Bottom Line: American cancer survivors, particularly those 64 years or younger, faced substantial medical financial hardship and sacrifices in spending, savings, or living situation, according to data from a survey.

Journal in Which the Study was Published: Cancer Epidemiology, Biomarkers, and Prevention, a journal of the American Association for Cancer Research

Author: Xuesong Han, PhD, senior principal scientist in Health Services Research at the American Cancer Society

Background: "As the number of cancer survivors grows, the costs of cancer treatments rise, and patient cost-sharing increases, there is a growing need for financial intervention at multiple levels to help cancer survivors minimize their risk of financial hardship," said Han. "We hope our findings will inform the development of future health policies and interventions in care delivery."

In the United States, the number of cancer survivors increased by 1.4 million people in the past three years, reaching more than 16.9 million as of January 1, 2019. The economic burden of cancer is significant for American cancer survivors: Previous studies have reported that as high as two-thirds of cancer survivors face medical financial hardship. However, few studies have examined the intensity of financial hardship across multiple domains, or sacrifices made as a result of cancer treatment and its longer-term effects.

How the Study Was Conducted: Han and colleagues identified cancer survivors from the 2016 Medical Expenditure Panel Survey (MEPS), a nationally representative survey that collected information on health insurance coverage, health care utilization and expenditures, and health conditions.

Participants detailed the effects of their cancer, cancer treatment, and how their cancer experience has affected their finances, health insurance coverage, and employment status. Financial hardships included problems paying medical bills, financial distress, or delaying or forgoing medical care due to cost concerns. Financial sacrifices due to cancer included changes in spending and use of savings as a result of cancer treatment and its lasting effects.

Because people over the age of 65 years are generally eligible for Medicare insurance coverage, Han and colleagues examined results for adult survivors under and over the age of 65.

Results: Of the 401 cancer survivors aged 18 to 64 years, 54 percent reported they had faced medical financial hardship as a result of cancer diagnosis and treatment, and 54 percent said they had made financial sacrifices in spending, savings, or their living situation. Nearly a quarter reported trouble paying medical bills, needing to borrow money, or filing for bankruptcy due to cancer diagnosis and treatment. More than 40 percent were worried about finances and almost 30 percent were worried about forgoing or delaying care because of cost concerns.

Of the 562 cancer survivors aged 65 years or older, medical financial hardship and sacrifices were less prevalent; 42 percent reported ever facing medical financial hardship, and 38 percent said they had made financial sacrifices.

Factors that were significantly associated with more intense financial hardship included low income and educational attainment, minority racial/ethnic status, comorbidity, lack of private insurance coverage, extended employment change, and recent cancer treatment.

Financial hardship has been linked to higher symptom burden and worse quality of life, and in extreme cases, such as bankruptcy, it is associated with an increased risk of death, Han explained.

Author's Comments: "Overall, health insurance coverage is critically important for cancer patients and survivors," said Han. "Even those who had private insurance coverage reported financial hardship, suggesting that the types of coverage and extent of patient cost-sharing are important too."

"Provisions of the Affordable Care Act that have expanded insurance coverage options, such as the Medicaid expansion, have been associated with reductions in financial hardship among cancer survivors in other studies," Han explained. "Employers can play a large role in mitigating hardship through flexible workplace accommodations such as availability of paid and unpaid sick leave, and supportive programs for both survivors and family members."

Study Limitations: The main limitations of the study were the potential for recall bias in the self-reported surveys and lack of data on clinical features of cancer stage and treatment. The researchers defined measures of insurance coverage, family income, and number of comorbidities as current estimates at survey time, however they defined measures of financial hardship and sacrifices as ever occurring.

Funding & Disclosures: The authors declare no conflict of interest.

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