Financial burden among older, long-term cancer survivors: Results from the LILAC study

Understanding racial differences in financial hardship among older adults surviving cancer

BACKGROUND

Despite Medicare coverage, financial hardship is a prevalent issue among those diagnosed with cancer at age 65 years and older, particularly among those belonging to a racial or ethnic minority group. Sociodemographic, clinical, and area-level factors may mediate this relationship; however, no studies have assessed the extent to which these factors contribute to the racial/ethnic disparities in financial hardship.

METHODS

Surveys assessing financial hardship were completed by 721 White (84%) or Black (16%) patients (aged 65 years and older) who were diagnosed with breast (34%), prostate (27%), lung (17%), or colorectal (14%) cancer or lymphoma (9%) at the University of Alabama at Birmingham between 2000 and 2019. Financial hardship included material, psychological, and behavioral domains. Nonlinear Blinder-Oaxaca effect decomposition methods were used to evaluate the extent to which individual and area-level factors contribute to racial disparities in financial hardship.

RESULTS

Black patients reported lower income (65% vs. 34% earning <$50,000) and greater scores on the Area Deprivation Index (median, 93.0 vs. 55.0). Black patients reported significantly higher rates of overall (39% vs. 18%), material (29% vs. 11%), and psychological (27% vs. 11%) hardship compared with White patients. Overall, the observed characteristics explained 51% of racial differences in financial hardship among cancer survivors, primarily because of differences in income (23%) and area deprivation (11%).

CONCLUSIONS

The current results identify primary contributors to racial disparities in financial hardship among older cancer survivors, which can be used to develop targeted interventions and allocate resources to those at greatest risk for financial hardship.

Out-of-pocket payments and loss of income among long-term breast cancer survivors in Germany: a multi-regional population-based study

PURPOSE

This study aims to examine the magnitude of out of pocket (OOP) payments and income loss, as well as to identify socioeconomic and clinical factors among long-term breast cancer (BC) survivors in Germany.

METHODS

We examine data from 2654 long-term BC survivors in Germany that participated in the "CAncEr Survivorship - A multi-Regional population-based study" (CAESAR) and who were at least 5 years post diagnosis. BC-related OOP payments and income loss both within the 12 months prior to the survey were analyzed. Two-part regression models were performed to identify socioeconomic and clinical factors.

RESULTS

OOP payments were incurred by 51.9% of survivors with a total mean spending of 566 euros. Income loss was present among 9.6% of survivors and averaged 5463 euros among those reporting such. Socioeconomic and clinical factors associated with higher OOP payments (p ≤ 0.05) included age at time of diagnosis (65-79 years), education (10-11 years), (early) retirement, stage of diagnosis (stage III), time from diagnosis (more than 10 years), comorbidities (at least 1), and the use of rehabilitation services. Regarding income loss, age at time of diagnosis (50-59 years), (early) retirement, stage of diagnosis (stage II), time from diagnosis (5-7 years), comorbidities (at least 1), and receiving chemotherapy treatment were associated with higher losses.

CONCLUSIONS

For some survivors in Germany, financial burden can be considerably high despite comprehensive healthcare and support from social security.

IMPLICATIONS FOR CANCER SURVIVORS

OOP payments related to domestic help and nursing staff as well as to outpatient care are most frequent.

Anticipatory Guidance: Developing a Patient Navigation Pathway to Reduce the Financial Toxicity of Cancer

Background

Healthcare providers have an influential role in the experience of financial toxicity among their cancer patients, yet patients commonly report unmet needs and dissatisfaction regarding communication with their providers about financial concerns.

Aims

The purpose of this study is to develop a novel financial navigation pathway that leverages existing patient financial services and resources with corresponding patient-centered, community-informed strategies, via study participants, that may be utilized in routine care to reduce financial hardship among cancer patients.

Methods

We conducted in-depth interviews (n=50) with 34 cancer patients and 16 cancer care professionals at a National Cancer Institute designated comprehensive cancer center located in a dense urban area of the US between December2022 to June 2023.

Results

Content analyses resulted in emergent themes and representative quotations on experiences of financial hardship within the material, behavioral, and psychosocial domains. Investigators used emergent themes to develop financial strategies and construct a financial navigation pathway to screen patients for and intervene upon the financial toxicity of cancer in routine care.

Conclusion

This study followed an innovative approach by constructing a financial navigation pathway tool that follows the oncological workflow at a National Cancer Institute designated comprehensive cancer center. Future research is needed to test the tool's impact on financial toxicity, cancer outcomes, and other health-related outcomes, and to better understand how much patient navigation is needed to bring about meaningful change.

Financial toxicity in thyroid cancer survivors

PURPOSE OF REVIEW

Financial burden and distress are high in patients with thyroid cancer. However, little has been done to evaluate potential interventions to mitigate financial toxicity in survivors. This review will cover current data on the impact of financial toxicity on quality of life and clinical outcomes in patients with thyroid cancer and highlight areas for future study.

RECENT FINDINGS

Thyroid cancer incidence has nearly tripled in the past decades, and cost of treatment is predicted to rise more than other cancers over the next decade. With mean age of diagnosis at 51 years, most patients begin treatment while still working, do not qualify for Medicare or Social Security, and are susceptible to higher financial burden. Though thyroid cancer has high survival rates, some studies suggest patients have worse quality of life and higher financial burden than more morbid cancers.

SUMMARY

Thyroid cancer survivors have high rates of financial toxicity, and there remains need for longitudinal studies to evaluate how financial burden may change during the treatment process while also assessing potential tools to mitigate this burden.

Impact of cancer on income, wealth and economic outcomes of adult cancer survivors: a scoping review

OBJECTIVE

To summarise peer-reviewed evidence on the effect of a cancer diagnosis on the different sources of income of individuals diagnosed with cancer during adulthood (age ≥18 years).

DESIGN

A scoping review following the Joanna Briggs Institute's methodological framework for conducting scoping reviews and reporting results following the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews checklist.

DATA SOURCES

Ovid MEDLINE, PsycINFO, CINAHL, EMBASE, Econ-Lit and Evidence-based Medicine Reviews, and reference lists of evidence syntheses. Published literature of any study type in English was searched from January 2000 to December 2020.

ELIGIBILITY AND CRITERIA

Study participants were individuals diagnosed with cancer during adulthood (age ≥18 years). Studies from any country and/or healthcare system were included. Primary outcomes were employment income (eg, individual or household); investment income (eg, stocks/bonds, properties, savings); government transfer payments (eg, disability income/pension); debt and bankruptcy.

DATA EXTRACTION AND SYNTHESIS

Findings are summarised descriptively and in tabular form.

RESULTS

From 6297 citations retrieved, 63 studies (67 articles) met our inclusion criteria. Most (51%) were published in 2016-2020; 65% were published in the USA or Scandinavia. Survivors incurred debt (24 studies), depleted savings (13 studies) and liquidated stocks/bonds (7 studies) in response to a cancer diagnosis. 41 studies reported changes to employment income; of these, 12 case-control studies reported varying results: 5 reported survivors earned less than controls, 4 reported no significant differences, 2 reported mixed results and 1 reported income increased. Initial declines in income tended to lessen over time.

CONCLUSIONS

Cancer's impact on survivors' income is complex and time-varying. Longitudinal studies are needed to document the trend of initial declines in income, with declines lessening over time, and its variations. Study designs using standardised income measures and capturing treatment type and follow-up time will improve our understanding of cancer's impact on survivors' income.

Evaluation of the key geriatric assessment constructs in primary brain tumor population - a descriptive study

INTRODUCTION

Despite an increasing aging population, older adults (≥ 65 years) with primary brain tumors (PBTs) are not routinely assessed for geriatric vulnerabilities. Recent reports of geriatric assessment (GA) in patients with glioblastomas demonstrated that GA may serve as a sensitive prognosticator of overall survival. Yet, current practice does not include routine evaluation of geriatric vulnerabilities and the relevance of GA has not been previously evaluated in broader cohorts of PBT patients. The objective of this descriptive study was to assess key GA constructs in adults with PBT dichotomized into older versus younger groups.

MATERIALS AND METHODS

A cross-sectional analysis of data collected from 579 participants with PBT recruited between 2016 and 2020, dichotomized into older (≥ 65 years, n = 92) and younger (≤ 64 years, n = 487) from an ongoing observational trial. GA constructs were evaluated using socio-demographic characteristics, Charlson Comorbidity Index (CCI), polypharmacy (>5 daily medications), Karnofsky Performance Status (KPS), Neurologic Function Score (NFS), and patient-reported outcome assessments including general health, functional status, symptom burden and interference, and mood. Descriptive statistics, t-tests, chi-square tests, and Pearson correlations were used to evaluate differences between age groups.

RESULTS

Older participants were more likely to have problems with mobility (58% vs. 44%), usual activities (64% vs 50%) and self-care (38% vs 26%) compared to the younger participants (odds ratios [ORs] = 1.3-1.4, ps < 0.05), while older participants were less likely to report feeling distressed (OR = 0.4, p < 0.05). Older participants also had higher CCI and were more likely to have polypharmacy (OR = 1.7, ps < 0.05). Increasing age strongly correlated with worse KPS score (r = -0.232, OR = 1.4, p < 0.001) and worse NFS (r = 0.210, OR = 1.5, p < 0.001). No differences were observed in overall symptom burden, symptom interference, and anxiety/depression scores.

DISCUSSION

While commonly used GA tools were not available, the study employed patient- and clinician-reported outcomes to identify potential future research directions for the use of GA in the broader neuro-oncology population. Findings illustrate missed opportunities in neuro-oncology practice and underscore the need for incorporation of GA into routine care of this population. Future studies are warranted to further evaluate the prognostic utility of GA and to better understand functional aging outcomes in this patient population.

Financial Hardship by Age at Diagnosis Including in Young Adulthood among African American Cancer Survivors

BACKGROUND

Financial hardship is most common among cancer survivors with the fewest financial resources at diagnosis; however, little is known about the financial outcomes of young adult (YA) survivors (ages 20-39 at diagnosis), despite their having fewer financial reserves than older adults.

METHODS

We utilized data from 3,888 participants in the population-based Detroit Research on Cancer Survivors cohort. Participants self-reported several forms of material and behavioral financial hardship (MFH and BFH, respectively). Psychological financial hardship (PFH) was measured using the Comprehensive Score for financial Toxicity (COST) score. Modified Poisson models estimated prevalence ratios (PR) and 95% confidence intervals (CI) for financial hardship by age at diagnosis controlling for demographic, socioeconomic, and cancer-related factors.

RESULTS

MFH prevalence was inversely associated with age such that 72% of YA survivors reported MFH, 62% ages 40 to 54, 49% ages 55 to 64, and 33% ages 65 to 79 (PRadjusted YA vs. 65+: 1.75; 95% CI, 1.49-2.04; Ptrend < 0.001). BFH was also more common among YA survivors (26%) than those ages 65 to 79 (20%; PRadjusted: 1.50; 95% CI, 1.08-2.08; Ptrend = 0.019). Age was positively associated with financial wellbeing. COST scores ranged from 20.7 (95% CI, 19.0-22.4) among YA survivors to 27.2 (95% CI, 26.1-28.2) among adults 65 to 79 years old (Ptrend < 0.001).

CONCLUSIONS

In this population of African American cancer survivors, MFH and BFH were more common, and PFH was more severe, in YA survivors compared with those diagnosed as older adults.

IMPACT

Young adulthood at diagnosis should be considered a risk factor for cancer-related financial hardship and addressed in work designed to reduce the adverse financial impacts of cancer.

Cannabis and the Cancer Patient

Session 2 of the National Cancer Institute's Cannabis, Cannabinoids, and Cancer Research Workshop opened with testimony from a lymphoma survivor who detailed medicinal cannabis-related improvements in nausea, low appetite, insomnia, and mental health and the limited clinical counsel she received regarding cannabis use. Discussion next turned to the evolution of the legal landscape of cannabis in the United States, one in which state and federal laws frequently conflict and the Controlled Substance Act renders cannabis Schedule I. This legal climate creates conundrums for US medicinal cannabis researchers who contend with limited funding opportunities, avenues to source trial drug, and procedural red tape and for oncology clinicians who recommend medicinal cannabis to patients with some frequency while perceiving themselves as ill equipped to make such clinical recommendations. Ultimately, it creates challenges for cancer patients who find themselves turning to nonmedical and anecdotal information sources. The risks of cannabis use by the cancer patient were discussed next. These include infection, pharmacodynamic and pharmacokinetic drug-botanical interactions, cyclic nausea and vomiting, e-cigarette or vaping product use-associated illness, legal issues, and high cost. The session concluded with a broad survey of the research supporting oncologic cannabinoid use, conclusive evidence for chemotherapy-induced nausea and vomiting, and suggestive evidence for cancer-related pain.

Health and life insurance-related problems in very long-term cancer survivors in Germany: a population-based study

Purpose

Limited research suggests that cancer survivors have problems with insurance. Our study aimed to gain insight into the proportion of very long-term (14–24 years post-diagnosis) survivors of breast, colorectal, and prostate cancers who had problems with health (HI) and life (LI) insurance.

Methods

We used data from CAESAR (CAncEr Survivorship—A multi-Regional population-based study). Participants completed questions on change in insurance providers since cancer diagnosis, problems with requesting (additional) HI or LI, and how potential problems were resolved. We conducted logistic regression to determine factors associated with change in statutory HI.

Results

Of the 2714 respondents, 174 (6%) reported having changed HI providers. Most switched between different statutory HI providers (86%), 9% from statutory to private, and 5% from private to statutory. Respondents who changed statutory HI providers were more likely to be prostate cancer survivors (OR 2.79, 95% CI 1.01–7.68) while being ≥ 65 years at time of diagnosis (OR 0.58, 95% CI 0.35–0.96) and having ≥ 2 comorbid conditions (OR 0.61, 95% CI 0.40–0.92) were associated with reduced odds for change. Problems in changing HI were minimal and were resolved with additional contribution. Of the 310 respondents who tried to get LI, 25 respondents reported having difficulties, of whom the majority had their request rejected.

Conclusion

Most cancer survivors did not change their HI nor tried to buy LI after cancer diagnosis. Problems with changing statutory HI were generally resolved with additional contribution while the main problem encountered when buying LI was rejection of request.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00432-021-03825-x.

Liens entre les besoins non satisfaits, la qualité de vie et les caractéristiques des survivantes de cancers gynécologiques en Indonésie

Les survivantes de cancers gynécologiques ont des besoins complexes très souvent négligés. La présente étude indonésienne vise à établir les liens entre les besoins non satisfaits, la qualité de vie et certaines caractéristiques particulières de ces survivantes. Au total, 298 participantes ont rempli le questionnaire sur les besoins non satisfaits des survivants au cancer (Cancer Survivor Unmet Needs ou CaSUN), le questionnaire sur la qualité de vie EORTC QLQ-C30 ainsi que les questionnaires démographiques et cliniques. L'étude, réalisée suivant un devis corrélationnel transversal, a établi un lien entre les besoins non satisfaits et la dégradation de la qualité de vie perçue. Plusieurs facteurs sont associés à l'augmentation des besoins insatisfaits: patients jeunes, revenu moindre, niveau d'éducation moyen, diagnostic récent, stade avancé de la maladie, et polythérapie (p < .05). Chez les survivantes indonésiennes d'un cancer gynécologique, le soutien financier (70,5 %) constitue le besoin le plus souvent insatisfait. À la fin des traitements primaires, elles ont besoin de soins globaux et continus pour gérer les problèmes, nouveaux comme anciens, causés par le cancer et le traitement.

The relationships of unmet needs with quality of life and characteristics of Indonesian gynecologic cancer survivors

Gynecologic cancer survivors' complex needs are too often overlooked. This study aimed to identify the associations between unmet needs and quality of life, and selected characteristics of Indonesian gynecologic cancer survivors. This study was a cross-sectional, correlation study. A total of 298 participants completed the Cancer Survivor Unmet Needs (CaSUN), EORTC QLQ-C30, and demographic and clinical-related questionnaires. A higher level of unmet needs was linked to lower perceived quality of life. Higher levels of unmet needs were associated with younger age, lower income, higher educational background, shorter time since diagnosis, more advanced cancer stage, and having combination therapies (p < 0.05). The most frequently reported unmet need of the Indonesian gynecologic cancer survivors was financial support (70.5%). The gynecologic cancer survivors who had completed primary treatment need continuous comprehensive cancer care to help them cope with the lingering or emerging problems related to cancer and its treatment.

Financial constraints on genetic counseling and further risk-management decisions among U.S. women at elevated breast cancer risk

Clinical guidelines recommend that women at high risk of breast cancer should consider various risk-management options, which remain widely underutilized. We conducted semi-structured, qualitative interviews with 50 high-risk women to understand how financial constraints affect use of genetic counseling, genetic testing, and further risk-management decisions. Inductive analyses revealed three categories of health-related financial constraint: (a) lack of insurance, (b) underinsurance, and (c) other financial constraints (e.g., medical debt, raising children, managing comorbidities). Various breast cancer risk-management actions were limited by these financial constraints, including genetic counseling, genetic testing, enhanced screening, and prophylactic surgeries. Women's narratives also identified complex relationships between financial constraint and perceptions of healthcare providers and insurance companies, particularly as related to bias, price transparency, and potential genetic discrimination. Results from this study have implications for further research and expansion of genetic counseling services delivery to more economically and racially diverse women.

Cancer survivor worries about treatment disruption and detrimental health outcomes due to the COVID-19 pandemic

PURPOSE

We examined cancer survivor worries about treatment, infection, and finances early in the U.S. COVID-19 pandemic.

DESIGN

Closed- and open-ended online survey questions were collected from adult cancer survivors (N = 972).

METHODS

Logistic regression identified factors associated with treatment, infection, and financial worry. Thematic qualitative analysis generated information around participants' experiences and worries related to COVID-19 and healthcare.

FINDINGS

Characteristics including marital status, race/ethnicity, cancer type, time since last treatment, education, and age were associated with health and healthcare worry outcomes. Survivors commonly expressed uncertainty about future care, fears about in-person appointments, rationed COVID-19 care, recurrence due to care delays, and distress about untreated symptoms, including mental health issues.

CONCLUSIONS

Early in the pandemic, survivors worried about and experienced cancer care delays, COVID infection, and how the pandemic would affect their prognosis.

IMPLICATIONS

Healthcare professionals need to be aware of cancer survivors' concerns and uncertainties to provide appropriate care.

Work changes and individual, cancer-related, and work-related predictors of decreased work participation among African American cancer survivors

African American cancer survivors disproportionately experience financial difficulties after cancer. Decreased work participation (going from being employed full time to part time or from employed to not employed) can contribute to financial hardship after cancer but employment outcomes among African American cancer survivors have not been well described. This study estimates the prevalence of work changes and identifies factors associated with decreased work participation among African American cancer survivors. We analyzed data from 916 African American breast, colorectal, lung, and prostate cancer survivors who participated in the Detroit Research on Cancer Survivors (ROCS) cohort and were employed before their cancer diagnosis. Modified Poisson models estimated prevalence ratios of decreased work participation and work changes, including changes to hours, duties, or schedules, between diagnosis and ROCS enrollment controlling for sociodemographic and cancer‐related factors. Nearly half of employed survivors made changes to their schedules, duties, or hours worked due to cancer and 34.6% took at least one month off of work, including 18% who took at least one month of unpaid time off. More survivors employed full time (vs. part time) at diagnosis were on disability at ROCS enrollment (18.7% vs. 12.6%, P < 0.001), while fewer were unemployed (5.9% vs. 15.7%, P < 0.001). Nearly half (47.5%) of employed survivors decreased work participation. Taking paid time off was not associated with decreased work participation; however, taking unpaid time off and making work changes were associated with prevalence ratios of decreased work participation of 1.29 (95% CI: 1.03, 1.62) and 1.37 (95% CI: 1.07, 1.75), respectively. Employment disruptions are common after a cancer diagnosis. Survivors who take unpaid time off and make other work changes may be particularly vulnerable to experiencing decreased work participation.

Financial Toxicity After Acute Respiratory Distress Syndrome: A National Qualitative Cohort Study

OBJECTIVES

The financial burdens and subsequent related distress of medical care, referred to as financial toxicity, may limit access to beneficial treatments. However, financial toxicity after acute care is less described-and may be an important but underexplored mechanism preventing full recovery after critical illnesses such as acute respiratory distress syndrome. We sought to identify the mechanisms by which financial toxicity manifested in patients with acute respiratory distress syndrome, protective factors against such toxicity, and the consequences of financial toxicity to survivors' lives following acute respiratory distress syndrome.

DESIGN

We conducted semistructured interviews following patients' hospitalization and during recovery as an ancillary study to a multicenter randomized clinical trial in acute respiratory distress syndrome. Patients were 9-16 months post randomization at the time of interview.

SETTING AND PARTICIPANTS

The Reevaluation Of Systemic Early Neuromuscular Blockade trial examined the use of early neuromuscular blockade in mechanically ventilated patients with moderate/severe acute respiratory distress syndrome. We recruited consecutive surviving patients who were English speaking, consented to follow-up, and were randomized between December 11, 2017, and May 4, 2018 (n = 79) from 29 U.S. sites.

MEASUREMENTS AND MAIN RESULTS

We asked about patients' perceptions of financial burden(s) that they associated with their acute respiratory distress syndrome hospitalization. Forty-six of 79 eligible acute respiratory distress syndrome survivors (58%) participated (from 22 sites); their median age was 56 (interquartile range 47-62). Thirty-one of 46 reported at least one acute respiratory distress syndrome-related financial impact. Financial toxicity manifested via medical bills, changes in insurance coverage, and loss of employment income. Respondents reported not working prior to acute respiratory distress syndrome, using Medicaid or Medicare, or, conversely, generous work benefits as factors which may have limited financial burdens. Patients reported multiple consequences of acute respiratory distress syndrome-related financial toxicity, including harms to their mental and physical health, increased reliance on others, and specific material hardships.

CONCLUSIONS

Financial toxicity related to critical illness is common and may limit patients' emotional, physical, and social recovery after acute respiratory distress syndrome hospitalization for at least a year.

Value and affordability of CAR T-cell therapy in the United States

In the United States the increasing number of Food and Drug Administration (FDA)-approved, innovative, and potentially effective commercial cancer therapies pose a significant financial burden on public and private payers. Chimeric antigen receptor (CAR) T cells are prototypical of this challenge. In 2017 and 2018, tisagenlecleucel (Kymriah, Novartis) and axicabtagene ciloleucel (Yescarta, Kite) were approved by the FDA for use after showing groundbreaking results in relapsed/refractory B-cell malignancies. In 2020 and 2021, four further submissions to the FDA are expected for CAR T-cell therapies for indolent and aggressive B-cell malignancies and plasma cell myeloma. Yet, with marketed prices of over $350,000 per infusion for the two FDA-approved therapies and similar price tags expected for the coming products, serious concerns are raised over value and affordability. In this review we summarize recent, peer-reviewed cost-effectiveness studies of tisagenlecleucel and axicabtagene ciloleucel in the United States; discuss key issues concerning the health plan budget impact of CAR T-cell therapy; and review policy, payment and scientific approaches that may improve the value and affordability of CAR T-cell therapy.

Clinical and Genome-Wide Analysis of Serum Platinum Levels after Cisplatin-Based Chemotherapy

PURPOSE

Serum platinum is measurable for years after completion of cisplatin-based chemotherapy (CBC). We report the largest investigation of serum platinum levels to date of 1,010 testicular cancer survivors (TCS) assessed 1-35 years after CBC and evaluate genetic contributions to these levels.

EXPERIMENTAL DESIGN

Eligible TCS given 300 or 400 (±15) mg/m2 cisplatin underwent extensive audiometric testing, clinical examination, completed questionnaires, and had crude serum platinum levels measured. Associations between serum platinum and various risk factors and toxicities were assessed after fitting a biexponential model adjusted for follow-up time and cumulative cisplatin dose. A genome-wide association study (GWAS) was performed using the serum platinum residuals of the dose and time-adjusted model.

RESULTS

Serum platinum levels exceeded the reference range for approximately 31 years, with a strong inverse relationship with creatinine clearance at follow-up (age-adjusted P = 2.13 × 10-3). We observed a significant, positive association between residual platinum values and luteinizing hormone (age-adjusted P = 6.58 × 10-3). Patients with high residual platinum levels experienced greater Raynaud phenomenon than those with medium or low levels (age-adjusted ORhigh/low = 1.46; P = 0.04), as well as a higher likelihood of developing tinnitus (age-adjusted ORhigh/low = 1.68, P = 0.07). GWAS identified one single-nucleotide polymorphism (SNP) meeting genome-wide significance, rs1377817 (P = 4.6 × 10-8, a SNP intronic to MYH14).

CONCLUSIONS

This study indicates that residual platinum values are correlated with several cisplatin-related toxicities. One genetic variant is associated with these levels.

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.

Financial burden among older, long-term cancer survivors: Results from the LILAC study

Background

Increasing attention is being paid to financial burdens of cancer survivorship, but little is known about the prevalence and predictors of these burdens in older, long‐term survivors.

Methods

We used data from 6012 participants diagnosed with cancer since enrolling in the Women's Health Initiative, and who participated in the Life and Longevity After Cancer (LILAC) ancillary study to estimate prevalence and identify predictors of financial burden. We used logistic regression to identify sociodemographic, socioeconomic, health‐ and cancer‐related factors associated with financial burden and backward selection to build a final multivariable model.

Results

Average age at LILAC participation was 79 and 9.2 years had elapsed since cancer diagnosis. Overall, 6% experienced some form of financial burden, including having an insurance company refuse a claim (2.6%), being denied loans or insurance due to cancer history (2.2%), or experiencing significant indebtedness (1.8%, including facing large debts or bills or declaring bankruptcy). Eight predictors remained associated (P < 0.05) with financial burden in the fully‐adjusted model: younger age, shorter time since diagnosis, African‐American race, household income <$20 000/year, modified Charlson comorbidity score ≥2, receipt of chemotherapy, regional stage at diagnosis, and no private health insurance. Education, cancer site, social support, receipt of radiation, and receipt of hormone therapy were not associated with financial burden. Predictors differed between types of financial burden experienced and age at diagnosis (<65 vs 65+).

Conclusion

Cancer‐related financial burden was rare in this population of older, female long‐term cancer survivors. The identification of several socioeconomic, health‐related and demographic predictors of financial burden may suggest targets of intervention to reduce financial burdens.

Precis

Financial burden was uncommon in older, female, long‐term survivors. Predictors of financial burden included age, race, income, comorbidities, time since diagnosis, stage, insurance, and receipt of chemotherapy.