Association of Medical Financial Hardship and Mortality Among Cancer Survivors in the United States

K. Robin Yabroff, PhD, MBA; Xuesong Han, PhD; Weishan Song, MS; Jingxuan Zhao, MS; Leticia Nogueira, PhD; Craig E. Pollack, MD, MPH; Ahmedin Jemal, DVM, PhD; Zhiyuan Zheng, PhD


J Natl Cancer Inst. 2022;114(6):863-870. 

In This Article

Abstract and Introduction


Background: Cancer survivors frequently experience medical financial hardship in the United States. Little is known, however, about long-term health consequences. This study examines the associations of financial hardship and mortality in a large nationally representative sample of cancer survivors.

Methods: We identified cancer survivors aged 18–64 years (n = 14 917) and 65–79 years (n = 10 391) from the 1997–2014 National Health Interview Survey and its linked mortality files with vital status through December 31, 2015. Medical financial hardship was measured as problems affording care or delaying or forgoing any care because of cost in the past 12 months. Risk of mortality was estimated with separate weighted Cox proportional hazards models by age group with age as the timescale, controlling for the effects of sociodemographic characteristics. Health insurance coverage was added sequentially to multivariable models.

Results: Among cancer survivors aged 18–64 years and 65–79 years, 29.6% and 11.0%, respectively, reported financial hardship in the past 12 months. Survivors with hardship had higher adjusted mortality risk than their counterparts in both age groups: 18–64 years (hazard ratio [HR] = 1.17, 95% confidence interval [CI] = 1.04 to 1.30) and 65–79 years (HR = 1.14, 95% CI = 1.02 to 1.28). Further adjustment for health insurance reduced the magnitude of association of hardship and mortality among survivors aged 18–64 years (HR = 1.09, 95% CI = 0.97 to 1.24). Adjustment for supplemental Medicare coverage had little effect among survivors aged 65–79 years (HR = 1.15, 95% CI = 1.02 to 1.29).

Conclusion: Medical financial hardship was associated with mortality risk among cancer survivors in the United States.


In the United States, cancer patients and survivors are more likely to report medical financial hardship, including problems affording care, distress, and delaying or forgoing needed care because of cost, than their counterparts without a cancer history.[1,2] Approximately 54% of survivors aged 18–64 years and 42% of survivors aged 65 years and older report having experienced some form of medical financial hardship at any time following their cancer diagnosis.[3] Cancer survivors also report nonmedical financial sacrifices because of their cancer, such as changes in spending and use of savings.[3] Medical financial hardship is associated with worse health-related quality of life,[4,5] but less is known about other health consequences.

A single study conducted in Washington State found that cancer patients who filed for bankruptcy protection had higher mortality risk than similar cancer patients who did not.[6] Bankruptcy is rare, however, and even though cancer patients were more likely to file for bankruptcy than those without a cancer history,[7] it does not fully encompass the multiple domains of medical financial hardship, including problems with care affordability and delaying or forgoing care because of cost.[2] Additionally, the study could not explore the role of health insurance coverage, one of the strongest and most consistent correlates of medical financial hardship[8,9] and predictors of mortality risk.[10] Further, findings from Washington State may not be generalizable to the rest of the country, which is more racially and ethnically diverse. In this study, we examined the association of medical financial hardship and mortality among cancer survivors with sequential adjustment for health insurance coverage using a large nationally representative cohort.