The Association between Financial Toxicity and Quality of Life in a Low-Income Cancer Population

Background and Purpose: When faced with a cancer diagnosis, individuals frequently encounter financial barriers to accessing medical care and cancer treatment, regardless of insurance status or acquired wealth.  The increasing costs of specialized medications to stall cancer’s growth often lead to medical debt, decisions to alter medical care, or early termination of treatment. Social determinants of health present additional stressors for individuals who, prior to their cancer diagnosis, live in poverty or are uninsured and underinsured. Subsequently, females, younger adults, and nonwhite individuals are more likely to file for cancer-related bankruptcy, a factor shown to increase risk for mortality. The construct of financial toxicity appears in cancer literature to describe the devastating financial impacts of cancer treatment and is commonly measured with the comprehensive score for financial toxicity (COST) measure.  Studies validating the COST include predominantly insured, white, educated, and wealthy samples and fail to investigate the construct of financial toxicity in samples with limited resources or acquired wealth.

With increasing cancer care costs, understanding how the cost of medical care affects patient outcomes, particularly for vulnerable populations, is imperative. This study aimed to identify associations between financial, psychosocial, and health outcomes. The secondary aim was to explore the construct of financial toxicity among a population of individuals who arrived at their cancer diagnosis financially distressed.

Methods: Adults, age 18 and above, receiving cancer drug therapy were recruited from an outpatient infusion center in the southern United States that serves individuals who are uninsured, underinsured, and have low incomes. This study employed a sequential mixed methods design. Participants completed two sets of patient-reported outcome (PRO) measures at study onset and three months later. The standardized assessment instruments included: the Functional Assessment of Cancer Therapy (FACT-G), the CAHPS Cancer Care Survey, the PROMIS NIH (Anxiety, Depression, Fatigue, Pain Interference, and Physical Function), and the Comprehensive Score for Financial Toxicity (COST). Following the second set of PRO measures, randomly selected participants completed one qualitative interview assessing the relevance and utility of the COST measure in identifying patients’ financial stressors.

Results: This study sample (n=115) included cancer survivors who were female (67%), non-Hispanic (59%), had stage IV cancer (69%), an annual household income below $25,000 (61.5%), and were un/underinsured (63%). Participants identified as White (62%), Black or African American (16%), Asian (3%) or other (19%). Findings from the study reveal that depression, pain interference, and financial toxicity were consistently significant predictors of quality of life in our study population, controlling for demographics and disease specific variables. Interviews revealed that the COST measure failed to accurately address the financial burdens, day-to-day barriers, and stressors low income and un/underinsured cancer survivors encounter.

Conclusions and Implications: Financial toxicity is a strong predictor of quality of life in uninsured and underinsured cancer survivors. Findings point to the imperative for interventions targeting transportation barriers, medication access, insurance and financial counseling, and access to pharmaceutical assistance. Future research should develop and validate a scale that measures the unique challenges faced by cancer populations with limited resources or acquired wealth.