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In another population-based survey of 3,133 women with breast cancer, Spanish-speaking women were at greater risk of financial decline related to breast cancer compared with whites (OR, 2.76; = .006), whereas English-speaking Latinas and African-Americans did not share this increased risk. In this same study, African-Americans and English-speaking Latinas were also more likely to report at least one privation as a result of breast cancer (i.e., economically motivated nonadherence or broader hardships related to medical expenses) compared with whites (OR, 2.62; Loss of productivity and employment can be considered both a risk factor for (predictor of) financial toxicity and a measure of financial toxicity (outcome).Several studies have shown that cancer patients experience loss of work, difficulty in returning to work, declines in income, and general loss of productivity as a result of cancer diagnoses.[1,15] Although employment and productivity loss can themselves be considered poor financial outcomes, employment loss has also been shown to be a risk factor for other material hardships, including debt and bankruptcy, whereas retirement has been shown to be protective.[7,9] In an analysis of data from 1,202 adult cancer survivors from the 2011 MEPS Experiences with Cancer questionnaire, change in employment after diagnosis (switching to part-time work and taking extended leave) was associated with a substantially increased risk of material financial hardship compared with no change (49.1% vs.
However, the presence of health insurance does not completely shield enrollees from high levels of out-of-pocket spending on health care services.In a study of multiple myeloma patients undergoing treatment at a single academic cancer center, cancer survivors had a mean COST score of 23 (score range, 0–44, with lower values equivalent to higher burden). Another study used the IFDFW Scale in a convenience sample of cancer patients receiving radiation therapy or chemotherapy at a single outpatient cancer center and found an average financial distress score of 5 (score range, 1–10, with lower numbers indicating higher distress). In other studies, financial burden scores were based on the count of affirmative responses to a series of questions,[21,25,29] and the mean number (e.g., 2.94 economic burden items related to work and hardship events) was calculated. Patients with advanced-stage cancers, cancers requiring chemotherapy or radiation therapy, and with underlying comorbidities have been shown to have a higher risk of financial hardship after diagnosis than do those without these characteristics.[1-4] In a study of 1,556 cancer survivors identified from the 2010 National Health Interview Survey (NHIS) who responded to a single survey item assessing financial burden, survivors were more likely to report high financial burden if they received chemotherapy (47.2% vs.30.8%; A number of studies have consistently demonstrated an association between younger age at cancer diagnosis and higher risk of various types of financial hardship.[3,6-9] In the setting of a health shock such as cancer, younger individuals may be particularly vulnerable to financial hardships because of a lack of savings and assets, as well as competing financial obligations (e.g., children).At the same time, commercial insurers in the United States have increasingly shifted medical care costs to patients through higher premiums, deductibles, and coinsurance and copayment rates.The 2014 Commonwealth Fund Biennial Health Insurance Survey indicated that 23% of insured adults aged 19 to 64 years experienced out-of-pocket costs equal to 10% or more of household income. Infused chemotherapy and supportive agents covered under patients’ medical benefits entail high out-of-pocket costs; these costs also appear to be growing as care shifts from the community into hospital-based outpatient departments.Household surveys generally include few newly diagnosed cancer patients, those with rare cancers, or those with projected short-term survival.
Because data about financial hardship are not routinely collected and can be difficult to measure, few studies have reported incidence of financial hardship among the newly diagnosed or newly treated.
Studies of cancer survivors have suggested that between 33% and 80% of the survivors have used savings to finance medical expenses,[15,20,23,25,27] and between 2% and 34% have borrowed money to pay for their care or have medical debt.[7,16,20,21,23] In a study of colon cancer survivors in Washington state, the mean debt among the survivors with debt was $26,860 (in 2009 dollars). To cope with expenses, cancer survivors have reported decreasing spending on leisure activities, food, clothing, and utilities; selling stocks, investments, possessions, or property; and changing housing.[20,23,25,27,29] One of the few studies to measure the incidence of financial hardship reported that 1.7% of cancer survivors filed for bankruptcy in the 5 years after diagnosis. Cancer survivors were 2.7 times more likely to file for bankruptcy than individuals without a cancer history. Others have reported a prevalence of bankruptcy ranging from 1.2% to 3% of the study populations of cancer survivors.[15,16,21,30] Several studies have found a prevalence of financial stress and worry about paying medical bills for cancer ranging from 22.5% in a nationally representative sample  to 64% in a sample of working-age cancer survivors.[6,16] About 45% of cancer survivors recruited from a single outpatient oncology clinic study reported wage concerns. Patients and their families may also experience difficulty and stress in interpreting complex medical bills, although this stress is less studied.
Several studies combine multiple components of financial hardship using summary measures, scores, or measures, including the Comprehensive Score for Financial Toxicity (COST) measure and the Personal Financial Wellness Scale (PFW Scale) (formerly known as the In Charge Financial Distress/Financial Well-Being Scale (IFDFW Scale), but the results are rarely presented in relation to the general population and can be difficult to interpret.
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A number of studies demonstrate that individuals with cancer are at higher risk of experiencing financial difficulty than are individuals without cancer.[1-5] This summary reviews the extant literature on Historically, cancer has been one of the most costly medical conditions to treat in the United States. Compared to a decade ago, cancer patients are receiving increasingly expensive chemotherapy and biologics, both alone and in combination.[2,3] The use of expensive supportive agents and hematopoietic growth factors has also increased. The cost of newly introduced chemotherapy and supportive drug-based treatments is growing,[2-4] and prices higher than $10,000 a month for individual drugs and biologic agents are common.
Productivity loss is typically measured as the inability to work or pursue usual activities, days lost from work or disability days, reduction in work hours, and days spent in bed.