (90%), were insured privately (70%) or by Medicare (25%), were college educated (78%), and reported household incomes of more than $74,000 (56%). Forty-three percent underwent breast-conserving surgery, 25% underwent mastectomy, 32% underwent bilateral mastectomy, and 36% underwent breast reconstruction. Twenty-eight percent reported that costs of treatment influenced their surgical decisions, and at incomes of $45,000 per year, costs were prioritized over breast preservation or appearance. Overall, 35% reported financial burden as a result of their cancer treatment, and 78% never discussed costs with their cancer team. When compared with breast-conserving surgery, bilateral mastectomy with or without reconstruction was significantly associated with higher incurred debt, significant to catastrophic financial burden, treatment-related financial hardship, and altered employment. Among the highest incomes, 65% of women were fiscally unprepared, reporting higher-than-expected (26%) treatment costs.

CONCLUSION

Cancer treatment costs influenced decisions for breast cancer surgery, and comparably effective surgical treatments differed significantly in their risk of patient-reported financial burden, debt, and impact on employment. Cost transparency may inform preference-sensitive surgical decisions and improve patient-centered care.

Race, financial hardship, and limiting care due to cost in a diverse cohort of cancer survivors

PURPOSE

Estimate prevalence of types of cancer-related financial hardship by race and test whether they are associated with limiting care due to cost.

METHODS

We used data from 994 participants (411 white, 583 African American) in a hospital-based cohort study of survivors diagnosed with breast, colorectal, lung, or prostate cancer since January 1, 2013. Financial hardship included decreased income, borrowing money, cancer-related debt, and accessing assets to pay for cancer care. Limiting care included skipping doses of prescribed medication, refusing treatment, or not seeing a doctor when needed due to cost. Logistic regression models controlled for sociodemographic factors.

RESULTS

More African American than white survivors reported financial hardship (50.3% vs. 41.0%, p = 0.005) and limiting care (20.0% vs. 14.2%, p = 0.019). More white than African American survivors reported utilizing assets (9.3% vs. 4.8%, p = 0.006), while more African American survivors reported cancer-related debt (30.5% vs. 18.5%, p < 0.001). Survivors who experienced financial hardship were 4.4 (95% CI: 2.9, 6.6) times as likely to limit care as those who did not. Borrowing money, cancer-related debt, and decreased income were each independently associated with limiting care, while accessing assets was not.

CONCLUSIONS

The prevalence of some forms of financial hardship differed by race, and these were differentially associated with limiting care due to cost.

IMPLICATIONS FOR CANCER SURVIVORS

The ability to use assets to pay for cancer care may protect survivors from limiting care due to cost. This has differential impacts on white and African American survivors.

Minimizing the burden of cancer in the United States: Goals for a high-performing health care system

Between 1991 and 2015, the cancer mortality rate declined dramatically in the United States, reflecting improvements in cancer prevention, screening, treatment, and survivorship care. However, cancer outcomes in the United States vary substantially between populations defined by race/ethnicity, socioeconomic status, health insurance coverage, and geographic area of residence. Many potentially preventable cancer deaths occur in individuals who did not receive effective cancer prevention, screening, treatment, or survivorship care. At the same time, cancer care spending is large and growing, straining national, state, health insurance plans, and family budgets. Indeed, one of the most pressing issues in American medicine is how to ensure that all populations, in every community, derive the benefit from scientific research that has already been completed. Addressing these questions from the perspective of health care delivery is necessary to accelerate the decline in cancer mortality that began in the early 1990s. This article, part of the Cancer Control Blueprint series, describes challenges with the provision of care across the cancer control continuum in the United States. It also identifies goals for a high-performing health system that could reduce disparities and the burden of cancer by promoting the adoption of healthy lifestyles; access to a regular source of primary care; timely access to evidence-based care; patient-centeredness, including effective patient-provider communication; enhanced coordination and communication between providers, including primary care and specialty care providers; and affordability for patients, payers, and society.

Rural-urban differences in financial burden among cancer survivors: an analysis of a nationally representative survey

PURPOSE

Rural cancer survivors may disproportionately experience financial problems due to their cancer because of greater travel costs, higher uninsured/underinsured rates, and other factors compared to their urban counterparts. Our objective was to examine rural-urban differences in reported financial problems due to cancer using a nationally representative survey.

METHODS

We used data from three iterations of the National Cancer Institute's Health Information and National Trends Survey (2012, 2014, and 2017) to identify participants who had a previous or current cancer diagnosis. Our outcome of interest was self-reported financial problems associated with cancer diagnosis and treatment. Rural-urban status was defined using 2003 Rural-Urban Continuum Codes. We calculated weighted percentages and Wald chi-square statistics to assess rural-urban differences in demographic and cancer characteristics. In multivariable logistic regression models, we examined the association between rural-urban status and other factors and financial problems, reporting the corresponding adjusted predicted probabilities.

FINDINGS

Our sample included 1359 cancer survivors. Rural cancer survivors were more likely to be married, retired, and live in the Midwest or South. Over half (50.5%) of rural cancer survivors reported financial problems due to cancer compared to 38.8% of urban survivors (p = 0.02). This difference was attenuated in multivariable models, 49.3 and 38.7% in rural and urban survivors, respectively (p = 0.06).

CONCLUSIONS

A higher proportion of rural survivors reported financial problems associated with their cancer diagnosis and treatment compared to urban survivors. Future research should aim to elucidate these disparities and interventions should be tested to address the cancer-related financial problems experienced by rural survivors.

Financial Toxicity in Advanced and Metastatic Cancer: Overburdened and Underprepared

Patients with metastatic or advanced cancer are likely to be particularly susceptible to financial hardship for reasons related both to the characteristics of metastatic disease and to the characteristics of the population living with metastatic disease. First, metastatic cancer is a resource-intensive condition with expensive treatment and consistent, high-intensity monitoring. Second, patients diagnosed with metastatic disease are disproportionately uninsured and low income and from racial or ethnic minority groups. These vulnerable subpopulations have higher cancer related financial burden even in earlier stages of illness, potentially resulting from fewer asset reserves, nonexisting or less generous health insurance benefits, and employment in jobs with less flexibility and fewer employment protections. This combination of high financial need and high financial vulnerability makes those with advanced cancer an important population for additional study. In this article, we summarize why financial toxicity is burdensome for patients with advanced disease; review prior work in the metastatic or advanced settings specifically; and close with implications and recommendations for research, practice, and policy.