Risk Factor for Early Death in Cancer Patients: Bankruptcy

Fran Lowry

January 28, 2016

For patients diagnosed with cancer, mortality rates are higher in those who file for bankruptcy because of the cost of their treatment than their counterparts who remain financially solvent.

In a study that linked data from the SEER Cancer Registry for the state of Washington with bankruptcy records for that region, the risk for death was 80% higher in cancer patients who filed for bankruptcy than in those who did not.

The study, led by Scott D. Ramsey, MD, PhD, from the Fred Hutchinson Cancer Research Center in Seattle, was published online January 25 in the Journal of Clinical Oncology.

"For people who experience extreme financial distress during cancer, mortality suffers greatly," Dr Ramsey told Medscape Medical News.

In earlier work, Dr Ramsey and his team of researchers found that many cancer patients are in danger of going bankrupt.

This is believed to be the first study to show an association between filing for bankruptcy and poorer survival.

There is no question about the validity.

"We linked several bankruptcy records with our SEER Cancer Registry, which is the National Cancer Institute's registry for Washington state, so the data are very accurate. There is no question about the validity of the bankruptcies, the deaths, or the cancer cases," he said.

Treatment Decision Needs to Consider Cost

Dr Scott Ramsey

"We have been involved in a number of studies that show that cancer patients suffer financial hardships. In fact, it's now a hot topic. The new term people are using is 'financial toxicity'," Dr Ramsey reported.

In fact, research has shown that more than one-third of cancer patients worry about bankruptcy because of the cost of treatment.

A previous study showed that 37.1% of 480 patients surveyed reported being "seriously or very seriously" concerned about bankruptcy because of medical bills, 41.7% reported paying more for healthcare during the previous 12 months, and one-third reported being were very concerned about the out-of-pocket costs for hospitalization, mediations, lab tests, and scans, as reported by Medscape Medical News.

Their fears are well-founded, Dr Ramsey noted.

In 2013, he and his group found that patients diagnosed with cancer were 2.5 times more likely to file for bankruptcy than those not diagnosed with cancer (Health Aff [Millwood]. 2013;32:1143-1152).

"Between 30% and 45% of patients who have cancer are now experiencing some degree of financial toxicity, which we define as remortgaging your house, selling your house, using up all your assets, or borrowing money from friends in order to pay for your treatment," he said.

In the current study, the SEER data showed that 231,596 Washingtonians were diagnosed with cancer from 1995 to 2009. Of these, 4728 filed for bankruptcy.

The team compared mortality outcomes in 3841 cancer patients who filed for bankruptcy and 3841 who did not.

Age, sex, cancer type, cancer stage, and socioeconomic status were similar in the two groups. Mean age was 53 years in the study cohort, mean income was $49,000, and 54% of the patients were men, 86% were white, 60% were married, 91% lived in urban areas, and 84% had local or regional disease at diagnosis.

initial treatments were similar in the two groups.

For patients who filed for bankruptcy, compared with those who did not, the adjusted hazard ratio (HR) for mortality was 1.79 (95% confidence interval [CI], 1.64 - 1.96).

For patients with specific cancers — breast, lung, colorectal, and prostate — mortality rates were significantly higher in those who filed for bankruptcy than in those who did not.

For patients with prostate cancer, the risk for mortality was twice as high in those who filed for bankruptcy as in those who did not (HR, 2.07; 95% CI, 1.56 - 2.74). For patients with colorectal patients, the risk was almost 2.5 times as high (HR, 2.47; 95% CI, 1.85 - 3.31).

"We suspect that even less-severe forms of financial distress that do not result in bankruptcy are also potentially fatal," Dr Ramsey stated. He speculated that bankruptcy might hasten death because patients are not finishing or even starting planned treatments.

"It may well be that the stress of the bankruptcy on top of the stress of the cancer has some physical effect. Those would be the most likely things, I would think," Dr Ramsey explained.

"The problem of the extreme cost of medical treatment is making it hard for people to get the care that they thought they were going to get. This is something that, as a society, we have not been able to face," he added.

Because cancer care is now so expensive, focusing on access to care is not sufficient, he pointed out. Cost can influence compliance with treatment, and should be taken into account during treatment deliberations.

For patients with gastric cancer, for example, costs can vary widely, according to treatment, but the differences in efficacy are negligible.

In fact, the least and most expensive treatments are equally recommended by guideline groups. But for 6 months of treatment, the least expensive is $800 and the most expensive is $57,000.

"Practitioners may need to consider the financial health of their patients as a matter of course, simultaneously with the initiation of therapy," Dr Ramsey said.

This study was funded by the National Institutes of Health. Dr Ramsey has disclosed no relevant financial relationships.

J Clin Oncol. Published online January 25, 2016. Abstract


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