The Medical Expenditure Panel Survey (MEPS) experiences with cancer survivorship supplement

Association between patient-reported financial burden and catastrophic health expenditures in cancer survivors

PURPOSE

To measure rates of patient-reported financial burden, compare them across cancer types, and determine whether they are predictive of catastrophic health expenditures (CHE).

METHODS

We extracted data from the Medical Expenditures Panel Survey from 2011 to 2017 to conduct a retrospective population-based cohort study and multivariable logistic regression to assess the financial burden of cancer across 16 cancer types and compare patient-reported metrics to CHE rates.

RESULTS

Patients with ovarian cancer were most likely to report inability paying bills (34.5 %) and filing for bankruptcy (9.4 %), while patients with thyroid cancer were most likely to incur debt (22.4 %). Patients with kidney cancer had the highest mean debt ($46,915). CHEs were independently predicted by inability to pay medical bills (OR [95 % CI], 1.96 [1.14-3.35]) and bankruptcy filing (OR [95 % CI], 3.90 [1.21-12.60].

CONCLUSIONS AND IMPLICATIONS

We report important variations in the financial burden across cancer types and underscore the importance of assessing how patient-reported measures are related to CHEs.

POLICY IMPLICATIONS

The financial burden of cancer care could explain the lack of improved outcomes with increased national health spending.

Marginal health care expenditures for melanoma care in the United States

BACKGROUND

The incidence of melanoma has increased significantly in the past few decades, posing a significant public health challenge. However, there is an evidence gap regarding the marginal costs of treating melanoma.

OBJECTIVE

To examine the marginal health care expenditures for melanoma compared with other nonskin cancers among US adults.

METHODS

This study examined individuals aged 18 years or older with melanoma, nonmelanoma skin cancer (NMSC), and other cancers from the 2011-2020 Medical Expenditure Panel Survey datasets. Direct health care expenditures involving hospital inpatient, outpatient, prescription medications, dental, vision, home health care, and other medical services for melanoma were analyzed using generalized linear models, and comparisons were made with expenditures for other types of cancers while adjusting for other patient characteristics.

RESULTS

There were 0.70 million individuals (95% CI = 0.61-0.78) diagnosed with melanoma annually. Total health care expenditures among individuals with melanoma, NMSC, and other cancers were $19,427, $13,744, and $23,741, respectively. A generally increasing trend of expenditure was observed over the years. Notably, office-based care (30.46%), inpatient services (28.78%), and prescription (18.27%) costs primarily accounted for the health care burden of patients with melanoma. Adjusted marginal total health care expenditures for melanoma were found to be lower ($-3,369.01 [95% CI = -$5,934.15 to -$803.85]) than other cancers but higher ($2,844.75 [95% CI = $2,204.77-$3,484.72]) compared with NMSC. Prescription expenditures were similar across the 3 cancer study groups.

CONCLUSIONS

This study found that adjusted marginal expenditures for melanoma were higher than those with NMSC but lower than other nonskin cancers, with office-based care and inpatient expenditures contributing to most of the expenditures. The findings suggest that concerted efforts are needed to control the primary cost drivers to reduce the associated burden of potentially preventable skin cancer like melanoma.

Addressing financial hardship in malignant hematology and hematopoietic cell transplant: a team approach

ABSTRACT

Financial hardship is a common experience for patients and their families after the diagnosis of a hematologic malignancy and is associated with worse outcomes. Health care costs, increased costs of living, income poverty, and inadequate wealth contribute to financial hardship after the diagnosis and treatment of a hematologic malignancy and/or hematopoietic cell transplant. Given the multidimensional nature of financial hardship, a multidisciplinary team-based approach is needed to address this public health hazard. Hematologists and oncologists may mitigate the impact of financial hardship by matching treatment options with patient goals of care and reducing symptom burden disruptive to employment. Social workers and financial navigators can assist with screening and resource deployment. Policymakers and researchers can identify structural and policy changes to prevent financial hardship. By alleviating this major health care burden from patients, care teams may improve survival and quality of life for patients with hematologic malignancies.

Racial and Ethnic Differences in Diabetes Care Quality in A National Sample of Cancer Survivors Relative to Non-Cancer Controls

BACKGROUND

Among cancer survivors, diabetes is associated with greater morbidity and mortality. The objective of this study is to describe racial/ethnic disparities in diabetes care quality (DCQ) among cancer survivors compared to non-cancer controls.

METHODS

We used Medical Expenditure Panel Survey Household Component data (2010-2018). Black, non-Hispanic White (NHW), and Hispanic respondents diagnosed with diabetes and cancer were frequency matched 1:5 to non-cancer controls. Multivariable logistic regression estimated associations for specific indices and overall DCQ by race/ethnicity stratified by cancer site/status in partially adjusted (not controlling for socioeconomic indicators) and fully adjusted models.

RESULTS

The final sample of 4775 included cancer survivors (n = 907 all cancers; n = 401 breast; n = 167 colon; n = 339 prostate) and non-cancer controls (n = 3868) matched by age, race/ethnicity, and year. In partially adjusted models, Black (adjusted odds ratio, AOR) 0.67 [95% CI 0.54-0.83]) and Hispanic (AOR 0.68 [95% CI 0.54-0.87]) non-cancer controls had significant disparities for overall DCQ compared to NHWs. Among cancer survivors, DCQ disparities for Black (AOR 0.62, [95% CI 0.4-0.96]) and Hispanics (AOR 0.60, [95% CI 0.38-0.97]) were identified. Among prostate cancer survivors, DCQ disparities were identified for Blacks (AOR 0.38; [95% CI 0.20-0.72]) and Hispanics (AOR 0.39; [95% CI 0.17-0.89]) compared to NHWs. Racial disparities among Black controls and Black prostate cancer survivors remained significant in fully adjusted models.

CONCLUSION

Diabetes care disparities are evident among cancer survivors and salient among non-cancer controls. Strategies to promote health equity should target specific care indices among survivors and emphasize equitable DCQ strategies among Black and Hispanic communities.

Discussions of Cancer Survivorship Care Needs: Are There Rural Versus Urban Inequities?

BACKGROUND

Rural cancer survivors may face greater challenges receiving survivorship care than urban cancer survivors.

PURPOSE

To test for rural versus urban inequities and identify other correlates of discussions about cancer survivorship care with healthcare professionals.

METHODS

Data are from the 2017 Medical Expenditure Panel Survey (MEPS), which included a cancer survivorship supplement. Adult survivors were asked if they discussed with a healthcare professional 5 components of survivorship care: need for follow-up services, lifestyle/health recommendations, emotional/social needs, long-term side effects, and a summary of treatments received. The Behavioral Model of Health Services guided the inclusion of predisposing, enabling, and need factors in ordered logit regression models of each survivorship care variable.

RESULTS

A significantly lower proportion of rural than urban survivors (42% rural, 52% urban) discussed in detail the treatments they received, but this difference did not persist in the multivariable model. Although 69% of rural and 70% of urban ssurvivors discussed in detail their follow-up care needs, less than 50% of both rural and urban survivors discussed in detail other dimensions of survivorship care. Non-Hispanic Black race/ethnicity and time since treatment were associated with lower odds of discussing 3 or more dimensions of survivorship care.

CONCLUSIONS

This study found only a single rural/urban difference in discussions about survivorship care. With the exception of discussions about the need for follow-up care, rates of discussing in detail other dimensions of survivorship care were low among rural and urban survivors alike.

"It was kind of a nightmare, it really was:" financial toxicity among rural women cancer survivors

PURPOSE

The purpose of this study was to examine how rural women cancer survivors experience and manage financial toxicity.

METHODS

A qualitative descriptive design was used to explore experiences of financial toxicity among rural women who received cancer treatment. We conducted qualitative interviews with 36 socioeconomically diverse rural women cancer survivors.

RESULTS

Participants were categorized into three groups: (1) survivors who struggled to afford basic living expenses but did not take on medical debt; (2) survivors who took on medical debt but were able to meet their basic needs; and (3) survivors who reported no financial toxicity. The groups differed by financial and job security and insurance type. We describe each group and, for the first two groups, the strategies they used to manage financial toxicity.

CONCLUSIONS

Financial toxicity related to cancer treatment is experienced differently by rural women cancer survivors depending on financial and job security and insurance type. Financial assistance and navigation programs should be tailored to support rural patients experiencing different forms of financial toxicity.

IMPLICATIONS FOR CANCER SURVIVORS

Rural cancer survivors with financial security and private insurance may benefit from policies aimed at limiting patient cost-sharing and financial navigation to help patients understand and maximize their insurance benefits. Rural cancer survivors who are financially and/or job insecure and have public insurance may benefit from financial navigation services tailored to rural patients that can assist with living expenses and social needs.

Age-related differences in employment, insurance, and financial hardship among colorectal cancer patients: a report from the ColoCare Study

PURPOSE

Employment and financial hardships are common issues for working-age colorectal cancer patients. We surveyed colorectal cancer survivors to investigate employment, insurance, and financial outcomes by age at diagnosis.

METHODS

Cross-sectional survey of six ColoCare Study sites regarding employment, insurance, and financial hardship outcomes. Eligible participants were 1 to 5 years from colorectal cancer diagnosis. Diagnosis age (18-49, 50-64, 65+ years) with outcomes of interest were compared using chi-square and t-tests. Multivariable logistic and Poisson regressions were fit to examine association of demographic factors with any material/psychological hardship (yes/no) and the count of hardships.

RESULTS

N = 202 participants completed the survey (age: 18-49 (n = 42, 20.8%), 50-64 (n = 79, 39.1%), 65+ (n = 81, 40.1%)). Most diagnosed age < 65 worked at diagnosis (18-49: 83%; 50-64: 64%; 65+ : 14%, p < 0.001) and continued working after diagnosis (18-49: 76%; 50-64: 59%; 65+ : 13%; p < 0.001). Participants age 18-49 reported cancer-related difficulties with mental (81.3%) and physical (89%) tasks at work more than those working in the older age groups (45%-61%). In regression models, among those reporting any hardship, the rates of material and psychological hardships were higher among those age 18-64 (Incidence Rate Ratios (IRR) range 1.5-2.3 vs. age 65+) and for those with < college (IRR range 1.3-1.6 vs. college +).

CONCLUSIONS

Younger colorectal cancer patients are more likely to work after a cancer diagnosis and during cancer treatment, but report higher levels of financial hardship than older patients.

IMPLICATIONS FOR CANCER SURVIVORS

Younger colorectal cancer patients may encounter financial hardship, thus may feel a need to work during and after treatment.

Financial-legal navigation reduces financial toxicity of pediatric, adolescent, and young adult cancers

BACKGROUND

Pediatric, adolescent, and young adult patients with cancer and their caregivers are at high risk of financial toxicity, and few evidence-based oncology financial and legal navigation programs exist to address it. We tested the feasibility, acceptability, and preliminary effectiveness of Financial and Insurance Navigation Assistance, a novel interdisciplinary financial and legal navigation intervention for pediatric, adolescent and young adult patients and their caregivers.

METHODS

We used a single-arm feasibility and acceptability trial design in a pediatric hematology and oncology clinic and collected preintervention and postintervention surveys to assess changes in financial toxicity (3 domains: psychological response/Comprehensive Score for Financial Toxicity [COST], material conditions, and coping behaviors); health-related quality of life (Patient-Reported Outcomes Measurement Information System Physical and Mental Health, Anxiety, Depression, and Parent Proxy scales); and perceived feasibility, acceptability, and appropriateness.

RESULTS

In total, 45 participants received financial navigation, 6 received legal navigation, and 10 received both. Among 15 adult patients, significant improvements in FACIT-COST (P = .041) and physical health (P = .036) were noted. Among 46 caregivers, significant improvements were noted for FACIT-COST (P < .001), the total financial toxicity score (P = .001), and the parent proxy global health score (P = .0037). We were able to secure roughly $335 323 in financial benefits for 48 participants. The intervention was rated highly for feasibility, acceptability, and appropriateness.

CONCLUSIONS

Integrating financial and legal navigation through Financial and Insurance Navigation Assistance was feasible and acceptable and underscores the benefit of a multidisciplinary approach to addressing financial toxicity.

CLINICALTRIALS.GOV REGISTRATION

NCT05876325.

Caring for Children in Relation to Financial Hardship, Advance Care Planning, and Genetic Testing Among Adolescent and Young Adults with Cancer

Purpose: When a cancer diagnosis coincides with caring for children, it may influence the financial impacts of cancer and decisions to pursue advance care planning (ACP) or genetic testing. We examined associations between caring for children and financial hardship, ACP, and genetic testing among female adolescent and young adult (AYA) cancer survivors in North Carolina and California. Methods: Participants were diagnosed at ages 15-39 years with breast, melanoma, gynecologic, lymphoma, or thyroid cancer during 2004-2016. We estimated adjusted prevalence differences (aPDs) and ratios (aPRs) for each outcome by child caring status using marginal structural binomial regression models. Results: Among 1595 women ages 19-54 years at survey (median = 7 years since diagnosis), 819 (51.3%) reported that they were caring for children at diagnosis. Women caring for children had a higher prevalence of material financial hardship (e.g., medical debt; 30% vs. 21.9%; aPD = 9%, 95% confidence interval [CI]: 3 to 14; aPR = 1.39, 95% CI: 1.12 to 1.72) but similar levels of psychological financial hardship compared to noncaregivers. Women caring for children were more likely to complete ACPs (42.2% vs. 30.7%; aPD = 9%, 95% CI: 3 to 16; aPR = 1.30, 95% CI: 1.08 to 1.57). Among the 723 survivors of breast, endometrial, and ovarian cancer, the prevalence of genetic testing was higher among women caring for children (89%) than noncaregivers (81%); this difference was not statistically significant. Conclusion: Women caring for children at diagnosis may be at elevated risk for adverse financial outcomes and may benefit from additional financial navigation support. Childcare responsibilities may further complicate health decision-making for AYAs diagnosed with cancer.

Determination of a cut-off COmprehensive Score for financial Toxicity (COST) for identifying cost-related treatment nonadherence and impaired health-related quality of life among Chinese patients with cancer

PURPOSE

This study aimed to determine a cut-off for the simplified Chinese version of the COmprehensive Score for financial Toxicity (COST) that could identify cost-related treatment nonadherence among Chinese patients with cancer. The study also sought to validate this cut-off score by using it to assess impaired health-related quality of life (HRQoL) in the same population.

METHODS

A secondary analysis was conducted using data from a cross-sectional survey of 1208 Chinese patients with cancer who were recruited from 12 hospitals in six cities across three provinces of the Chinese mainland. Sociodemographic information and data on financial toxicity (FT), cost-related treatment nonadherence, and HRQoL were used in the analysis. Receiver operating characteristic (ROC) analysis was used to determine the optimal cut-off for the simplified Chinese version of the COST.

RESULTS

The ROC analysis identified a COST cut-off of 18.5 for identifying cost-related treatment nonadherence, yielding a sensitivity of 76.5% and specificity of 71.4%. In the validation study, this cut-off score yielded a sensitivity of 64.2% and a specificity of 67.1% for identifying impaired HRQoL.

CONCLUSION

Early and dynamic assessment of cancer-related FT in routine clinical practice may play a crucial role in the early identification and management of FT. Accordingly, a COST cut-off of 18.5 was identified to indicate cost-related treatment nonadherence and impaired HRQoL in a population of patients with cancer from the Chinese mainland. This finding may facilitate the implementation of universal FT screening among patients with cancer in specific settings such as the Chinese mainland.

Financial hardship differences by LGBTQ+ status among assigned female at birth adolescent and young adult cancer survivors: a mixed methods analysis

BACKGROUND

Adolescent and young adult (AYA) cancer survivors are at an elevated risk of financial hardship. However, financial hardship among LGBTQ+ AYAs has not been widely explored. Thus, we used qualitative and quantitative survey data from the Horizon Study cohort to assess financial hardship of AYAs by LGBTQ+ status.

METHODS

Multivariable logit models, predicted probabilities, average marginal effects or differences in predicted probabilities (AME) and 95% confidence intervals (CI) were used to assess the association of LGBTQ+ status and two components of financial hardship: material and psychological. Qualitative content analysis of an open-ended survey question about financial sacrifices was used to describe the third component of financial hardship, behavioral.

RESULTS

Among 1,635 participants, 4.3% self-identified as LGBTQ+. Multivariable logit models controlling for demographic factors revealed that LGBTQ+ AYAs had an 18-percentage point higher probability of experiencing material financial hardship (95%CI 6-30%) and a 14-percentage point higher probability of experiencing psychological financial hardship (95%CI 2-26%) than non-LGBTQ+ AYAs. Controlling for economic factors attenuated the association of LGBTQ+ status with psychological financial hardship (AME = 11%; 95%CI - 1-23%), while the material financial hardship association remained statistically significant (AME = 14%; 95%CI 3-25%). In the qualitative analysis, LGBTQ+ AYAs frequently reported educational changes and costs (e.g., quitting school), unpaid bills and debt (e.g., medical debt, taking on credit card debt), as well as changes in housing and poor housing conditions (e.g., moving into less expensive house).

CONCLUSIONS

LGBTQ + targeted and tailored interventions are needed to move toward equity for LGBTQ+ AYAs-an overlooked minority population.

Breast cancer treatment receipt and the role of financial stress, health literacy, and numeracy among diverse breast cancer survivors

PURPOSE

Disparities in breast cancer treatment for low-income and minority women are well documented. We examined economic hardship, health literacy, and numeracy and whether these factors were associated with differences in receipt of recommended treatment among breast cancer survivors.

METHODS

During 2018-2020, we surveyed adult women diagnosed with stage I-III breast cancer between 2013 and 2017 and received care at three centers in Boston and New York. We inquired about treatment receipt and treatment decision-making. We used Chi-squared and Fisher's exact tests to examine associations between financial strain, health literacy, numeracy (using validated measures), and treatment receipt by race and ethnicity.

RESULTS

The 296 participants studied were 60.1% Non-Hispanic (NH) White, 25.0% NH Black, and 14.9% Hispanic; NH Black and Hispanic women had lower health literacy and numeracy and reported more financial concerns. Overall, 21 (7.1%) women declined at least one component of recommended therapy, without differences by race and ethnicity. Those not initiating recommended treatment(s) reported more worry about paying large medical bills (52.4% vs. 27.1%), worse household finances since diagnosis (42.9% vs. 22.2%), and more uninsurance before diagnosis (9.5% vs. 1.5%); all P < .05. No differences in treatment receipt by health literacy or numeracy were observed.

CONCLUSION

In this diverse population of breast cancer survivors, rates of treatment initiation were high. Worry about paying medical bills and financial strain were frequent, especially among non-White participants. Although we observed associations of financial strain with treatment initiation, because few women declined treatments, understanding the scope of impact is limited. Our results highlight the importance of assessments of resource needs and allocation of support for breast cancer survivors. Novelty of this work includes the granular measures of financial strain and inclusion of health literacy and numeracy.

Informal and Formal Financial Assistance to Rural Women during Cancer Treatment

Introduction

Rural women with cancer are at heightened risk of financial toxicity. Financial assistance is an important, yet underexamined, aspect of how patients with cancer cope with financial toxicity. This study aims to examine the types of financial assistance rural women with cancer received during cancer treatment and how they described the impact of that assistance.

Material and Methods

Using data from interviews with 36 rural women with cancer histories, this study used a qualitative descriptive design to explore the types of financial assistance participants received during cancer treatment.

Results

Participants described two forms of financial assistance they received: informal and formal financial assistance. Informal financial assistance was provided by social networks and local communities and included cash support, community fundraisers, and in-kind donations. Formal financial assistance was provided by healthcare systems and charitable organizations and included resource navigation and cash grants. Both forms of financial assistance were helpful for many patients with cancer; however, not all participants who needed financial assistance received it.

Discussion

Informal and formal financial assistance are significant forms of support for some rural women undergoing cancer treatment. However, such support is unequally distributed and may exacerbate existing inequalities. Financial assistance is not an adequate substitute for public policy that reduces the economic toll of cancer treatment on patients.

Health behaviors, obesity, and marital status among cancer survivors: a MEPS study

PURPOSE

Promoting positive health behaviors helps improve cancer survivors' health outcomes during survivorship; however, little is known about whether health behaviors differ by marital status. The purpose is to examine whether health behaviors and obesity among cancer survivors vary by marital status and whether the type of cancer and sociodemographic factors influence the relationship.

METHODS

We examined smoking, physical activity, and body mass index (BMI) among 1880 individuals diagnosed with prostate, breast, or colon cancer who were identified from the 2011-2017 Medical Expenditure Panel Survey (MEPS). We used Rao-Scott design-adjusted chi-square tests and weighted multivariable logistic regressions to achieve the research aims.

RESULTS

Current smoking behavior and BMI were significantly related to marital status. Survivors who had never married were the most likely to be current smokers across all cancer types. Married survivors were the most likely to be overweight or obese, while widowed survivors were the most likely to have a normal weight. The relationship between BMI and marital status varied by cancer type. Widowed colon cancer survivors were least likely to be overweight or obese; divorced/separated colon cancer survivors were most likely to be obese or overweight. Health behavior disparities were found among cancer survivors of different age, sex, race, and levels of education and income.

CONCLUSIONS

There were relationships between marital status, health behaviors, and obesity among cancer survivors.

IMPLICATIONS FOR CANCER SURVIVORS

Our results suggested that relationship status and sociodemographic factors need to be considered in tailoring interventions to promote health behaviors among cancer survivors.

Health-related quality of life in adolescents and young adults with cancer who received radiation therapy: a scoping review

PURPOSE

Radiation therapy (RT) is a critical component of treatment for adolescents and young adults (AYAs, age 15-39 years old) diagnosed with cancer. Limited prior studies have focused on AYAs receiving RT despite the potentially burdensome effects of RT. We reviewed the literature to assess health-related quality of life (HRQOL) in AYAs with cancer who received RT.

METHODS

The MEDLINE, EMBASE, and Web of Science databases were searched in January 2022 to identify studies that analyzed HRQOL measured by patient-reported outcomes in AYAs who received RT. After title (n = 286) and abstract (n = 58) screening and full-text review (n = 19), articles that met eligibility criteria were analyzed.

RESULTS

Six studies were analyzed. Two studies included AYAs actively receiving treatment and all included patients in survivorship; time between diagnosis and HRQOL data collection ranged from 3 to > 20 years. Physical and mental health were commonly assessed (6/6 studies) with social health assessed in three studies. AYA-relevant HRQOL needs were rarely assessed: fertility (1/6 studies), financial hardship (1/6), body image (0/6), spirituality (0/6), and sexual health (0/6). No study compared HRQOL between patients actively receiving RT and those post-treatment. None of the studies collected HRQOL data longitudinally.

CONCLUSION

HRQOL data in AYAs receiving RT is limited. Future studies examining longitudinal, clinician- vs. patient-reported, and AYA-relevant HRQOL are needed to better understand the unique needs in this population.

Economic burden of skin cancer treatment in the USA: an analysis of the Medical Expenditure Panel Survey Data, 2012-2018

PURPOSE

We report the prevalence and economic cost of skin cancer treatment compared to other cancers overall in the USA from 2012 to 2018.

METHODS

Using the Medical Expenditure Panel Survey full-year consolidated data files and associated medical conditions and medical events files, we estimate the prevalence, total costs, and per-person costs of treatment for melanoma and non-melanoma skin cancer among adults aged ≥ 18 years in the USA. To understand the changes in treatment prevalence and treatment costs of skin cancer in the context of overall cancer treatment, we also estimate the prevalence, total costs, and per-person costs of treatment for non-skin cancer among US adults.

RESULTS

During 2012-15 and 2016-18, the average annual number of adults treated for any skin cancer was 5.8 (95% CI: 5.2, 6.4) and 6.1 (95% CI: 5.6, 6.6) million, respectively, while the average annual number of adults treated for non-skin cancers rose from 10.8 (95% CI: 10.0, 11.5) to 11.9 (95% CI: 11.2, 12.6) million, respectively. The overall estimated annual costs rose from $8.0 (in 2012-2015) to $8.9 billion (in 2016-18) for skin cancer treatment and $70.2 to $79.4 billion respectively for non-skin cancer treatment.

CONCLUSION

The prevalence and economic cost of skin cancer treatment modestly increased in recent years. Given the substantial cost of skin cancer treatment, continued public health attention to implementing evidence-based sun-safety interventions to reduce skin cancer risk may help prevent skin cancer and the associated treatment costs.

Financial Hardship in Adult Survivors of Childhood Cancer in the Era After Implementation of the Affordable Care Act: A Report From the Childhood Cancer Survivor Study

PURPOSE

To estimate the prevalence of financial hardship among adult survivors of childhood cancer compared with siblings and identify sociodemographic, cancer diagnosis, and treatment correlates of hardship among survivors in the era after implementation of the Affordable Care Act.

METHODS

A total of 3,555 long-term (≥ 5 years) survivors of childhood cancer and 956 siblings who completed a survey administered in 2017-2019 were identified from the Childhood Cancer Survivor Study. Financial hardship was measured by 21 survey items derived from US national surveys that had been previously cognitively tested and fielded. Principal component analysis (PCA) identified domains of hardship. Multiple linear regression examined the association of standardized domain scores (ie, scores divided by standard deviation) with cancer and treatment history and sociodemographic characteristics among survivors.

RESULTS

Survivors were more likely than siblings to report hardship in ≥ 1 item (63.4% v 53.7%, P < .001). They were more likely to report being sent to debt collection (29.9% v 22.3%), problems paying medical bills (20.7% v 12.8%), foregoing needed medical care (14.1% v 7.8%), and worry/stress about paying their rent/mortgage (33.6% v 23.2%) or having enough money to buy nutritious meals (26.8% v 15.5%); all P < .001. Survivors reported greater hardship than siblings in all three domains identified by principal component analysis: behavioral hardship (mean standardized domain score 0.51 v 0.35), material hardship/financial sacrifices (0.64 v 0.46), and psychological hardship (0.69 v 0.44), all P < .001. Sociodemographic (eg,

CONCLUSION

Survivors of childhood cancer were more likely to experience financial hardship than siblings. Correlates of hardship can inform survivorship care guidelines and intervention strategies.

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MESH Headings

• United States
• Adult
• Humans
• Child
• Neoplasms/therapy
• Cancer Survivors
• Patient Protection and Affordable Care Act
• Financial Stress
• Cost of Illness
• Survivors
• Surveys and Questionnaires

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Grants

• U24 CA055727 NCI NIH HHS

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Affiliation(s)

Paul C. Nathan The Hospital for Sick Children, Division of Hematology/Oncology, The University of Toronto, Toronto, Ontario, Canada
I-Chan Huang St Jude Children's Research Hospital, Department of Epidemiology & Cancer Control, Memphis, TN
Yan Chen University of Alberta, Edmonton, School of Public Health Alberta, Edmonton, Alberta, Canada
Tara O. Henderson University of Chicago Comer Children's Hospital, Section of Pediatric Hematology, Oncology and Stem Cell Transplantation, Chicago, IL
Elyse R. Park Massachusetts General Hospital Cancer Center, Boston, MA
Anne C. Kirchhoff Huntsman Cancer Institute, Cancer Control and Population Sciences, University of Utah, Salt Lake City, UT
Leslie L. Robison St Jude Children's Research Hospital, Department of Epidemiology & Cancer Control, Memphis, TN
Kevin Krull St Jude Children's Research Hospital, Department of Epidemiology & Cancer Control, Memphis, TN
Wendy Leisenring Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA
Gregory T. Armstrong St Jude Children's Research Hospital, Department of Epidemiology & Cancer Control, Memphis, TN
Rena M. Conti Department of Markets, Public Policy and Law, Questrom School of Business, Boston University, Boston, MA
Yutaka Yasui St Jude Children's Research Hospital, Department of Epidemiology & Cancer Control, Memphis, TN
K. Robin Yabroff Surveillance and Health Equity Science Department, American Cancer Society, Atlanta, GA

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Financial Hardship and Quality of Life Among Patients With Advanced Cancer Receiving Outpatient Palliative Care: A Pilot Study

BACKGROUND

Patients with advanced cancer are increasingly experiencing financial hardship (FH) and associated negative health outcomes.

OBJECTIVE

The aims of this study were to describe FH and explore its relationship to quality of life (QOL) in patients with advanced cancer receiving outpatient palliative care (PC).

METHODS

Validated questionnaires assessed FH, QOL dimensions, symptom burden, and sociodemographic and clinical characteristics. Descriptive statistics characterized the sample and described FH. Pearson correlation and linear regression assessed relationships between FH and QOL.

RESULTS

The average participant (n = 78) age was 56.6 (SD, 12.2) years. Most were female (56.4%), White (50%) or Black (46.2%), and had a range of education, partner statuses, and cancer diagnoses. Median time since cancer diagnosis was 35.5 months (interquartile range, 9-57.3 months). Highest mean symptom burden scores were for pain (2.5 [SD, 1.0]) and fatigue (2.0 [SD, 1.1]), on a 0- to 3-point scale (higher score representing worse symptom burden). The median COST (COmphrehensive Score for financial Toxicity) score was 15.0 (interquartile range, 9.0-23.0). Most (70%) had some (n = 43) or extreme (n = 9) difficulty paying for basic needs. Greater than 28% (n = 21) incurred cancer-related debt. Multivariate models indicated that FH negatively affected role limitations due to physical health ( P = .008), pain ( P = .003), and emotional well-being ( P = .017) QOL dimensions.

CONCLUSIONS

Financial hardship, QOL, and symptom burden scores demonstrate need for continued support for and research among patients with advanced cancer. Data support links between FH and important QOL dimensions. Larger, longitudinal studies are needed to understand how FH affects QOL in patients with advanced cancer.

IMPLICATIONS FOR PRACTICE

Proactive financial assessment and interventions are needed to support patients with advanced cancer experiencing the cumulative effects of cancer and its treatment.

Breast cancer knowledge and understanding treatment rationales among diverse breast cancer survivors

Purpose

The degree to which breast cancer survivors know about their tumors and understand treatment rationales is not well understood. We sought to identify information gaps within a diverse sample and explore whether knowledge about breast cancer and treatment may impact care.

Methods

We conducted a one-time, interviewer-administered survey of women who were diagnosed with breast cancer during 2013–2017 and received care at one of three centers in Boston, MA, and New York, NY. We examined knowledge of breast cancer and treatment rationales, information preferences, and treatment receipt.

Results

During 2018–2020, we interviewed 313 women (American Association for Public Opinion Research Cooperation Rates 58.4–76.5% across centers) who were 56.9% White, 23.6% Black, 14.1% Hispanic, and 5.4% other. Among the 296 included in analyses, we observed high variability in knowledge of breast cancer and treatment rationales, with a substantial number demonstrating limited knowledge despite feeling highly informed; > 25% actively avoided information. Black and Hispanic (vs. White) women consistently knew less about their cancers. Lack of understanding of treatment rationales for chemotherapy, radiation, and hormonal therapy was common but not consistently different by race and ethnicity. Understanding treatment rationale (but not cancer knowledge) was associated with treatment initiation, but small sample sizes limited in-depth examination.

Conclusions

Our study highlights the need for enhanced informational support for breast cancer survivors, who are challenged with complex information during the decision-making process and beyond. More research is needed to understand how to further educate and empower diverse populations of patients with breast cancer.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10549-022-06752-8.

A History of Health Economics and Healthcare Delivery Research at the National Cancer Institute

With increased attention to the financing and structure of healthcare, dramatic increases in the cost of diagnosing and treating cancer, and corresponding disparities in access, the study of healthcare economics and delivery has become increasingly important. The Healthcare Delivery Research Program (HDRP) in the Division of Cancer Control and Population Sciences at the National Cancer Institute (NCI) was formed in 2015 to provide a hub for cancer-related healthcare delivery and economics research. However, the roots of this program trace back much farther, at least to the formation of the NCI Division of Cancer Prevention and Control in 1983. The creation of a division focused on understanding and explaining trends in cancer morbidity and mortality was instrumental in setting the direction of cancer-related healthcare delivery and health economics research over the subsequent decades. In this commentary, we provide a brief history of health economics and healthcare delivery research at NCI, describing the organizational structure and highlighting key initiatives developed by the division, and also briefly discuss future directions. HDRP and its predecessors have supported the growth and evolution of these fields through the funding of grants and contracts; the development of data, tools, and other research resources; and thought leadership including stimulation of research on previously understudied topics. As the availability of new data, methods, and computing capacity to evaluate cancer-related healthcare delivery and economics expand, HDRP aims to continue to support this growth and evolution.

Fertility Preservation and Financial Hardship among Adolescent and Young Adult Women with Cancer

BACKGROUND

Financial hardship among adolescents and young adults (AYA) with cancer who receive gonadotoxic treatments may be exacerbated by the use of fertility services. This study examined whether AYA women with cancer who used fertility preservation had increased financial hardship.

METHODS

AYA women with cancer in North Carolina and California completed a survey in 2018-2019. Cancer-related financial hardship was compared between women who cryopreserved oocytes or embryos for fertility preservation after cancer diagnosis (n = 65) and women who received gonadotoxic treatment and reported discussing fertility with their provider, but did not use fertility preservation (n = 491). Multivariable log-binomial regression was used to estimate prevalence ratios and 95% confidence intervals (CI).

RESULTS

Women were a median age of 33 years at diagnosis and 7 years from diagnosis at the time of survey. Women who used fertility preservation were primarily ages 25 to 34 years at diagnosis (65%), non-Hispanic White (72%), and had at least a Bachelor's degree (85%). In adjusted analysis, use of fertility preservation was associated with 1.50 times the prevalence of material financial hardship (95% CI: 1.08-2.09). The magnitude of hardship was also substantially higher among women who used fertility preservation: 12% reported debt of ≥$25,000 versus 5% in the referent group.

CONCLUSIONS

This study provides new evidence that cryopreserving oocytes or embryos after cancer diagnosis for future family building is associated with increased financial vulnerability.

IMPACT

More legislation that mandates insurance coverage to mitigate hardships stemming from iatrogenic infertility could improve access to fertility preservation for young women with cancer.

The Urban-Rural Disparities and Associated Factors of Health Care Utilization Among Cancer Patients in China

Objective

This study aimed to examine the urban-rural disparities and associated factors of health care utilization among cancer patients in China.

Methods

This study used the data collected from a cross-sectional survey conducted in China. A total of 1,570 cancer survivors from three urban districts and five rural counties were selected by using a multistage stratified random sampling method. We measured health care utilization with the way of cancer diagnosis, the number of hospitals visited, and receiving alternative therapies. Chi-square test was used to examine the differences between urban and rural cancer patients. Binary logistic regression analysis was performed to explore the determinants of health care utilization.

Results

Among 1,570 participants, 84.1% were diagnosed with cancer after developing symptoms, 55.6% had visited two and above hospitals, and 5.7% had received alternative therapies. Compared with urban cancer patients, rural ones were more likely to be diagnosed with cancer after developing symptoms (χ2 = 40.04, p < 0.001), while they were less likely to visit more than one hospital (χ2 = 27.14, p < 0.001). Residence area (urban/rural), health insurance type, household income, age at diagnosis, tumor site, stage of tumor, and survival years were significantly associated with health care utilization of cancer patients (p < 0.01).

Conclusions

Health care utilization was suboptimal among cancers patients in China. Rural cancer patients had less health care utilization including screenings and treatments than urban ones. Policymakers should implement specific strategies to ensure equitable utilization of cancer care. More attention should be paid to the disadvantaged groups and rural cancer patients. Prioritizing health resources allocation is needed to prevent, screen, and treat cancers in rural areas.

A sequential explanatory study of the employment experiences of population-based breast, colorectal, and prostate cancer survivors

PURPOSE

Cancer treatment often leads to work disruptions including loss of income, resulting in long-term financial instability for cancer survivors and their informal caregivers.

METHODS

In this sequential explanatory study, we conducted a cross-sectional survey of employment experiences among ethnically diverse, working-age individuals diagnosed with breast, colorectal, or prostate cancer. Following the survey, we conducted semi-structured interviews with cancer survivors and informal caregivers to explore changes in employment status and coping techniques to manage these changes.

RESULTS

Among employed survivors (n = 333), cancer caused numerous work disruptions including issues with physical tasks (53.8%), mental tasks (46.5%) and productivity (76.0%) in the workplace. Prostate cancer survivors reported fewer work disruptions than female breast and male and female colorectal cancer survivors. Paid time off and flexible work schedules were work accommodations reported by 52.6% and 36.3% of survivors, respectively. In an adjusted regression analysis, household income was positively associated with having received a work accommodation. From the qualitative component of the study (survivors n = 17; caregivers n = 11), three key themes emerged: work disruptions, work accommodations, and coping mechanisms to address the disruptions. Survivors and caregivers shared concerns about lack of support at work and resources to navigate issues caused by changes in employment.

CONCLUSIONS

This study characterized employment changes among a diverse group of cancer survivors. Work accommodations were identified as a specific unmet need, particularly among low-income cancer survivors. Addressing changes in employment among specific groups of cancer survivors and caregivers is critical to mitigate potential long-term consequences of cancer.

Association of co-morbidities with financial hardship in survivors of adult cancer

PURPOSE

To evaluate the impact of co-morbidities on financial hardship in adult cancer survivors and the role of health insurance and a usual source of care (i.e., a particular doctor's office/health center/other place that the person usually goes if he/she is sick or needs advice) in relieving this impact.

METHODS

Using the Medical Expenditure Panel Survey, we estimated prevalence of two financial hardships, out-of-pocket (OOP) burden and financial worry, among 1196 adult cancer survivors. A modified Charlson co-morbidity index (CCI) assessed co-morbidities, which represent a medical event (e.g., a doctor's appointment) associated with co-morbid conditions within the past 1 year. Multivariable logistic regression tested the influence of health insurance and a usual source of care on associations of co-morbidities with financial hardship by middle/high vs. low-income families and by working vs. retirement-age individuals.

RESULTS

Years since cancer diagnosis ranged from 0 to 76 years (mean: 10.3, SD: 9.8), 10 and 25% of survivors experienced OOP burden and financial worry. For OOP burden, increased CCI was a risk factor among survivors of low-income families, ORs: 1.91 (95% CI: 1.06, 3.46) for a CCI 1-2 and 3.37 (95% CI: 1.72, 6.61) for a CCI ≥ 3 vs. CCI of 0. For financial worry, increased CCI was a risk factor among working-age survivors, ORs: 1.58 (95% CI: 1.02, 2.47) for a CCI 1-2 and 2.15 (95% CI: 1.19, 3.87) for a CCI ≥ 3 vs. CCI of 0. However, having health insurance and a usual source of care did not mitigate impact of co-morbidities on financial hardship (P values > 0.05).

CONCLUSIONS

Impact of co-morbidities on OOP and financial worry burden was greatest in survivors of low-income families and working-age, respectively. Health insurance and a usual source of care did not relieve the impact of co-morbidities on financial hardship.

IMPLICATIONS

Effective strategies are warranted to mitigate financial hardship for survivors.

Patient-Reported Financial Burden in Thyroid Cancer

BACKGROUND

The incidence of thyroid cancer is increasing at a rapid rate. Prior studies have demonstrated financial burden and decreased quality of life in patients with thyroid cancer. Here, we characterize patient-reported financial burden in patients with thyroid cancer over a 28y period.

MATERIALS AND METHODS

Patients who underwent thyroidectomy for thyroid cancer from 1990-2018 completed a phone survey assessing financial burden and its related psychological financial hardship. Descriptive statistics were performed to characterize these outcomes and correlation with sociodemographic data was assessed.

RESULTS

Respondents (N = 147) were 73% female, 75% white, and had a median follow up of 7 y. The majority had a full-time job (59%) and private insurance (81%) at the time of diagnosis. Overall, 16% of respondents reported financial burden and 50% reported psychological financial hardship. Those reporting financial burden were disproportionately impacted by psychological financial hardship (87% versus 43%, P < 0.001). One in four (25%) respondents reported not being adequately informed about costs.

CONCLUSIONS

Financial burdens are important outcomes of thyroid cancer which occur even among patients with protective financial factors, suggesting an even greater impact on the general population of patients with thyroid cancer. Further research is needed to explore the intersection of financial burden, cost, and quality of life.

Patient-provider discussion about emotional and social needs, mental health outcomes, and benefit finding among U.S. Adults living with cancer

Background

A discussion about patient's nonmedical needs during treatment is considered a crucial component of high‐quality patient–provider communication. We examined whether having a patient–provider discussion about cancer patients’ emotional and social needs is associated with their psychological well‐being.

Methods

Using the 2016–2017 Medical Expenditure Panel Survey‐Experiences with Cancer Survivorship Supplement (MEPS–ECSS) data, we identified the cancer survivors in the United States (US) who reported having a detailed discussion about emotional and social needs during cancer care. We used multivariable logistic regression to assess the association between having a patient–provider discussion and the patients’ psychological well‐being outcomes (depressive symptoms, severe psychological distress, and worrying about cancer recurrence/worsening condition) and benefit finding experience after a cancer diagnosis.

Results

Among 1433 respondents (equivalent to 13.8 million cancer survivors in the US), only 33.6% reported having a detailed patient–provider discussion about their emotional and social needs. Having a discussion was associated with 55% lower odds (odds ratio [OR], 0.45; 95% confidence interval [CI], 0.26–0.77) of having depressive symptoms and 97% higher odds (OR, 1.97; 95% CI, 1.46–2.66) of having benefit finding experience. There was no statistically significant association between patient–provider discussion and psychological distress or worrying about cancer recurrence/worsening.

Conclusion

Detailed patient–provider discussion about the cancer patients’ emotional and social needs was associated with a lower likelihood of depressive symptoms and a higher likelihood of experiencing benefit finding. These findings stress the importance of improving the patient–provider discussion about psychosocial needs in cancer survivorship.

Understanding the characteristics of US cancer survivors with informal caregivers

BACKGROUND

Although informal caregivers such as family and friends provide people with cancer needed physical care and emotional support, little is known about which individuals have access to such caregivers. The purpose of this article is to provide a nationally representative description of the sociodemographic characteristics of cancer survivors who have or had an informal caregiver in the United States.

METHODS

Cross-sectional data were taken from the Experiences With Cancer Survivorship Supplement of the Medical Expenditure Panel Survey in 2011, 2016, and 2017. People were cancer survivors from diagnosis until the end of life. The study population consisted of adult survivors of cancer other than nonmelanoma skin cancer who were treated for cancer less than 3 years before the survey and were living in the community (n = 720). The main outcome measure was whether or not the cancer survivor reported having an informal caregiver.

RESULTS

In the United States, 55.2% of cancer survivors reported having an informal caregiver during or after their cancer treatment. The relationship of the caregiver to the survivor varied by sex: males were more likely to have a spouse as their caregiver, and females were more likely to have a child as their caregiver. In multivariate analyses, cancer survivors who were female, were married, were of a race/ethnicity other than White, or were in poor health were more likely to have an informal caregiver.

CONCLUSIONS

Future research can examine whether those without informal caregivers might need more formal support as they undergo cancer treatment and transition into cancer survivorship.

Assessing the relationship between patient-provider communication quality and quality of life among rural cancer survivors

PURPOSE

We explored relationships between patient-provider communication quality (PPCQ) and three quality of life (QOL) domains among self-identified rural cancer survivors: social well-being, functional well-being, and physical well-being. We hypothesized that high PPCQ would be associated with greater social and functional well-being, but be less associated with physical well-being, due to different theoretical mechanisms.

METHODS

All data were derived from the 2017-2018 Illinois Rural Cancer Assessment (IRCA). To measure PPCQ and QOL domains, we respectively used a dichotomous measure from the Medical Expenditure Panel Survey's Experience Cancer care tool (high, low/medium) and continuous measures from the Functional Assessment of Cancer Therapy-General (FACT-G).

RESULTS

Our sample of 139 participants was largely female, non-Hispanic White, married, and economically advantaged. After adjusting for demographic and clinical variables, patients who reported high PPCQ exhibited greater social well-being (Std. β = 0.20, 95% CI: 0.03, 0.35, p = 0.02) and functional well-being (Std. β = 0.20, 95% CI: 0.05, 0.35, p = 0.03) than patients with low/medium PPCQ. No association was observed between PPCQ and physical well-being (Std. β = 0.06, 95% CI: - 2.51, 0.21, p = 0.41). Sensitivity analyses found similar, albeit attenuated, patterns.

CONCLUSION

Our findings aligned with our hypotheses. Future researchers should explore potential mechanisms underlying these differential associations. Specifically, PPCQ may be associated with social and functional well-being through interpersonal mechanisms, but may not be as associated with physical well-being due to multiple contextual factor rural survivors disproportionately face (e.g., limited healthcare access, economic hardship) and stronger associations with clinical factors.

Breast Cancer-Related Employment Disruption and Financial Hardship in the Sister Study

Background

More than one-half of breast cancer cases are diagnosed among women aged younger than 62 years, which may result in employment challenges. This study examined whether cancer-related employment disruption was associated with increased financial hardship in a national US study of women with breast cancer.

Methods

Women with breast cancer who were enrolled in the Sister or Two Sister Studies completed a survivorship survey in 2012. Employment disruption was defined as stopping work completely or working fewer hours after diagnosis. Financial hardship was defined as: 1) experiencing financial problems paying for cancer care, 2) borrowing money or incurring debt, or 3) filing for bankruptcy because of cancer. Prevalence ratios and 95% confidence intervals for the association between employment disruption and financial hardship were estimated using multivariable Poisson regression with robust variance.

Results

We analyzed data from women employed at diagnosis (n = 1628). Women were a median age of 48 years at diagnosis and 5.6 years from diagnosis at survey completion. Overall, 27.3% of women reported employment disruption (15.4% stopped working; 11.9% reduced hours), and 21.0% experienced financial hardship (16.0% had difficulty paying for care; 12.6% borrowed money or incurred debt; 1.8% filed for bankruptcy). In adjusted analysis, employment disruption was associated with nearly twice the prevalence of financial hardship (prevalence ratio = 1.93, 95% confidence interval = 1.58 to 2.35).

Conclusions

Women experiencing employment disruptions after breast cancer may be more vulnerable to financial hardship. Findings highlight the need to target risk factors for employment disruption, facilitate return to work or ongoing employment, and mitigate financial consequences after cancer.

Unmet Care Needs and Financial Hardship in Patients With Metastatic Non-Small-Cell Lung Cancer on Immunotherapy or Chemoimmunotherapy in Clinical Practice

PURPOSE

Immunotherapy or chemoimmunotherapy is now standard treatment for most patients with metastatic non-small-cell lung cancer (mNSCLC), yet patient supportive care needs (SCNs) on immunotherapy are not well defined. This study characterized the SCNs and financial hardship of patients with mNSCLC treated with immunotherapy or chemoimmunotherapy and examined the relationship between patient and caregiver cancer-related employment reductions and patient financial hardship.

METHODS

Patients with mNSCLC on immunotherapy or chemoimmunotherapy from a single academic medical center completed the SCNs Survey-34, items indexing material, psychological, and behavioral financial hardship, and the Comprehensive Score for Financial Toxicity. Univariate and bivariate analyses examined care needs, financial hardship, and impact of cancer-related employment reductions on patient financial hardship.

RESULTS

Sixty patients (40% male; 75% White, mean age = 62.5 years, 57% on immunotherapy alone) participated. Fifty-five percent reported unmet needs in physical or daily living and psychological domains. Financial hardship was common (33% material, 63% psychological, and 57% behavioral). Fifty-two percent reported hardship in at least two domains. Forty percent reported a caregiver cancer-related employment reduction. Caregiver employment reduction was related to patient financial hardship (68% of those reporting caregiver employment reduction reported at least two domains of hardship v 40% of those without reduction, P = .03) and patient financial distress (mean Comprehensive Score for Financial Toxicity = 19.6 among those with caregiver employment reduction v 26.8 without, P = .01).

CONCLUSION

Patients with mNSCLC treated with immunotherapy or chemoimmunotherapy report multiple unmet care needs and financial hardship. Psychological, functional, financial, and caregiver concerns merit assessment and intervention in this population.

Factors Associated With Health-Related Quality of Life Among Cancer Survivors in the United States

Background

With increasing prevalence of cancer survivors in the United States, health-related quality of life (HRQOL) has become a major priority. We describe HRQOL in a nationally representative sample of cancer survivors and examine associations with key sociodemographic, clinical, and lifestyle characteristics.

Methods

Cancer survivors, defined as individuals ever diagnosed with cancer (N = 877), were identified from the 2016 Medical Expenditure Panel Survey-Experiences with Cancer Survivorship Supplement, a nationally representative survey. Physical and mental health domains of HRQOL were measured by the Global Physical Health (GPH) and Global Mental Health (GMH) subscales of the Patient-Reported Outcomes Measurement Information System Global-10. Multivariable linear regression was used to examine associations of sociodemographic, clinical, and lifestyle factors with GPH and GMH scores. All statistical tests were 2-sided.

Results

Cancer survivors' mean GPH (49.28, SD = 8.79) and mean GMH (51.67, SD = 8.38) were similar to general population means (50, SD = 10). Higher family income was associated with better GPH and GMH scores, whereas a greater number of comorbidities and lower physical activity were statistically significantly associated with worse GPH and GMH. Survivors last treated 5 years ago and longer had better GPH than those treated during the past year, and current smokers had worse GMH than nonsmokers (all β > 3 and all P < .001).

Conclusions

Cancer survivors in the United States have generally good HRQOL, with similar physical and mental health scores to the general US population. However, comorbidities, poor health behaviors, and recent treatment may be risk factors for worse HRQOL. Multimorbidity management and healthy behavior promotion may play a key role in maximizing HRQOL for cancer survivors.

Material and psychological financial hardship related to employment disruption among female adolescent and young adult cancer survivors

BACKGROUND

The importance of addressing adverse financial effects of cancer among adolescents and young adults (AYAs) is paramount as survival improves. In the current study, the authors examined whether cancer-related employment disruption was associated with financial hardship among female AYA cancer survivors in North Carolina and California.

METHODS

AYA cancer survivors identified through the North Carolina Central Cancer Registry and the Kaiser Permanente Northern/Southern California tumor registries responded to an online survey. Disrupted employment was defined as reducing hours, taking temporary leave, or stopping work completely because of cancer. Financial hardship was defined as material conditions or psychological distress related to cancer. Descriptive statistics and chi-square tests were used to characterize the invited sample and survey respondents. Marginal structural binomial regression models were used to estimate prevalence differences (PDs) and 95% confidence intervals (95% CIs).

RESULTS

Among 1328 women employed at the time of their diagnosis, women were a median age of 34 years at the time of diagnosis and 7 years from diagnosis at the time of the survey and approximately 32% experienced employment disruption. A substantial percentage reported financial hardship related to material conditions (27%) or psychological distress (50%). In adjusted analyses, women with disrupted employment had a 17% higher burden of material conditions (95% CI, 10%-23%) and an 8% higher burden of psychological distress (95% CI, 1%-16%) compared with those without disruption.

CONCLUSIONS

Financial hardship related to employment disruption among female AYA cancer survivors can be substantial. Interventions to promote job maintenance and transition back to the workforce after treatment, as well as improved workplace accommodations and benefits, present an opportunity to improve cancer survivorship.

Employment changes among Chinese family caregivers of long-term cancer survivors

Background

Family caregivers (FCGs) play a key role in the plan of care provision for long-term cancer survivors, yet few studies have been conducted on the impact of long-term caregiving on FCGs and their employment patterns. This study aims to further our understanding of the effect that caregiving role has on FCGs by identifying what cancer-related characteristics influence reduction of employment hours among FCGs in the post-treatment phase in China.

Methods

A total of 1155 cancer survivors participated in this study. Patients reported changes in the employment patterns of their FCGs. Descriptive analysis looked at demographic and cancer-related characteristics of cancer survivors and types of FCGs’ employment changes in both primary- and post-treatment phases. Chi-square test was used to statistically test the association between survivors’ characteristics and changes in FCGs’ hours of labor force work in post-treatment phase. Separate multivariable logistic regression models were used to examine the relationship between cancer-related characteristics of participants and employment reduction patterns among FCGs in post-treatment phase while controlling for demographic factors.

Results

In the primary-treatment phase, 45.6% of all FCGs reduced their working hours and 17.4% stopped working altogether. In the post-treatment phase, 25.2% of FCGs worked fewer hours and 6.6% left the workforce completely. The results show that a higher probability of change in employment hours among FCGs is associated with the following patient characteristics: having comorbidities, receiving chemotherapy treatment, limited ability to perform physical tasks, limited ability to perform mental tasks, and diagnosis of stage II of cancer.

Conclusions

Care for cancer patients in both primary- and post- treatment phases may have substantial impacts on hours of formal employment of Chinese FCGs. Interventions helping FCGs balance caregiving duties with labor force work are warranted.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-020-09922-9.

Work changes and individual, cancer-related, and work-related predictors of decreased work participation among African American cancer survivors

African American cancer survivors disproportionately experience financial difficulties after cancer. Decreased work participation (going from being employed full time to part time or from employed to not employed) can contribute to financial hardship after cancer but employment outcomes among African American cancer survivors have not been well described. This study estimates the prevalence of work changes and identifies factors associated with decreased work participation among African American cancer survivors. We analyzed data from 916 African American breast, colorectal, lung, and prostate cancer survivors who participated in the Detroit Research on Cancer Survivors (ROCS) cohort and were employed before their cancer diagnosis. Modified Poisson models estimated prevalence ratios of decreased work participation and work changes, including changes to hours, duties, or schedules, between diagnosis and ROCS enrollment controlling for sociodemographic and cancer‐related factors. Nearly half of employed survivors made changes to their schedules, duties, or hours worked due to cancer and 34.6% took at least one month off of work, including 18% who took at least one month of unpaid time off. More survivors employed full time (vs. part time) at diagnosis were on disability at ROCS enrollment (18.7% vs. 12.6%, P < 0.001), while fewer were unemployed (5.9% vs. 15.7%, P < 0.001). Nearly half (47.5%) of employed survivors decreased work participation. Taking paid time off was not associated with decreased work participation; however, taking unpaid time off and making work changes were associated with prevalence ratios of decreased work participation of 1.29 (95% CI: 1.03, 1.62) and 1.37 (95% CI: 1.07, 1.75), respectively. Employment disruptions are common after a cancer diagnosis. Survivors who take unpaid time off and make other work changes may be particularly vulnerable to experiencing decreased work participation.

Understanding Posttreatment Patient-Provider Communication and Follow-Up Care Among Self-Identified Rural Cancer Survivors in Illinois

PURPOSE

As disparities in rural-urban cancer survivorship rates continue to widen, optimizing patient-provider communication regarding timely follow-up care is a potential mechanism to improving survivorship-related outcomes. The current study examines sociodemographic and health predictors of posttreatment patient-provider communication and follow-up care and associations between written communication and timely follow-up care for cancer survivors who identify as rural.

METHODS

Data were analyzed from posttreatment cancer survivor respondents of the Illinois Rural Cancer Assessment Study. The current study tested associations between sociodemographic variables and health factors on the quality of patient-provider communication and timely posttreatment follow-up care, defined as visits ≤ 3 months posttreatment, and associations between the receipt of written patient-provider communication on timely posttreatment follow-up care.

RESULTS

Among 90 self-identified rural cancer survivors, respondents with annual incomes < $50,000 and ≤ High School diploma were more likely to report a high quality of posttreatment patient-provider communication. Posttreatment written communication was reported by 62% of the respondents and 52% reported timely follow-up visits during the first 3 years of posttreatment care. Patients who reported receiving written patient-provider communication were more likely to have timely posttreatment follow-up care after completing active treatment than patients who had not received written patient-provider communication.

CONCLUSIONS

Our findings suggest that written patient-provider communication improved timely follow-up care for self-identified rural cancer survivors. This research supports policy and practice that recommend the receipt of written survivorship care plans. Implementation of written survivorship care recommendations has the potential to improve survivorship care for rural cancer survivors.

Association of healthcare utilization with financial worry and anxiety in a general population sample

This study examined the association of healthcare use (HCU) with financial outcomes in a general population sample (n = 395) to determine if HCU was associated with increased financial worry as most research has examined socioeconomic indicators and material financial problems. Participants reported six types of HCUin the previous year, financial anxiety (FA) and worry about affording healthcare (WAH) in an online survey. In bivariate comparisons, WAH was associated with all forms of HCU and FA was associated with all forms of HCU except outpatient visits. In multivariate analyses, WAH was associated with outpatient visits, emergency room visits, number of doctors, number of scans and number of blood tests (p's<0.05) but not urgent care visits. FA was associated with emergency room visits, urgent care visits, and number of doctors (p's<0.05) but not other forms of HCU in multivariate comparisons. As many forms of HCU were associated with more WAH and FA, policy initiatives and patient-level interventions should focus on managing costs rather than shifting from emergency to outpatient care. Results also suggest that the financial costs of healthcare, as indexed by HCU, may have an effect on anxiety and worry specific to healthcare even when controlling for socioeconomic factors.

Cardiovascular disease, risk factors, and health behaviors among cancer survivors and spouses: A MEPS Study

Purpose

The purpose of this study was to examine the prevalences of CVD, CVD risk factors. and health behaviors among cancer survivor‐spouse dyads, assess how these prevalences differ by role (survivor vs spouse) and gender, and report congruences in health behaviors between survivors and their spouses.

Methods

We identified 1026 survivor‐spouse dyads from the 2010‐2015 Medical Expenditure Panel Survey. We used weighted multivariable logistic and linear regressions to analyze the data related to CVD, CVD risk factors, and health behaviors.

Results

Survivors and spouses reported high prevalences of CVD and CVD risk factors but low engagement in healthy behaviors, including non‐smoking, physical activity, and maintaining a healthy weight (proxy for healthy diet). Gender and role differences were significantly related to the prevalence of CVD, CVD risk factors, and health behaviors among survivors and spouses. From 39% to 88% of survivors and spouses were congruent in their current smoking status, physical activity engagement/disengagement, and BMI.

Conclusion

Cancer survivors and spouses have high rates of CVD and CVD risk factors and poor engagement in healthful lifestyle behaviors. A high proportion of survivors and spouses were congruent in their current smoking status, physical activity engagement/disengagement, and BMI. Effective lifestyle interventions are needed for this high‐risk population. Couple‐focused interventions may be well‐suited for these dyads and warrant further study.

Implications for Cancer Survivors

Both cancer survivors and their spouses need to be non‐moking, more physically active, and maintain normal BMI in order to reduce their high risk of CVD and CVD risk factors.

Relationships Between Fear of Cancer Recurrence and Lifestyle Factors Among Cancer Survivors

We examine the relationships between fear of cancer recurrence (FCR), physical activity, smoking status, and engagement in healthier habits in a US population-based sample of post-treatment cancer survivors. We used data from the 2011 Medical Expenditure Panel Survey (MEPS) Experience with Cancer Survivorship Supplement. Multivariable logistic regression was used to test the relationship of FCR to physical activity, smoking status, and engagement in healthier habits. In all analyses, MEPS survey weights were applied to account for the survey design. Compared with those reporting no FCR, survivors reporting high FCR had significantly lower odds of reporting that they were not currently smokers (odds ratio [OR] = 0.46; 95% CI 0.24, 0.91) and those with any level of FCR had significantly higher odds of reporting healthier habits since diagnosis relative to those with no FCR (low FCR OR = 1.97; 95% CI 1.36, 2.85; high FCR OR = 2.40; 95% CI 1.33, 4.32). FCR was not associated with the odds of reporting physical activity. Findings from this large population-based survey suggest that some of survivors' lifestyle factors may be related to their level of FCR. Understanding the effects of FCR on lifestyle factors may help survivors, survivorship care providers, and policy makers better understand important differences among cancer survivors and personalize interventions in clinical care.

Shared Care During Breast and Colorectal Cancer Treatment: Is It Associated With Patient-Reported Care Quality?

There is growing evidence that shared care, where the oncologist, primary care physician, and/or other specialty physicians jointly participate in care, can improve the quality of patients' cancer care. This cross-sectional study of breast and colorectal cancer patients (N = 534) recruited from the New Jersey State Cancer Registry examined patient and health system factors associated with receipt of shared care during cancer treatment into the early survivorship phase. We also assessed whether shared care was associated with quality indicators of cancer care: receipt of comprehensive care, follow-up care instructions, and written treatment summaries. Less than two-thirds of participants reported shared care during their cancer treatment. The odds of reporting shared care were 2.5 (95% CI: 1.46-4.17) times higher for colorectal than breast cancer patients and 52% (95% CI: 0.24-0.95) lower for uninsured compared with privately insured, after adjusting for other sociodemographic, clinical/tumor, and health system factors. No significant relationships were observed between shared care and quality indicators of cancer care. Given a substantial proportion of patients did not receive shared care, there may be missed opportunities for integrating primary care and nononcology specialists in cancer care, who can play critical roles in care coordination and managing comorbidities during cancer treatment.

Financial hardship in Chinese cancer survivors

BACKGROUND

The purpose of this study was to estimate the proportion of Chinese cancer survivors experiencing financial hardship and then examine the relationship between material and behavioral financial hardship.

METHODS

This study surveyed 964 cancer survivors who were 30 to 64 years old and 644 survivors who were 65 years old or older during 2015-2016 (1608 survivors in all). Material financial hardship was measured by whether they had borrowed money because of cancer, its treatment, or the lasting effects of treatment, and behavioral financial hardship was measured by whether they had forgone some cancer-related medical care because of cost. Multivariable logistic regression models were used to examine factors associated with material financial hardship by age group.

RESULTS

Approximately 44% of the cancer survivors who were 65 years old or older borrowed money or went into debt because of cancer, and 54% of younger patients (P < .01) reported cancer-related debts. Among these survivors with cancer care debt, survivors aged 65 years old or older had a lower proportion of borrowing more than 50,000 Chinese yuan (CNY; approximately US $7700) than survivors aged 30 to 64 years (14% vs 20%). In both age groups, approximately 10% of cancer survivors reported that they had experienced behavioral financial hardship. After adjustments for covariates, cancer survivors who reported material financial problems were more likely to report behavioral financial hardship (odds ratio [OR] for those aged 30-64 years, 3.72; 95% confidence interval [CI], 2.13-6.50; OR for those aged 65 years or older, 5.48; 95% CI, 2.69-11.15).

CONCLUSIONS

Older cancer survivors in China experience significant material financial hardship, but it is not as noticeable as younger patients' hardship. The results highlight the importance of identifying cancer survivors who are more likely to experience financial hardship and improving the affordability of cancer care in China.

Comorbidities, treatment-related consequences, and health-related quality of life among rural cancer survivors

PURPOSE

We explored how lifetime comorbidities and treatment-related cancer symptoms were associated with quality of life (QOL) in rural cancer survivors.

METHODS

Survivors (n = 125) who were rural Illinois residents aged 18+ years old were recruited from January 2017 to September 2018. We conducted 4 multivariable regressions with QOL domains as outcomes (social well-being, functional well-being, mental health-MHQOL, physical health-PHQOL); the number of physical and psychological comorbidities (e.g., arthritis, high blood pressure, stroke) and treatment-related cancer symptoms (e.g., worrying, feeling sad, lack of appetite, lack of energy) as predictors; and, cancer-related and demographic factors related to these variables as covariates.

RESULTS

The number of comorbidities and number of treatment-related symptoms were inversely associated with functional well-being (Std β = - 0.36, p < 0.0001 and - 0.18, p = 0.03), and MHQOL (Std β = - 0.30, p = 0.001 and Std β = - 0.25, p = 0.004). Comorbidities were associated inversely with social well-being (Std β = - 0.27, p = .003). Comorbidities and treatment-related symptoms were not associated with PHQOL (p = 0.20-0.24). Sensitivity analyses suggested that psychological comorbidities, treatment-related psychological symptoms, and physical comorbidities were associated with social well-being, functional well-being, and MHQOL.

CONCLUSIONS

Our study highlights the utility of risk-based survivorship care plans to address the negative, additive impact of comorbidities and the treatment-related symptoms to improve the health-related QOL among rural survivors. Future research should assess how contextual factors (e.g., geographic distance to oncologists and other providers) should be incorporated in survivorship care planning and implementation for rural survivors.

Cancer-Related Debt and Mental-Health-Related Quality of Life among Rural Cancer Survivors: Do Family/Friend Informal Caregiver Networks Moderate the Relationship?

Social connectedness generally buffers the effects of stressors on quality of life. Is this the case for cancer-related debt among rural cancer survivors? Drawing on a sample of 135 rural cancer survivors, we leverage family/friend informal caregiver network data to determine if informal cancer caregivers buffer or exacerbate the effect of cancer-related debt on mental-health-related quality of life (MHQOL). Using data from the Illinois Rural Cancer Assessment, a survey of cancer survivors in rural Illinois, we estimate the association between cancer-related debt and MHQOL and whether informal caregiver network size and characteristics moderate this association. Over a quarter of survivors (27%) reported cancer-related debt, and those who did reported worse MHQOL. However, this association only held for survivors who had an informal caregiver network. These findings supplement what is already known about the role of social connectedness in cancer survivors' health outcomes. We offer possible explanations for these findings.

General Health Care Utilization Among Nonelderly Cancer Survivors Before and After Affordable Care Act Implementation: Early Results

PURPOSE

The number of nonelderly cancer survivors is expected to grow and so are their health care costs. Many cancer survivors worry about medical bills. This study examined the impact of the Affordable Care Act (ACA) on the rate of insurance, average annual health care expenditure, and patient care experience among cancer survivors and investigated the patient characteristics that were associated with highly rated care experiences before and after ACA implementation.

METHODS

The study is a cross-sectional analysis of adult, nonelderly cancer survivors in the 2011 and 2016 Medical Expenditure Panel Survey who completed health care experience questionnaires. Percent covered by insurance both before and after the ACA was calculated, including total out-of-pocket (OOP) expenses as a percentage of overall health care expenditure per patient. Regression was performed to determine characteristics associated with patient experience ratings.

RESULTS

Health insurance coverage for cancer survivors was higher in 2016 than in 2011 (98.4% v 94.4%; P = .006). OOP spending as a percentage of health care expenditure among those with expenses decreased and was most striking in those with no insurance. Privately insured individuals were 3 times as likely to rate their care experience high compared with those with no insurance (odds ratio, 3.31; P < .0001). Those with above-average ratings of self-health and with few comorbidities rated their care experiences highly.

CONCLUSION

After the ACA, OOP costs have decreased for all types of insurance coverage. The association between patient experience and health status warrants additional study to better manage and coordinate the care of such patients.

Medical Financial Hardship Intensity and Financial Sacrifice Associated with Cancer in the United States

BACKGROUND

With rising costs of cancer care, this study aims to estimate the prevalence of, and factors associated with, medical financial hardship intensity and financial sacrifices due to cancer in the United States.

METHODS

We identified 963 cancer survivors from the 2016 Medical Expenditures Panel Survey - Experiences with Cancer. Medical financial hardship due to cancer was measured in material (e.g., filed for bankruptcy), psychological (e.g., worry about paying bills and finances), and behavioral (e.g., delaying or forgoing care due to cost) domains. Nonmedical financial sacrifices included changes in spending and use of savings. Multivariable logistic models were used to identify characteristics associated with hardship intensity and sacrifices stratified by age group (18-64 or 65+ years).

RESULTS

Among cancer survivors ages 18 to 64 years, 53.6%, 28.4%, and 11.4% reported at least one, two, or all three domains of hardship, respectively. Among survivors ages 65+ years, corresponding percentages were 42.0%, 12.7%, and 4.0%, respectively. Moreover, financial sacrifices due to cancer were more common in survivors ages 18 to 64 years (54.2%) than in survivors 65+ years (38.4%; P < 0.001). Factors significantly associated with hardship intensity in multivariable analyses included low income and educational attainment, racial/ethnic minority, comorbidity, lack of private insurance coverage, extended employment change, and recent cancer treatment. Most were also significantly associated with financial sacrifices.

CONCLUSIONS

Medical financial hardship and financial sacrifices are substantial among cancer survivors in the United States, particularly for younger survivors.

IMPACT

Efforts to mitigate financial hardship for cancer survivors are warranted, especially for those at high risk.

Challenges of using nationally representative, population-based surveys to assess rural cancer disparities

Population-based surveys provide important information about cancer-related health behaviors across the cancer care continuum, from prevention to survivorship, to inform cancer control efforts. These surveys can illuminate cancer disparities among specific populations, including rural communities. However, due to small rural sample sizes, varying sampling methods, and/or other study design or analytical concerns, there are challenges in using population-based surveys for rural cancer control research and practice. Our objective is three-fold. First, we examined the characterization of "rural" in four, population-based surveys commonly referenced in the literature: 1) Health Information National Trends Survey (HINTS); 2) National Health Interview Survey (NHIS); 3) Behavioral Risk Factor Surveillance System (BRFSS); and 4) Medical Expenditures Panel Survey (MEPS). Second, we identified and described the challenges of using these surveys in rural cancer studies. Third, we proposed solutions to address these challenges. We found that these surveys varied in use of rural-urban classifications, sampling methodology, and available cancer-related variables. Further, we found that accessibility of these data to non-federal researchers has changed over time. Survey data have become restricted based on small numbers (i.e., BRFSS) and have made rural-urban measures only available for analysis at Research Data Centers (i.e., NHIS and MEPS). Additionally, studies that used these surveys reported varying proportions of rural participants with noted limitations in sufficient representation of rural minorities and/or cancer survivors. In order to mitigate these challenges, we propose two solutions: 1) make rural-urban measures more accessible to non-federal researchers and 2) implement sampling approaches to oversample rural populations.

Has the Quality of Patient-Provider Communication About Survivorship Care Improved?

PURPOSE

The aim of the current study was to assess whether the quality of patient-provider communication on key elements of cancer survivorship care changed between 2011 and 2016.

METHODS

Participating survivors completed the 2011 or 2016 Medical Expenditure Panel Survey Experiences with Cancer Surveys (N = 2,266). Participants reported whether any clinician ever discussed different aspects of survivorship care. Responses ranged from "Did not discuss at all" to "Discussed it with me in detail". Distributions of responses were compared among all respondents and only among those who had received cancer-directed treatment within 3 years of the survey.

RESULTS

In 2011, the percentage of survivors who did not receive detailed instructions on follow-up care, late or long-term adverse effects, lifestyle recommendations, and emotional or social needs were 35.1% (95% CI, 31.9% to 38.4%), 54.2% (95% CI, 50.7% to 57.6%), 58.9% (95% CI, 55.3% to 62.5%), and 69.2% (95% CI, 65.9% to 72.3%), respectively, and the corresponding proportions for 2016 were 35.4% (95% CI, 31.9% to 37.8%), 55.5% (95% CI, 51.7% to 59.3%), 57.8% (95% CI, 54.2% to 61.2%), and 68.2% (95% CI, 64.3% to 71.8%), respectively. Findings were similar among recently treated respondents. Only 24% in 2011 and 22% in 2016 reported having detailed discussions about all four topics. In 2016, 47.6% of patients (95% CI, 43.8% to 51.4%) reported not having detailed discussions with their providers about a summary of their cancer treatments.

CONCLUSION

Clear gaps in the quality of communication between survivors of cancer and providers persist. Our results highlight the need for continued efforts to improve communication between survivors of cancer and providers, including targeted interventions in key survivorship care areas.

Work and income changes after cancer in rural China: A cross-sectional survey

Background

The present study aimed to first describe the work‐related outcomes of cancer survivors and to then identify those characteristics that influenced the decision to stop working in rural China.

Methods

We assessed 752 cancer survivors (residents of rural areas, working at the time of diagnosis, >1 year since completing treatment) from the cross‐sectional study “China Survey of Experiences with Cancer”. Participants reported changes in employment status, income, and the ability to perform physical jobs due to cancer, as well as the work‐related outcomes of their informal caregivers. Logistic regression analyses were used to examine the association between sociodemographic characteristics, cancer characteristics, and changes in work (ie, continue to work vs not working).

Results

The participants were largely farmers (96%), women (56%), younger than 65 years old (69%), and diagnosed with colorectal (31%) and breast cancer (31%). Thirty‐nine percent reported reducing working hours, and 40% reported stopping work altogether. Approximately 7% of informal caregivers also stopped working in order to take care of those diagnosed with cancer. Thirty‐three percent of cancer survivors and 5% of their informal caregivers had no source of income following treatment. Controlling for other variables, lower educational attainment, physical limitations in work, and different cancer sites were significantly associated with ending employment in both men and women, while among men specifically, we observed that older age, being unmarried, and being diagnosed at later stages were significantly associated with an end to working.

Conclusion

Rural cancer survivors are at a high risk for stopping work after completing treatment, and many survivors and their caregivers experience poor work‐related outcomes and economic hardship. These results highlight the importance of paying attention to the work experiences of cancer survivors in rural China.

Financial burden of thyroid cancer in the United States: An estimate of economic and psychological hardship among thyroid cancer survivors

BACKGROUND

Annual cancer-related healthcare expenditure in the United States is estimated to exceed $150 billion by 2020. As the prevalence of thyroid cancer increases worldwide, thyroid cancer survivorship is associated with increasing personal and cumulative costs. Few studies have examined the psychological and material economic costs experienced by thyroid cancer survivors. We seek to estimate the comparative prevalence of financial and psychological hardship among thyroid cancer and non-thyroid cancer patients in the United States.

METHODS

The 2011 Medical Expenditure Panel Survey Experiences with Cancer databank was queried to identify thyroid and non-thyroid (colon, breast, lung, prostate) cancer survivors. This survey includes assessments of financial stress, material hardship, and psychological financial hardship. Cancer incidence-based weighted estimates of responses were compared between thyroid and non-thyroid cancer survivors. Independent predictors of material and psychological financial burden were identified through separate multivariate regression models.

RESULTS

Thyroid cancer survivors more frequently reported psychological financial burden compared to non-thyroid cancer (46.1% vs 24.0%, P = .04). Material financial hardship (28.1% vs 19.9%, P = .37) and concurrent material and psychological hardship (25.1% vs 12.5%, P = .09) were noted at similar frequencies between thyroid and non-thyroid cancer survivors. However, on multivariate analysis, only younger age and lack of health insurance coverage were independently associated with psychological financial hardship.

CONCLUSION

Thyroid cancer survivors report greater psychological financial hardship than non-thyroid cancer survivors. Because this financial burden may be underrecognized in the medical community, further studies should be conducted to aid physicians in better understanding the impact of a thyroid cancer diagnosis.

Experiences with cancer survey in China

BACKGROUND

China accounts for approximately 27% of global cancer deaths. However, to the authors' knowledge, the lasting effects of cancer and cancer treatments on patients have not been investigated in China. The authors developed a questionnaire, the China Survey of Experiences with Cancer, for Chinese cancer survivors. This article introduces the study design and domains covered in the questionnaire.

METHODS

The Cancer Survivorship Supplement of the Medical Expenditure Panel Survey (MEPS) was used as a reference to develop the questionnaire. The final in-person surveys were conducted in 2015 and 2016. Samples were chosen through multistage sampling. The authors described the characteristics of the study participants and their cancer experiences.

RESULTS

At the time of last follow-up, a total of 1166 patients had completed at least 1 component of the survey. Approximately 59% of the cancer survivors were aged ≥60 years. Greater than one-half of the participants had an elementary education level or less (51%) and a yearly family income of <$3174. Chinese cancer survivors were more likely to retire earlier than planned compared with American cancer survivors (37% vs 9%). The majority of Chinese cancer survivors (84%) reported that their work abilities were hindered by their cancer or cancer treatments. Approximately one-half of patients in China had to incur debt because of cancer, whereas <10% of patients in the United States reported having incurred debt.

CONCLUSIONS

The survey provides information regarding the burden of cancer in China that to the authors' knowledge currently is unavailable from other sources, including medical care use, financial impacts, employment patterns, and life experience after a cancer diagnosis for survivors and their families.

Prevalence of cardiovascular disease and risk factors, quality of life, and health behaviors of cancer survivors and their spouses: findings from MEPS

PURPOSE

Few population-based studies have examined the prevalence of cardiovascular disease (CVD) and risk factors, quality of life (QOL), and health behaviors of cancer survivors and their spouses. This case-control study aimed to fill this gap using the data from a set of large-scale surveys of individuals and families across the USA.

METHODS

Data were obtained from the 2010-2015 Medical Expenditure Panel Survey (MEPS). Using one-to-many (1:5) propensity score matching, we identified cancer survivors (N = 1037) and noncancer-matched controls (N = 5185), as well as survivor spouses (N = 1038) and matched controls (N = 5190). We used weighted multivariable logistic and linear regressions to examine the categorical and numerical outcomes.

RESULTS

Compared with noncancer controls, survivors have higher rates of stroke (p < .05), hypertension (p < .05), high cholesterol (p < .01), fair or poor health (p < .0001), and report self-reported worse physical QOL scores (PCS) (p < .0001). A higher percentage of survivors report receiving BP checks (p < .01), serum cholesterol assessments (p < .001), routine physical checkups (p < .01), blood stool tests (p < .05), colonoscopies (p < .0001), and flu vaccinations (p < .05). Survivor spouses, compared to their respective matched controls, reported higher rates of serum cholesterol testing (p < .001), routine physical checkups (p < .01), and flu vaccinations (p < .01).

CONCLUSIONS

Compared to the general population, cancer survivors are at higher risk for CVD, report worse physical QOL, and, along with their spouses, more frequently receive certain preventive health care services.

IMPLICATIONS FOR CANCER SURVIVORS

There is a need for intervention to more fully engage cancer survivors and spouses in lifestyle behavior change associated with decreased CVD and related risk factors and improved QOL.