The Death Spiral of Cancer and Financial Hardship

It is a sad irony that for many patients, the diagnosis of cancer comes not only with physical, mental, and emotional hardship, but financial hardship as well. Not only do cancer patients have to navigate a new vocabulary of potential treatments and side effects, but there exists a myriad of financial impacts as a result of life-saving care: copays, lost wages, and care that is not covered by insurance. The term “financial toxicity” has been coined to describe the financial burden carried by patients and subsequent distress caused by this burden (1). However, though the immediate financial toxicity of cancer care has been described, continued national assessment of financial hardship in the years after diagnosis is needed. In this issue of the Journal, Doroudi et al. (2) have elegantly laid out the potential long-term financial implications of a cancer diagnosis, using data from a nationally representative sample. Simply put, the investigators found that cancer survivors had greater debt and lower net worth compared with respondents without a cancer diagnosis. Where others (3) also investigated the same Medical Expenditure Panel Survey (MEPS) and found greater acute financial burden (as defined by spending more than 20% of one’s income on health care), Doroudi et al. have shown that the financial implications of cancer are also chronic and last for many years after diagnosis (2). Furthermore, the impact of cancer impacts different age groups in different ways—likely reflecting different financial status and goals. For young patients age 18 to 34 years, there was significantly more debt. For survivors age 45 to 54 years, there was substantially less home ownership. As the authors point out, “Working-age individuals with a history of cancer have less financial stability, even many years after a cancer diagnosis.” Academically, Doroudi et al. (2) have once more shown the importance of nationally representative data on medical expenditures. Without the dedicated men and women of the Agency for Healthcare Research and Quality (AHRQ; and funding for the AHRQ), our understanding of the cost of cancer care would be more limited. We would be in the dark as to the extent of the hardship facing our patients. Surveys such as MEPS inform the continued fight to lower treatment costs and improve insurance coverage. Regularly obtained contemporary data tell us that the fight is still not won. Doroudi et al. (2) have also reminded us that recognizing and counseling patients with regards to financial burden is an important component of survivorship care. Fortunately, addressing the financial concerns of cancer survivors is part of the US Centers for Disease Control and Prevention survivorship information (4) and Oncolink (5) and is mentioned in the American Society of Clinical Oncology survivorship care planning sheets (6). However, beyond these resources, perhaps integrating free financial planning and navigation should be part of all cancer therapy (7). Surely, as Doroudi et al. note, “Studies. . .will be important to assess. . .and inform the development of interventions to reduce financial hardship.” Now that we have identified the problem, we need to do something about it. An important takeaway point is that, once again, we have a study that shows that cancer impacts patients beyond the physical symptoms of disease, treatment, and recovery. Financial well-being impacts all aspects of a patient’s life, from their ability to shelter and clothe themselves and their families to the types of leisure activities they can participate in, to the educational and career opportunities they can access, to their ability to obtain adequate nutrition and exercise. Doroudi et al. (2) have shown that, too often, cancer diagnosis equals no home, no car, and no financial assets. Limiting the analysis by Doroudi et al. (2) is the dilemma faced by most observational studies: correlation does not prove causation. Perhaps cancer patients were more likely to have measures of financial burden prior to their cancer diagnosis. We certainly know that there remain socioeconomic disparities in cancer diagnosis and outcomes (8,9). We also know that poverty contributes to cancer rates and outcomes in a myriad of ways: poor nutrition, higher rates of smoking and obesity, lack of access to care, and worse quality of care contribute to greater cancer incidence and worse cancer outcomes (8,10). In other words, we know poverty can contribute to cancer incidence. At the same time, as noted above, cancer causes financial instability. Which situation has Doroudi stumbled upon? In all likelihood, both situations are present—cancer has caused poverty, and poverty caused cancer.