Financial Toxicity in Adults With Cancer: Adverse Outcomes and Noncompliance

Thomas G. Knight; Allison M. Deal; Stacie B. Dusetzina; Hyman B. Muss; Seul Ki Choi; Jeannette T. Bensen; Grant R. Williams


J Oncol Pract. 2018;14(11) 

In This Article


Table 1 lists the study demographics. The study cohort consisted of 1,988 participants. The mean age was 59 (standard deviation, 12.3) years, 62% were women, 81% were white, and 16% were black. The most common tumor types were breast (31%), GI (23%), and genitourinary (17%; Table 1). Most participants reported educational attainment of less than a college degree (55%) and were not currently working for pay (60%). More than half of the participants (56%) had received a cancer diagnosis within 2 years of their participation in the survey.

Of the 1,988 participants, 524 respondents (26%) agreed or strongly agreed that they had to pay more for medical care than they could afford. In a univariable comparison of those who did and did not report financial toxicity, the patients who reported financial toxicity were more likely be ≤ 65 years of age (82% v 62%) and nonwhite (30% v 16%). They were also more likely to be unmarried (42% v 28%) and possess less education than a college degree (68% v 50%; all P <.001). The group reporting financial toxicity were also more likely to have received a cancer diagnosis within the last 3 years (73% v 66%, P <.001) as opposed to ≥ 3 years from the time of the survey. Finally, as measured by the FACT-GP, patients reporting financial toxicity also had significantly lower physical, functional, emotional, and social well-being compared with those patients without financial toxicity (all P < .001).

Table 2 lists the adjusted relative risks (RRs) for reporting financial toxicity. In an adjusted model that included all covariables, some risk factors identified as statistically significant independent predictors of financial toxicity were lower education levels (RR, 2.41; 95% CI, 1.59 to 3.65 for not having a high school diploma), being unmarried (RR, 1.35; 95% CI, 1.13 to 1.62), and being of black race (RR, 1.63; 95% CI, 1.34 to 1.99). Protective factors included age > 65 years (RR, 0.41; 95% CI, 0.36 to 0.66) and being longer than 3 years from diagnosis (RR, 0.78; 95% CI, 0.63 to 0.97). Cancer type was not significant on adjusted analysis.

The cohort of patients meeting the criteria for financial toxicity was also more likely to report noncompliance in key areas of treatment, because of an inability to afford their medical care over the past year (Table 3). This was true even when we adjusted for age, race, education, and days from diagnosis to baseline survey. Specifically, in this model, participants reporting financial toxicity were more likely to report needing but being unable to afford prescription (RR, 3.55; 95% CI, 2.53 to 4.98) and over-the-counter (RR, 2.24; 95% CI, 1.40 to 3.59) medications. They also reported noncompliance because of cost concerns of other key components of medical care, such as doctor's visits (RR, 2.98; 95% CI, 1.97 to 4.51), medical tests (RR, 2.54; 95% CI, 1.49 to 4.34), mental health care (RR, 3.89; 95% CI, 2.04 to 7.45), and dental visits (RR, 2.86; 95% CI, 2.20 to 3.73).

Finally, participants were asked if they had delays getting care in the year before the survey and the reasons leading to this delay. Multiple reasons were identified for delayed care, which were found to be more prevalent in patients reporting financial toxicity even when adjusted for age, race, education, and days from diagnosis to baseline survey. These reasons included not having transportation (RR, 1.82; 95% CI, 1.04 to 3.20), lack of insurance (RR, 1.92; 95% CI, 1.33 to 2.76), inability to pay their general household expenses (RR, 2.73; 95% CI, 2.01 to 3.70), inability to pay for travel (RR, 2.32;95%CI, 1.40 to 3.86), and an inability to take time off of work (RR, 2.72;95%CI, 1.67 to 4.42; all P < .05).