Financial Hardship and Quality of Life among African American and White Cancer Survivors: The Role of Limiting Care Due to Cost

Prevalence of Health-Related Social Needs and Associated Missed Imaging Appointments Among Patients With Cancer

PURPOSE

Health-related social needs (HRSNs) lead to health disparities and impact cancer care, but their link with missed imaging appointments in patients with cancer is unclear. We assessed screen rate and prevalance of HRSNs and their association with missed imaging appointments among patients with cancer.

METHODS

Patients aged ≥18 years with cancer who completed an oncology wellness form as part of usual care between January 1, 2022, and September 30, 2023, who had an imaging examination scheduled at the same health system within 3 months after form completion were included. The form assessed HRSNs (financial, transportation, and housing) and patients' preference for written or verbal information about HRSNs services. Multivariable regression models evaluated the association between HRSNs and missed imaging appointments.

RESULTS

In all, 3,495 (16.6%) of patients had a completed oncology wellness form during 3,964 (4.3%) encounters; of those, 2,890 had imaging scheduled in the next 3 months and were included (mean age: 61.6 ± 15.9 years; 50.2% female; 20.1% Asian, 2.8% Black, 57% White, 20.6% Hispanic). HRSNs were reported during 22.9% of encounters, with 82.9%, 40.2%, and 37.5% of reported HRSNs being due to financial hardship, transportation, and housing issues. Only 6.5% and 4.4% of encounters positive for HRSNs reported a desire for written information or to speak with someone about their HRSNs, respectively. At least one imaging encounter was missed by 70% in the subsequent 3 months. Adjusting for sociodemographic factors, patients reporting HRSNs were more likely to miss their imaging appointment (odds ratio, 1.29; 95% confidence interval, 1.03-1.61).

CONCLUSION

Patients with cancer with self-reported HRSNs tend to have higher missed imaging appointments.

Gerotherapeutics: aging mechanism-based pharmaceutical and behavioral interventions to reduce cancer racial and ethnic disparities

The central premise of this article is that a portion of the established relationships between social determinants of health and racial and ethnic disparities in cancer morbidity and mortality is mediated through differences in rates of biological aging processes. We further posit that using knowledge about aging could enable discovery and testing of new mechanism-based pharmaceutical and behavioral interventions ("gerotherapeutics") to differentially improve the health of cancer survivors from minority populations and reduce cancer disparities. These hypotheses are based on evidence that lifelong differences in adverse social determinants of health contribute to disparities in rates of biological aging ("social determinants of aging"), with individuals from minoritized groups experiencing accelerated aging (ie, a steeper slope or trajectory of biological aging over time relative to chronological age) more often than individuals from nonminoritized groups. Acceleration of biological aging can increase the risk, age of onset, aggressiveness, and stage of many adult cancers. There are also documented negative feedback loops whereby the cellular damage caused by cancer and its therapies act as drivers of additional biological aging. Together, these dynamic intersectional forces can contribute to differences in cancer outcomes between survivors from minoritized vs nonminoritized populations. We highlight key targetable biological aging mechanisms with potential applications to reducing cancer disparities and discuss methodological considerations for preclinical and clinical testing of the impact of gerotherapeutics on cancer outcomes in minoritized populations. Ultimately, the promise of reducing cancer disparities will require broad societal policy changes that address the structural causes of accelerated biological aging and ensure equitable access to all new cancer control paradigms.

Correlates of health-related quality of life in African Americans diagnosed with cancer: a review of survivorship studies and the Detroit research on cancer survivors cohort

Advances in cancer screening and treatment have improved survival after a diagnosis of cancer. As the number of cancer survivors as well as their overall life-expectancy increases, investigations of health-related quality of life (HRQOL) are critical in understanding the factors that promote the optimal experience over the course of survivorship. However, there is a dearth of information on determinants of HRQOL for African American cancer survivors as the vast majority of cohorts have been conducted predominantly among non-Hispanic Whites. In this review, we provide a review of the literature related to HRQOL in cancer survivors including those in African Americans. We then present a summary of published work from the Detroit Research on Cancer Survivors (ROCS) cohort, a population-based cohort of more than 5000 African American cancer survivors. Overall, Detroit ROCS has markedly advanced our understanding of the unique factors contributing to poorer HRQOL among African Americans with cancer. This work and future studies will help inform potential interventions to improve the long-term health of this patient population.

Financial Toxicity Among Women with Breast Cancer Varies by Age and Race

INTRODUCTION

Financial toxicity negatively affects clinical outcomes in breast cancer. Underrepresented demographics may be at higher risk for financial toxicity. We characterized disparities on the basis of age and other factors.

PATIENTS AND METHODS

Surveys completed by women with stage 0-IV breast cancer treated at Memorial Sloan Kettering Cancer Center between 06/2022 and 05/2023 were analyzed. The comprehensive score for financial toxicity (COST) scale was used to assess financial toxicity. Descriptive statistics were calculated for differences in financial toxicity/related factors, and outcomes by age and race. Associations between variables of interest and COST scores were analyzed using linear regression.

RESULTS

Of 8512 respondents (75% white, 9.3% Asian, 8.4% Black), most (68%) had clinical stage 0/I disease. Stratified by age, young Black women had higher financial toxicity than young white or Asian women (p < 0.001). On multivariable analysis, women age < 45 years experienced higher financial toxicity than older women (coefficient - 2.0, 95% CI - 2.8 to - 1.1, p < 0.001). Compared with white women, financial toxicity was greater among Black (coefficient - 6.8, 95% CI - 7.8 to - 5.8) and Asian women (coefficient - 3.5, 95% CI - 4.4 to - 2.5). Cost-related medication non-adherence was more frequent among Black and Asian women (p < 0.001). Asian women more often paid for treatment with savings than white and Black women (p < 0.001). Young women reported using savings for treatment-related costs more than older (45% vs. 32%); p < 0.001).

CONCLUSIONS

Racial minorities and young patients are disproportionately affected by financial toxicity. Further studies are planned to determine how financial toxicity evolves over time and whether referral to financial services effectively reduces toxicity.

Understanding and Addressing LGBTQ+ Cancer Health Disparities

Lesbian, gay, bisexual, transgender, and queer (LGBTQ+) cancer survivors disproportionately experience physical and mental health comorbidities compared with their heterosexual and cisgender counterparts. A recent study by Waters and colleagues evaluates associations between LGBTQ+ identity and physical and mental health comorbidities and activity limitations using Behavioral Risk Factor Surveillance System data. Consistent with previous work, their findings suggest that LGBTQ+ survivors have higher odds of several chronic conditions, including asthma, depressive disorders, heart attacks, kidney disease, stroke, and diabetes, as well as reporting disabilities related to vision and cognition and difficulty with activities of daily living, including walking, dressing, and running errands. Waters and colleagues expand on previous work by providing estimates separately for sexual orientation and gender identity. Their results for lesbian, gay, and bisexual survivors were similar to those for LGBTQ+ survivors overall. In novel findings, they report much stronger associations between identifying as transgender or gender nonconforming and nearly all comorbidities compared with cisgender survivors, including those who identify as lesbian, gay, or bisexual. This commentary advocates for the importance of future work considering the drivers of disparities in cancer outcomes based on sexual orientation and gender identity. See related article by Waters et al., p. 1405.

Association of patient-reported financial barriers with healthcare utilization among Medicare beneficiaries with a history of cancer

PURPOSE

We examined characteristics associated with financial barriers to healthcare and the association of financial barriers with adverse healthcare events among US adult cancer survivors enrolled in Medicare.

METHODS

We used nationally representative Medicare Current Beneficiary Survey data (2011-2013, 2015-2017) to identify adults with a history of non-skin cancer. We defined financial barriers as cost-related trouble accessing and/or delayed care in the prior year. Using propensity-weighted multivariable logistic regression, we examined associations between financial barriers and adverse healthcare events (any ED visits, any inpatient hospitalizations).

RESULTS

Overall, 11.0% of adult Medicare beneficiaries with a history of cancer reported financial barriers in the prior year, with higher burden among beneficiaries < 65 years of age vs. ≥ 65 (32.5% vs. 8.2%, p < 0.0001) and with annual income < $25,000 vs. ≥ $25,000 (18.1% vs. 6.9%, p < 0.0001). In bivariate models, financial barriers were associated with a 7.8 percentage point (95% CI: 1.5-14.0) increase in the probability of ED visits. In propensity-weighted models, this association was not statistically significant. The association between financial barriers and hospitalizations was not significant in the overall population; however, financial barriers were associated with a decreased probability of hospitalization among Black/African American beneficiaries.

CONCLUSIONS

Despite Medicare coverage, beneficiaries with a history of cancer are at risk for experiencing financial barriers to healthcare. In the overall population, financial barriers were not associated with ED visits or hospitalizations.

IMPLICATIONS FOR CANCER SURVIVORS

Policies limiting Medicare patient out-of-pocket spending and care models addressing health-related social needs are needed to reduce financial barriers experienced.

Financial hardship screening among Native American patients with cancer: a qualitative analysis

BACKGROUND

Cancer-related financial hardship is an increasingly recognized concern for patients, families, and caregivers. Many Native American (NA) patients are at increased risk for cancer-related financial hardship due to high prevalence of low income, medical comorbidity, and lack of private health insurance. However, financial hardship screening (FHS) implementation for NA patients with cancer has not been reported. The objective of this study is to explore facilitators and barriers to FHS implementation for NA patients.

METHODS

We conducted key informant interviews with NA patients with cancer and with clinical staff at an academic cancer center. Included patients had a confirmed diagnosis of cancer and were referred to the cancer center through the Indian Health Service, Tribal health program, or Urban Indian health program. Interviews included questions regarding current financial hardship, experiences in discussing financial hardship with the cancer care and primary care teams, and acceptability of completing a financial hardship screening tool at the cancer center. Clinical staff included physicians, advanced practice providers, and social workers. Interviews focused on confidence, comfort, and experience in discussing financial hardship with patients. Recorded interviews were transcribed and thematically analyzed using MAXQDA® software.

RESULTS

We interviewed seven patients and four clinical staff. Themes from the interviews included: 1) existing resources and support services; 2) challenges, gaps in services, and barriers to care; 3) nuances of NA cancer care; and 4) opportunities for improved care and resources. Patients identified financial challenges to receiving cancer care including transportation, lodging, food insecurity, and utility expenses. Patients were willing to complete a FHS tool, but indicated this tool should be short and not intrusive of the patient's financial information. Clinical staff described discomfort in discussing financial hardship with patients, primarily due to a lack of training and knowledge about resources to support patients. Having designated staff familiar with I/T/U systems was helpful, but perspectives differed regarding who should administer FHS.

CONCLUSIONS

We identified facilitators and barriers to implementing FHS for NA patients with cancer at both the patient and clinician levels. Findings suggest clear organizational structures and processes are needed for financial hardship to be addressed effectively.

Cancer cost-related subjective financial distress among breast cancer: a scoping review

PURPOSE

This article provided a comprehensive scoping review, synthesizing existing literature on the financial distress faced by breast cancer patients. It examined the factors contributing to financial distress, the impact on patients, coping mechanisms employed, and potential alleviation methods. The goal was to organize existing evidence and highlight possible directions for future research.

METHODS

We followed the scoping review framework proposed by the Joanna Briggs Institute (JBI) to synthesize and report evidence. We searched electronic databases, including PubMed, Web of Science, Embase, and Cochrane Library, for relevant literature. We included English articles that met the following criteria: (a) the research topic was financial distress or financial toxicity, (b) the research subjects were adult breast cancer patients, and (c) the article type was quantitative, qualitative, or mixed-methods research. We then extracted and integrated relevant information for reporting.

RESULTS

After removing duplicates, 5459 articles were retrieved, and 43 articles were included based on the inclusion and exclusion criteria. The articles addressed four main themes related to financial distress: factors associated with financial distress, impact on breast cancer patients, coping mechanisms, and potential methods for alleviation. The impact of financial distress on patients was observed in six dimensions: financial expenses, financial resources, social-psychological reactions, support seeking, coping care, and coping lifestyle. While some studies reported potential methods for alleviation, few discussed the feasibility of these solutions.

CONCLUSIONS

Breast cancer patients experience significant financial distress with multidimensional impacts. Comprehensive consideration of possible confounding factors is essential when measuring financial distress. Future research should focus on exploring and validating methods to alleviate or resolve this issue.

A scoping review of racial, ethnic, socioeconomic, and geographic disparities in the outcomes of older adults with cancer

INTRODUCTION

Cancer health disparities are widespread. Nevertheless, the disparities in outcomes among diverse survivors of cancer ages 65 years and older ("older") have not been systematically evaluated.

METHODS

We conducted a scoping review of original research articles published between January 2016 and September 2023 and indexed in Medline (Ovid), Embase, Scopus, and CINAHL databases. We included studies evaluating racial, ethnic, socioeconomic disadvantaged, geographic, sexual and gender, and/or persons with disabilities disparities in treatment, survivorship, and mortality among older survivors of cancer. We excluded studies with no a priori aims related to a health disparity, review articles, conference proceedings, meeting abstracts, studies with unclear methodologies, and articles in which the disparity group was examined only as an analytic covariate. Two reviewers independently extracted data following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis reporting guidelines.

RESULTS

After searching and removing duplicates, 2573 unique citations remained and after screening 59 articles met the inclusion criteria. Many investigated more than one health disparity, and most focused on racial and ethnic (n = 44) or socioeconomic (n = 25) disparities; only 10 studies described geographic disparities, and none evaluated disparities in persons with disabilities or due to sexual and gender identity. Research investigating disparities in outcomes among diverse older survivors of cancer is increasing gradually-68% of eligible articles were published between 2020 and 2023. Most studies focused on the treatment phase of care (n = 28) and mortality (n = 26), with 16 examined disparities in survivorship, symptoms, or quality of life. Most research was descriptive and lacked analyses of potential underlying mechanisms contributing to the reported disparities.

CONCLUSION

Little research has evaluated the effect of strategies to reduce health disparities among older patients with cancer. This lack of evidence perpetuates cancer inequities and leaves the cancer care system ill equipped to address the unique needs of the rapidly growing and increasingly diverse older adult cancer population.

Association of household net worth with healthcare costs after radical cystectomy using real-world data

BACKGROUND

Financial toxicity of bladder cancer care may influence how patients utilize healthcare resources, from emergency department (ED) encounters to office visits. We aim to examine whether greater household net worth (HHNW) confers differential access to healthcare resources after radical cystectomy (RC).

METHODS

This population-based cohort study examined the association between HHNW and healthcare utilization costs in the 90 days post-RC in commercially insured patients with bladder cancer. Costs accrued from the index hospitalization to 90 days after including health plan costs (HPC) and out-of-pocket costs (OPC). Multivariable logistic regression models were generated by encounter (acute inpatient, ED, outpatient, and office visit).

RESULTS

A total of 141,903 patients were identified with HHNW categories near evenly distributed. Acute inpatient encounters incurred the greatest HPC and OPC. Office visits conferred the lowest HPC while ED visits had the lowest OPC. Black patients harbored increased odds of an acute inpatient encounter (OR 1.22, 95% CI 1.16-1.29) and ED encounter (OR 1.20, 95% CI 1.14-1.27) while Asian (OR 0.76, 95% CI 0.69-0.85) and Hispanic (OR 0.74, 95% CI 0.69-0.78, p < 0.001) patients had lower odds of an outpatient encounter, compared to White counterpart. Increasing HHNW was associated with decreasing odds of acute inpatient or ED encounters and greater odds of office visits.

CONCLUSIONS

Lower HHNW conferred greater risk of costly inpatient encounters while greater HHNW had greater odds of less costly office visits, illustrating how financial flexibility fosters differences in healthcare utilization and lower costs. HHNW may serve as a proxy for financial flexibility and risk of financial hardship than income alone.

Access to Financial Assistance Programs and Their Impact on Overall Spending on Oral Anticancer Medications at an Integrated Specialty Pharmacy

PURPOSE

Financial assistance (FA) programs are increasingly used to help patients afford oral anticancer medications (OAMs), but access to such programs and their impact on out-of-pocket (OOP) spending has not been well explored. This study aimed to (1) characterize the impact of receipt of FA on both OOP spending and likelihood of catastrophic spending on OAMs and (2) evaluate racial/ethnic disparities in access to FA programs.

METHODS

Patients with a cancer diagnosis prescribed an OAM anytime between January 1, 2021, and December 31, 2021 were included in this retrospective, single-center study at an integrated specialty pharmacy affiliated with a tertiary academic cancer center. Fixed-effect regression models were used to characterize the impact of receipt of FA on overall spending and likelihood of catastrophic spending on OAMs, as well as explore the association of race/ethnicity with receipt of FA.

RESULTS

Across 1,186 patients prescribed an OAM, 37% received FA. Receipt of FA was associated with lower annual spending on OAMs (β = -$1,236 US dollars [USD; 95% CI, -$1,841 to -$658], P < .001) but not reduced risk of catastrophic spending (odds ratio [OR], 0.442 [95% CI, 0.755 to 3.199], P = .23). Non-White patients (OR, 0.60 [95% CI, 0.43 to 0.85], P = .004) and patients who spoke English as a second language (OR, 0.46 [95% CI, 0.23 to 0.90], P = .02) were less likely to receive FA compared with White and English-speaking patients, respectively.

CONCLUSION

FA programs can mitigate high OOP spending but not for patients who spend at catastrophic levels. There are racial/ethnic and language disparities in access to such programs. Future studies should evaluate access to FA programs across diverse delivery settings.

Economic Hardship and Associated Factors of Women With Early-Stage Breast Cancer Prior to Chemotherapy Initiation

INTRODUCTION

Economic hardship (EH) can negatively influence cancer outcomes. Little is known about the factors that are associated with higher levels of EH among patients with breast cancer (BC). This paper describes EH in women with early-stage BC prior to or at their first chemotherapy treatment (baseline) and explores whether there are differences by race, area deprivation, stress, symptom distress, and social support.

PATIENTS AND METHODS

A descriptive comparative/correlational design was employed using baseline data of a multisite, longitudinal, multimethod study comparing the symptom experience and management prior to prescribed chemotherapy for women with early-stage BC. Participants completed measures for EH, perceived stress, symptom distress, and social support. Race was measured by self-report. Area deprivation indices (ADI) measuring neighborhood economic factors were calculated from publicly available websites.

RESULTS

Participants (N = 248; age = 52.9 ± 12.3 years) were 62% White and 38% Black, 54% partnered, and 98% insured. Compared to White patients, Black patients reported higher (worse) EH (1.2 ± 3.0 vs. -0.7 ± 2.4), lived in areas of greater deprivation (80.1 ± 2.1 vs. 50.5 ± 23.5),and were more likely to report inadequate household income (Black: 30.5%; White: 11.1%). Adjusting for race and age, being Black (P< .001), living in an area of greater deprivation (P = .049), higher perceived stress (P = .008), lower perceived appraisal (P = .040), and less tangible support (P < .001) contributed to greater EH. Worse symptom distress trended toward greater EH (P = .07).

CONCLUSIONS

This study emphasizes the importance of incorporating baseline holistic assessment to identify patients most likely to experience EH during early-stage BC treatment.

Enhancing Cancer Economic Data Resources: The Interagency Consortium to Promote Health Economics Research on Cancer (HEROiC)

BACKGROUND

Cancer diagnosis and treatment can substantially affect health and financial outcomes for patients and families. Research in health care delivery across the cancer control continuum includes diverse activities led by multiple government and private sector organizations. Assessing the economic drivers and influencing factors associated with costs across this continuum is challenging as organizations leading research efforts often do not have forums to share data, develop linkages, and explore collaborative opportunities.

OBJECTIVE

To describe the objectives, activities, and goals of the Interagency Consortium to Promote Health Economics Research on Cancer (HEROiC) to strengthen data resources and capacity for collaborative patient-focused cancer health economics research.

MAIN ARGUMENT

HEROiC's goals include assessing the economic burden of cancer; examining the effects of policies, health care setting/system factors, and health service delivery approaches across the cancer control continuum; and enhancing collaborations among researchers and organizations.

CONCLUSIONS

Data resources to study economic outcomes associated with cancer control are highly fragmented; HEROIC provides a forum to collaboratively develop, enhance, and utilize data resources and infrastructure for patient-centered cancer health economics research. This includes sharing data resources, developing linkages, identifying new data collection venues, and creating and supporting the dissemination of evidence-based information to diverse stakeholders. These efforts provide critical information to address the economic burden of cancer.

RELEVANCE TO THE SPECIAL ISSUE

Cancer diagnosis and treatment affect patient health and financial outcomes. This commentary describes how HEROiC will enhance research data infrastructure and collaborations to support patient-centered research with the goal of reducing the economic burden of cancer.

Returning to employment following allogeneic hematopoietic stem cell transplant: A major problem among survivors

Quality of life (QoL) is an important aspect of cancer survivorship. One of the most acute problems that impact survivors in many aspects of activities of daily living and compromise their QoL is the inability to return to employment following successful cancer therapy. This is most prominent among survivors after allogeneic hematopoietic stem cell transplant (allo-HSCT). More than 50% of the survivors following allo-HSCT remain unemployed one year after the procedure. This problem extends beyond the initial few years; unemployment rates among those who underwent allo-HSCT during their childhoods or adolescence have remained high. The inability to return to employment imposes a financial burden. Survivors following allo-HSCT also experience a multitude of chronic psychosocial complications that may be both contributing and consequential to the inability to return to employment. However, many transplant programs and cancer centers do not have return-to-employment programs. In this review paper, we discuss the prevalence of unemployment following allo-HSCT. We examine the psychosocial symptoms experienced by survivors and how they may affect survivors' ability to return to employment. Finally, we propose a multi-disciplinary multi-pronged occupation-focused approach to address the complex and inter-related psychosocial symptoms to help alleviate the problem.

The costs and inequities of precision medicine for patients with prostate cancer: A call to action

Financial toxicity is a growing problem in the delivery of cancer care and contributes to inequities in outcomes across the cancer care continuum. Racial/ethnic inequities in prostate cancer, the most common cancer diagnosed in men, are well described, and threaten to widen in the era of precision oncology given the numerous structural barriers to accessing novel diagnostic studies and treatments, particularly for Black men. Gaps in insurance coverage and cost sharing are 2 such structural barriers that can perpetuate inequities in screening, diagnostic workup, guideline-concordant treatment, symptom management, survivorship, and access to clinical trials. Mitigating these barriers will be key to achieving equity in prostate cancer care, and will require a multi-pronged approach from policymakers, health systems, and individual providers. This narrative review will describe the current state of financial toxicity in prostate cancer care and its role in perpetuating racial inequities in the era of precision oncology.

Providers' communication-related concerns in helping patients address the financial impact of cancer

OBJECTIVES

This study describes the communication-related concerns of oncology providers in addressing financial issues with patients.

METHODS

We conducted semi-structured interviews with 17 providers (9 clinicians, 5 social workers/navigators, 3 attorneys) who addressed financial concerns with cancer patients and analyzed resulting transcripts using qualitative thematic analysis. Interview topics included cost-related concerns of patients, resources providers used, and unmet needs related to addressing financial issues. Here we present codes and content related to a cross-cutting cost communication, stratified by provider discipline.

RESULTS

Communication-related issues varied by provider type. Clinicians identified lack of information, lack of time, and the need for additional support as major barriers to effective cost discussions. Social workers/navigators expressed the importance of establishing a relationship before discussing costs and on the need to revisit cost concerns over time to meet patients' changing needs. The attorneys endorsed the need for more and earlier cost communication to prevent financial hardship.

CONCLUSION

Communication concerns and strategies were central to providers' experiences of addressing cancer patient cost concerns.

PRACTICE IMPLICATIONS

Understanding the experiences of diverse oncology providers can inform the development and implementation of interventions to prevent and mitigate financial hardship in people with cancer.

Ten-year work burden after prostate cancer treatment

INTRODUCTION

We aim to characterize the magnitude of the work burden (weeks off from work) associated with prostate cancer (PCa) treatment over a 10-year period after PCa diagnosis and identify those at greatest risk.

MATERIALS AND METHODS

We identified men diagnosed with PCa treated with radical prostatectomy, radiation therapy, or active surveillance/watchful waiting within CaPSURE. Patients self-reported work burden and SF36 general health scores via surveys before and 1,3,5, and 10 years after treatment. Using multivariate repeated measures generalized estimating equation modeling we examined the association between primary treatment with risk of any work weeks lost due to care.

RESULTS

In total, 6693 men were included. The majority were White (81%, 5% Black, and 14% Other) with CAPRA low- (60%) or intermediate-risk (32%) disease and underwent surgery (62%) compared to 29% radiation and 9% active surveillance. Compared to other treatments, surgical patients were more likely to report greater than 7 days off work in the first year, with relatively less time off over time. Black men (RR 0.64, 95% CI 0.54-0.77) and those undergoing radiation (vs. surgery, RR 0.46, 95% CI 0.41-0.51) were less likely to report time off from work over time. Mean baseline GH score (73 [SD 18]) was similar between race and treatment groups, and stable over time.

CONCLUSIONS

The work burden of cancer care continued up to 10 years after treatment and varied across racial groups and primary treatment groups, highlighting the multifactorial nature of this issue and the call to leverage greater resources for those at greatest risk.

Association of Employment Disruptions and Financial Hardship Among Individuals Diagnosed with Cancer in the United States: Findings from a Nationally Representative Study

Financial hardship (FH), defined as adverse patient effects due to cancer costs, is experienced by approximately half of individuals diagnosed with cancer. Many individuals diagnosed with cancer also experience disruptions with their employment. This study examines associations of employment disruptions and FH among a nationally representative sample of individuals diagnosed with cancer in the United States. We utilized 2016/2017 Medical Expenditure Panel Survey Experiences with Cancer data from individuals who worked for pay following cancer diagnosis. Employment disruption included taking extended paid time off work; switching to part-time/less demanding jobs; and/or retiring early due to cancer diagnosis/treatment. FH domains included: material (e.g., borrowing money/financial sacrifices); psychologic (e.g., worrying about medical bills/income); and behavioral (delaying/forgoing healthcare services because of cost). Multivariable logistic regression analyses determined associations of employment disruption and FH. Among 732 individuals with a cancer history, 47.4% experienced employment disruptions; 55.9% experienced any FH. Any FH was significantly more common among individuals with versus without employment disruptions across multiple measures and domains (68.7% vs. 44.5%; P value of difference <0.0001). Individuals with employment disruptions were more likely to have any FH [OR, 2.38; 95% confidence interval (CI), 1.62-3.52] and more FHs (OR, 2.76; 95% CI, 1.96-3.89]. This study highlights that employment disruptions are common and significantly associated with multiple domains of FH among individuals with a cancer history. Employer workplace accommodation, physician discussions regarding potential impacts of cancer care on employment, and other policies to minimize employment disruptions among individuals diagnosed with cancer may reduce FH in this vulnerable population.

Significance

Individuals diagnosed with cancer may have employment disruptions; they may also develop FHs. People with cancer who have employment changes are more likely to also have FHs. Physicians and employers can help individuals with cancer through advancing planning, workplace assistance, and improved medical leave and insurance policies.

Financial hardship and psychosocial well-being and quality of life among prostate cancer survivors in the United States

Prostate cancer is the most common cancer diagnosis among men in the United States and the prevalence of prostate cancer survivors is growing. Cancer treatment and lasting or late effects of disease and treatment can adversely affect financial health, psychosocial well-being, and health-related quality of life for prostate cancer survivors, even many years after cancer diagnosis and treatment. These outcomes are important, especially because most men live for many years following a prostate cancer diagnosis. In this essay, we describe health care spending associated with prostate cancer, including patient out-of-pocket costs, and summarize research examining medical financial hardship and associations of financial hardship and psychosocial well-being and health-related quality of life among cancer survivors. We then discuss implications for health care delivery and opportunities to mitigate financial hardship for patients with prostate cancer and their families.

Expanding research on the impact of financial hardship on emotional well-being: guidance of diverse stakeholders to the Emotional Well-Being and Economic Burden of Disease (EMOT-ECON) Research Network

The Emotional Well-Being and Economic Burden (EMOT-ECON) Research Network is one of six research networks funded by the National Institutes of Health (NIH) to advance research about emotional well-being (EWB), and the only one that focuses on addressing how economic burden due to disease or illness affects EWB. The network convened researchers, patients, patient advocates, health care providers and other stakeholders from across the US to discuss the significance of addressing the impact of the economic burden of disease on EWB, the complexity of this prevalent problem for patients and families, and the research gaps that still need to be studied to ultimately develop strategies to reduce the impact of economic burden of disease on EWB and health. Participants identified some important future areas of research as those investigating: (i) prevalent and relevant emotions for patients experiencing economic burden of disease and financial hardship, and how their broader outlook on life is impacted; (ii) constructs and contexts that influence whether the economic burden is stressful; (iii) strategies to deal and cope and their positive or negative effects on EWB and health; and (iv) multi-level and multi-stakeholder interventions to address economic factors (e.g., costs, ability to pay), administrative burdens, education and training, and especially patients' emotional as well as financial status.

Factors associated with health-related quality of life in a cohort of cancer survivors in New Jersey

BACKGROUND

Although there is extensive literature on correlates of health-related quality of life (HRQoL) among cancer survivors, there has been less attention paid to the role of socioeconomic disadvantage and survivorship care transition experiences in HRQoL. There are few large cohort studies that include a comprehensive set of correlates to obtain a full picture of what is associated with survivors' HRQ0L. This cohort study of recent cancer survivors in New Jersey aimed to explore the association between social determinants of health, health history, health behaviors, survivorship care experiences, and psychosocial factors in HRQoL.

METHODS

Eligible survivors were residents of New Jersey diagnosed with genitourinary, female breast, gynecologic, colorectal, lung, melanoma, or thyroid cancers. Participants completed measures of social determinants, health behaviors, survivorship care experiences, psychosocial factors, and HRQoL. Separate multiple regression models predicting HRQoL were conducted for each of the five domains (social determinants, health history, health behaviors, survivorship care experiences, psychosocial factors). Variables attaining statistical significance were included in a hierarchical multiple regression arranged by the five domains.

RESULTS

864 cancer survivors completed the survey. Lower global HRQoL was associated with being unemployed, more comorbidities, a less healthy diet, lower preparedness for survivorship, more unmet support needs, and higher fear about cancer recurrence. Two psychosocial factors, unmet support needs and fear of recurrence, played the most important role in HRQoL, accounting for more than 20% of the variance. Both unmet support needs and fear of recurrence were significant correlates of physical, functional, and emotional HRQoL domains.

CONCLUSIONS

Interventions seeking to improve cancer survivors' HRQoL may benefit from improving coordinated management of comorbid medical problems, fostering a healthier diet, addressing unmet support needs, and reducing survivors' fears about cancer recurrence.

Financial toxicity in prostate cancer survivors: A national cross-sectional assessment of subjective financial burden

BACKGROUND

In prostate cancer (CaP) survivorship, subjective financial burden (SFB), an aspect of financial toxicity, has not been studied using a national sample. Our goal was to explore and identify factors associated with patient-reported SFB in CaP survivors.

MATERIALS AND METHODS

We conducted a retrospective, cross-sectional study of 264 adult individuals with a history of CaP that completed the AHRQ - Medical Expenditures Panel Survey - Household Component and Cancer Self-Administered Questionnaire Supplement in 2016 or 2017. Primary outcomes were the presence of cancer-related SFB and the severity of this burden. Multivariable ordinal logistic regression and logistic regression models were used to identify factors associated with the severity of SFB and different domains of burden.

RESULTS

Most participants were non-Hispanic white, had 3 or more comorbidities and had a median age of 72 years. 62.1% of survivors indicated SFB associated with their CaP care and long-term effects. 49.2% of CaP survivors indicated coping SFB, 27.7% psychological, and 29.2% material. Older (OR: 0.95, 95%CI 0.92-0.98) was associated with less SFB. Low-income level (OR: 2.1, 95%CI 1.01-4.36) was associated with higher SFB. Hispanic survivors (OR: 2.8 95%CI 1.1-7.4) indicated more psychologic SFB. Presence of a caregiver was noted as a predictor of material (OR 2.6, 95%CI 1.45-4.49) and psychological (OR: 2.2, 95%CI 1.13-3.91) SFB.

CONCLUSIONS

Many CaP survivors experience SFB and associated factors differ in domain of financial burden. This provides evidence and groundwork for understanding financial burden and improving the quality of counseling and care for this population.

Financial Toxicity Among Patients With Breast Cancer Worldwide: A Systematic Review and Meta-analysis

Importance

Financial toxicity (FT) is the negative impact of cost of care on financial well-being. Patients with breast cancer are at risk for incurring high out-of-pocket costs given the long-term need for multidisciplinary care and expensive treatments.

Objective

To quantify the FT rate of patients with breast cancer and identify particularly vulnerable patient populations nationally and internationally.

Data Sources

A systematic review and meta-analysis were conducted. Four databases-Embase, PubMed, Global Index Medicus, and Global Health (EBSCO)-were queried from inception to February 2021. Data analysis was performed from March to December 2022.

Study Selection

A comprehensive database search was performed for full-text, English-language articles reporting FT among patients with breast cancer. Two independent reviewers conducted study screening and selection; 462 articles underwent full-text review.

Data Extraction and Synthesis

A standardized data extraction tool was developed and validated by 2 independent authors; study quality was also assessed. Variables assessed included race, income, insurance status, education status, employment, urban or rural status, and cancer stage and treatment. Pooled estimates of FT rates and their 95% CIs were obtained using the random-effects model.

Main Outcomes and Measures

FT was the primary outcome and was evaluated using quantitative FT measures, including rate of patients experiencing FT, and qualitative FT measures, including patient-reported outcome measures or patient-reported severity and interviews. The rates of patients in high-income, middle-income, and low-income countries who incurred FT according to out-of-pocket cost, income, or patient-reported impact of expenditures during breast cancer diagnosis and treatment were reported as a meta-analysis.

Results

Of the 11 086 articles retrieved, 34 were included in the study. Most studies were from high-income countries (24 studies), and the rest were from low- and middle-income countries (10 studies). The sample size of included studies ranged from 5 to 2445 people. There was significant heterogeneity in the definition of FT. FT rate was pooled from 18 articles. The pooled FT rate was 35.3% (95% CI, 27.3%-44.4%) in high-income countries and 78.8% (95% CI, 60.4%-90.0%) in low- and middle-income countries.

Conclusions and Relevance

Substantial FT is associated with breast cancer treatment worldwide. Although the FT rate was higher in low- and middle-income countries, more than 30% of patients in high-income countries also incurred FT. Policies designed to offset the burden of direct medical and nonmedical costs are required to improve the financial health of vulnerable patients with breast cancer.

Impact of a Comprehensive Financial Resource on Financial Toxicity in a National, Multiethnic Sample of Adult, Adolescent/Young Adult, and Pediatric Patients With Cancer

PURPOSE

Financial toxicity is a well-recognized problem for patients with cancer. However, a crucial gap remains in describing and implementing mitigation strategies. We conducted a national survey of a multiethnic adolescent/pediatric and adult patient population served by Family Reach, a nonprofit organization focused on removing financial barriers to cancer care, to evaluate the impact of a comprehensive financial resource on patient-reported financial toxicity.

METHODS

An electronic survey was administered to characterize patients' current financial health and the impact of Family Reach's resources on financial toxicity. The survey was e-mailed to all patients or caregivers who received resources from Family Reach between January 1, 2020, and June 30, 2020. Factors associated with higher financial stress and higher potential impact of resources on financial burden were evaluated through separate multivariate regression models. Qualitative responses were analyzed using manual coding and thematic analysis.

RESULTS

Three hundred thirty socioeconomically and racially diverse respondents (overall response rate 40%; 46% non-Hispanic White; 48% with incomes below the federal poverty line) completed the survey and were included in the analysis. More than half of respondents reported high financial stress in the previous week. Hispanic ethnicity, Black race, and low annual household income were associated with higher financial toxicity. A greater amount of financial assistance was associated with a higher confidence rating that resources provided would decrease financial stress. In open-ended comments, respondents highlighted the impact of the COVID-19 pandemic and resulting job loss on financial toxicity, the importance of financial navigation, the benefits of financial assistance, and anxiety about long-term financial health.

CONCLUSION

A comprehensive financial resource, particularly financial assistance, alleviated financial toxicity in a multiethnic national sample of patients with cancer. Ongoing work is critical to address sustainable funding sources and financial navigation to support patients during treatment and survivorship.

Delivering Genetic Testing for Patients with Prostate Cancer: Moving Beyond Provider Knowledge as a Barrier to Care

INTRODUCTION

The 2018 National Comprehensive Cancer Network guidelines for prostate cancer genetic testing expanded access to genetic services. Few studies have examined how this change has affected provider practice outside of large cancer centers.

METHODS

We conducted a qualitative study of multi-disciplinary health care providers treating patients with prostate cancer at a safety-net hospital. Participants completed an interview that addressed knowledge, practices, and contextual factors related to providing genetic services to patients with prostate cancer. A thematic analysis using both inductive and deductive coding was undertaken.

RESULTS

Seventeen providers completed interviews. Challenges in identifying eligible patients for genetic testing stemmed from a lack of a) systems that facilitate routine patient identification, and b) readily available family history data for eligibility determination. Providers identified non-medical patient characteristics that influenced their referral process, including health literacy, language, cultural beliefs, patient distress, and cost. Providers who see patients at different times along the cancer care continuum viewed benefits of testing differently.

CONCLUSION

The use of digital technologies that systematically identify those eligible for genetic testing referrals may mitigate some but not all challenges identified in this study. Further research should determine how individual provider perceptions influence referral practices and patient access to genetics both within and across cancer specialties.

Characterizing Cancer and Work Disparities Using Electronic Health Records

Advancements in cancer diagnosis and treatment have resulted in improvements in survivor outcomes; however, cancer survivors are more likely to experience adverse employment outcomes such as job loss, reduced working hours, and early retirement. The purpose of this study was to examine employment disparities among cancer survivors. Our study collected data from 29,136 cancer survivors (ages 18-65) between 2015 and 2021 using electronic health records (EHR) and linked to cancer registry data. Of those with employment information (n = 7296), differences in employment status were explored by race, ethnicity, sex, geography, marital status, education, age, and cancer site. Of the patients with employment status available, 61% were employed, 28% were not employed, 9% were disabled, 2% were retired. Logistic regression results revealed adjusted effects: a positive association between employment and marriage, while racial and ethnic minority adults, rurality, and certain age categories were less likely to be employed. Unadjusted results showed a positive association between employment and education. These results contribute to an emerging body of literature showing adverse employment outcomes for cancer survivors.

Navigating financial toxicity in patients with cancer: A multidisciplinary management approach

Approximately one-half of individuals with cancer face personal economic burdens associated with the disease and its treatment, a problem known as financial toxicity (FT). FT more frequently affects socioeconomically vulnerable individuals and leads to subsequent adverse economic and health outcomes. Whereas multilevel systemic factors at the policy, payer, and provider levels drive FT, there are also accompanying intervenable patient-level factors that exacerbate FT in the setting of clinical care delivery. The primary strategy to intervene on FT at the patient level is financial navigation. Financial navigation uses comprehensive assessment of patients' risk factors for FT, guidance toward support resources, and referrals to assist patient financial needs during cancer care. Social workers or nurse navigators most frequently lead financial navigation. Oncologists and clinical provider teams are multidisciplinary partners who can support optimal FT management in the context of their clinical roles. Oncologists and clinical provider teams can proactively assess patient concerns about the financial hardship and employment effects of disease and treatment. They can respond by streamlining clinical treatment and care delivery planning and incorporating FT concerns into comprehensive goals of care discussions and coordinated symptom and psychosocial care. By understanding how age and life stage, socioeconomic, and cultural factors modify FT trajectory, oncologists and multidisciplinary health care teams can be engaged and informative in patient-centered, tailored FT management. The case presentations in this report provide a practical context to summarize authors' recommendations for patient-level FT management, supported by a review of key supporting evidence and a discussion of challenges to mitigating FT in oncology care. CA Cancer J Clin. 2022;72:437-453.

Financial Hardship by Age at Diagnosis Including in Young Adulthood among African American Cancer Survivors

BACKGROUND

Financial hardship is most common among cancer survivors with the fewest financial resources at diagnosis; however, little is known about the financial outcomes of young adult (YA) survivors (ages 20-39 at diagnosis), despite their having fewer financial reserves than older adults.

METHODS

We utilized data from 3,888 participants in the population-based Detroit Research on Cancer Survivors cohort. Participants self-reported several forms of material and behavioral financial hardship (MFH and BFH, respectively). Psychological financial hardship (PFH) was measured using the Comprehensive Score for financial Toxicity (COST) score. Modified Poisson models estimated prevalence ratios (PR) and 95% confidence intervals (CI) for financial hardship by age at diagnosis controlling for demographic, socioeconomic, and cancer-related factors.

RESULTS

MFH prevalence was inversely associated with age such that 72% of YA survivors reported MFH, 62% ages 40 to 54, 49% ages 55 to 64, and 33% ages 65 to 79 (PRadjusted YA vs. 65+: 1.75; 95% CI, 1.49-2.04; Ptrend < 0.001). BFH was also more common among YA survivors (26%) than those ages 65 to 79 (20%; PRadjusted: 1.50; 95% CI, 1.08-2.08; Ptrend = 0.019). Age was positively associated with financial wellbeing. COST scores ranged from 20.7 (95% CI, 19.0-22.4) among YA survivors to 27.2 (95% CI, 26.1-28.2) among adults 65 to 79 years old (Ptrend < 0.001).

CONCLUSIONS

In this population of African American cancer survivors, MFH and BFH were more common, and PFH was more severe, in YA survivors compared with those diagnosed as older adults.

IMPACT

Young adulthood at diagnosis should be considered a risk factor for cancer-related financial hardship and addressed in work designed to reduce the adverse financial impacts of cancer.

Racial Disparities in the Management of Locoregional Colorectal Cancer

Racial disparities pervade nearly all aspects of management of locoregional colorectal cancer, including time to treatment, receipt of resection, adequacy of resection, postoperative complications, and receipt of neoadjuvant and adjuvant multimodality therapies. Disparate gaps in treatment translate into enduring effects on survivorship, recurrence, and mortality. Efforts to reduce these gaps in care must be undertaken on a multilevel basis and focus on modifiable factors that underlie racial disparity.

Association of Race With Cancer-Related Financial Toxicity

PURPOSE

We investigated the association between race and FT among previous patients with cancer. Studies show that patients with cancer experience financial toxicity (FT) because of their cancer treatment.

METHODS

Data on individuals with a cancer history were collected in this cross-sectional study during 2012, 2014, and 2017, from the US Health Information National Trends Survey. This survey is conducted by mail with monetary compensation as an incentive. We specifically assessed responses to two questions: Has cancer hurt you financially? Have you been denied health insurance because of cancer? Multivariable logistic regression analyses were used to assess the associations between these questions and race.

RESULTS

Of 10,592 individuals participating, 1,328 men and women (12.5%) with a cancer history were assessed. Compared with Blacks, Whites were found to have a higher rate of insurance (95.4% v 90.0%), were more likely to receive cancer treatment (93.9% v 85%), and had a higher rate of surgical treatment than Blacks (77% v 60%), Hispanics (55%), and others (77%, 60%, 55%, and 74.2%, respectively, P < .001). On multivariable analysis, Blacks were more than five times as likely to be denied insurance (odds ratio, 5.003; 95% CI, 2.451 to 10.213; P < .001) and more than twice as likely to report being hurt financially because of cancer (odds ratio, 2.448; 95% CI, 1.520 to 3.941; P < .001) than Whites. Of all cancer groups analyzed (genitourinary, gynecologic, gastrointestinal, and breast), genitourinary malignancies were the only group in which the rate of reporting being hurt financially varied in a statistically significant manner (Whites 36.7%, Hispanics 62.5%, and Blacks 59.3%, P = .004).

CONCLUSION

Our data suggest that race is significantly associated with FT because of cancer. Awareness of racial inequality with regards to FT should be raised among health care workers.

The DISCO App: A pilot test of a multi-level intervention to reduce the financial burden of cancer through improved cost communication☆

Objective

Financial toxicity affects 30–50% of people with cancer in the US. Although experts recommend patients and physicians discuss treatment cost, cost discussions occur infrequently. We pilot-tested the feasibility, acceptability and influence on outcomes of the DIScussions of COst (DISCO) App, a multi-level communication intervention designed to improve cost discussions and related outcomes.

Methods

While waiting to see their physician, patients (n = 32) used the DISCO App on a tablet. Physicians were given a cost discussion tip sheet. Clinic visits were video recorded and patients completed pre- and post-intervention measures of self-efficacy for managing costs, self-efficacy for interacting with physicians, cost-related distress, and perceptions of the DISCO App. Coders observed the recordings to determine the presence of cost discussions, initiators, and topics.

Results

Most patients reported needing ≤15 min to use the DISCO App, and that it made it easier to ask cost-related questions. Findings showed increased self-efficacy for managing treatment costs (p = .02) and for interacting with physicians (p = .001). All visits included a cost discussion.

Conclusions

Prompting patients to discuss costs may improve cost treatment discussions and related outcomes.

Innovation

An app-based and tailorable treatment-cost communication intervention is feasible, acceptable, and demonstrates promise in prompting cost discussions and improving outcomes.

Trial registration: Clinical Trials.gov registration number: NCT03676920 (September 19, 2018).

Demographic Analysis of Financial Hardships Faced by Brain Tumor Survivors

OBJECTIVE

Quantitative analysis of the financial hardship faced by patients with brain tumors is lacking. The present study sought to conduct a longitudinal analysis of responses to the National Health Interview Survey by patients diagnosed with brain tumors and characterize the impact of demographic factors on financial hardship indices.

METHODS

National Health Interview Survey respondents between 1997 and 2018 who reported previous diagnosis with cancer of the brain and who responded to 4 survey questions that assessed financial stress were included. Sociodemographic exposures included age, ethnicity/race, marriage status, insurance status, and degree of highest educational attainment.

RESULTS

Educational attainment, marital status, and insurance status were the most significant risk factors for temporary or indefinite delays to necessary medical care. Those with only a high-school diploma had 9.6 times higher odds (adjusted odds ratio, 9.68; 95% confidence interval, 2.96-31.70; P < 0.001) of reporting that, in the past 12 months, one of their family members had to limit their medical care in an effort to save money. Similarly, patients with brain tumors who were not married had 3.94 times greater odds (adjusted odds ratio, 3.94; 95% confidence interval, 1.49-10.44; P = 0.009) of avoiding necessary medical care because of an inability to afford it.

CONCLUSIONS

Given this variation in self-reported financial burden, demographics clearly have an impact on a patient's holistic experience after a brain cancer diagnosis. Therefore, by using the comparisons in this study, we hope that medical institutions and neurosurgical societies can more accurately predict which patients are most susceptible to significant financial stress and distribute resources accordingly.

A Review of Research on Disparities in the Care of Black and White Patients With Cancer in Detroit

Racial disparities in cancer incidence and outcomes are well-documented in the US, with Black people having higher incidence rates and worse outcomes than White people. In this review, we present a summary of almost 30 years of research conducted by investigators at the Karmanos Cancer Institute's (KCI's) Population Studies and Disparities Research (PSDR) Program focusing on Black-White disparities in cancer incidence, care, and outcomes. The studies in the review focus on individuals diagnosed with cancer from the Detroit Metropolitan area, but also includes individuals included in national databases. Using an organizational framework of three generations of studies on racial disparities, this review describes racial disparities by primary cancer site, disparities associated with the presence or absence of comorbid medical conditions, disparities in treatment, and disparities in physician-patient communication, all of which contribute to poorer outcomes for Black cancer patients. While socio-demographic and clinical differences account for some of the noted disparities, further work is needed to unravel the influence of systemic effects of racism against Black people, which is argued to be the major contributor to disparate outcomes between Black and White patients with cancer. This review highlights evidence-based strategies that have the potential to help mitigate disparities, improve care for vulnerable populations, and build an equitable healthcare system. Lessons learned can also inform a more equitable response to other health conditions and crises.

Associations of Household Income with Health-Related Quality of Life Following a Colorectal Cancer Diagnosis Varies With Neighborhood Socioeconomic Status

BACKGROUND

Existing evidence indicates household income as a predictor of health-related quality of life (HRQoL) following a colorectal cancer diagnosis. This association likely varies with neighborhood socioeconomic status (nSES), but evidence is limited.

METHODS

We included data from 1,355 colorectal cancer survivors participating in the population-based Puget Sound Colorectal Cancer Cohort (PSCCC). Survivors reported current annual household income; we measured HRQoL via the Functional Assessment of Cancer Therapy - Colorectal (FACT-C) tool. Using neighborhood data summarized within a 1-km radial buffer of Census block group centroids, we constructed a multidimensional nSES index measure. We employed survivors' geocoded residential addresses to append nSES score for Census block group of residence. With linear generalized estimating equations clustered on survivor location, we evaluated associations of household income with differences in FACT-C mean score, overall and stratified by nSES. We used separate models to explore relationships for wellbeing subscales.

RESULTS

We found lower household income to be associated with clinically meaningful differences in overall FACT-C scores [<$30K: -13.6; 95% confidence interval (CI): -16.8 to -10.4] and subscale wellbeing after a recent colorectal cancer diagnosis. Relationships were slightly greater in magnitude for survivors living in lower SES neighborhoods.

CONCLUSIONS

Our findings suggest that recently diagnosed lower income colorectal cancer survivors are likely to report lower HRQoL, and modestly more so in lower SES neighborhoods.

IMPACT

The findings from this work will aid future investigators' ability to further consider the contexts in which the income of survivors can be leveraged as a means of improving HRQoL.

Patient reported outcomes affecting quality of life in socioeconomically disadvantaged cancer patients

PURPOSE

The aim of this study was to identify correlates of quality of life (QOL) for socioeconomically disadvantaged cancer patients receiving care in the "safety net" health system.

DESIGN

This cross-sectional study used linear regressions to determine the effect of patient reported outcome measures (PRO) on QOL.Sample/Methods: Cancer patients (n = 115) receiving drug therapy completed a series of PROs including: Functional Assessment of Cancer Therapy (FACT-G), PROMIS (Anxiety, Depression, Fatigue, Pain Interference, and Physical Function), and the Comprehensive Score for Financial Toxicity.

FINDINGS

More than 60% of patients reported an annual income below $24,999. Forty-five percent of patients were either uninsured or county-funded. Depression, pain, and financial toxicity were found to be consistently significant correlates of QOL.Implications: Cancer patients with existing financial strain have unique psychosocial stressors. This study provides insight into the relationship between these stressors, and the need for targeted screening and intervention that address such aspects of care.

Genetic Variations and Health-Related Quality of Life (HRQOL): A Genome-Wide Study Approach

Simple Summary

Health-related quality of life (HRQOL) is associated with cancer prognosis as well as with age, sex, race, and lifestyle factors, including diet and physical activity. To investigate the hypothesis that HRQOL has genetic underpinnings in patients with cancer, we performed a genome-wide association study to evaluate genetic variants (single nucleotide polymorphisms, SNPs) associated with mental and physical QOL as measured by the PROMIS assessment tool in breast cancer survivors participating in a longitudinal cohort study, the Mayo Clinic Breast Disease Registry (MCBDR). Age and financial concerns were associated with worse physical and mental health, and previous receipt of chemotherapy was associated with worse mental health. SNPs in SCN10A, LMX1B, SGCD, PARP12, and SEMA5A were associated with physical and mental QOL, but none at the genome-wide significance thresholds of p < 5 × 10⁻⁸.

Abstract

Health-related quality of life (HRQOL) is an important prognostic patient-reported outcome in oncology. Because prior studies suggest that HRQOL is, in part, heritable, we performed a GWAS to elucidate genetic factors associated with HRQOL in breast cancer survivors. Physical and mental HRQOL were measured via paper surveys that included the PROMIS-10 physical and mental health domain scales in 1442 breast cancer survivors participating in the Mayo Clinic Breast Disease Registry (MCBDR). In multivariable regression analyses, age and financial concerns were significantly associated with global physical health (age: p = 1.6 × 10⁻²³; financial concerns: p = 4.8 × 10⁻⁴⁰) and mental health (age: p = 3.5 × 10⁻⁷; financial concerns: p = 2.0 × 10⁻⁶⁹⁾. Chemotherapy was associated with worse global mental health (p = 0.01). In the GWAS, none of the SNPs reached the genome-wide association significance threshold of 5 × 10⁻⁸ for associations with either global physical or global mental health, however, a cluster of SNPs in SCN10A, particularly rs112718371, appeared to be linked to worse global physical health (p = 5.21 × 10⁻⁸). Additionally, SNPs in LMX1B, SGCD, PARP12 and SEMA5A were also moderately associated with worse physical and mental health (p < 10⁻⁶). These biologically plausible candidate SNPs warrant further study as possible predictors of HRQOL.

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.

Social needs and health-related quality of life among African American cancer survivors: Results from the Detroit Research on Cancer Survivors study

BACKGROUND

Social needs may affect cancer survivors' health-related quality of life (HRQOL) above and beyond sociodemographic and cancer-related factors. The purpose of this study was to estimate associations between social needs and HRQOL.

METHODS

Results included data from 1754 participants in the Detroit Research on Cancer Survivors cohort, a population-based study of African American survivors of breast, colorectal, lung, and prostate cancer. Social needs included items related to food insecurity, utility shutoffs, housing instability, not getting health care because of cost or a lack of transportation, and perceptions of neighborhood safety. HRQOL was measured with the validated Functional Assessment of Cancer Therapy-General (FACT-G). Linear regression models controlled for demographic, socioeconomic, and cancer-related factors.

RESULTS

More than one-third of the survivors (36.3%) reported social needs including 17.1% of survivors reported 2 or more. The prevalence of social needs ranged from 14.8% for food insecurity to 8.9% for utility shutoffs. FACT-G score differences associated with social needs were -12.2 (95% confidence interval [CI] to -15.2 to -9.3) for not getting care because of a lack of transportation, -11.3 (95% CI, -14.2 to -8.4) for housing instability, -10.1 (95% CI, -12.7 to -7.4) for food insecurity, -9.8 (95% CI, -12.7 to -6.9) for feeling unsafe in the neighborhood, -8.6 (95% CI, -11.7 to -5.4) for utility shutoffs, and -6.7 (95% CI, -9.2 to -4.1) for not getting care because of cost.

CONCLUSIONS

Social needs were common in this cohort of African American cancer survivors and were associated with clinically significant differences in HRQOL. Clinical oncology care and survivorship care planning may present opportunities to screen for and address social needs to mitigate their impact on survivors' HRQOL.

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.

Heritable Susceptibility to Breast Cancer among African-American Women in the Detroit Research on Cancer Survivors Study

BACKGROUND

African-American women have high rates of breast cancer associated with hereditary features. However, no studies have reported the prevalence of inherited variation across all genes known to be breast cancer risk factors among African-American patients with breast cancer not selected for high-risk characteristics.

METHODS

We evaluated 182 African-American women diagnosed with invasive breast cancer in metropolitan Detroit via targeted capture and multiplex sequencing of 13 well-established breast cancer risk genes and five suggested breast cancer risk genes.

RESULTS

We identified 24 pathogenic variants in 23 women [12.6%; 95% confidence interval (CI), 8.2%-18.4%] and five genes (BRCA2, BRCA1, ATM, RAD50, CDH1). BRCA1 and BRCA2 accounted for 58.3% of all pathogenic variants. An additional six pathogenic variants were found in suggested breast cancer risk genes (MSH6, MUTYH, NF1, BRIP1).

CONCLUSIONS

The prevalence of germline pathogenic variants is relatively high among African-American patients with breast cancer unselected for high-risk characteristics across a broad spectrum of genes.

IMPACT

This study helps to define the genomic landscape of breast cancer susceptibility in African-American women who could benefit from enhanced surveillance and screening.

Medical financial hardship reported by Native Hawaiian and Pacific Islander cancer survivors compared with non-Hispanic whites

BACKGROUND

Although medical financial hardship (MFH) resulting from sequelae of cancer and treatment has been reported in other racial/ethnic populations, little is known about MFH among Native Hawaiian and Pacific Islander (NHPI) cancer survivors.

METHODS

One hundred fifty adult NHPI cancer survivors were identified from the 2014 NHPI National Health Interview Survey (NHIS). Cancer survivors were those with a history of cancer (excluding nonmelanoma/unknown type of skin cancer). MFH was defined by 3 domains: 1) material (problem paying or unable to pay medical bills); 2) psychological (worrying about paying medical bills); and 3) behavioral (delaying or forgoing medical care for financial reasons). For comparison, 2098 non-Hispanic white (NHW) cancer survivors were identified from the 2014 NHIS. Logistic regressions were used to identify sociodemographic and health factors associated with experiencing MFH. Stratified analysis by age (<65 vs ≥65 years) and sensitivity analysis using propensity score-matched NHPI and NHW cancer survivors were conducted. Nationally representative estimates were generated using survey weights.

RESULTS

Among elderly cancer survivors, more NHPIs reported any MFH (59% vs 32%; P = .001), psychological MFH (36% vs 22%; P = .040), and behavioral MFH (27% vs 9%; P = .004) than NHWs. Among survivors aged <65 years, NHPIs reported less MFH (46% vs. 65%; P = .034). Even after propensity score matching, these patterns persisted. Female NHPIs and NHPIs with a college degree were significantly more likely to report MFH, especially material and psychological MFH.

CONCLUSIONS

A significantly higher proportion of elderly NHPI cancer survivors reported MFH, and this difference persisted even after propensity score matching, which warrants further investigation.

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.

Employment Outcomes, Financial Burden, Anxiety, and Depression Among Caregivers of African American Cancer Survivors

PURPOSE

Caregivers of cancer survivors may need to take time off work or make other employment changes to handle caregiving demands. Work impacts of caregiving, financial burden, and psychosocial outcomes of caregivers are not well understood.

METHODS

Results include information from surveys completed by 202 employed caregivers of participants in the Detroit Research on Cancer Survivors cohort, a population-based cohort of African American survivors of breast, colorectal, lung, or prostate cancer. Relationships between work outcomes, financial burden, and anxiety and depression were assessed using logistic regression models controlling for demographic and cancer-related factors.

RESULTS

Most (73.8%) caregivers made some employment change. Sixty percent changed their schedule, hours, duties, or employment status; 15.3% took at least 1 month off to provide care, and 38% reported difficulty balancing work and caregiving. Employment changes were strongly associated with difficulty balancing work and caregiving (odds ratio [OR], 5.83; 95% CI, 2.38 to 14.0) and financial burden (OR, 2.12; 95% CI, 1.05 to 4.27). Difficulty balancing work and caregiving was associated with symptoms of anxiety (OR, 1.86; 95% CI, 1.01 to 3.43) and depression (OR, 2.40; 95% CI, 1.16 to 4.96). High (v low) financial burden was associated with symptoms of anxiety (OR, 2.85; 95% CI, 1.01 to 8.06).

CONCLUSION

Difficulty balancing work and caregiving is common among caregivers of African American cancer survivors and is associated with symptoms of depression and anxiety. Supports for caregivers facing employment challenges may improve their psychosocial well-being.