Bankruptcy May Portend Greater Mortality Risk in Patients with Cancer

Bankruptcy May Portend Greater Mortality Risk in Patients with Cancer

Dr. Aasthaa Bansal

As if a cancer diagnosis is not distressing enough, an observational study (Abstract 6509) suggests that severe financial distress resulting from out-of-pocket costs associated with cancer treatment is associated with increased risk of death by 79%. The Abstract was presented during a Clinical Science Symposium, Sunday, May 31.

“We found a consistent, positive association between bankruptcy filing and higher mortality risk across individual cancers,” Aasthaa Bansal, PhD, of the University of Washington, who presented the findings, said.

Despite a handful of limitations resulting from the observational study design, Yousuf Zafar, MD, MHS, of Duke University Medical Center, said that “Dr. Bansal’s study adds a major item to … a growing list of evidence-based financial toxicities that our patients experience because of the treatments we prescribe. … I hope it prompts us to move beyond describing the problem of financial toxicity and actually intervening.”

Although the links between a cancer diagnosis and financial toxicity are well established, this is the first time a correlation has been made between severe financial distress and increased early mortality in patients.

Previous data suggest that individuals with cancer are approximately 2.5 times more likely to go bankrupt than individuals without cancer, yet health-related financial discussions between patients and providers often get sidestepped in everyday practice.

To determine whether greater attention needs to be paid to supporting patients’ financial health, on par with the efforts made to promote their physical and emotional health, the Washington-based research team examined whether financial distress, as represented by bankruptcy filing, correlates with poorer patient outcomes—namely, survival. Investigators linked Surveillance, Epidemiology, and End Results (SEER) cancer registry records and federal bankruptcy records for individuals in western Washington from 1995-2009.

Of 231,596 individuals aged 21 or older who were diagnosed with cancer during this time period, just over 2% filed for bankruptcy. Compared with those who remained financially solvent, these individuals were more likely to be younger at diagnosis, female, nonwhite, and have local or regional disease at diagnosis.

Given that some of these factors typically predict better survival and others predict poorer survival, Dr. Bansal said that there was a need to control for potential confounding effects. To level the statistical playing field, propensity score matching was used to eliminate selection bias, rendering the bankruptcy and nonbankruptcy groups comparable in terms of baseline socioeconomic and cancer characteristics.

After applying the analytical methods, the adjusted hazard ratio (HR) for mortality in patients with cancer in the setting of bankruptcy versus nonbankruptcy was 1.79 (95% CI [1.64, 1.96]; p < 0.001; Fig.1). Closer inspection revealed that the correlation between bankruptcy and excess mortality risk held across several different types of cancer, including colorectal (HR 2.47, 95% CI [1.85, 3.31]; p < 0.001), prostate (HR 2.07, 95% CI [1.56, 2.74]; p < 0.001), lung (HR 1.55, 95% CI [1.22, 1.98]; p < 0.001), and breast (HR 1.48, 95% CI [1.15, 1.91]; p = 0.003). Moreover, these correlations changed little after excluding patients with distant-stage disease at diagnosis in efforts to eliminate any variability in prognosis, treatment selection, response to treatment, survivorship bias, and other factors.

The mortality risk estimates from this study may be conservative. Dr. Bansal said that bankruptcy represents an extreme end of financial hardship and that patients with potentially lesser degrees of financial stress were included in the nonbankruptcy group.

Dr. Bansal indicated that the observational nature of the study does not permit exploration of the causal pathway between bankruptcy and early mortality. However, she acknowledged that “future research is needed to understand the process by which this association is occurring and to find factors that could mitigate mortality risk.”  

Watch the session: Visit the ASCO Virtual Meeting website.