Financial worry and psychological distress among cancer survivors in the United States, 2013-2018

Multidisciplinary Team Intervention: Catalysts for Changing Prognosis in Advanced Breast Cancer

PURPOSE

Multidisciplinary team (MDT) discussions are standard in cancer care; however, their effect on advanced breast cancer (ABC) prognosis is not well-documented. This study examined the impact of MDT intervention on ABC patient survival.

METHODS

A retrospective analysis of ABC patients diagnosed 2018 to 2021 was conducted by dividing them into MDT and non-MDT groups. Kaplan-Meier analysis was used to compare progression-free survival (PFS) and overall survival (OS) between the groups. Prognostic factors were evaluated using multivariate Cox regression analysis with subgroup analysis and 1:1 propensity score matching (PSM) to control for confounders.

RESULTS

Total 707 patients were included, with 72.8% (515/707) underwent MDT intervention. After a median follow-up of 43.73 months (interquartile range, 34.87-55.67 months), MDT intervention improved the median PFS (12.00 vs. 8.00 months; hazard ratio [HR], 0.75 [95% confidence interval {CI}, 0.63-0.89]; p = 0.001) and median OS (55.67 vs. 40.07 months; HR, 0.77 [95% CI, 0.61-0.97]; p = 0.030). Multivariate Cox analysis showed MDT as an independent factor for disease progression control (HR, 0.82 [95% CI, 0.68-0.98]; p = 0.041), but not for OS (HR, 0.88 [95% CI, 0.69-1.12]; p = 0.286). Subgroup analysis indicated that MDT benefited patients aged ≤ 39 years, those with disease status (de novo metastatic breast cancer), post-menopausal status, T4 stage, N3 stage, G3, visceral metastasis, > one organ metastasis and first-line systemic treatment, regardless of PFS or OS. After PSM, 172 matched patients were in the cohort. MDT still significantly controlled disease progression (12.00 vs. 8.00; HR, 0.74 [95% CI, 0.59-0.93]; p = 0.009) but did not significantly impact the OS (49.00 vs. 39.00; HR, 0.80 [95% CI, 0.59-1.08]; p = 0.121).

CONCLUSION

MDT effectively controlled the disease progression and improved OS in specific patient subgroups.

Assessing the effect of virtual navigation interventions to improve health insurance literacy and decrease financial burden in cancer survivors: The HINT II study protocol

BACKGROUND

Childhood cancer survivors often face high healthcare costs to monitor and manage new or lasting effects of their treatment. Enhancing survivors' health insurance literacy (HIL) - the knowledge, ability, and confidence in enrolling in and navigating health plans - is vital for minimizing financial burden. Few studies have assessed the effect of a health insurance navigation program on improving HIL among survivors. We present the protocol for an ongoing randomized controlled trial (RCT) assessing the effectiveness of two health insurance navigation programs (HINT-S and HINT-A) on improving HIL, financial burden, out-of-pocket costs, and healthcare utilization for adult survivors of childhood cancer.

METHODS

This three-arm RCT assesses the effectiveness of two digitally delivered health insurance navigation interventions and enhanced usual care (EUC) on improving HIL at six and 12 months in a national cohort of childhood cancer survivors. While HINT-S is composed of five synchronous, navigator-led sessions, HINT-A is an asynchronous, prerecorded set of five videos. EUC participants receive only a health insurance informational booklet. Financial burden, medical out-of-pocket costs, and healthcare utilization (receipt of preventive care, recommended screenings/vaccinations, and acute care) are assessed at 12 months. Moderators to the interventions' effectiveness will be investigated, as well as implementation outcomes (feasibility, acceptability, appropriateness, fidelity, and cost-effectiveness).

CONCLUSIONS

There is a strong need for interventions to improve cancer survivors' HIL, helping them navigate the complexity of the U.S. healthcare system. This trial will elucidate the potential effectiveness and implementation of health insurance navigation programs that may benefit many cancer survivors.

TRIAL REGISTRATION

NCT05527392.

Associations between social determinants of health and cardiovascular and cancer mortality in cancer survivors: a prospective cohort study

AIMS

The cause-specific mortality implications of social determinants of health (SDOH) in cancer survivors were unclear. This study aimed to explore associations between SDOH and cardiovascular and cancer mortality in cancer survivors.

METHODS AND RESULTS

Data from 2013 to 2017 National Health Interview Survey were used for this prospective cohort study. Social determinants of health were quantified using a 38 point, 6 domain score, with higher points indicating worse deprivation. Associations between SDOH and outcomes (primary: cardiovascular mortality; secondary: cancer and all-cause mortality) were assessed using cause-specific multivariable Cox regression, with cancer survivors and individuals without cancer modelled separately. Post hoc analyses were performed among cancer survivors to explore associations between each domain of SDOH and the risks of outcomes. Altogether, 37 882 individuals were analysed (4179 cancer survivors and 33 703 individuals without cancer). Among cancer survivors, worse SDOH was associated with higher cardiovascular [adjusted hazard ratio (aHR) 1.31 (1.02-1.68)], cancer [aHR 1.20 (1.01-1.42)], and all-cause mortality [aHR 1.16 (1.02-1.31)] when adjusted for demographics, comorbidities, and risk factors. Among individuals without cancer, SDOH was associated with cardiovascular mortality and all-cause when only adjusted for demographics, but not when further adjusted for comorbidities and risk factors; no associations between SDOH and cancer mortality were found. Among cancer survivors, psychological distress, economic stability, neighbourhood, physical environment and social cohesion, and food insecurity were varyingly associated with the outcomes.

CONCLUSION

Social determinants of health were independently associated with all-cause, cardiovascular, and cancer mortality among cancer survivors but not among individuals without cancer. Different domains of SDOH may have different prognostic importance.

Digital Health Interventions to Improve Mental Health in Patients With Cancer: Umbrella Review

BACKGROUND

Mental health plays a key role across the cancer care continuum, from prognosis and active treatment to survivorship and palliative care. Digital health technologies offer an appealing, cost-effective tool to address psychological needs.

OBJECTIVE

This umbrella review aims to summarize and evaluate the available evidence on the efficacy of digital health interventions for improving mental health and psychosocial outcomes for populations with cancer.

METHODS

Literature searches were conducted in Embase, PsycINFO, PubMed, CINAHL, the Cochrane Library, and Web of Science from their inception to February 4, 2024. Systematic reviews (with or without meta-analysis) investigating the efficacy of digital health interventions for psychosocial variables in patients with cancer were included. Quality was assessed using the Assessing the Methodological Quality of Systematic Reviews-2 tool.

RESULTS

In total, 78 systematic reviews were included in this review. Among diverse delivery modalities and types of digital interventions, websites and smartphone apps were the most commonly used. Depression was the most frequently addressed, followed by quality of life, anxiety, fatigue, and distress. The qualities of the reviews ranged from critically low to high. Generally, despite great heterogeneity in the strength and credibility of the evidence, digital health interventions were shown to be effective for mental health in patients with cancer.

CONCLUSIONS

Taken together, digital health interventions show benefits for patients with cancer in improving mental health. Various gaps were identified, such as little research specifically focusing on older adult patients with cancer, a scarcity of reporting high-precision emotion management, and insufficient attention to other certain mood indicators. Further exploration of studies with standardized and rigorous approaches is required to inform practice.

TRIAL REGISTRATION

PROSPERO CRD42024565084; https://tinyurl.com/4cbxjeh9.

Cancer Survivors' Experience of Care and Financial Toxicity: Results From a National Survey

PURPOSE

Financial toxicity (FT) can adversely affect quality of life, treatment adherence, and clinical outcomes. Patient experience of care (PEC) captures patient's perspectives on interactions with health care providers (HCPs) and systems, but the impact of PEC on FT is unknown. This study examined the relationship between PEC and FT.

METHODS

We used data from the 2016-2017 Medical Expenditure Panel Survey (MEPS) Experience with Cancer Survivorship Supplement. PEC was assessed by patient-reported frequencies of their HCPs providing explanations that were easy to understand, listening carefully, showing respect, and spending enough time with the patient. FT was assessed by nine items to measure material, psychological, and behavioral FT. Analyses were performed using multivariable logistic regression controlling for sociodemographic and clinical characteristics and weighted to produce nationally representative estimates and account for survey nonresponse.

RESULTS

Data from 1,068 individuals diagnosed with cancer at age >18 years were assessed. A total of 30% reported material FT, 35% reported psychological FT, and 27% reported behavioral FT. Examining PEC, 64% of respondents indicated that HCPs always explained things, 60% always listened, 66% always showed respect, and 57% always spent adequate time with them. Odds of psychological FT were significantly (P < .05) lower among patients reporting HCPs always (v never/sometimes) listened to them (odds ratio [OR], 0.37 [95% CI, 0.19 to 0.70]), showed them respect (OR, 0.36 [95% CI, 0.16 to 0.81]), and spent enough time with them (OR, 0.47 [95% CI, 0.26 to 0.86]). Significant associations with PEC were also found with MEPS psychological FT items on worry about paying medical bills, family's financial stability, and keeping job/income because of cancer.

CONCLUSION

Worry/anxiety regarding costs can be a major factor affecting individuals diagnosed with cancer. Improving patient-provider interactions to enhance patient experience of care may reduce psychological financial toxicity.

Strategies for Mitigating Cancer-Related Financial Toxicity in China: A Multiperspective Qualitative Study Based on the Socioecological Framework

PURPOSE

To explore strategies related to cancer-related financial toxicity (FT) from the perspectives of cancer survivors and stakeholders in China and to evaluate their views within the context of the social ecological model (SEM).

METHODS

Between March and July 2022, we conducted a descriptive qualitative study with semistructured interviews of 23 cancer survivors and 14 stakeholders. Qualitative content analysis on the basis of the SEM was used to analyze the data with NVivo 12.

RESULTS

Guided by the SEM, we identified 12 subthemes that described how to mitigate FT. Individual-level strategies included increasing cost-related health literacy, strengthening adherence to standardized treatments, and improving resilience to cancer and financial changes. Interpersonal-level strategies included strengthening family support and social networks. Organizational-level strategies included using evidence-based treatments, effective communication of costs, and providing financial information support. Community-level strategies included improving symptom management throughout survivorship and providing psychosocial support. Policy-level strategies included optimizing health insurance policies and promoting collaboration among medical institutions.

CONCLUSION

Our findings provide a comprehensive understanding of strategies pertaining to FT, offering insights that could support the development of future interventions. This research suggests that interventions that encompass multiple levels-individual, interpersonal, organizational, community, and policy-rather than focusing on only one level might be the most beneficial for managing FT.

Mediating and moderating factors between stigma and adaptability to return to work for cancer survivors

Adaptability to return to work is a process by which cancer survivors(CSs) utilize accessible resources to reconstruct themselves. While the stigma, financial situation and social support are known to influence their adaptability to return to work, the mechanisms by which these factors work remain unclear. This study proposes a moderated mediation model to signify a pathway linking stigma to the adaptability to return to work. Data were analyzed using the PROCESS macro for R version 4.3.1. A total of 238 CSs, aged between 18 and 60 years (73.5% female), of whom 42.1% had returned to work, completed the ARTWS, SIS, COST-PROM, SSRS, HeLMS. Stigma had a negative associations on the adaptability to return to work. Both financial toxicity and social support mediated the relationship between stigma and the adaptability to return to work. Health literacy moderated both the direct pathway and the second half of the pathway mediated by financial toxicity. Specifically, the negative effects of stigma and financial toxicity on the adaptability to return to work were significantly attenuated when health literacy levels were high. CSs with higher health literacy may not experience excessive stigma, and experience less financial toxicity than those with lower health literacy. CSs possessing greater social support will be more effective in utilizing external resources to buffer the influence of financial toxicity, and thus adapt better to work.

Evaluating the impact of financial worry on mental health: a cross-sectional study among Kenyan radiographers

BACKGROUND

Psychological distress is a major public health concern that has many influencing factors. One of them is the financial capability of an individual. Despite the integral role of radiographers in healthcare delivery, there is limited literature about radiographers in Kenya and more so regarding their mental well-being. A descriptive cross-sectional study was conducted to evaluate the effect of perceived financial worry on mental health among Kenyan radiographers.

METHODS

Data was collected from registered radiographers in Kenya through an online survey conducted between December 2023 and January 2024. Multivariable binary logistic regression was used to evaluate the association between financial worry and psychological distress.

RESULTS

Out of the 2055 radiographers invited to participate in the survey, 245 responded (11.92% response rate). The gender distribution of the respondents was 39.2% female and 60.8% male, closely mirroring the latest data on registered radiographers (37.3% female and 62.7% male). Most respondents in our study were under 30 years old (56.7%). The majority of radiographers (62.4%) reported poor social support. Additionally, most radiographers experienced some level of financial concern across various issues, with an average financial worry score of 16.75 (standard deviation: 4.97; minimum 3, maximum 24). A significant proportion (36.7%) also showed signs of psychological distress. Individuals with higher levels of financial worry were noted to be more likely to experience psychological distress after adjusting for the socioeconomic and health-related variables (adjusted odds ratio, AOR 1.20, 95% confidence interval, CI 1.10-1.31, p < 0.001). Furthermore, individuals with at least moderate social support (AOR: 0.39; 95% CI 0.18-0.86, p = 0.019) and larger families (AOR: 0.11; 95% CI 0.02-0.78, p = 0.027) were less likely to experience psychological distress compared to their peers.

CONCLUSIONS

A significant number of radiographers reported experiencing financial worry which was associated with an increased likelihood of psychological distress. This emphasizes the need for policies and mechanisms to address financial worry and psychological distress to have a more resilient medical workforce in Kenya.

Financial Toxicity Among Asian American Cancer Survivors

This Viewpoint highlights financial toxicity specific to Asian American cancer survivors and presents steps forward within the framework of the social ecological model of health, considering individual, interpersonal, community, and policy-level dimensions.

Modifiable Lifestyle Risk Factors in Adult Survivors of Childhood Cancer: A Nationally Representative Study

OBJECTIVES

Given the vulnerable health condition of adult childhood cancer survivors, it is essential that they develop positive health behaviors to minimize controllable health risks. Therefore, we evaluated if adult survivors of non-childhood cancer and childhood cancer differ in the odds of each modifiable risk factor compared with each other and compared with the general population.

METHODS

This nationally representative study leveraged the National Health Interview Survey (NHIS) sample from 2000 to 2018 and the Behavioral Risk Factor Surveillance System (BRFSS) sample from 2016 to 2021. Our study population included adults diagnosed with cancer when they were ≤14 years of age. Outcomes included physical activity, body mass index (BMI), current smoking, ever-smoking, alcohol use, and binge drinking.

RESULTS

Insufficient physical activity was not statistically significant in the BRFSS, but in the NHIS, childhood cancer survivors had significantly more insufficient physical activity compared with non-childhood cancer survivors (aOR 1.29, P =0.038) and the general population (aOR 1.40, P =0.006). Childhood cancer survivors also had a higher likelihood of being significantly underweight (aOR 1.84, P =0.018) and having ever-smoked (aOR 1.42, P =0.001) compared with the general population in the NHIS. There was a significantly higher likelihood of smoking among childhood cancer survivors in the BRFSS (aOR 2.02, P =0.004).

CONCLUSIONS

The likelihoods of many risky behaviors between adult childhood cancer survivors and general population controls were comparable, although rates of physical activity may be decreased, and rates of smoking may be increased among childhood cancer survivors. Targeted interventions are needed to promote healthy behaviors in this vulnerable population.

Medical financial hardship in the Southern United States: the struggle continues across generations pre- and post- the Affordable Care Act

INTRODUCTION

Medical financial hardship in the United States is a growing public health concern. This study aims to assess the south vs. non-south disparities in medical financial hardship among US adults of different generations - Boomers (born between 1946 and 1964), Generation X (born between 1965 and 1980), and the Millennials (born between 1981 and 1996) across periods pre- and post- Affordable Care Act (ACA).

METHODS

This observational study utilizes data from multiple waves of the National Health Interview Survey (NHIS) split into three periods: pre-ACA (2011-2013), ii) post ACA (2015-2018), and iii) COVID-19 pandemic (2021-2022). Multivariable logistic regressions were fitted, separately for each generation in each period, to compare the extent of medical financial hardship among those from South to rest of the US, and Karlson-Holm-Breen (KHB) decomposition was applied to analyze whether there was a mediating impact of health insurance coverage.

RESULTS

Adults living in the South were more likely to experience medical financial hardship in all three periods. Residing in the South was associated with 1.7 to 2.6% points (pp) higher probability of medical financial hardship among boomers, 1.8 to 4.0 pp among generation Xers, and 1.7 to 2.8 pp among millennials. The relationship was robust after accounting for chronic comorbidities, sociodemographic and socioeconomic attributes and was partially mediated through differences in health insurance coverage.

CONCLUSIONS

The problem of medical financial hardship has been deeply rooted in the South across generations, which was partly attributable to the regional differences in health insurance coverage.

Contemporary Patterns of Financial Toxicity Among Patients With Rheumatologic Disease in the United States

BACKGROUND/OBJECTIVE

Rheumatologic diseases encompass a group of disabling conditions that often require expensive clinical treatments and limit an individual's ability to work and maintain a steady income. The purpose of this study was to evaluate contemporary patterns of financial toxicity among patients with rheumatologic disease and assess for any associated demographic factors.

METHODS

The cross-sectional National Health Interview Survey was queried from 2013 to 2018 for patients with rheumatologic disease. Patient demographics and self-reported financial metrics were collected or calculated including financial hardship from medical bills, financial distress, food insecurity, and cost-related medication (CRM) nonadherence. Multivariable logistic regressions were used to assess for factors associated with increased financial hardship.

RESULTS

During the study period, 20.2% of 41,502 patients with rheumatologic disease faced some degree of financial hardship due to medical bills, 55.0% of whom could not pay those bills. Rheumatologic disease was associated with higher odds of financial hardship from medical bills (adjusted odds ratio, 1.29; 95% confidence interval, 1.22-1.36; p < 0.001) with similar trends for patients suffering from financial distress, food insecurity, and CRM nonadherence (p < 0.001 for all). Financial hardship among patients with rheumatologic disease was associated with being younger, male, Black, and uninsured ( p < 0.001 for all).

CONCLUSION

In this nationally representative study, we found that a substantial proportion of adults with rheumatologic disease in the United States struggled with paying their medical bills and suffered from food insecurity and CRM nonadherence. National health care efforts and guided public policy should be pursued to help ease the burden of financial hardship for these patients.

Psychological Distress, Emergency Room Utilization, and Mortality Risk Among US Adults With History of Prostate Cancer

PURPOSE

Adults with a history of prostate cancer experience several physical and mental stressors. However, limited information is available about the prevalence of psychological distress in this population and its association with clinical outcomes in a nationally representative sample.

METHODS

We identified adults with history of prostate cancer from a nationally representative cohort (2000-2018 US National Health Interview Survey) and its linked mortality files through December 31, 2019. The six-item Kessler Psychological Distress Scale (K6) was used to assess psychological distress. The associations between psychological distress severity, emergency room (ER) usage, and mortality risk were estimated using multivariable logistic and Cox proportional hazards models, which were both adjusted for age, survey year, race/ethnicity, region, education, health insurance, comorbidities, functional limitations, and time since cancer diagnosis.

RESULTS

Among the 3,451 adults with history of prostate cancer surveyed, 96 (2.4%), 434 (11.3%), and 2,921 (86.3%) reported severe, moderate, or low/no mental distress, respectively. During the 12 months preceding the survey, 812 (22.8%) adults with history of prostate cancer visited the ER. After a median follow-up of 81 months, 937 (25.5%) deaths occurred. Compared with participants with low/no mental distress, those with severe mental distress reported the highest utilization of the ER (adjusted odds ratio [aOR], 2.57 [95% CI, 1.51 to 4.37]) and exhibited the highest all-cause mortality (adjusted hazard ratio [aHR], 1.83 [95% CI, 1.29 to 2.60]), followed by those with moderate mental distress (ER use aOR, 1.76 [95% CI, 1.29 to 2.42]; all-cause mortality aHR, 1.22 [95% CI, 0.92 to 1.62]).

CONCLUSION

Among US adults with history of prostate cancer, psychological distress was associated with increased ER use and mortality risk. Notably, severe psychological distress was correlated with the highest rates of ER visits and mortality risk. However, given the retrospective nature of this study, uncontrolled confounding variables need to be considered when interpreting the findings.

Psychological Distress, Emergency Room Utilization, and Mortality Risk Among US Adults With History of Prostate Cancer

PURPOSE

Adults with a history of prostate cancer experience several physical and mental stressors. However, limited information is available about the prevalence of psychological distress in this population and its association with clinical outcomes in a nationally representative sample.

METHODS

We identified adults with history of prostate cancer from a nationally representative cohort (2000-2018 US National Health Interview Survey) and its linked mortality files through December 31, 2019. The six-item Kessler Psychological Distress Scale (K6) was used to assess psychological distress. The associations between psychological distress severity, emergency room (ER) usage, and mortality risk were estimated using multivariable logistic and Cox proportional hazards models, which were both adjusted for age, survey year, race/ethnicity, region, education, health insurance, comorbidities, functional limitations, and time since cancer diagnosis.

RESULTS

Among the 3,451 adults with history of prostate cancer surveyed, 96 (2.4%), 434 (11.3%), and 2,921 (86.3%) reported severe, moderate, or low/no mental distress, respectively. During the 12 months preceding the survey, 812 (22.8%) adults with history of prostate cancer visited the ER. After a median follow-up of 81 months, 937 (25.5%) deaths occurred. Compared with participants with low/no mental distress, those with severe mental distress reported the highest utilization of the ER (adjusted odds ratio [aOR], 2.57 [95% CI, 1.51 to 4.37]) and exhibited the highest all-cause mortality (adjusted hazard ratio [aHR], 1.83 [95% CI, 1.29 to 2.60]), followed by those with moderate mental distress (ER use aOR, 1.76 [95% CI, 1.29 to 2.42]; all-cause mortality aHR, 1.22 [95% CI, 0.92 to 1.62]).

CONCLUSION

Among US adults with history of prostate cancer, psychological distress was associated with increased ER use and mortality risk. Notably, severe psychological distress was correlated with the highest rates of ER visits and mortality risk. However, given the retrospective nature of this study, uncontrolled confounding variables need to be considered when interpreting the findings.

Association of financial worry with substance use, mental health, and quality of life in cancer patients

PURPOSE

Financial worry is an under-appreciated negative effect of cancer. The relationship of financial worry and health behaviors in cancer is poorly characterized and has important clinical implications. This study examined the association of financial worry with substance misuse, mood, and quality of life.

METHODS

People with cancer (n = 1473; 6 to 20 months after diagnosis) were recruited from a SEER cancer registry in the Pacific Northwest. Participants completed an online survey assessing financial worry; misuse of cannabis, alcohol, and prescription drugs; tobacco smoking status; quality of life (physical and mental dimensions); anxiety; and depression. Multivariable regressions tested the association of financial worry to each health indicator and outcome.

RESULTS

In adjusted analyses, financial worry was associated with being a current vs. never smoker (odds ratio (OR) = 1.91, 95% confidence interval (CI): 1.01, 3.60), and a positive screen for an anxiety (OR = 3.01, 95% CI: 1.93, 4.68) and depressive (OR = 3.08, 95% CI: 1.89, 5.00) disorder. Financial worry was not associated with cannabis, alcohol, or prescription drug misuse (all ps > 0.05), but was associated with a decrease in physical (β =  - 2.97, 95% CI: - 4.15, - 1.79) and mental (β =  - 5.27, 95% CI: - 6.59, - 3.96) quality of life.

CONCLUSION

Financial worry among cancer survivors is associated with anxiety, depression, and worse quality of life. Of the evaluated substances, there was only an increased odds of current tobacco use with financial worry. Future longitudinal studies should inform the relationships between these factors.

IMPLICATIONS FOR CANCER SURVIVORS

Financial worry and material hardship may both need to be addressed in cancer survivorship.

Assessing the pre-implementation context for financial navigation in rural and non-rural oncology clinics

Background

Financial navigation (FN) is an evidence-based intervention designed to address financial toxicity for cancer patients. FN's success depends on organizations' readiness to implement and other factors that may hinder or support implementation. Tailored implementation strategies can support practice change but must be matched to the implementation context. We assessed perceptions of readiness and perceived barriers and facilitators to successful implementation among staff at nine cancer care organizations (5 rural, 4 non-rural) recruited to participate in the scale-up of a FN intervention. To understand differences in the pre-implementation context and inform modifications to implementation strategies, we compared findings between rural and non-rural organizations.

Methods

We conducted surveys (n = 78) and in-depth interviews (n = 73) with staff at each organization. We assessed perceptions of readiness using the Organizational Readiness for Implementing Change (ORIC) scale. In-depth interviews elicited perceived barriers and facilitators to implementing FN in each context. We used descriptive statistics to analyze ORIC results and deductive thematic analysis, employing a codebook guided by the Consolidated Framework for Implementation Research (CFIR), to synthesize themes in barriers and facilitators across sites, and by rurality.

Results

Results from the ORIC scale indicated strong perceptions of organizational readiness across all sites. Staff from rural areas reported greater confidence in their ability to manage the politics of change (87% rural, 76% non-rural) and in their organization's ability to support staff adjusting to the change (96% rural, 75% non-rural). Staff at both rural and non-rural sites highlighted factors reflective of the Intervention Characteristics (relative advantage) and Implementation Climate (compatibility and tension for change) domains as facilitators. Although few barriers to implementation were reported, differences arose between rural and non-rural sites in these perceived barriers, with non-rural staff more often raising concerns about resistance to change and compatibility with existing work processes and rural staff more often raising concerns about competing time demands and limited resources.

Conclusions

Staff across both rural and non-rural settings identified few, but different, barriers to implementing a novel FN intervention that they perceived as important and responsive to patients' needs. These findings can inform how strategies are tailored to support FN in diverse oncology practices.

Leveraging national and global political determinants of health to promote equity in cancer care

Health and politics are deeply intertwined. In the context of national and global cancer care delivery, political forces-the political determinants of health-influence every level of the cancer care continuum. We explore the "3-I" framework, which structures the upstream political forces that affect policy choices in the context of actors' interests, ideas, and institutions, to examine how political determinants of health underlie cancer disparities. Borrowing from the work of PA Hall, M-P Pomey, CJ Ho, and other thinkers, interests are the agendas of individuals and groups in power. Ideas represent beliefs or knowledge about what is or what should be. Institutions define the rules of play. We provide examples from around the world: Political interests have helped fuel the establishment of cancer centers in India and have galvanized the 2022 Cancer Moonshot in the United States. The politics of ideas underlie global disparities in cancer clinical trials-that is, in the distribution of epistemic power. Finally, historical institutions have helped perpetuate disparities related to racist and colonialist legacies. Present institutions have also been used to improve access for those in greatest need, as exemplified by the Butaro Cancer Center of Excellence in Rwanda. In providing these global examples, we demonstrate how interests, ideas, and institutions influence access to cancer care across the breadth of the cancer continuum. We argue that these forces can be leveraged to promote cancer care equity nationally and globally.

Disparities and barriers in the assessment of psychological distress, access to and use of psycho-oncological support in Europe: current perspectives

The implementation of psycho-oncological support has shown important results in positively influencing treatment outcomes and quality of life in cancer patients and survivors. In the last few decades, the importance of mental health has been brought to attention to the general public and healthcare professionals on a national, institutional and organisational level. Official guidelines, policies, and training programs have been developed suggesting that psycho-oncological support should be considered as a non-negotiable requirement for quality cancer care in many hospitals and clinical centres across Europe. Health organisations, associations, institutions, and societies, such as the International Psycho-Oncology Society (IPOS) and the European Partnership for Action Against Cancer (EPAAC), are forming alliances, funding research projects and organising congresses in order to study, understand, and discuss the reasons for barriers and disparities in psycho-oncological support and, eventually, to overcome the existing cancer divide. Nevertheless, the World Health Organization's (WHO) estimations indicate that the cancer burden is still increasing, and relevant barriers and disparities in accessing psycho-oncological support continue to exist and influence the health conditions and quality of life of cancer patients and survivors. The present work will present the current disparities and barriers regarding assessment, access to and use of psycho-oncological support in the countries of the European Union, making suggestions for further research and possible solutions.

Financial Toxicity in Cancer Care: Implications for Clinical Care and Potential Practice Solutions

Patients with cancer face an array of financial consequences as a result of their diagnosis and treatment, collectively referred to as financial toxicity (FT). In the past 10 years, the body of literature on this subject has grown tremendously, with a recent focus on interventions and mitigation strategies. In this review, we will briefly summarize the FT literature, focusing on the contributing factors and downstream consequences on patient outcomes. In addition, we will put FT into context with our emerging understanding of the role of social determinants of health and provide a framework for understanding FT across the cancer care continuum. We will then discuss the role of the oncology community in addressing FT and outline potential strategies that oncologists and health systems can implement to reduce this undue burden on patients with cancer and their families.

Association of social service counseling in breast cancer patients with financial problems, role functioning and employment-results from the prospective multicenter BRENDA II study

BACKGROUND

This study examined the relationship between social service counseling (SSC) and financial and role functioning problems in primary breast cancer (BC) patients over a 5-year observation period.

METHODS

In the multicenter prospective study, patients were approached before surgery (t1), before initiation of adjuvant treatment (t2), after therapy completion (t3), and 5 years after surgery (t4). We examined the proportion of BC survivors who had financial and role functioning problems and the proportion who were employed at t4. We examined how frequently patients were informed about, offered, or used SSC, and we used multivariate logistic regression analyses to examine the relationship between this and financial and role functioning problem prevalence.

RESULTS

Of the 456 BC survivors, 33% had financial problems and 22% reported role functioning problems at t4. There was no evidence that women with increased financial problems were informed about SSC more often than those without (OR 1.1, p = 0.84) or that they used SSC more often (OR 1.3, p = 0.25). However, women with role functioning problems were informed about SSC significantly more often (OR 1.7, p = 0.02) and attended counseling significantly more often (OR 1.6, p = 0.03). Among participants aged < 65 years at t4 (n = 255), 70% were employed. Patients who had received SSC were more likely to be employed at t4 than patients who did not (OR 1.9, p = 0.04).

CONCLUSION

These findings underline the importance of SSC for BC patients with role functioning issues. They indicate that individuals who use SSC are more likely to be employed later on than individuals who do not.

Financial hardship and mental health among cancer survivors during the COVID-19 pandemic: An analysis of the US COVID-19 Household Impact Survey

Purpose

Our objective was to (1) identify associated characteristics of financial hardship (FH), and (2) evaluate associations of FH with mental health symptoms among cancer survivors during the COVID-19 pandemic.

Methods

Using data from the nationally representative COVID-19 Impact Survey, we defined cancer survivors as those with a self-reported diagnosis of cancer (n = 854,7.6%). We defined FH using the following question: "Based on your current financial situation, how would you pay for an unexpected $400 expense?" Multivariable Poisson regression was used to estimate adjusted prevalence ratios (aPR) with 95% confidence intervals (95%CI) to identify associated characteristics of FH and associations of FH with mental health symptoms among cancer survivors overall and by age (18-59 years/60+ years).

Results

Forty-one percent of cancer survivors reported FH, with 58% in 18-59 and 33% in 60+ year old respondents. Compared to cancer survivors aged 60+ years, those aged 30-44 (aPR:1.74,95% CI:1.35-2.24), and 45-59 years (aPR:1.60,95% CI:1.27-1.99) were more likely to report FH. Compared to non-Hispanic(NH)-White cancer survivors, NH-Black cancer survivors had a 56% higher prevalence of FH (aPR:1.56; 95% CI: 1.23-1.97). Among 60+ years aged cancer survivors, NH-Black (aPR:1.80; 95% CI: 1.32-2.45) and NH-Asian cancer survivors (aPR:10.70,95% CI:5.6-20.7) were more likely to experience FH compared to their NH-White counterparts. FH was associated with feeling anxious (aPR:1.51,95% CI:1.11-2.05), depressed (aPR:1.66,95% CI:1.25-2.22), and hopeless (aPR:1.84,95% CI:1.38-2.44).

Conclusion

Minoritized communities, younger adults, and cancer survivors with low socioeconomic status had a higher burden of FH, which was associated with feelings of anxiety, depression, and hopelessness.

Patient-reported supportive care needs among Asian American cancer patients

PURPOSE

Cancer is the leading cause of death for Asian Americans. However, few studies have documented supportive care needs from the perspective of Asian American cancer patients. This study describes the needs reported by Asian American patients with colorectal, liver, or lung cancer over a 6-month period during their treatment.

METHODS

Participants were recruited through the Greater Bay Area Cancer Registry and from cancer care providers in San Francisco. Participants self-identified as Asian or Asian American; were age 21 or older; spoke English, Chinese, or Vietnamese; and had stage I-III colon, rectum, liver, or lung cancer. Participants were matched with a language concordant patient navigator who provided support during a 6-month period. Needs were assessed by surveys at baseline, 3, and 6 months.

RESULTS

Among 24 participants, 58% were 65 years or older, 42% did not complete high school, and 75% had limited English proficiency (LEP). At baseline, the most prevalent needs were cancer information (79%), nutrition and physical activity (67%), language assistance (54%), and daily living (50%). At the 3- and 6-month follow-up surveys, there was a higher reported need for mental health resources and healthcare access among participants.

CONCLUSION

In this pilot study of Asian American cancer patients who predominantly had LEP, participants reported many needs, with cancer information and language assistance as the most prominent. The findings highlight the importance of culturally and linguistically appropriate patient navigators in addressing supportive care needs among cancer patients with LEP.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03867916.

Shared burden: the association between cancer diagnosis, financial toxicity, and healthcare cost-related coping mechanisms by family members of non-elderly patients in the USA

PURPOSE

There has been little research on the healthcare cost-related coping mechanisms of families of patients with cancer. Therefore, we assessed the association between a cancer diagnosis and the healthcare cost-related coping mechanisms of participant family members through their decision to forego or delay seeking medical care, one of the manifestations of financial toxicity.

METHODS

Using data from the National Health Interview Survey (NHIS) between 2000 and 2018, sample weight-adjusted prevalence was calculated and multivariable logistic regressions defined adjusted odds ratios (aORs) for participant family members who needed but did not get medical care or who delayed seeking medical care due to cost in the past 12 months, adjusting for relevant sociodemographic covariates, including participant history of cancer (yes vs. no) and participant age (18-45 vs. 46-64 years old). The analysis of family members foregoing or delaying medical care was repeated using a cancer diagnosis * age interaction term.

RESULTS

Participants with cancer were more likely than those without a history of cancer to report family members delaying (19.63% vs. 16.31%, P < 0.001) or foregoing (14.53% vs. 12.35%, P = 0.001) medical care. Participants with cancer in the 18 to 45 years old age range were more likely to report family members delaying (p_interaction = 0.028) or foregoing (p_interaction < 0.001) medical care. Other factors associated with cost-related coping mechanisms undertaken by the participants' family members included female sex, non-married status, poorer health status, lack of health insurance coverage, and lower household income.

CONCLUSION

A cancer diagnosis may be associated with familial healthcare cost-related coping mechanisms, one of the manifestations of financial toxicity. This is seen through delayed/omitted medical care of family members of people with a history of cancer, an association that may be stronger among young adult cancer survivors. These findings underscore the need to further explore how financial toxicity associated with a cancer diagnosis can affect patients' family members and to design interventions to mitigate healthcare cost-related coping mechanisms.

Reading Wishes from the Lips: Cancer Patients' Need for Psycho-Oncological Support during Inpatient and Outpatient Treatment

Background: Psycho-oncological support (PO) is an effective measure to reduce distress and improve the quality of life in patients with cancer. Currently, there are only a few studies investigating the (expressed) wish for PO. The aim of this study was to evaluate the number of patients who request PO and to identify predictors for the wish for PO. Methods: Data from 3063 cancer patients who had been diagnosed and treated at a Comprehensive Cancer Center between 2011 and 2019 were analyzed retrospectively. Potential predictors for the wish for PO were identified using logistic regression. As a novelty, a Back Propagation Neural Network (BPNN) was applied to establish a prediction model for the wish for PO. Results: In total, 1752 patients (57.19%) had a distress score above the cut-off and 14.59% expressed the wish for PO. Patients’ requests for pastoral care (OR = 13.1) and social services support (OR = 5.4) were the strongest predictors of the wish for PO. Patients of the female sex or who had a current psychiatric diagnosis, opioid treatment and malignant neoplasms of the skin and the hematopoietic system also predicted the wish for PO, while malignant neoplasms of digestive organs and older age negatively predicted the wish for PO. These nine significant predictors were used as input variables for the BPNN model. BPNN computations indicated that a three-layer network with eight neurons in the hidden layer is the most precise prediction model. Discussion: Our results suggest that the identification of predictors for the wish for PO might foster PO referrals and help cancer patients reduce barriers to expressing their wish for PO. Furthermore, the final BPNN prediction model demonstrates a high level of discrimination and might be easily implemented in the hospital information system.

Association of Chronic Disease With Patient Financial Outcomes Among Commercially Insured Adults

Importance

The bidirectional association between health and financial stability is increasingly recognized.

Objective

To describe the association between chronic disease burden and patients' adverse financial outcomes.

Design, Setting, and Participants

This cross-sectional study analyzed insurance claims data from January 2019 to January 2021 linked to commercial credit data in January 2021 for adults 21 years and older enrolled in a commercial preferred provider organization in Michigan.

Exposures

Thirteen common chronic conditions (cancer, congestive heart failure, chronic kidney disease, dementia, depression and anxiety, diabetes, hypertension, ischemic heart disease, liver disease, chronic obstructive pulmonary disease and asthma, serious mental illness, stroke, and substance use disorders).

Main Outcomes and Measures

Adjusted probability of having medical debt in collections, nonmedical debt in collections, any delinquent debt, a low credit score, or recent bankruptcy, adjusted for age group and sex. Secondary outcomes included the amount of medical, nonmedical, and total debt among individuals with nonzero debt.

Results

The study population included 2 854 481 adults (38.4% male, 43.3% female, 12.9% unknown sex, and 5.4% missing sex), 61.4% with no chronic conditions, 17.7% with 1 chronic condition, 14.8% with 2 to 3 chronic conditions, 5.4% with 4 to 6 chronic conditions, and 0.7% with 7 to 13 chronic conditions. Among the cohort, 9.6% had medical debt in collections, 8.3% had nonmedical debt in collections, 16.3% had delinquent debt, 19.3% had a low credit score, and 0.6% had recent bankruptcy. Among individuals with 0 vs 7 to 13 chronic conditions, the predicted probabilities of having any medical debt in collections (7.6% vs 32%), any nonmedical debt in collections (7.2% vs 24%), any delinquent debt (14% vs 43%), a low credit score (17% vs 47%) or recent bankruptcy (0.4% vs 1.7%) were all considerably higher for individuals with more chronic conditions and increased with each added chronic condition. Among individuals with medical debt in collections, the estimated amount increased with the number of chronic conditions ($784 for individuals with 0 conditions vs $1252 for individuals with 7-13 conditions) (all P < .001). In secondary analyses, results showed significant variation in the likelihood and amount of medical debt in collections across specific chronic conditions.

Conclusions and Relevance

This cross-sectional study of commercially insured adults linked to patient credit report outcomes shows an association between increasing burden of chronic disease and adverse financial outcomes.

Health-related quality of life in breast cancer patients in Asia: A meta-analysis and systematic review

Objectives

The primary purposes of this meta-analysis and systematic review were to evaluate the health-related quality of life (HRQoL) of Asian breast cancer (BC) patients to understand their holistic HRQoL level and provide medical and nursing recommendations to improve and preserve their quality of life.

Methods

A comprehensive literature search was conducted to find cross-sectional studies published in Chinese and English concerning HRQoL in BC patients from the inceptions of databases to 14 March 2022. The databases consulted were PubMed, Web of Science, Embase, Cochrane, PsyclNFO, CINAHL, and CNKI. Literature screening, data extraction, risk bias assessment, and data synthesis were independently carried out by two researchers. The Endnote X9 and Stata 15.0 software programs were used during the meta-analysis process.

Results

Out of the 8,563 studies identified, 23 cross-sectional studies involving 3,839 Asian BC patients were included in this meta-analysis. Two tools, namely, European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire C30 (EORTC QLQ-C30) and Quality of Life Questionnaire Breast Cancer module 23 (EORTC QLQ-BR23)—were used to evaluate the HRQoL of BC patients in Asia. The pooled mean of the global health status of Asian BC patients was 58.34 (95% confidence interval [CI]: 53.66–63.02). According to functional subscales of EORTC QLQ-C30 and EORTC QLQ-BR23, Asian BC patients suffered from the worst emotional functioning (pooled mean=66.38; 95% CI: 59.66–73.11) and sexual enjoyment (pooled mean=49.31; 95% CI: 31.97–63.36). In addition, fatigue (pooled mean=42.17; 95% CI: 34.46–49.88) and being upset by hair loss (pooled mean=48.38; 95% CI: 36.64–60.12) were the most obvious symptoms that Asian BC patients experienced according to the meta-analysis results of the EORTC QLQ-C30 and EORTC QLQ-BR23 symptom subscales.

Conclusion

Asian BC patients experience a relatively low HRQoL due to the prominent decline in their body functions, as well as the unpleasant experiences caused by their symptoms. It is suggested that timely, appropriate, and targeted intervention should be provided in relation to the physical, psychological, and social aspects of Asian BC patients’ lives to enhance their ability to function, relieve them of adverse symptoms, and improve their overall HRQoL.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022321165.

Disparities in timely treatment among young women with breast cancer

BACKGROUND

Although evidence suggests worse breast cancer-specific survival associated with treatment delay beyond 90 days, little is known regarding the sociodemographic predictors of delays in cancer-directed surgery among young women with breast cancer. This is particularly notable, given that 5-10% of new diagnoses occur in younger women aged <40 years, commonly with more aggressive features than in older women.

METHODS

We used the National Cancer Database (2004-2017) to assess sociodemographic disparities in delay of upfront surgery beyond 90 days among young women with non-metastatic breast cancer, using multivariable logistic regression and predictive marginal modeling.

RESULTS

Black women experienced treatment delays more frequently than white women (aOR: 1.93 [95% CI: 1.76-2.11], p < 0.001). Adjusted rates of treatment delay were 4.91% [95% CI: 4.51%-5.30%] and 2.60% [95% CI: 2.47%-2.74%] for Black and white women, respectively, and 2.97% [95% CI: 2.83%-3.12%], 2.36% [95% CI: 2.03%-2.68%], and 1.18% [95% CI: 0.54%-1.81%] for women from metro, urban, and rural areas, respectively.

CONCLUSION

These results suggest that improving access to timely treatment may be leveraged as a means through which to lessen the breast cancer disparities experienced by Black women.

Associations of readiness for hospital discharge with symptoms and non-routine utilization of post-discharge services among cancer patients receiving oral chemotherapy at home: A prospective study

BACKGROUND

Readiness for hospital discharge is associated with patients' health outcomes after they return home. However, little is known about this association among cancer patients receiving oral chemotherapy at home. This study aimed to examine whether patients' reported readiness for hospital discharge was associated with symptoms and non-routine utilization of post-discharge services among cancer patients receiving oral chemotherapy at home.

METHODS

A prospective study was conducted, and 151 cancer patients receiving oral chemotherapy were recruited from a provincial level hospital in South China between October 2018 and December 2019. The primary outcome was readiness for hospital discharge assessed by the Readiness for Hospital Discharge Scale-Short Form on the day of discharge. The secondary endpoints were symptoms assessed by MD Anderson Symptom Inventory and non-routine utilization of post-discharge services within one cycle of chemotherapy at home (21 days).

RESULTS

Among these 151 participants, 74.2% of them reported as ready for discharge. Patients who were employed, lived in suburban area or villages, had a higher Eastern Cooperative Oncology Group score, took Tegafur as oral chemotherapy, and took oral chemotherapy for the first time reported lower readiness for hospital discharge. These five factors explained 28.1% of variance in readiness for hospital discharge. Patients who were not ready for discharge were prone to report higher symptom severity (p = 0.038). No differences in non-routine utilization of post-discharge services were found between the readiness versus non-readiness for discharge groups (p = 0.891).

CONCLUSIONS

Most cancer patients receiving oral chemotherapy at home were ready for discharge, which was influenced by employment status, residence status, Eastern Cooperative Oncology Group score, type of oral chemotherapy drug, and the experience of taking oral chemotherapy at home. Patients with lower readiness reported worse symptom severity at home. Routine assessment was suggested to recognize unready patients, and more extensive preparations for discharge were recommended to help them manage symptoms at home.

Financial difficulties in breast cancer survivors with and without migration background in Germany-results from the prospective multicentre cohort study BRENDA II

Purpose

We aimed to explore the trajectory of financial difficulties among breast cancer survivors in the German health system and its association with migration background.

Methods

In a multicentre prospective study, breast cancer survivors were approached four times (before surgery, before and after adjuvant therapy, five years after surgery) and asked about their migration history and financial difficulties.

Migrants were defined as born/resided outside Germany or having citizenship/nationality other than German. Financial difficulties were ascertained with the financial difficulties item of the European Organisation for Research and Treatment of Cancer Core Instrument (EORTC QLQ-C30) at each time-point (cut-off > 17). Financial difficulties were classified in trajectories: always (every time-point), never (no time-point), initial (first, not fourth), delayed (only fourth), and acquired (second and/or third, not first).

A logistic regression was conducted with the trajectories of financial difficulties as outcome and migration background as exposure. Age, trends in partnership status, and educational level were considered as confounders.

Results

Of the 363 participants included, 49% reported financial difficulties at at least one time-point.

Financial difficulties were reported always by 7% of the participants, initially by 5%, delayed by 10%, and acquired by 21%.

Migrants were almost four times more likely to report delayed (odds ratio [OR] = 3.7; 95% confidence interval [CI] 1.3, 10.5) or acquired (OR = 3.6; 95% CI 1.6, 8.4) financial difficulties compared to non-migrant participants.

Conclusion

Survivors with a migration background are more likely to suffer from financial difficulties, especially in later stages of the follow-up. A linguistically/culturally competent active enquiry about financial difficulties and information material regarding supporting services/insurances should be considered.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00520-022-07074-7.

Association between requests for supportive care assistance and patients' characteristics, prior to treatment in a comprehensive cancer center

Purpose

Patients with cancer experience a wide array of distress symptoms (emotional, practical, physical, and functional), which often hinders their quality of life and survival. Unfortunately, only a small proportion of these patients request assistance for these problems. This study explored the relationship between requests for supportive care assistance and distress of patients newly diagnosed with cancer.

Methods

This study was conducted at city of hope, an NCI‐designated comprehensive cancer center, and included 2658 patients treated between 2009 and 2017. Patients were asked to complete a 30‐item biopsychosocial problem‐related distress survey via SupportScreen^®, prior to any treatment. Correlations between requests for assistance and distress domains were evaluated. Primary types of requests were examined for all patients, and general linear modeling was used to determine the significant predictors of requests for assistance. p‐values <0.05 were considered significant.

Results

Strong correlations were observed between distress subscales and requests for assistance (r ranging from 0.67 to 0.69). The primary types of requests varied by domain: items such as feeling anxious or fearful, finances, and sleep ranked first within the emotional, practical, and physical‐functional domains respectively (∼20% requests for each item). Verbal assistance was generally preferred to the written form of assistance, with the exception of a few items, including finances. Overall, household income of <$100,000 and completing the survey in Spanish were significant predictors of requests for assistance. Regarding the practical and physical‐functional domains, having an advanced stage of disease was significantly related to an increase in demands for assistance. Being older was associated to a decrease in requests for assistance vis‐à‐vis both the emotional and physical functional subscales.

Conclusion

We demonstrated that distress levels were strongly correlated with requests for assistance. Patients' clinical and demographic characteristics such as age, household income, disease stage and survey language were associated with inquiries for psychosocial support, highlighting the importance of targeting interventions towards those most likely to need them, to better aim patients' needs. Therefore, tailoring supportive care assistance to patients' characteristics could help boost the frequency of requests, reduce distress burden, and improve health outcomes.

Divergent Patterns in Care Utilization and Financial Distress between Patients with Blood Cancers and Solid Tumors: A National Health Interview Survey Study, 2014-2020

Introduction: Important differences exist between the presentation, treatment, and survivorship of patients and survivors with blood cancers. Furthermore, existing research in financial toxicity has not fully addressed the relationship between medical care utilization and patient-reported outcomes of financial barriers and distress. We answered these questions by using a nationally representative survey. Methods: Respondents with blood cancers and solid tumors from the National Health Interview Survey were identified (2014−2020). We identified 23 survey questions as study outcomes and grouped them into three domains of medical care utilization, financial barriers to care, and financial distress. Associations between the three domains and associations of study outcomes between cancer types were examined using weighted univariate analyses and multivariable linear and logistic regressions. Results: The final study group consisted of 6248 respondents with solid tumors and 398 with blood cancers (diagnosed ≤ 5 years). Across all respondents with cancer, higher medical care utilization is generally associated with increased financial barriers to care. Compared to respondents with solid tumors, respondents with blood cancers had a higher level of medical care utilization (β = 0.36, p = 0.02), a lower level of financial barriers to care (β = −0.19, p < 0.0001), and a higher level of financial distress in affording care (β = 0.64, p = 0.03). Conclusions: Patients and survivors with blood cancers and solid tumors demonstrate divergent patterns in care utilization, financial barriers, and financial distress. Future research and interventions on financial toxicity should be tailored for individual cancer groups, recognizing the differences in medical care utilization, which affect the experienced financial barriers.

Financial Worry and Psychological Distress Among Immigrants in the United States, 2013-2018

The coronavirus disease 2019 (COVID-19) pandemic has highlighted links among economic stability, health outcomes, and migration. The facets of financial worry and their associated psychological burden have been understudied among the immigrant population. The goal of this study was to determine the specific facets of financial worry and associated psychological burden in immigrants. This cross-sectional study, which used data from the 2013 to 2018 National Health Interview Survey (NHIS), examined patient-reported measures of worry regarding financial strain. The NHIS is a household survey of noninstitutionalized, nonmilitary adults in the United States. Multivariable ordinal logistic regressions were used to define adjusted odds ratios (AORs) for financial worry and psychological distress, adjusting for various sociodemographic variables. Among 131,669 US-born and 26,155 non-US-born participants who responded to all 6 questions on the 6-item Kessler Psychological Distress Scale (K6), the overall prevalence of participants reporting any serious psychological distress (K6 score ≥13) was 3.0% and 2.25%, respectively. Despite these overall prevalence data, there were specific areas of financial worries that were higher in non-US-born participants than in US-born participants. Compared with US-born participants, non-US-born participants had higher rates of financial worries regarding retirement [75.78% vs. 69.08%, AOR=1.37, 95% confidence interval (CI) 1.29-1.45, P<0.001], medical costs due to illness (worry about not being able to pay medical costs of a serious illness or accident) (74.94% vs. 65.27%, AOR=1.37, 95% CI: 1.29-1.45, P<0.001), standard of living (74.25% vs. 65.29%, AOR=1.42, 95% CI: 1.34-1.51, P<0.001), and medical cost of health care (worry about not having enough to pay medical costs for normal health care) (66.52% vs. 52.67%, AOR=1.51, 95% CI: 1.43-1.60, P<0.001), among other costs. Notably, serious psychological distress in non-US-born individuals was associated with increased financial worry relative to US-born individuals with a similar level of psychological distress. Further research is needed to evaluate the role physicians can play in mitigating psychological distress in patients with increased financial worry.

Symptom Clusters and Quality of Life in Gastric Cancer Patients Receiving Chemotherapy

CONTEXT

Although gastric cancer is one of the most common tumors worldwide, there is little knowledge about symptom clusters and quality of life (QoL) in this population.

OBJECTIVES

The objectives were to identify the symptom clusters in gastric cancer patients receiving chemotherapy, and explore their effects on QoL.

METHODS

Gastric cancer patients receiving chemotherapy were recruited. Data were collected using the Memorial Symptom Assessment Scale Short Form, the Functional Assessment of Cancer Therapy-Gastric and the self-designed General Information Evaluation Form. The symptom clusters were extracted through the exploratory factor analysis. The influencing factors of symptom clusters and their effects on QoL were identified using multiple linear regression analysis.

RESULTS

A total of 322 participants were enrolled from three medical centers. Five factors were identified in this exploratory factor analysis based on symptom prevalence, namely fatigue related symptom cluster, epithelial symptom cluster, neurologic symptom cluster, malnutrition related symptom cluster and psychological symptom cluster (χ² = 31.470, P < 0.05). The affecting factors across symptom clusters and QoL subscales were relatively stable, but also different. Generally, fatigue related symptom cluster, malnutrition related symptom cluster and psychological symptom cluster demonstrated significantly negative effects on all aspects of QoL except social well being.

CONCLUSION

Five symptom clusters were identified in gastric cancer patients receiving chemotherapy in mainland China. The symptom clusters negatively contributed to the variance in all aspects of QoL except social well being. Further studies should examine interventions for symptom clusters, their influencing factors, and their effects on improving QoL.

Racial and ethnic differences in perception of provider cultural competence among patients with depression and anxiety symptoms: a retrospective, population-based, cross-sectional analysis

BACKGROUND

Racial and ethnic minorities face disparities in access to health care. Culturally competent care might lessen these disparities. Few studies have studied the patients' view of providers' cultural competence, especially in psychiatric care. We aimed to examine the associations of race, ethnicity, and mental health status with patient-reported importance of provider cultural competence.

METHODS

Our retrospective, population-based, cross-sectional study used data extracted from self-reported questionnaires of adults aged at least 18 years who participated in the US National Health Interview Survey (NHIS; 2017 cycle). We included data on all respondents who answered supplementary cultural competence questions and the Adult Functioning and Disability survey within the NHIS. We classified participants as having anxiety or depression if they reported symptoms at least once a week or more often, and responded that the last time they had symptoms the intensity was "somewhere between a little and a lot" or "a lot." Participant answers to cultural competency survey questions (participant desire for providers to understand or share their culture, and frequency of access to providers who share their culture) were the outcome variables. Multivariable ordinal logistic regressions were used to estimate adjusted odds ratios (aORs) for the outcome variables in relation to sociodemographic characteristics (including race and ethnicity), self-reported health status, and presence of symptoms of depression, anxiety, or both.

FINDINGS

3910 people had available data for analysis. Mean age was 52 years (IQR 36-64). 1422 (39·2%, sample weight adjusted) of the participants were men and 2488 (60·9%) were women. 3290 (82·7%) were White, 346 (9·1%) were Black or African American, 31 (0·8%) were American Indian or Alaskan Native, 144 (4·8%) were Asian American, and 99 (2·6%) were Mixed Race. 380 (12·5%) identified as Hispanic ethnicity and 3530 (87·5%) as non-Hispanic. Groups who were more likely to express a desire for their providers to share or understand their culture included participants who had depression symptoms (vs those without depression or anxiety symptoms, aOR 1·57 [95% CI 1·13-2·19], p=0·008) and participants who were of a racial minority group (Black vs White, aOR 2·54 [1·86-3·48], p=0·008; Asian American vs White, aOR 2·57 [1·66-3·99], p<0·001; and Mixed Race vs White, aOR 1·69 [1·01-2·82], p=0·045) or ethnic minority group (Hispanic vs non-Hispanic, aOR 2·69 [2·02-3·60], p<0·001); these groups were less likely to report frequently being able to see providers who shared their culture (patients with depression symptoms vs those without depression or anxiety symptoms, aOR 0·63 (0·41-0·96); p=0·030; Black vs White, aOR 0·56 [0·38-0·84], p=0·005; Asian American vs White, aOR 0·38 [0·20-0·72], p=0·003; Mixed Race vs White, aOR 0·35 [0·19-0·64], p=0·001; Hispanic vs non-Hispanic, aOR 0·61 [0·42-0·89], p=0·010). On subgroup analysis of participants reporting depression symptoms, patients who identified their race as Black or African American, or American Indian or Alaskan Native, and those who identified as Hispanic ethnicity, were more likely to report a desire for provider cultural competence.

INTERPRETATION

Racial and ethnic disparities exist in how patients perceive their providers' cultural competence, and disparities are pronounced in patients with depression. Developing a culturally competent and humble approach to care is crucial for mental health providers.

FUNDING

None.