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

Healthcare professionals' perspectives of barriers to cancer care delivery for American Indian, rural, and frontier populations

Objective

This descriptive qualitative study sought to understand the barriers affecting cancer care delivery from the perspective of healthcare professionals (HCPs) serving American Indian (AI), rural, and frontier populations.

Methods

One-on-one, semi-structured interviews with multidisciplinary HCPs (N = 18) who provide cancer care to AI, rural, and frontier populations were conducted between January and April 2022. Interviews were conducted via Zoom. Data were analyzed following thematic content analysis methodologies.

Results

Thematic content analysis revealed three major themes: (a) Access, (b) Time, and (c) Isolation. The themes represent the HCP perspectives of the needs and barriers of persons with cancer to whom they provide cancer care. Furthermore, these themes also reflect the barriers HCPs experience while providing cancer care to AI, rural and frontier populations.

Conclusions

This study provides preliminary evidence for the need and strong multidisciplinary support for an early palliative care intervention in rural and frontier South Dakota (SD). This intervention could support the needs of persons with advanced cancer as well as the HCPs delivering cancer care in rural settings.

Innovation

This study is the initial step to develop the first culturally responsive, nurse-led, early palliative care intervention for AI, rural, and frontier persons with advanced cancer in SD.

Discussions of Cancer Survivorship Care Needs: Are There Rural Versus Urban Inequities?

BACKGROUND

Rural cancer survivors may face greater challenges receiving survivorship care than urban cancer survivors.

PURPOSE

To test for rural versus urban inequities and identify other correlates of discussions about cancer survivorship care with healthcare professionals.

METHODS

Data are from the 2017 Medical Expenditure Panel Survey (MEPS), which included a cancer survivorship supplement. Adult survivors were asked if they discussed with a healthcare professional 5 components of survivorship care: need for follow-up services, lifestyle/health recommendations, emotional/social needs, long-term side effects, and a summary of treatments received. The Behavioral Model of Health Services guided the inclusion of predisposing, enabling, and need factors in ordered logit regression models of each survivorship care variable.

RESULTS

A significantly lower proportion of rural than urban survivors (42% rural, 52% urban) discussed in detail the treatments they received, but this difference did not persist in the multivariable model. Although 69% of rural and 70% of urban ssurvivors discussed in detail their follow-up care needs, less than 50% of both rural and urban survivors discussed in detail other dimensions of survivorship care. Non-Hispanic Black race/ethnicity and time since treatment were associated with lower odds of discussing 3 or more dimensions of survivorship care.

CONCLUSIONS

This study found only a single rural/urban difference in discussions about survivorship care. With the exception of discussions about the need for follow-up care, rates of discussing in detail other dimensions of survivorship care were low among rural and urban survivors alike.

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.

Medical financial hardship between young adult cancer survivors and matched individuals without cancer in the United States

BACKGROUND

Young adult cancer survivors face medical financial hardships that may lead to delaying or forgoing medical care. This study describes the medical financial difficulties young adult cancer survivors in the United States experience in the post-Patient Protection and Affordable Care Act period.

METHOD

We identified 1009 cancer survivors aged 18 to 39 years from the National Health Interview Survey (2015-2022) and matched 963 (95%) cancer survivors to 2733 control individuals using nearest-neighbor matching. We used conditional logistic regression to examine the association between cancer history and medical financial hardship and to assess whether this association varied by age, sex, race and ethnicity, and region of residence.

RESULTS

Compared with those who did not have a history of cancer, young adult cancer survivors were more likely to report material financial hardship (22.8% vs 15.2%; odds ratio = 1.65, 95% confidence interval = 1.50 to 1.81) and behavior-related financial hardship (34.3% vs 24.4%; odds ratio = 1.62, 95% confidence interval = 1.49 to 1.76) but not psychological financial hardship (52.6% vs 50.9%; odds ratio = 1.07, 95% confidence interval = 0.99 to 1.16). Young adult cancer survivors who were Hispanic or lived in the Midwest and South were more likely to report psychological financial hardship than their counterparts.

CONCLUSIONS

We found that young adult cancer survivors were more likely to experience material and behavior-related financial hardship than young adults without a history of cancer. We also identified specific subgroups of young adult cancer survivors that may benefit from targeted policies and interventions to alleviate medical financial hardship.

Material financial hardship and insurance-related experiences among Utah's rural and urban cancer survivors

PURPOSE

Describe material financial hardship (e.g., using savings, credit card debt), insurance, and access to care experienced by Utah cancer survivors; investigate urban-rural differences in financial hardship.

METHODS

Cancer survivors were surveyed from 2018 to 2021 about their experiences with financial hardship, access to healthcare, and job lock (insurance preventing employment changes). Weighed percentage responses, univariable and multivariable logistic regression models for these outcomes compared differences in survivors living in rural and urban areas based on Rural-Urban Commuting Area Codes.

RESULTS

The N = 1793 participants were predominantly Non-Hispanic White, female, and 65 or older at time of survey. More urban than rural survivors had a college degree (39.8% vs. 31.0%, p = 0.04). Overall, 35% of survivors experienced ≥ 1 financial hardship. In adjusted analyses, no differences were observed between urban and rural survivors for: material financial hardship, the overall amount of hardship reported, insurance status at survey, access to healthcare, or job lock. Hispanic rural survivors were less likely to report financial hardship than Hispanic urban survivors (odds ratio (OR) = 0.24, 95%CI = 0.08-0.73)). Rural survivors who received chemo/immune therapy as their only treatment were more likely to report at least one instance of financial hardship than urban survivors (OR = 2.72, 95%CI = 1.08-6.86).

CONCLUSIONS

The relationship between rurality and financial hardship among survivors may be most burdensome for patients whose treatments require travel or specialty medication access.

IMPLICATIONS FOR CANCER SURVIVORS

The impact of living rurally on financial difficulties after cancer diagnoses is complex. Features of rurality that may alter financial difficulty after a cancer diagnosis may vary geographically and instead of considering rurality as a stand-alone factor, these features should be investigated independently.

Describing financial toxicity among cancer patients in different income countries: a systematic review and meta-analysis

Background

There is limited evidence of financial toxicity (FT) among cancer patients from countries of various income levels. Hence, this study aimed to determine the prevalence of objective and subjective FT and their measurements in relation to cancer treatment.

Methods

PubMed, Science Direct, Scopus, and CINAHL databases were searched to find studies that examined FT. There was no limit on the design or setting of the study. Random-effects meta-analysis was utilized to obtain the pooled prevalence of objective FT.

Results

Out of 244 identified studies during the initial screening, only 64 studies were included in this review. The catastrophic health expenditure (CHE) method was often used in the included studies to determine the objective FT. The pooled prevalence of CHE was 47% (95% CI: 24.0-70.0) in middle- and high-income countries, and the highest percentage was noted in low-income countries (74.4%). A total of 30 studies focused on subjective FT, of which 9 used the Comprehensive Score for FT (COST) tool and reported median scores ranging between 17.0 and 31.9.

Conclusion

This study shows that cancer patients from various income-group countries experienced a significant financial burden during their treatment. It is imperative to conduct further studies on interventions and policies that can lower FT caused by cancer treatment.

Cancer-Related Financial Hardship Screening as Part of Practice Transformation

BACKGROUND

Data on financial hardship, an "adverse event" in individuals with cancer, are needed to inform policy and supportive care interventions and reduce adverse economic outcomes.

METHODS

Lay navigator-led financial hardship screening was piloted among University of Alabama at Birmingham oncology patients initiating treatment in October 2020. Financial hardship screening, including reported financial distress and difficulty, was added to a standard-of-care treatment planning survey. Screening feasibility and completion and proportions of reported financial distress and difficulty were calculated overall and by patient race and rurality. The risk of financial distress by patient sociodemographics was estimated.

RESULTS

Patients who completed a treatment planning survey (N=2741) were 18% Black, Indigenous, or persons of color (BIPOC) and 16% rural dwelling. The majority of patients completed financial hardship screening (90%), surpassing the target feasibility completion rate of 75%. The screening revealed 34% of patients were experiencing financial distress, including 49% of BIPOC and 30% of White patients. Adjusted models revealed BIPOC patients had a 48% higher risk of financial distress compared with those who were White (risk ratio 1.48, 95% CI, 1.31-1.66). Large differences in reported financial difficulties were seen comparing patients who were BIPOC and White (utilities: 33% vs. 10%, upfront medical payments: 44% vs. 23%, transportation: 28% vs. 12%, respectively).

CONCLUSIONS

The collection of patient-reported financial hardship data via routine clinical care was feasible and identified racial inequities at treatment initiation. Efforts to collect patient economic data should support the design, implementation, and evaluation of patient-centered interventions to improve equity and reduce the impact of financial hardship.

Lessening the Impact of Financial Toxicity (LIFT): a protocol for a multi-site, single-arm trial examining the effect of financial navigation on financial toxicity in adult patients with cancer in rural and non-rural settings

BACKGROUND

Almost half of the patients with cancer report cancer-related financial hardship, termed "financial toxicity" (FT), which affects health-related quality of life, care retention, and, in extreme cases, mortality. This increasingly prevalent hardship warrants urgent intervention. Financial navigation (FN) targets FT by systematically identifying patients at high risk, assessing eligibility for existing resources, clarifying treatment cost expectations, and working with patients and caregivers to develop a plan to cope with cancer costs. This trial seeks to (1) identify FN implementation determinants and implementation outcomes, and (2) evaluate the effectiveness of FN in improving patient outcomes.

METHODS

The Lessening the Impact of Financial Toxicity (LIFT) study is a multi-site Phase 2 clinical trial. We use a pre-/post- single-arm intervention to examine the effect of FN on FT in adults with cancer. The LIFT trial is being conducted at nine oncology care settings across North Carolina in the United States. Sites vary in geography (five rural, four non-rural), size (21-974 inpatient beds), and ownership structure (governmental, non-profit). The study will enroll 780 patients total over approximately 2 years. Eligible patients must be 18 years or older, have a confirmed cancer diagnosis (any type) within the past 5 years or be living with advanced disease, and screen positive for cancer-related financial distress. LIFT will be delivered by full- or part-time financial navigators and consists of 3 components: (1) systematic FT screening identification and comprehensive intake assessment; (2) connecting patients experiencing FT to financial support resources via trained oncology financial navigators; and (3) ongoing check-ins and electronic tracking of patients' progress and outcomes by financial navigators. We will measure intervention effectiveness by evaluating change in FT (via the validated Comprehensive Score of Financial Toxicity, or COST instrument) (primary outcome), as well as health-related quality of life (PROMIS Global Health Questionnaire), and patient-reported delayed or forgone care due to cost. We also assess patient- and stakeholder-reported implementation and service outcomes post-intervention, including uptake, fidelity, acceptability, cost, patient-centeredness, and timeliness.

DISCUSSION

This study adds to the growing evidence on FN by evaluating its implementation and effectiveness across diverse oncology care settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04931251. Registered on June 18, 2021.

Cost-Related Medication Nonadherence and Patient Cost Responsibility for Rural and Urban Cancer Survivors

PURPOSE

The relationship between out-of-pocket spending and cost-related medication nonadherence among older rural- and urban-dwelling cancer survivors is not well understood.

METHODS

This retrospective cohort study used the Surveillance, Epidemiology, and End Results Program, Medicare claims, and the Consumer Assessment of Healthcare Providers and Systems survey linked data resource linked data (2007-2015) to investigate the relationship between cancer survivors' cost responsibility in the year before and after report of delaying or not filling a prescription medication because of cost in the past 6 months (cost-related medication nonadherence). Secondary exposures and outcomes included Medicare spending and utilization. Generalized linear models assessed bidirectional relationships between cost-related medication nonadherence, spending, and utilization. Effects of residence were assessed via interaction terms.

RESULTS

Of 6,591 older cancer survivors, 13% reported cost-related medication nonadherence. Survivors were a median 8 years (interquartile range, 4.5-12.5 years) from their cancer diagnosis, 15% were dually Medicare/Medicaid-eligible, and prostate (40%) and breast (32%) cancer survivors were most prevalent. With every $500 USD increase in patient cost responsibility, risk of cost-related medication nonadherence increased by 3% (risk ratio, 1.03; 95% CI, 1.02 to 1.04). After report of cost-related medication nonadherence, patient cost responsibility was 22% higher (95% CI, 1.11 to 1.32) compared with those not reporting nonadherence, amounting to $523 USD (95% CI, $430 USD to $630 USD). Medicare spending and utilization were also higher before and after report of cost-related nonadherence versus none. For survivors residing in rural (18%) and urban (82%) areas, residence did not modify adherence or cost outcomes.

CONCLUSION

A bidirectional relationship exists between patient cost responsibility and cost-related medication nonadherence. Interventions reducing urban- and rural-dwelling survivor health care costs and cost-related adherence barriers are needed.

Trends in Healthcare Expenditures among Adults in the United States by Cancer Diagnosis Status, 2008-2016: A Cross Sectional Study

BACKGROUND

This study aims to assess trends in direct medical expenditures and indirect costs between adults with and without a prior cancer diagnosis from 2008-2016.

METHODS

Nine years of data (2008-2016) from the Medical Expenditure Panel Survey (weighted N=236,811,875) were used. The outcomes included medical expenditures (total expenditure, inpatient, office-based, medications, outpatient, dental, emergency room visits, home health, other) and health-related missed workdays. The predictor was prior cancer diagnosis. Covariates included demographic characteristics, comorbidities, and calendar year at time of survey completion. Two-part statistical modeling with a combination of binomial and positive distributions was used to estimate medical expenditures and missed workdays. Data were clustered into five timepoints: 2008-2009, 2010-2011, 2012-2013, 2014-2015, and 2016.

RESULTS

Eleven percent of the sample (n=25,005,230) had a prior cancer diagnosis. Compared to those without a prior cancer diagnosis, those with a prior cancer diagnosis had higher mean incremental total expenditures across all years. Between 2008-2016, the adjusted annual incremental total expenditures were $3,522 (95%CI $3,072, $3,972); office-based visits ($1,085;95% CI $990, $1180); inpatient hospitalizations ($810;95%CI $627, $992); outpatient appointments ($517;95%CI $434, $600); and medications ($409;95%CI $295, $523); and health-related missed workdays (0.75;95%CI 0.45, 1.04) compared to adults without a prior cancer diagnosis.

CONCLUSIONS

Adults with a prior cancer diagnosis had significantly increased healthcare expenditures and health-related missed workdays compared to those with no cancer diagnosis.

IMPACT

Our findings highlight the need for increasing strategies to remedy the impact of increasing direct and indirect costs associated with cancer survivorship as the population grows and ages.

Trends in surgical treatment of early-stage breast cancer reveal decreasing mastectomy use between 2003 and 2016 by age, race, and rurality

PURPOSE

To examine trends in the surgical treatment of breast cancer by age, rurality, and among Black women in a populous, racially diverse, state in the Southeastern United States of America.

METHODS

We identified women diagnosed with localized or regional breast cancer between 2003 and 2016 in the North Carolina Central Cancer Registry (n = 86,776). Using Joinpoint regression we evaluated the average annual percentage change in proportion of women treated with mastectomy versus breast-conserving surgery overall, by age group, among Black women, and for women residing in rural areas.

RESULTS

Overall, the rate of mastectomy usage in the population declined 2.5% per year between 2003 and 2016 (95% CI - 3.2, - 1.7). Over this same time interval, breast-conserving surgery increased by 1.6% per year (95% CI 0.9, 2.2). These temporal trends in surgery were also observed among Black women and rural residing women. Trends in surgery type varied by age group: mastectomy declined over time among women > 50 years, but not among women aged 18-49 at diagnosis.

DISCUSSION

In contrast to national studies that reported increasing use of mastectomy, we found declining mastectomy rates in the early 2000s in a Southern US state with a racially and geographically diverse population. These decreasing trends were consistent among key subgroups affected by cancer inequities, including Black and White rural women.

Urban-rural differences in financial toxicity and its effect on cancer survivors' health-related quality of life and emotional status: a latent class analysis

OBJECTIVE

This study aimed to investigate the urban-rural differences in associations between financial toxicity (FT), physical health-related quality of life (HRQoL), negative emotional status, and the effect of patients' socioeconomic status and clinical and cost-related characteristics on the levels of FT in a sample of Chinese cancer survivors.

METHODS

Data were obtained from a cross-sectional survey conducted by the oncology department at two tertiary level hospitals in China. The COmprehensive Score for financial Toxicity, Euroqol five-level instrument (EQ-5D), and Depression Anxiety Stress Scale - 21 (DASS-21) were used to measure patients' FT, physical HRQoL, and negative emotional status. A latent class analysis was used to identify patient subgroups with distinct symptom experiences based on self-reported data on symptom occurrence using the EQ-5D and DASS-21.

RESULTS

Four distinct latent classes were identified: all low (47.6%); high physical and low psych (18.6%); low physical and high psych (17.1%); and all high (17.1%). Rural patients younger than 50 years showed a statistically significantly higher FT than urban patients. Rural patients who were male, highly educated, insured, first hospitalization, new cases, received surgery or immunotherapy, and had low cancer-related costs in all low classes showed a higher FT than urban patients.

CONCLUSIONS

Rural patients with cancer suffered from higher FT than their urban counterparts, and the negative impact of psychological distress on FT was higher than that of physical HRQoL.

Core functions of a financial navigation intervention: An in-depth assessment of the Lessening the Impact of Financial Toxicity (LIFT) intervention to inform adaptation and scale-up in diverse oncology care settings

Background

Lessening the Impact of Financial Toxicity (LIFT) is an intervention designed to address financial toxicity (FT) and improve cancer care access and outcomes through financial navigation (FN). FN identifies patients at risk for FT, assesses eligibility for financial support, and develops strategies to cope with those costs. LIFT successfully reduced FT and improved care access in a preliminary study among patients with high levels of FT in a single large academic cancer center. Adapting LIFT requires distinguishing between core functions (components that are key to its implementation and effectiveness) and forms (specific activities that carry out core functions). Our objective was to complete the first stage of adaptation, identifying LIFT core functions.

Methods

We reviewed LIFT's protocol and internal standard-operating procedures. We then conducted 45-90 min in-depth interviews, using Kirk's method of identifying core functions, with key LIFT staff (N = 8), including the principal investigators. Interviews focused on participant roles and intervention implementation. Recorded interviews were transcribed verbatim. Using ATLAS.ti and a codebook based on the Model for Adaptation Design and Impact, we coded interview transcripts. Through thematic analysis, we then identified themes related to LIFT's intervention and implementation core functions. Two report back sessions with interview participants were incorporated to further refine themes.

Results

Six intervention core functions (i.e., what makes LIFT effective) and five implementation core functions (i.e., what facilitated LIFT's implementation) were identified to be sufficient to reduce FT. Intervention core functions included systematically cataloging knowledge and tracking patient-specific information related to eligibility criteria for FT relief. Repeat contacts between the financial navigator and participant created an ongoing relationship, removing common barriers to accessing resources. Implementation core functions included having engaged sites with the resources and willingness necessary to implement FN. Developing navigators' capabilities to implement LIFT-through training, an established case management system, and connections to peer navigators-were also identified as implementation core functions.

Conclusion

This study adds to the growing evidence on FN by characterizing intervention and implementation core functions, a critical step toward promoting LIFT's implementation and effectiveness.

Association Between Household Income and Self-Perceived Health Status and Poor Mental and Physical Health Among Cancer Survivors

Background: Health-related quality of life (HRQoL) is multidimensional and is composed of, at a minimum, self-perceived health status, physical functioning, and psychological well-being. HRQoL measures reflect the extent of disability and dysfunction associated with a chronic disease such as cancer. The objective of this study is to examine factors associated with HRQoL among cancer survivors.

Methods: Data from the 2009 Behavioral Risk Factor Surveillance System survey was used to examine factors associated with HRQoL among participants who reported having ever been diagnosed with cancer. Four questions associated with HRQoL included self-perceived health status, number of bad physical health days, and number of bad mental health days per month. Least square regression and logistic regression models, adjusted for confounding variables, were used for an ordinal and dichotomous [5 (bad) vs. 1–4 (excellent, very good, good, fair)] scale of HRQoL, respectively.

Results: Fifty nine thousand one hundred seventy three participants reported having ever been diagnosed with cancer. Adjusted mean self-perceived health status (5-point scale) among survivors of thyroid, colon, lung, cervical, breast, prostate, and ovarian cancer was 3.83 (0.05), 4.02 (0.04), 4.36 (0.06), 3.77 (0.03), 3.88 (0.03), 3.78 (0.04), and 3.96 (0.05), respectively. After adjusting for confounders, a positive dose-response effect was observed between income range and all three HRQoL measures across all seven cancer sites. Income was consistently and inversely associated with a higher chance for reporting poorer HRQoL [OR: 0.64, 95% CI: 0.57–0.71], [OR: 0.63, 95% CI: 0.48–0.82], [OR: 0.67, 95% CI: 0.56–0.80], [OR: 0.69, 95% CI: 0.56–0.86], [OR: 0.55, 95% CI: 0.49–0.62], [OR:0.55, 95% CI: 0.44–0.69], [OR: 0.75, 95% CI: 0.62–0.91] among those with thyroid, colon, lung, cervical, breast, prostate, and ovarian cancer, respectively.

Discussion: This study found that income range was associated with HRQoL among cancer survivors. It is plausible that financial resources may lessen the overall burden of cancer survivors, which could improve health-related quality of life among cancer survivors.

Cancer history, insurance coverage, and cost-related medication nonadherence in Medicare beneficiaries, 2013-2018

BACKGROUND: Cancer survivors are at risk of financial hardships and cost-related medication nonadherence, particularly among those without adequate insurance coverage. OBJECTIVE: To examine the association between cancer history and cost-related medication nonadherence, as well as the association between insurance coverage and nonadherence among Medicare beneficiaries. METHODS: We used the 2013-2018 Medicare Current Beneficiary Survey Public Use File, a survey on the health, health service utilization, access to care, and satisfaction among a nationally representative sample of Medicare beneficiaries. Cost-related medication nonadherence was defined as often or sometimes reporting any of the following: (1) took smaller dose of medication, (2) skipped doses to make medication last, (3) delayed medication because of cost, and (4) not get medication because of cost. Logistic regression was used to estimate the odds ratio of cost-related nonadherence associated with cancer history, adjusting for survey year and sociodemographic characteristics of the respondents, including age, sex, race and ethnicity, highest grade completed, income level, marital status, and number of chronic conditions. We also included Medicare Part D, an interaction between Part D and the low-income subsidy, and Medicare Advantage in the model to examine the effect of insurance coverage on cost-related nonadherence. RESULTS: From 2013 to 2018, there were 12,492 cancer survivors and 53,262 respondents without a history of cancer in our sample, and 16.5% reported cost-related medication nonadherence. After adjusting for characteristics of the respondents, cancer survivors were more likely than those without a history of cancer to report cost-related medication nonadherence (adjusted OR = 1.10; 95% CI = 1.02-1.19). Having unsubsidized Part D-Part D without the low-income subsidy-was associated with a greater likelihood of reporting cost-related medication nonadherence (adjusted OR = 1.63, 95% CI = 1.49-1.78), while having subsidized Part D was not (adjusted OR = 0.96; 95% CI = 0.85-1.08). Finally, being on Medicare Advantage was associated with lower likelihood of reporting cost-related nonadherence compared with traditional fee-for-service Medicare (adjusted OR = 0.86; 95% CI = 0.80-0.92). CONCLUSIONS: Expanding the low-income subsidy and capping out-of-pocket drug expenditure can be effective policy options to reduce cost-sharing burden and cost-related nonadherence. DISCLOSURES: For this study, Li was partially supported by a research grant from the National Cancer Institute (R01CA225647). The sponsor had no role in the design or implementation of the study, analysis or interpretation of the data, or drafting or approval the manuscript. The authors report no conflicts of interest.

Unmet Care Needs and Financial Hardship in Patients With Metastatic Non-Small-Cell Lung Cancer on Immunotherapy or Chemoimmunotherapy in Clinical Practice

PURPOSE

Immunotherapy or chemoimmunotherapy is now standard treatment for most patients with metastatic non-small-cell lung cancer (mNSCLC), yet patient supportive care needs (SCNs) on immunotherapy are not well defined. This study characterized the SCNs and financial hardship of patients with mNSCLC treated with immunotherapy or chemoimmunotherapy and examined the relationship between patient and caregiver cancer-related employment reductions and patient financial hardship.

METHODS

Patients with mNSCLC on immunotherapy or chemoimmunotherapy from a single academic medical center completed the SCNs Survey-34, items indexing material, psychological, and behavioral financial hardship, and the Comprehensive Score for Financial Toxicity. Univariate and bivariate analyses examined care needs, financial hardship, and impact of cancer-related employment reductions on patient financial hardship.

RESULTS

Sixty patients (40% male; 75% White, mean age = 62.5 years, 57% on immunotherapy alone) participated. Fifty-five percent reported unmet needs in physical or daily living and psychological domains. Financial hardship was common (33% material, 63% psychological, and 57% behavioral). Fifty-two percent reported hardship in at least two domains. Forty percent reported a caregiver cancer-related employment reduction. Caregiver employment reduction was related to patient financial hardship (68% of those reporting caregiver employment reduction reported at least two domains of hardship v 40% of those without reduction, P = .03) and patient financial distress (mean Comprehensive Score for Financial Toxicity = 19.6 among those with caregiver employment reduction v 26.8 without, P = .01).

CONCLUSION

Patients with mNSCLC treated with immunotherapy or chemoimmunotherapy report multiple unmet care needs and financial hardship. Psychological, functional, financial, and caregiver concerns merit assessment and intervention in this population.

The Intersection of Rural Residence and Minority Race/Ethnicity in Cancer Disparities in the United States

One in every twenty-five persons in America is a racial/ethnic minority who lives in a rural area. Our objective was to summarize how racism and, subsequently, the social determinants of health disproportionately affect rural racial/ethnic minority populations, provide a review of the cancer disparities experienced by rural racial/ethnic minority groups, and recommend policy, research, and intervention approaches to reduce these disparities. We found that rural Black and American Indian/Alaska Native populations experience greater poverty and lack of access to care, which expose them to greater risk of developing cancer and experiencing poorer cancer outcomes in treatment and ultimately survival. There is a critical need for additional research to understand the disparities experienced by all rural racial/ethnic minority populations. We propose that policies aim to increase access to care and healthcare resources for these communities. Further, that observational and interventional research should more effectively address the intersections of rurality and race/ethnicity through reduced structural and interpersonal biases in cancer care, increased data access, more research on newer cancer screening and treatment modalities, and continued intervention and implementation research to understand how evidence-based practices can most effectively reduce disparities among these populations.

Response to "Built and Natural Environment Barriers and Facilitators to Physical Activity in Rural, Suburban, and Small Urban Neighborhoods"

DeGuzman et al. (2019) should be commended for their article "Built and Natural Environment Barriers and Facilitators to Physical Activity in Rural, Suburban, and Small Urban Neighborhoods." The work is a meaningful contribution to the oncology field, given the health disparity among patients with cancer living in rural and suburban communities. Nurses need to be part of the larger conversation and advocate for patients through policy reform that supports access to an equitable built environment. DeGuzman et al.'s (2019) article starts this conversation. In this letter, I wish to build on that initial conversation by deepening the discussion of built environment and costs as significant barriers to physical activity in cancer survivors.

Challenges of using nationally representative, population-based surveys to assess rural cancer disparities

Population-based surveys provide important information about cancer-related health behaviors across the cancer care continuum, from prevention to survivorship, to inform cancer control efforts. These surveys can illuminate cancer disparities among specific populations, including rural communities. However, due to small rural sample sizes, varying sampling methods, and/or other study design or analytical concerns, there are challenges in using population-based surveys for rural cancer control research and practice. Our objective is three-fold. First, we examined the characterization of "rural" in four, population-based surveys commonly referenced in the literature: 1) Health Information National Trends Survey (HINTS); 2) National Health Interview Survey (NHIS); 3) Behavioral Risk Factor Surveillance System (BRFSS); and 4) Medical Expenditures Panel Survey (MEPS). Second, we identified and described the challenges of using these surveys in rural cancer studies. Third, we proposed solutions to address these challenges. We found that these surveys varied in use of rural-urban classifications, sampling methodology, and available cancer-related variables. Further, we found that accessibility of these data to non-federal researchers has changed over time. Survey data have become restricted based on small numbers (i.e., BRFSS) and have made rural-urban measures only available for analysis at Research Data Centers (i.e., NHIS and MEPS). Additionally, studies that used these surveys reported varying proportions of rural participants with noted limitations in sufficient representation of rural minorities and/or cancer survivors. In order to mitigate these challenges, we propose two solutions: 1) make rural-urban measures more accessible to non-federal researchers and 2) implement sampling approaches to oversample rural populations.