Breast Cancer Wariness: Half Pursued by Debt Collectors

'Staggering Statistic,' Says Observer

Nick Mulcahy

October 10, 2018

Nearly half of a sample of American patients with metastatic breast cancer reported being pursued by debt collectors, according to a financial survey reported last week at the American Society of Clinical Oncology (ASCO) Quality Care Symposium (QCS) in Phoenix, Arizona.

The 1054-patient survey included individuals from 41 states; 49% reported contact from debt collectors related to cancer treatment bills.

"We found a very high level of debt collection," lead author Stephanie Wheeler, PhD, MPH, of the University of North Carolina Lineberger Comprehensive Cancer Center in Chapel Hill, told Medscape Medical News.

This is a "staggering statistic on financial toxicity in cancer care," commented Nate Handley, MD, MBA, of the Kimmel Cancer Center at Jefferson University in Philadelphia, who attended the meeting and mentioned the study on Twitter.

The study participants were a mix of insured (n = 738) and uninsured (n = 316) patients.

Unsurprisingly, most of the uninsured patients (90%) were subject to debt collection. By contrast, only about one third of the insured patients were.

We found a very high level of debt collection. Dr Stephanie Wheeler

The survey did not explore the frequency of the collections contacts or the methods (eg, telephone calls, email, postal service). Wheeler explained: "Most of the time when debt collectors contact patients, they do it in multiple formats."

The survey also found that 54% of participants reported stopping or refusing treatment because of cost.

All of the patients who participated were members of the Metastatic Breast Cancer Network advocacy organization. They responded to an email invitation to take the 20-minute online survey. Respondents received a $10 Amazon gift card.

About 50% of the survey participants had had a diagnosis of metastatic disease for 1 to 2 years. Fewer than 5% had been diagnosed for 5 years or longer.

Although some metastatic breast cancer patients live 10 years or longer after diagnosis, the median survival for metastatic breast cancer patients in the United States is 26.9 months, according to a recent study from National Cancer Institute staff.

How Representative?

The new research is atypical, in a number of ways. Most financial toxicity research is carried out among people with early-stage cancers, and "little is known" about financial distress among patients with metastatic disease, the authors comment.

Wheeler also acknowledged that the results could "possibly" be inflated. "We might have attracted people to the survey who were struggling with cost of care," she said. It is "hard to know" how representative the results are, she added.

Furthermore, the mean age of the study population was about 42 years, which is relatively young for breast cancer patients.

The survey is also novel, being the first to address all three pillars of "financial toxicity" (material burden, psychological distress, and behavioral response) in a metastatic cancer patient population. Financial toxicity is the now popular buzz phrase for adverse outcomes related to medical costs.

The survey found that 56% of respondents did not have enough in savings to cover their bills from cancer care.

"This is a precursor to debt collection — when people say they don't have enough savings [to cover bills]," said Wheeler.

Worry about the financial problems caused by cancer treatment was the most commonly reported quality/attribute in the study (68% of respondents).

"It makes sad — the amount of worry that people had about the financial stress that their cancer had caused for their family," said Wheeler.

Health insurance expansion is necessary but is insufficient to address cancer-associated financial burden, the study authors argue.

"We need additional interventions within our health care system to try to prevent and mitigate financial toxicity, including trained financial navigators who can identify patients' financial needs and help them determine eligibility for, and gain access to, assistance programs," said Wheeler in a press statement.

In the survey, uninsured patients with metastatic cancer were more likely to identify themselves as being a member of a racial or ethnic minority, as having lower income, and as working full time.

However, having insurance and a privileged socioeconomic status did not exempt survey participants from financial and emotional distress.

"Insurance is not fully protective against debt," said Wheeler.

"High coinsurance and deductibles mean that many patients are still shouldering an enormous financial burden out of pocket and feeling anxious about what it will mean for their own and their families' finances and financial legacy," she said.

Funding for this project was provided through the National Comprehensive Cancer Network and Pfizer Independent Grants for Learning and Change. Some study authors have financial ties to Pfizer.

American Society of Clinical Oncology (ASCO) Quality Care Symposium (QCS). Abstract 32, presented September 29, 2018.

Follow Medscape senior journalist Nick Mulcahy on Twitter: @MulcahyNick

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