Pothole vs Sinkhole: Cancer Money Burden in Whites, Blacks

Roxanne Nelson, BSN, RN

January 30, 2017

SAN DIEGO — There are significant racial differences when it comes to financial hardship among older patients with cancer, say the researchers of a new study presented at the Cancer Survivorship Symposium (CSS) Advancing Care and Research.

Overall, black patients experience the financial burden more acutely than white patients, even though they had lower out-of-pocket (OOP) spending and increased dual Medicare/Medicaid enrollment.

However, their resources were lower on average prior to the cancer diagnosis, and this aspect played a large role in how they coped with the cost incurred by cancer and its treatment.

"Out-of-pocket expenses are very high, and I think this contextualizes what this can mean for older patients," said study author Emily Castellanos, MD, an instructor in medicine at Vanderbilt University, Nashville, Tennessee. "But it's not the whole story, as the average out-of-pocket spending was actually higher for white patients, but pre-existing financial resources tremendously impact when this means for financial burden."

"Significant disparities in financial resources were seen in this study and low socioeconomic status was associated with an increased likelihood of financial toxicity," said Dr Castellanos.

In a discussion of the paper, Shawna V. Hudson, PhD, assistant professor of family medicine at the University of Medicine & Dentistry of New Jersey, Robert Wood Johnson Medical School, New Brunswick, said that "one thing that struck me right off was the distance between black and white patients — in terms of their debt, in terms of the new [cancer-related] debt, in terms of the total household debt — it's almost double that of white patients."

Dr Hudson compared the situation to a pot hole vs a sink hole. "We have individuals without a lot of resources," she commented about those more likely to fall into a bigger financial hole.

In recent years, the financial toxicity associated with cancer treatments has received a great deal of attention, with studies showing that financial toxicity can lead to bankruptcy, cause treatment nonadherence, and result in lifestyle changes that negatively affect quality of life and increase morbidity and mortality.

"A number of studies have assessed financial toxicity and all of the issues involved," said Dr Castellanos. "All patients incur direct and indirect medical costs, but the indirect costs are harder to quantify."

However, the relationship of the OOP medical burden to racial disparities has not been well investigated. This study examined the effect of a cancer diagnosis on older adults who were eligible for Medicare and how the financial burden differed between black and white patients.

Dr Castellanos used the Health and Retirement Study, a national longitudinal survey of US households from 1992 to 2012 to identify 2158 white and 322 black patients with cancer.

Financial hardship was defined as new financial insolvency, a more than 50% decline in net worth, the acquisition of new debt or insolvency in a previously solvent individual, or high medical burden (OOP medical spending > 20% of income).

Dr Castellanos then determined the proportions of black and white patients with cancer who reported experiencing financial hardship, as well as OOP medical spending, household debt, income, net worth, and insurance status.

Black patients were less likely to be married or partnered, have supplemental insurance, or have a higher education level, Dr Castellanos reported. They were also more likely to be covered by both Medicare and Medicaid insurance (23.1% vs 7.4% for whites).

Both groups reported high OOP, and, on average, it was significantly higher in the white population than the black one: $8472 vs $5760.

On average, black patients also had a lower household income, higher household debt, and lower average net worth. They were also more likely to report household debt of more than $10,000 and more likely to report new financial insolvency following a cancer diagnosis (6.8% vs 1.6%; P < .0001), to report loss of greater than 50% of their net worth (26.7% vs 15.3%; P < .0001), or to incur new debt (27.6% vs 14.9%; P < .0001).

However, the rate of high medical burden was similar between black and white patients (22.1% vs 21.6%).

"Because of the rising costs of cancer care, and increasing evidence that financial consequences of cancer and cancer treatments may be harmful to patients and caregivers, understanding the drivers of financial toxicity is critical to improving the patient experience and disease outcomes," Dr Castellanos concluded.

In her discussion, Dr Hudson noted that this "paper provided a new lens for examining high costs, since it's not really a surprise that there are burdens are associated with cancer."

"Existing limited resources, in addition to out-of-pocket expenses, significantly increase the medical burden and financial toxicity of cancer and result in a series of stressors for patients," she said.

"Even though medical spending for both populations was pretty much equal, when put in terms of household incomes, there was a huge gap for black patients that wasn't seen for white ones," Dr Hudson added. "There was a significantly lower capacity to absorb the burden placed on individuals in terms of financial toxicity."

Dr Castellanos and Dr Hudson have disclosed no relevant financial relationships.

Cancer Survivorship Symposium (CSS) Advancing Care and Research. Abstract 3. Presented January 28, 2017.


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