In the JournalsPerspective

Bankruptcy increases risk for cancer mortality

Filing for bankruptcy protection after a cancer diagnosis appeared associated with an increased risk for death, according to the results of a registry study.

Patients diagnosed with colorectal, prostate and lung cancer who filed for bankruptcy appeared to have the highest mortality risks, results showed.

“Doctors and health systems that care for patients with cancer have to start considering patients’ financial situations when they initiate conversations about cancer care,” Scott D. Ramsey, MD, PhD, professor of medicine at University of Washington and director of the Hutchinson Institute for Cancer Outcomes Research at Fred Hutchinson Cancer Research Center, told HemOnc Today. “If it is true that patients experiencing extreme financial distress have a significantly higher mortality risk, that wipes out the potential gains of certain therapies.”

Scott Ramsey

Scott D. Ramsey, MD, PhD

In a prior study, Ramsey and colleagues linked cancer diagnoses with a 2.5-fold increase in the risk for bankruptcy. However, the impact of a severe financial burden on health outcomes among patients with cancer remained unknown.

Thus, the researchers sought to determine the relationship between bankruptcy and survival. They linked the Western Washington SEER Cancer Registry with federal bankruptcy records for the region.

The researchers identified 231,596 individuals diagnosed with cancer between 1995 and 2009. Of this cohort, 4,728 filed for bankruptcy (Chapter 7, n = 3,909; Chapter 13, n = 819).

Characteristics associated with filing for bankruptcy included younger age, female sex, nonwhite race, local or regional disease at diagnosis, and treatment receipt.

Ramsey and colleagues performed propensity score matching to account for differences in demographic and clinical factors between patients who filed for bankruptcy and those who did not. After adjustments, 3,841 patients remained in each group (mean age, 53 years; 54% men; 86% white).

The mean income of the cohort was $49,000 per year. Sixty percent of patients were married, 91% lived in urban areas, and 84% presented with local or regional disease at diagnosis.

Mortality rates appeared higher among patients with cancer who filed for bankruptcy than among those who did not (HR = 1.79; 95% CI, 1.64-1.96).

The association between severe financial burdens and mortality varied across cancer subtypes. Patients with prostate cancer who filed for bankruptcy appeared twice as likely to die as patients who did not (HR = 2.07; 95% CI, 1.56-2.74).

For patients with colorectal cancer, the increase in mortality associated with bankruptcy was nearly 2.5-fold (HR = 2.47; 95% CI, 1.85-3.31).

Other subtypes with significant bankruptcy-associated risks included breast cancer (HR = 1.48; 95% CI, 1.15-1.91) and lung cancer (HR = 1.55; 95% CI, 1.22-1.98).

Of these four subtypes, patients with lung cancer showed the highest cumulative risk for bankruptcy (47%) and the poorest OS (38%) at 5 years from diagnosis.

Researchers also observed an increased risk for mortality associated with bankruptcy among patients with melanoma (HR = 1.5; 95% CI, 0.83-2.72), thyroid cancer (HR = 1.71; 95% CI, 0.69-4.27), leukemia or lymphoma (HR = 1.22; 95% CI, 0.93-1.61), and uterine cancer (HR = 1.09; 95% CI, 0.55-2.16), but these associations did not reach statistical significance.

The exclusion of patients with distant-stage disease did not appear to affect the results, according to the researchers.

“Getting patients into financial counseling services if they are deemed at risk for bankruptcy may be helpful,” Ramsey said. “We should also try to make the care plan to have as little out-of-pocket burden as possible, which might allow more patients to complete their therapy as planned, without having to cease care due to financial problems.” – by Cameron Kelsall

For more information:

Scott D. Ramsey, MD, PhD, can be reached at sramsey@fredhutch.org.

Disclosure: The researchers report no relevant financial disclosures.

Filing for bankruptcy protection after a cancer diagnosis appeared associated with an increased risk for death, according to the results of a registry study.

Patients diagnosed with colorectal, prostate and lung cancer who filed for bankruptcy appeared to have the highest mortality risks, results showed.

“Doctors and health systems that care for patients with cancer have to start considering patients’ financial situations when they initiate conversations about cancer care,” Scott D. Ramsey, MD, PhD, professor of medicine at University of Washington and director of the Hutchinson Institute for Cancer Outcomes Research at Fred Hutchinson Cancer Research Center, told HemOnc Today. “If it is true that patients experiencing extreme financial distress have a significantly higher mortality risk, that wipes out the potential gains of certain therapies.”

Scott Ramsey

Scott D. Ramsey, MD, PhD

In a prior study, Ramsey and colleagues linked cancer diagnoses with a 2.5-fold increase in the risk for bankruptcy. However, the impact of a severe financial burden on health outcomes among patients with cancer remained unknown.

Thus, the researchers sought to determine the relationship between bankruptcy and survival. They linked the Western Washington SEER Cancer Registry with federal bankruptcy records for the region.

The researchers identified 231,596 individuals diagnosed with cancer between 1995 and 2009. Of this cohort, 4,728 filed for bankruptcy (Chapter 7, n = 3,909; Chapter 13, n = 819).

Characteristics associated with filing for bankruptcy included younger age, female sex, nonwhite race, local or regional disease at diagnosis, and treatment receipt.

Ramsey and colleagues performed propensity score matching to account for differences in demographic and clinical factors between patients who filed for bankruptcy and those who did not. After adjustments, 3,841 patients remained in each group (mean age, 53 years; 54% men; 86% white).

The mean income of the cohort was $49,000 per year. Sixty percent of patients were married, 91% lived in urban areas, and 84% presented with local or regional disease at diagnosis.

Mortality rates appeared higher among patients with cancer who filed for bankruptcy than among those who did not (HR = 1.79; 95% CI, 1.64-1.96).

The association between severe financial burdens and mortality varied across cancer subtypes. Patients with prostate cancer who filed for bankruptcy appeared twice as likely to die as patients who did not (HR = 2.07; 95% CI, 1.56-2.74).

For patients with colorectal cancer, the increase in mortality associated with bankruptcy was nearly 2.5-fold (HR = 2.47; 95% CI, 1.85-3.31).

Other subtypes with significant bankruptcy-associated risks included breast cancer (HR = 1.48; 95% CI, 1.15-1.91) and lung cancer (HR = 1.55; 95% CI, 1.22-1.98).

Of these four subtypes, patients with lung cancer showed the highest cumulative risk for bankruptcy (47%) and the poorest OS (38%) at 5 years from diagnosis.

Researchers also observed an increased risk for mortality associated with bankruptcy among patients with melanoma (HR = 1.5; 95% CI, 0.83-2.72), thyroid cancer (HR = 1.71; 95% CI, 0.69-4.27), leukemia or lymphoma (HR = 1.22; 95% CI, 0.93-1.61), and uterine cancer (HR = 1.09; 95% CI, 0.55-2.16), but these associations did not reach statistical significance.

The exclusion of patients with distant-stage disease did not appear to affect the results, according to the researchers.

“Getting patients into financial counseling services if they are deemed at risk for bankruptcy may be helpful,” Ramsey said. “We should also try to make the care plan to have as little out-of-pocket burden as possible, which might allow more patients to complete their therapy as planned, without having to cease care due to financial problems.” – by Cameron Kelsall

For more information:

Scott D. Ramsey, MD, PhD, can be reached at sramsey@fredhutch.org.

Disclosure: The researchers report no relevant financial disclosures.

    Perspective
    Matthew P. Banegas, PhD, MPH

    Matthew P. Banegas, PhD, MPH

    The new study from Ramsey and colleagues shows that patients who file for bankruptcy following their cancer diagnosis have a significantly greater risk for death compared with patients with cancer who do not file for bankruptcy. This study is among the first to show the poor health outcomes that patients are likely to suffer following the experience of financial hardship as a result of their cancer diagnosis. By documenting the sequence of events from cancer diagnosis to financial hardship to death, these findings highlight why it is so important for stakeholders across the health care system to recognize the need to discuss the costs of care with patients and to take action to prevent — or at least reduce — the financial burden that patients diagnosed with cancer may experience.

    Although this study provides valuable evidence, additional research is necessary to develop interventions that address the issue of financial hardship among patients diagnosed with cancer.

    In an article published in 2015 in Journal of the National Cancer Institute, Tucker-Seeley and Yabroff outline the steps that researchers and other stakeholders need to take to achieve the goal of developing interventions that target financial hardship. These include to:  

    • Develop clearly defined concepts and measures of financial hardship experienced by patients and their families as they navigate through the cancer care experience;
    • Systematically document measures that capture the socioeconomic conditions of patients and their families over time, from the period prior to cancer diagnosis through survivorship;
    • Comprehensively characterize those populations at greatest risk of financial hardship to prevent the widening of health disparities between populations; and
    • Clearly articulate the roles of multidisciplinary clinical and support team members in ensuring that discussions about cost are part of the care process.

    The surmounting evidence that rising costs of cancer care lead to detrimental financial outcomes for patients is striking and indicates that the experience of financial hardship among patients with cancer is becoming an all-too-common phenomenon. The findings of Ramsey and colleagues take this area of research one important step further by documenting that financial hardship is associated with key health outcomes.

    Reference: Tucker-Seeley RD and Yabroff KR. J Natl Cancer Inst. 2015;doi: 10.1093/jnci/djv410.

     

    • Matthew P. Banegas, PhD, MPH
    • Kaiser Permanente The Center for Health Research

    Disclosures: Banegas reports no relevant financial disclosures.