Financial Burden Higher With CVD Than Cancer

Anna Goshua

June 24, 2021

Cardiovascular disease is associated with even higher financial distress — so-called financial toxicity (FT) — than the well-documented association with cancer, and worst off were those with both diagnoses, a new study suggests.

A population-based analysis of financial hardship among patients with atherosclerotic cardiovascular disease (ASCVD), cancer, or both showed that ASCVD patients reported higher FT regardless of cancer status. Patients with both ASVD and a cancer diagnosis had the highest FT.

Javier Valero-Elizondo

"Most of this type of research has been done in oncology. We realized that we knew next to nothing about financial toxicity in cardiovascular disease," said senior author of the study, Javier Valero-Elizondo, MD, Houston Methodist DeBakey Heart and Vascular Center, in an interview with Medscape Medical News.

The researchers' next steps involve developing "tools that can help us identify, prevent, or mitigate financial burden in individuals with cardiovascular disease," said Valero-Elizondo.

The results were published in the June issue of JACC: CardioOncology.

For this analysis, the researchers used National Health Interview Survey data on 141,286 adults 18 to 65 years of age with self-reported ASCVD, which included coronary or cerebrovascular disease, and/or cancer from 2013 to 2018. Of these patients, 6,093 had ASCVD, 6,887 had cancer, 971 had both, and 127,875 had neither.

Although their main analysis only involved nonelderly patients, to capture patients who do not have access to public insurance, like Medicare, they also performed a subgroup analysis of 48,287 elderly patients (≥65 years), which included 8,167 with ASCVD, 8,457 with cancer, and 3,211 with both diagnoses.

Financial toxicity was defined as any of the following: "any difficulty paying medical bills, high financial distress, cost-related medication nonadherence, food insecurity, and/or foregone/delayed care due to cost." The components of FT were analyzed individually after adjustment for age, sex, race/ethnicity, income, education, insurance type, comorbidities, geographic region, cardiovascular risk factor profile, and medical bill burden.

Overall, FT was more prevalent among patients with ASCVD than among those with cancer (54% vs 41%; P < .001).

ASCVD patients were more likely to:

  • have difficulty paying medical bills (odds ratio [OR], 1.22; 95% CI, 1.09 - 1.36)

  • be unable to pay bills (OR, 1.25; 95% CI: 1.04 - 1.50)

  • have cost-related medication nonadherence (OR, 1.28; 95% CI: 1.08 - 1.51)

  • have food insecurity (OR, 1.39; 95% CI: 1.17 - 1.64)

  • delay or forego medical care because of cost (OR, 1.17; 95% CI: 1.01 - 1.36).

Although effect sizes were larger, they saw no statistical differences between patients with ASCVD only and those with both ASCVD and cancer in the adjusted analyses, the authors write. "Our findings further reinforce the notion that presence of ASCVD was a key determinant of the presence and severity of FT," they note.

In addition, patients with either ASCVD or ASCVD and cancer were significantly more likely to report at least three of these factors than those with cancer (23% vs 30% vs 13%; P for trend < .001).

The same pattern was observed in elderly people, but rates were lower than in nonelderly people.

Cardiovascular disease and cancer are the two leading causes of mortality in the United States. Although health outcomes have improved for these patients, this has "resulted in increasing costs of health care both at the system level and for individual patients," write Reza Arsanjani, MD, and Nandita Khera, MD, both from Mayo Clinic Arizona, Phoenix, in an accompanying editorial.

For patients with both ASCVD and cancer, "the multimorbidity places a significant physiological stress that increases the risk of mortality as well as resulting in higher out-of-pocket (OOP) spending due to both expensive medication use and increased hospitalizations," they note.

To help patients navigate financial burdens related to treatment, Valero-Elizondo urged physicians to "talk to your patients today because there's a lot we can do as physicians to help."

The editorialists add that "more rigorous research, policy level initiatives, and better integration with clinical workflow can ensure that catastrophic financial consequences for patients do not undermine the scientific progress by making ability to pay a limiting criterion for treatment."

Specifically, they call for research dedicated to tackling FT in vulnerable populations in which FT is more prevalent, such as patients of lower socioeconomic status, younger patients, and patients belonging to racial minorities.

The funders had no role in the study. Valero-Elizondo, Arsanjani, and Kehra declare no relevant financial relationships. Financial relationships for Valero-Elizondo's coauthors are detailed in the publication.

JACC CardioOncol. 2021;3:236-246, 247-249. Full text, Editorial

Anna Goshua is a reporting intern with Medscape. She is a dual medical and journalism student who has previously written for STAT, Scientific American, Slate, and other outlets. She can be reached at or @AnnaGoshua.

For more news, follow Medscape on Facebook, Twitter, Instagram, and YouTube


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.