Hidden Costs of Breast Cancer: How Interpersonal Processes Are Associated with Financial Toxicity Among Young Women

Background and Purpose: Financial toxicity (FT) is a multi-faceted construct, encompassing material hardship, psychological responses, and coping behaviors. The financial burden of cancer can manifest in various ways, such as high out-of-pocket expenses, loss of income due to time off work, and reduced access to healthcare because of lack of insurance coverage or inadequate insurance plans. Approximately 50% of cancer survivors experience financial difficulties. FT disproportionately affects socioeconomically vulnerable individuals, minoritized racial/ethnic groups, and adolescent and young adult survivors. Furthermore, financial difficulties adversely impact patients’ mental health, health-related quality of life, and treatment adherence. Despite growing understanding of the implications FT has for cancer survivors, few studies have investigated the role of partners and relationship characteristics among young breast cancer (BC) survivors. The present study therefore examines sociodemographic, clinical, and psychosocial factors associated with FT and the relationship between financial difficulties and mental health outcomes.

Methods: A sample of 83 female BC survivors, ages 18-45 years, receiving care at an NCI-designated comprehensive cancer center completed a cross-sectional survey. Validated questionnaires of psychological distress (PHQ-9; GAD-7) and dyadic coping (Dyadic Coping Inventory) were administered. Financial toxicity was assessed with the Symptoms Subscale of the EORTC-QLQ C30. Descriptive statistics were used to depict the sample key characteristics; multiple regression analyses were conducted to examine predictors of financial toxicity. Additionally, the moderating role of dyadic coping in the relationship between financial difficulties and mental health outcomes was assessed using the PROCESS macro. SPSS version 28 was utilized for data management and analysis.

Results: Participants were diagnosed with BC (stage II, 34%) in their thirties [mean: 38.8 (SD=4.7)]. Overall, respondents were non-Hispanic white (74.3%), college educated (45.1%), and currently employed (62%). Young BC survivors reported statistically significant higher financial difficulties scores than normative data for female patients (t ₍₇₃₎ = 2.79, p<.01) and healthy comparisons (t ₍₇₃₎ = 4.92, p<.001). Multiple regression (F _(4,68) = 10.1, p<.001) analysis indicated that younger age (β = -0.22, p<.05), lower income (β= -0.35, p<.01), greater distress (β= 0.21, p<.05) and lower stress communication (β= -0.29, p<.01) were associated with greater FT scores. Additionally, the relationship between financial difficulties and anxiety was moderated by stress communication (p<.05), supportive (p<.01) and negative (p<.05) dyadic coping behaviors enacted by the partner. Thus, there was a reduced impact of FT on the mental health of young BC survivors who reported that their partners felt comfortable disclosing concerns, were supportive, and had interactions characterized by limited ambivalence and hostility.

Conclusions and Implications: FT is a prevalent issue among young BC survivors, as compared to female patients and healthy peers. The present study confirms extant literature suggesting greater vulnerability for younger age groups, individuals from low socioeconomic backgrounds, and those experiencing distress. Results highlight the important role of self and partner-reported dyadic coping behaviors alleviating the burden of FT on anxiety. These findings reinforce the need for interventions to address the financial burden of cancer. Such interventions may include financial navigation for patients/partners, referrals to oncology social workers, and advocacy for cost-reducing policies.