Bearing the Burden: Race and Gender Disparities in Exposure to Cancer-Related Financial Hardship

Background and purpose: Rising out of pocket treatment costs have caused a great deal of financial hardship for American cancer patients and survivors. Cancer-related financial hardship is associated with poorer health and treatment outcomes, including early mortality. This study analyzed survey data from a sample of people in the U.S. affected by cancer in order to: (1) identify and measure unique cost-coping behaviors, (2) explore differences in coping by race/ethnicity, income, and gender while accounting for meaningful variables related to health status and behaviors, (3) measures the impact of each cost-coping behavior on psychological distress.

Methods: Online survey data from a sample (n=511) of U.S. cancer patients and survivors was analyzed using a selection of multivariate statistical methods including principal axis factor analysis, domain-based stepwise regression and Hayes’ PROCESS analyses for mediation and moderation.  

Results: Principal axis factor analysis of 32 items revealed four problem-focused coping strategies: care-altering, lifestyle-altering, self-advocacy and financial help-seeking. Two of these coping strategies played significant intermediary roles in the relationship between financial hardship and mental health outcomes. In regression-based mediation and moderation modeling, self-advocacy significantly moderated the impact of financial stress on mental health (B = -.01, p < .01), while lifestyle-altering significantly mediated the relationship between stress and poor mental health outcomes (B = 0.08, p < .05). When accounting for other relevant health and behavioral factors, individuals with higher household incomes were more likely to self-advocate (OR = 2.45), while women (OR = 1.73), people identifying as African American (OR = 1.83) or Hispanic (OR = 2.67) were more likely alter lifestyle in response to cancer-related financial hardship.

Conclusions and implications: These findings suggest that women and people of color are more likely to engage in cost-coping behaviors that undermine mental health outcomes and are therefore unduly burdened, materially and psychologically, by out of pocket costs of cancer treatment. This finding is made more notable when paired with the finding that people with higher income, regardless of race, are more likely to engage in coping strategies that reduce stress and protect mental health. Implications for social work practice and health policy, such as self-advocacy training interventions and limited cost-sharing insurance designs, will be discussed.