In the Journals

Younger cancer survivors particularly vulnerable to financial hardship

Cancer survivors carry greater financial burdens related to medical bills and debt payments than individuals who never had cancer, according to an analysis of data from National Health Interview Survey.

Younger cancer survivors appeared particularly vulnerable to financial hardship, as did individuals with private insurance who were enrolled in high-deductible plans and did not have health savings accounts.

“Interventions designed to reduce financial hardship should consider multiple domains of hardship, as well as insurance benefit design,” Zhiyuan Zheng, PhD, director of economics and health care delivery research for American Cancer Society, and colleagues wrote.

There are more than 15.5 million cancer survivors in the United States, and that number is expected to reach 26 million by 2040.

Prior research showed high medical bills may lead to high debt levels and personal bankruptcy among cancer survivors, particularly younger survivors who may be trying to pay off student loans, buy their first home or start a family.

Zheng and colleagues used data from the 2013 to 2016 National Health Interview Survey to examine three domains of financial hardship — material (eg, problems paying medical bills), psychological (eg, worry about paying medical bills) and behavioral (eg, delaying or forgoing care due to cost) — among a nationally representative sample of 134,790 adults.

The cohort included 10,354 cancer survivors (age 18 to 49 years; n = 1,424; 50 to 64 years, n = 2,916; 65 years or older, n = 6,014) and 124,436 individuals with no cancer history (age 18 to 49 years, n = 66,951; 50 to 64 years, n = 31,741; 65 years or older, n = 25,744).

Researchers assessed patterns of cancer-associated material, psychological and behavioral hardship by age.

They also evaluated associations between two key aspects of health insurance — high-deductible status and use of health savings accounts — and medical financial hardship among privately insured individuals aged 18 to 64 years..

Cancer survivors appeared more vulnerable to financial hardship than those with no cancer history.

The difference was most apparent among younger cancer survivors, who were significantly more likely than cancer-free individuals to report any material hardship (18 to 49 years, 43.4% vs. 30.1%; 50 to 64 years, 32.8% vs. 27.8%), psychological hardship (18 to 49 years, 53.5% vs. 47.1%) or behavioral hardship (18 to 49 years, 30.6% vs. 21.8%, 50 to 64 years, 27.2% vs. 23.4%; P < .01 for all).

Younger cancer survivors were significantly more likely to report multiple domains of hardship (P < .01).

There are multiple potential explanations for why cancer survivors aged 18 to 49 years appear most vulnerable to financial hardship, according to the researchers.

“It may be that they do not have the opportunity to accumulate financial assets to pay for medical expenses,” Zheng said in a press release. “In addition, a cancer diagnosis might interrupt employment, and consequently limit access to employer-sponsored health insurance coverage. Although we could not identify the underlying reasons for greater hardship intensity in the younger group in this study, we believe it will be an important area for additional research.”

Among cancer survivors with private insurance, those who had high-deductible health plans without a health savings account appeared more vulnerable to hardship than those who had low-deductible insurance.

“Identifying patients with medical financial hardship will be important for primary care and oncology care providers,” Zheng said in the release. “Developing and evaluating interventions to minimize medical financial hardship will be important for the research community. It may also require attention from health policymakers.”

Researchers acknowledged potential limitations of their study. National Health Interview Survey participants self-reported cancer history, health insurance information and medical financial hardship measures, making them subject to recall bias, and researchers did not collect detailed clinical information about cancer diagnosis and treatment history.

In addition, the survey asks respondents whether they or family members are having difficulty paying medical bills, so findings related to material hardship may not only refer to cancer survivors but rather indicate that families with cancer survivors are more likely than families without cancer survivors to experience financial hardship.

The findings have implications for clinicians, according to the researchers.

“To reduce the financial burden among cancer survivors in the United States, [ASCO] has identified patient-oncologist communication regarding cost as an important component of joint treatment decision-making. However, patients may worry that conversations regarding costs distract oncologists from recommending the best care,” Zheng and colleagues wrote.

“Furthermore, oncologists may only consider clinical toxicity, but not financial hardship, as a potential harm of cancer treatments,” they added. “Therefore, more information regarding the likely costs and potential for medical financial hardship, as well as expected clinical risks and benefits of treatment, are needed to facilitate patient-clinician discussions. The findings of the current study can help clinicians to recognize the importance of distinct medical financial hardship domains, especially for younger cancer survivors.” – by Mark Leiser

Disclosures:

Zheng reports employment with American Cancer Society and work in the intramural research department, which received a grant from Merck for research outside the submitted work. Please see the study for all other authors’ relevant financial disclosures.

Cancer survivors carry greater financial burdens related to medical bills and debt payments than individuals who never had cancer, according to an analysis of data from National Health Interview Survey.

Younger cancer survivors appeared particularly vulnerable to financial hardship, as did individuals with private insurance who were enrolled in high-deductible plans and did not have health savings accounts.

“Interventions designed to reduce financial hardship should consider multiple domains of hardship, as well as insurance benefit design,” Zhiyuan Zheng, PhD, director of economics and health care delivery research for American Cancer Society, and colleagues wrote.

There are more than 15.5 million cancer survivors in the United States, and that number is expected to reach 26 million by 2040.

Prior research showed high medical bills may lead to high debt levels and personal bankruptcy among cancer survivors, particularly younger survivors who may be trying to pay off student loans, buy their first home or start a family.

Zheng and colleagues used data from the 2013 to 2016 National Health Interview Survey to examine three domains of financial hardship — material (eg, problems paying medical bills), psychological (eg, worry about paying medical bills) and behavioral (eg, delaying or forgoing care due to cost) — among a nationally representative sample of 134,790 adults.

The cohort included 10,354 cancer survivors (age 18 to 49 years; n = 1,424; 50 to 64 years, n = 2,916; 65 years or older, n = 6,014) and 124,436 individuals with no cancer history (age 18 to 49 years, n = 66,951; 50 to 64 years, n = 31,741; 65 years or older, n = 25,744).

Researchers assessed patterns of cancer-associated material, psychological and behavioral hardship by age.

They also evaluated associations between two key aspects of health insurance — high-deductible status and use of health savings accounts — and medical financial hardship among privately insured individuals aged 18 to 64 years..

Cancer survivors appeared more vulnerable to financial hardship than those with no cancer history.

The difference was most apparent among younger cancer survivors, who were significantly more likely than cancer-free individuals to report any material hardship (18 to 49 years, 43.4% vs. 30.1%; 50 to 64 years, 32.8% vs. 27.8%), psychological hardship (18 to 49 years, 53.5% vs. 47.1%) or behavioral hardship (18 to 49 years, 30.6% vs. 21.8%, 50 to 64 years, 27.2% vs. 23.4%; P < .01 for all).

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Younger cancer survivors were significantly more likely to report multiple domains of hardship (P < .01).

There are multiple potential explanations for why cancer survivors aged 18 to 49 years appear most vulnerable to financial hardship, according to the researchers.

“It may be that they do not have the opportunity to accumulate financial assets to pay for medical expenses,” Zheng said in a press release. “In addition, a cancer diagnosis might interrupt employment, and consequently limit access to employer-sponsored health insurance coverage. Although we could not identify the underlying reasons for greater hardship intensity in the younger group in this study, we believe it will be an important area for additional research.”

Among cancer survivors with private insurance, those who had high-deductible health plans without a health savings account appeared more vulnerable to hardship than those who had low-deductible insurance.

“Identifying patients with medical financial hardship will be important for primary care and oncology care providers,” Zheng said in the release. “Developing and evaluating interventions to minimize medical financial hardship will be important for the research community. It may also require attention from health policymakers.”

Researchers acknowledged potential limitations of their study. National Health Interview Survey participants self-reported cancer history, health insurance information and medical financial hardship measures, making them subject to recall bias, and researchers did not collect detailed clinical information about cancer diagnosis and treatment history.

In addition, the survey asks respondents whether they or family members are having difficulty paying medical bills, so findings related to material hardship may not only refer to cancer survivors but rather indicate that families with cancer survivors are more likely than families without cancer survivors to experience financial hardship.

The findings have implications for clinicians, according to the researchers.

“To reduce the financial burden among cancer survivors in the United States, [ASCO] has identified patient-oncologist communication regarding cost as an important component of joint treatment decision-making. However, patients may worry that conversations regarding costs distract oncologists from recommending the best care,” Zheng and colleagues wrote.

“Furthermore, oncologists may only consider clinical toxicity, but not financial hardship, as a potential harm of cancer treatments,” they added. “Therefore, more information regarding the likely costs and potential for medical financial hardship, as well as expected clinical risks and benefits of treatment, are needed to facilitate patient-clinician discussions. The findings of the current study can help clinicians to recognize the importance of distinct medical financial hardship domains, especially for younger cancer survivors.” – by Mark Leiser

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Disclosures:

Zheng reports employment with American Cancer Society and work in the intramural research department, which received a grant from Merck for research outside the submitted work. Please see the study for all other authors’ relevant financial disclosures.