Roxanne Nelson

June 16, 2011

June 16, 2011 (Chicago, Illinois) — The high cost of care is an ever-increasing problem for cancer patients, but surviving the disease can exact an even greater financial toll. A new study suggests that the longer a patient survives, the higher the rate of insolvency.

Bankruptcy rates were nearly twice as high among cancer patients 1 year after their diagnosis as among the general population, the study found. The median time to bankruptcy was 2.5 years after diagnosis.

The study results were presented here at the American Society of Clinical Oncology 2011 Annual Meeting.

"Patients diagnosed with cancer may face significant financial stress, owing to income loss and out-of-pocket costs associated with their treatment," said lead author Scott Ramsey, MD, PhD, a healthcare economist and internist at the Fred Hutchinson Cancer Research Center in Seattle, Washington. "On average, bankruptcy rates increased 4-fold within 5 years of diagnosis."

But the risk for bankruptcy is not well characterized in cancer patients, he pointed out, adding that the risk varies with cancer type, stage at diagnosis, treatments received, and personal factors.

"Another important trend is that across all cancers studied, younger patients are at particular risk for bankruptcy," Dr. Ramsey said. "We think this is due to several factors; younger individuals are likely to have lower income and assets and less access to health insurance."

Patients Feel the Burden

Medical illness is one of the leading causes of bankruptcy filings in the United States, and part of the larger problem of healthcare that continues to become increasingly expensive. The growth in healthcare spending is greater than the growth in gross domestic product, and that is unsustainable, said Neal J. Meropol, MD, in a discussion of the study.

"The National Institutes of Health estimates that in 2010, the total costs for cancer were $264 billion, with $103 billion for direct medical costs," said Dr. Meropol, who is chief of the division of hematology and oncology at University Hospitals Case Medical Center in Cleveland, Ohio. "It's expected that in the next few decades, it'll easily exceed $150 billion."

Total spending on healthcare in the United States is about $2.5 trillion, he pointed out. "On the one hand, cancer is only a small percentage — less than 10% — of our overall healthcare spending. On the other hand, this has huge implications for individual patients who are facing a life-threatening condition."

The cost of care has a wide impact, he said. "At the end of the day, individual patients are the ones feeling the burden, and these burdens are related to being uninsured, insurance premiums, copays and coinsurance, tiered formularies, and Part D donut holes."

"These influences result in increased financial burdens on families, delays in seeking treatment, and the potential to limit or alter treatment," he added.

Longer Survival, Higher Bankruptcy Risk

In their study, Dr. Ramsey and colleagues linked cancer registry data in Washington State to federal bankruptcy court records in 13 counties in western Washington. They then measured the rate of bankruptcy after a first cancer diagnosis and identified factors that increased bankruptcy risk among people with common cancers.

"There have been previous studies looking at cancer and bankruptcy, but they have primary relied on self-reports about medically related reasons for bankruptcy filing," said Dr. Ramsey.

The cancer patients in this study were those filing for their first bankruptcy (chapter 7 or chapter 13) from 1995 to 2009 after receiving their cancer diagnosis.

"There was a law that significantly changed bankruptcy filing in 2005, and we accounted for that with a time-dependent covariable," he noted.

The team identified 231,799 cancer cases; of this cohort, 4805 people (2.1%) filed for bankruptcy after a mean follow-up of 4.3 years. The mean time to bankruptcy was 2.5 years, and insolvency rates increase along with the length of survival.

In the general population in the same area, the bankruptcy rate was only 0.28%.

"Lung cancer patients fortunate enough to live up to 5 years after their diagnosis had the highest bankruptcy rates — 8%," said Dr. Ramsey. "The risk increases as survival time increases, and the risk varies substantially across cancer types."

The bankruptcy risk varied widely across cancer types. Lung, thyroid, and leukemia/lymphoma cancers had the highest conditional probabilities at 1 year (1.5%, 0.9%, and 0.6%, respectively), 2 years (3.1%, 2.0%, and 1.4%, respectively), and 5 years (7.7%, 4.8%, and 3.6%, respectively) from diagnosis.

The risk for bankruptcy was also higher for lung, colorectal, and breast cancer patients who underwent surgery (hazard ratio [HR], 2.0 to 4.1) and received chemotherapy (HR, 1.4 to 1.5).

Patients older than 65 years, who are typically on Medicare, had a much lower risk for bankruptcy than younger patients. Dr. Ramsey noted that recent trends in bankruptcy rates suggest that the financial crisis has significantly increased financial hardship for cancer patients.

"The bankruptcy laws of 2005 had a large influence on the timing of filing for bankruptcy," he added. "There was a huge spike after the enactment of that law, followed by a decline."

The researchers assumed that prior to the law going into effect, most people who felt that they were at imminent risk for bankruptcy simply moved their schedule ahead. "We're not sure what the overall influence on those filings would have been without that law," said Dr. Ramsey.

Looking at the issue on a larger scale, Dr. Meropol explained that trends in healthcare spending and the economic recession threaten the nation's health.

"Oncologists should recognize and address the impact of cancer care costs on individual patients," he said, "and insurance designs should encourage high-value interventions, not merely increase cost sharing based on the cost of the therapy, but on the value of particular medical interventions."

The study was funded by the National Cancer Institute. Dr. Ramsey has disclosed no relevant financial relationships. Dr. Meropol reports serving as a consultant/advisor for AstraZeneca, Genentech, Genomic Health, and Helsinn; and receiving research funding from Genomic Health.

American Society of Clinical Oncology (ASCO®) 2011 Annual Meeting: Abstract 6007. Presented June 6, 2011.

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