Medical Financial Hardship Linked With Worse Cancer Survival

Financial hardship had a significant association with premature death among cancer survivors, irrespective of health insurance coverage, an analysis of 25,000 cancer survivors showed.

Almost 30% of patients, ages 18-64, reported medical financial hardship, which was associated with a 17% excess mortality risk compared with same-age patients who did not report medical financial hardship, according to K. Robin Yabroff, PhD, MBA, of the American Cancer Society in Kennesaw, Georgia, and colleagues.

In addition, medical financial hardship was less common among older patients, but was nonetheless associated with a 14% excess mortality risk. Adjustment for health insurance coverage reduced, but did not eliminate, the excess mortality in the younger age group, and Medicare supplementation had no impact on mortality risk among older survivors, they stated in the Journal of the National Cancer Institute.

The results are consistent with an earlier study showing an increased mortality risk in cancer survivors who filed for bankruptcy. In contrast to bankruptcy, which is relatively uncommon, medical financial hardship, which covers a range of economic stressors, is common, noted Yabroff and colleagues.

“Cancer survivors frequently experience medical financial hardship; however, little research has examined its associations with long-term health consequences,” Yabroff said in a statement. “Our findings show the need to address financial hardship to ensure that cancer survivors do not delay or forgo necessary care because they cannot afford it.”

Financial hardship after a cancer diagnosis is a common, serious issue for patients and must be addressed, said Julie Gralow, MD, chief medical officer for the American Society for Clinical Oncology.

“There is no question that financial hardship following a diagnosis of cancer can have a profound detrimental effect on patients and survivors,” Gralow told MedPage Today via email. “This study found a correlation between those reporting medical financial hardship and mortality. Assuring adequate healthcare coverage that limits out-of-pocket costs — limiting ‘financial toxicity’ — is an important goal.”

The study has several noteworthy limitations that may affect its applicability to all cancer survivors, Gralow added. For example, the data did not allow investigators to distinguish between patients with active cancer and currently on treatment — who, by definition, have a higher mortality risk — and those with a history of cancer.

“It may be that this is relevant to all, including long-cured [patients], but this study does not have the ability to separate that population out,” she said.

Moreover, the study period (1997-2014) included only the first few years after implementation of the Affordable Care Act, and Medicaid expansion in states did not begin until 2014. Those two events could have affected financial hardship in recent years, Gralow noted.

A recent study showed that more than half of cancer survivors (ages 18-64) and 42% of older cancer survivors report some form of medical financial hardship following cancer diagnosis. Medical financial hardship is associated with worse health-related quality of life, but little is known about other health-related consequences, Yabroff and colleagues noted.

In an attempt to address the data void and possibly inform policy decisions, investigators analyzed data from the National Health Interview Survey (NHIS) for the years 1997-2014 and linked mortality files with vital status through 2015. The analysis comprised 14,917 cancer survivors (ages 18-64) and 10,391 survivors (ages 65-79).

Medical financial hardship was defined as problems affording care or delaying or forgoing care because of cast within the past 12 months. Context for the definition came from answers to questions that were included consistently in the NHIS throughout the study period. Examples included problems paying for prescriptions, mental healthcare and/or counseling, or dental care, and delaying or forgoing medical care because of cost.

The results showed that 29.6% of cancer survivors (ages 18-64) and 11.0% of older survivors reported financial hardship within the previous 12 months. The younger survivors with medical financial hardship had an estimated mortality hazard of 1.17 (95% CI 1.04-1.30), whereas the excess hazard was 1.14 in the older age group (95% CI 1.02-1.28).

Adjustment for health insurance reduced the mortality hazard to 1.09 for younger survivors, which was no longer statistically significant (95% CI 0.97-1.24). Supplemental Medicare coverage did not significantly reduce the impact of medical financial hardship on older cancer survivors (HR 1.15, 95% CI 1.02-1.29).

“Our findings underscore the protective effects of Medicare coverage and highlight the importance of comprehensive health insurance coverage in mitigating financial hardship for cancer survivors under 65,” said Yabroff. “Efforts to address financial hardship as part of oncology practice and survivorship care are needed.”

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