Financial Toxicity and Its Association With Prostate and Colon Cancer Screening

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  • 1 Pediatrics Department, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio;
  • | 2 The Bob Shapell School of Social Work, Tel-Aviv University, Tel-Aviv, Israel;
  • | 3 Performing Arts Medicine Department, Shenandoah University, Winchester, Virginia;
  • | 4 USC Norris Cancer Center, Keck Medical Center, University of Southern California, Los Angeles, California;
  • | 5 Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts;
  • | 6 Memorial Sloan Kettering Cancer Center, New York, New York;
  • | 7 Department of Urology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania; and
  • | 8 Urology Department, and
  • | 9 Hematology/Oncology Department, State University of New York Upstate Medical University, Syracuse, New York.

Background: The term “financial toxicity” or “hardship” is a patient-reported outcome that results from the material costs of cancer care, the psychological impacts of these costs, and the coping strategies that patients use to deal with the strain that includes delaying or forgoing care. However, little is known about the impact of financial toxicity on cancer screening. We examined the effects of financial toxicity on the use of screening tests for prostate and colon cancer. We hypothesized that greater financial hardship would show an association with decreased prevalence of cancer screening. Methods: This cross-sectional survey–based US study included men and women aged ≥50 years from the National Health Interview Survey database from January through December 2018. A financial hardship score (FHS) between 0 and 10 was formulated by summarizing the responses from 10 financial toxicity dichotomic questions (yes or no), with a higher score associated with greater financial hardship. Primary outcomes were self-reported occurrence of prostate-specific antigen (PSA) blood testing and colonoscopy for prostate and colon cancer screening, respectively. Results: Overall, 13,439 individual responses were collected. A total of 9,277 (69.03%) people had undergone colonoscopies, and 3,455 (70.94%) men had a PSA test. White, married, working men were more likely to undergo PSA testing and colonoscopy. Individuals who had not had a PSA test or colonoscopy had higher mean FHSs than those who underwent these tests (0.70 and 0.79 vs 0.47 and 0.61, respectively; P≤.001 for both). Multivariable logistic regression models demonstrated that a higher FHS was associated with a decreased odds ratio for having a PSA test (0.916; 95% CI, 0.867–0.967; P=.002) and colonoscopy (0.969; 95% CI, 0.941–0.998; P=.039). Conclusions: Greater financial hardship is suggested to be associated with a decreased probability of having prostate and colon cancer screening. Healthcare professionals should be aware that financial toxicity can impact not only cancer treatment but also cancer screening.

Background

The United States has the highest healthcare expenditure of any country but has some of the poorest health outcomes among leading Western countries, including the lowest average life expectancy and the highest infant and maternal mortality rates.1,2 The United States is also the only major economic power without publicly financed universal healthcare. Healthcare access in the United States is directly related to workplace-based insurance and a patient’s personal finances.1,2 American wages have been relatively stagnant since the 1970s, but healthcare and living costs have continued to increase, and the ability of patients to afford healthcare or health insurance has decreased proportionately.3,4

The prohibitive cost of healthcare has been demonstrated many times. The number of Americans delaying or forgoing medical care because of costs has increased dramatically in recent years.5 Those who delay or forgo treatment because of cost are significantly less likely to report good health status and significantly more likely to have low quality-of-life scores than those who never delayed or forwent treatment because of cost.5 Delayed healthcare is associated with worse outcomes and higher overall costs.6 Although access to health insurance has been shown to reduce delays, improve outcomes, and decrease costs, Americans with insurance and those with chronic conditions also report that they delayed seeking medical services because of fears about the excessive costs of healthcare.79

The terms “financial toxicity” and “financial distress” or “hardship” are patient-reported outcomes that result from the material costs of cancer care, the psychological impacts of these costs, and the coping strategies that patients use to deal with this strain, which includes delaying or forgoing care.10 Unsurprisingly, given the high costs of cancer care, up to 50% of all patients with cancer will report financial toxicity. Material costs are driven by high out-of-pocket costs,11 which can include copays, deductibles, or the entire cost of treatment. Indirect costs such as reduced or lost wages, early retirement, and transportation are significant for patients as well as their caregivers, typically spouses and/or adult children. Financial toxicity has been linked to delaying or forgoing cancer care after diagnosis.1214 However, little is known about the effect of financial toxicity on cancer prevention. Delaying recommended cancer screenings can potentially increase the financial burden caused by cancer because this delay may lead to diagnosis at a more advanced stage, with greater morbidity and mortality.

To address this important knowledge gap, we examined the effects of financial toxicity on the use of screening tests for prostate and colon cancers. The American Urologic Association guidelines recommend screening for prostate cancer with a prostate-specific antigen (PSA) blood test from ages 55 to 69 years at a frequency of every 2 years or more often.15 For all adults, the US Preventive Services Task Force recommends screening for colon cancer with an approved modality from ages 50 to 75 years (grade A) at a frequency of every 10 years.16 Colonoscopy remains the gold standard because it is both diagnostic and therapeutic.16

In this study, we gauged cancer screening use for these cancers based on a US nationally representative survey–based data source. We hypothesized that greater financial hardship would be associated with decreased prevalence of prostate and colon cancer screening.

Methods

Data Source and Study Design

The National Health Interview Survey (NHIS) is the principal source of information on the health of the civilian noninstitutionalized population residing within the 50 US states and the District of Columbia. It is one of the major data collection programs of the National Center for Health Statistics, a part of the CDC. The NHIS is regarded as the “gold standard” for US health survey data.17 These data are routinely collected with the main objective of monitoring the health of the US population through the collection and analysis of data on a broad range of health topics. All data were previously deidentified and publicly available (https://www.cdc.gov/nchs/nhis/about_nhis.htm), waiving the need for Institutional Review Board approval.

In this study, we identified all men and women living in the United States who were included in the annual national survey from the 2018 cycle (January–December 2018). Prior cycles were not included, because questions assessing our outcomes were not added to the survey until the 2018 cycle.

Sampling and Survey

The NHIS target population includes residents of households and noninstitutionalized group housing. Persons residing temporarily in student dormitories or temporary housing are sampled within the households in which they reside permanently. Persons excluded from the survey are those with no fixed household, active duty military personnel and civilians living on military bases, persons in long-term care institutions, persons in correctional facilities, and US nationals living in foreign countries. Although active duty Armed Forces personnel cannot be sampled for inclusion in the survey, any civilians residing with Armed Forces personnel in nonmilitary housing are eligible for inclusion.17

To keep survey operations manageable, cost-effective, and timely, the NHIS uses geographically clustered sampling techniques to select the sample of dwelling units for the NHIS.17 Sampling is designed so that each month’s data are nationally representative. Data collection for the NHIS is continuous (ie, from January to December each year). The sampling plan is redesigned after every decennial census.

The US Census Bureau, under contractual agreement, is the data collection agent for the NHIS. Data are collected continuously throughout the year by Census Bureau interviewers. The NHIS is conducted using computer-assisted personal interviewing. Face-to-face interviews are conducted in respondents’ homes, but follow-up to complete interviews may be conducted over the phone.

Inclusion Criteria and Endpoints

For prostate cancer screening, inclusion criteria were limited to all-male respondents aged ≥55 years who answered the question whether they had ever had a PSA test. For colon cancer screening, the inclusion criteria were limited to all men and women aged ≥50 years who answered the question whether they had undergone a colonoscopy. The primary outcomes of the study were self-reported occurrence of PSA blood testing and colonoscopy for prostate and colon cancer screening, respectively.

Covariates

We collected all available predetermined demographic variables thought to be relevant in assessing the prevalence of cancer screening. These included current age, sex, race (American Indian/Alaska Native [AIAN], Asian, Black, White, multiple races, unknown), US geographic region (Northeast, Midwest, South, West), marital status, and sexual orientation. Health-related covariates collected included smoking status (current everyday smokers, current some-days smokers, former smokers, never-smokers, unknown smoking status). Occupational covariates were also collected, including current work status (working/not working), lifetime work status (has the respondent ever worked: yes/no), and mean years working.

Ten financial toxicity covariates were collected as part of the survey, including the following:

  • In the past 12 months, were you unable to afford ____?

    • • prescription medication

    • • mental healthcare

    • • dental care

    • • eyeglasses

  • In the past 12 months, have you ____ to save money?

    • • skipped medication doses

    • • taken less medicine

    • • delayed filling a prescription

    • • asked a doctor for lower-cost medication

    • • bought a prescription from another country

    • • used alternative therapies

A financial hardship score (FHS) was formulated by summarizing the responses from these 10 financial toxicity dichotomic questions (yes/no), where each question was answered with either 0 (no) or 1 (yes). The total FHS ranged from 0 to 10, with a higher score associated with greater financial hardship.

Missing Data and Statistical Analyses

The NHIS survey website uses hot-deck imputation for missing data.17,18 In this procedure, every case with a missing value is assigned the corresponding value of a “similar” case in the same imputation class. Descriptive analyses included mean and standard deviations for continuous variables and proportions for discrete variables. For comparison of discrete and continuous variables, the chi-square and the Kruskal-Wallis test were used, respectively. Multivariable logistic regression analyses assessed the association between the prevalence of self-reported PSA test and colonoscopy with preselected variables, including age, sex, working status, marital status, sexual orientation, race, US region, smoking status, and FHS. All statistical tests were 2-tailed, and P<.05 was considered significant. Statistical analyses were performed using SPSS Statistics, version 23 (IBM Corp).

Results

Overall, 13,439 individual survey responses were collected during 2018. Of these, 4,870 (36.24%) respondents were male and 8,569 (63.76%) were female. Demographic and socioeconomic characteristics of this cohort are represented in Table 1, stratified by self-reported PSA test and colonoscopy history. In total, 9,277 (69.03%) men and women aged ≥50 years had undergone colonoscopies. Of the men surveyed, 3,455 (70.94%) aged ≥55 years had had a PSA test. Mean [SD] age was higher in those who had a PSA test (68.41 [8.31] vs 65.70 [8.50] years; P≤.001) and in those who had a colonoscopy (67.29 [9.46] vs 63.16 [10.32] years; P≤.001). White individuals were more likely to undergo a PSA test and colonoscopy, whereas Black, AIAN, and Asian individuals were less likely to do so (P<.001). Both screening tests were also more prevalent among married versus unmarried individuals (P<.001). Both PSA testing and colonoscopies were more common among individuals who have worked in the past than among those who have never worked (P<.001). Last, current smokers were less likely to have undergone both screening tests, whereas former and never-smokers were more likely to have undergone both tests (P<.001).

Table 1.

Baseline Demographic Data

Table 1.

Table 2 shows a stratification by the 10 distinct financial questions used to derive the FHS. In summary, individuals stating they were unable to afford prescription medication, dental care, or eyeglasses in the past 12 months were less likely to undergo any of the 2 analyzed screening tests (P<.001). In addition, those who had to skip medication doses (P=.007), take less medicine (P=.002), or delay filling a prescription (P=.010) to save money were less likely to undergo both screening tests.

Table 2.

Overview of the 10 Financial Hardship Score Questions

Table 2.

The calculated FHS for patients who were screened for prostate and colon cancer is depicted in Figure 1. The mean FHS was higher for those who had not had a PSA test or a colonoscopy (0.70 and 0.79 vs 0.47 and 0.61, respectively; P≤.001 for both).

Figure 1.
Figure 1.

Mean financial hardship score for screening of prostate and colon cancer.

Abbreviation: PSA, prostate-specific antigen.

Citation: Journal of the National Comprehensive Cancer Network 20, 9; 10.6004/jnccn.2022.7036

Table 3 demonstrates the multivariable logistic regression models assessing associations between various covariates with a history of a PSA test or colonoscopy. Notably, a greater FHS was associated with a decreased odds ratio for having a PSA test of 0.916 (95% CI, 0.867–0.967; P=.002) and for having a colonoscopy of 0.969 (95% CI, 0.941–0.998; P=.039). These models also showed that increasing age, having a spouse (vs no spouse), and gay or lesbian orientation (vs heterosexual orientation) were associated with an increased odds ratio of having a PSA test and colonoscopy. In contrast, AIAN and Asian race (vs White) and current smokers (vs never-smokers) were associated with a lower probability of undergoing both screening tests.

Table 3.

Logistic Multivariable Regression Models Assessing Associations With Having PSA Test and Colonoscopy

Table 3.

Discussion

In this nationally representative US survey–based study of self-reported cancer screening in adults, 70.94% of males aged ≥55 years reported a history of having had a PSA test, and 69.03% of adults aged ≥50 years reported having had a colonoscopy. FHS was higher in those who had never had a colonoscopy or PSA test. Multivariable models adjusting for available known confounders confirmed that a higher FHS was associated with a decreased likelihood of having had a PSA test or colonoscopy. These findings support the hypothesis that those experiencing greater financial hardship are less likely to undergo cancer screening.

Increasing age, having a spouse (vs no spouse), and gay or lesbian orientation (vs heterosexual orientation) were associated with an increased likelihood of undergoing a PSA test and colonoscopy. These findings are in line with previous data demonstrating that cancer prevalence increases with age19 and that marital status is strongly associated with increased screening for prostate and colon cancers.2022 Previous studies have shown that gay or lesbian orientation is associated with higher rates of colonoscopies, but it is currently unclear whether sexual orientation impacts PSA testing.2327

In contrast, a lower probability of undergoing both screening tests was associated with AIAN and Asian race (vs White) and current smokers (vs never-smokers). Asian and AIAN race has previously been found to be associated with decreased use of prostate and colon cancer screening in the United States.2830 Research suggests that current smokers are less likely than never-smokers to receive guideline-concordant screening for prostate and colon cancer.31

Financial toxicity has largely been studied in the context of cancer diagnosis and treatment. Cancer treatment is exorbitantly expensive to patients, even those with insurance, and the costs are increasing significantly over time.3234 To ensure their survival, patients are understandably motivated to pay these high costs, but this can mean spending their retirement savings, borrowing money, altering lifestyles, or selling possessions or property to pay for treatment. However, even these extreme measures do not protect patients from incurring massive debt or medical bankruptcy.35 Interestingly, employment status was not shown to significantly impact undergoing cancer screening in our analyses. This is in accordance with the previously mentioned observation that even for insured patients, health-related costs are increasing significantly, limiting their ability to undergo cancer screening due to financial hardship.

Our data suggest that in addition to cancer diagnosis and treatment, cancer screening is also impacted by financial toxicity. A report prepared by Brevoort et al36 in 2020 found that 46% of US households could not cover an unexpected $400 expense with cash or equivalent. On average, a colonoscopy costs $3,153 per person. A screening PSA test costs <$50 per person, but diagnostic testing for prostate cancer after a positive screening test can cost >$500 per person for urologic consultation with transrectal ultrasound-guided prostate biopsy.37,38 With almost half of US households unable to cover the sudden expense of a colonoscopy or PSA test with a diagnostic biopsy, it is evident that cancer screening may be forgone for financial reasons alone.

The present study has several limitations. First, the data are retrospective, are affected by inherent selection bias, and may be confounded by inaccurate or unreported data entry. As a survey-based study, it is prone to recall bias among responding subjects. In addition, although this database accounts for many significant socioeconomic and clinical factors, information on other relevant clinical information is lacking, such as known malignancy risk factors. All analyses were based on self-reported outcomes without confirmation of type, the timing of cancer diagnosis, or cancer grade at diagnosis. Despite these limitations, our study represents the first nationally representative survey of US men and women addressing the problem of financial toxicity in the context of prostate and colon cancer screening.

Conclusions

Financial toxicity is a critical problem in modern healthcare that demands a solution. Individuals should be able to undergo cancer screening as recommended by national guidelines, and be diagnosed and treated accordingly, regardless of their socioeconomic status. Men and women should not have to choose between health and more tangible aspects of survival, such as shelter, food, or transportation. Our data suggest that greater financial hardship is independently associated with a decreased probability of undergoing cancer screening for 2 common cancers. To address this problem and to improve use of beneficial cancer screening modalities, the financial burden of cancer screening to the patient must be addressed.

Physicians need to be aware of their patients’ financial concerns and educated about financial toxicity as a factor in patients’ compliance with the recommended cancer screening tests. Healthcare administrators, institutions, and insurance companies should identify individuals at risk for financial toxicity and attempt to reduce the costs to these patients, making cancer screening more accessible. This could be done with appropriately used support systems helping patients in the financial aspect. Further research examining the association of financial toxicity and cancer screening is needed, and awareness of this specific association with financial toxicity needs to be raised across all levels of the US healthcare system.

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Submitted February 3, 2022; final revision received May 22, 2022; accepted for publication May 23, 2022.

Author contributions: Study concept and design: Goldberg. Data collection and analysis: Herriges, Goldberg. Writing—original draft: Herriges, Peck, Goldberg. Writing—review and editing: Shenhav-Goldberg, Peck, Bhanvadia, Morgans, Chino, Chandrasekar, Shapiro, Jacob, Basnet, Bratslavsky, Goldberg.

Disclosures: Dr. Morgans has disclosed receiving grant/research support from Astellas Pharma US, Inc., Bayer HealthCare, Myovant Sciences, Pfizer Inc., sanofi-aventis US, and Seagen Inc.; serving as a principal investigator for Alliance Pharma Inc., Bayer HealthCare, Myovant Sciences, and Pfizer Inc; serving as a advisory board member for AAA Pharmaceutical, Inc., Astellas Pharma US, AstraZeneca Pharmnaceuticals LP, Bayer HealthCare, Dendreon Corporation, Lantheus Holdings, Inc., Myovant Sciences, Merck & Co., Inc., Myriad Genetic Laboratories, Inc., Pfizer Inc., Seagen Inc., and sanofi-aventis US; and serving as a consultant for AAA Pharmaceutical, Inc., Astellas Pharma US, AstraZeneca Pharmaceuticals LP, Bayer HealthCare, Lantheus Holdings, Inc., Myovant Sciences, Novartis Pharmaceuticals Corporation, Pfizer Inc., and sanofi-aventis US. The remaining authors have disclosed that they have not received any financial consideration from any person or organization to support the preparation, analysis, results, or discussion of this article.

Funding: Dr. Chino has disclosed receiving research support from the NCI of the NIH (award P30 CA008748).

Correspondence: Hanan Goldberg, MD, MSc, Urology Department, State University of New York Upstate Medical University, 750 East Adams Street, Syracuse, NY 13210. Email: gohanan@gmail.com

View associated content

  • View in gallery

    Mean financial hardship score for screening of prostate and colon cancer.

    Abbreviation: PSA, prostate-specific antigen.

  • 1.

    Schroeder SA. Shattuck Lecture. We can do better—improving the health of the American people. N Engl J Med 2007;357:12211228.

  • 2.

    Squires D, Anderson C. US health care from a global perspective: spending, use of services, prices and health in 13 countries. Accessed July 5, 2021. Available at: http://www.commonwealthfund.org/∼/media/files/publications/issue-brief/2015/oct/1819_squires_us_hlt_care_global_perspective_oecd_intl_brief_v3.pdf

    • Search Google Scholar
    • Export Citation
  • 3.

    Mishel L, Gould E, Bivens J. Wage stagnation in nine charts. Accessed July 6, 2021. Available at: https://www.epi.org/publication/charting-wage-stagnation/

    • Search Google Scholar
    • Export Citation
  • 4.

    Bush M. Addressing the root cause: rising health care costs and social determinants of health. N C Med J 2018;79:2629.

  • 5.

    Chen J, Rizzo JA, Rodriguez HP. The health effects of cost-related treatment delays. Am J Med Qual 2011;26:261271.

  • 6.

    Kraft AD, Quimbo SA, Solon O, et al. The health and cost impact of care delay and the experimental impact of insurance on reducing delays. J Pediatr 2009;155:281285.e1.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7.

    Galbraith AA, Soumerai SB, Ross-Degnan D, et al. Delayed and forgone care for families with chronic conditions in high-deductible health plans. J Gen Intern Med 2012;27:11051111.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8.

    Ward BW. Barriers to health care for adults with multiple chronic conditions: United States, 2012-2015. NCHS Data Brief 2017;275:18.

    • Search Google Scholar
    • Export Citation
  • 9.

    Tolbert J, Orgera K, Damico A. Key facts about the uninsured population. Accessed July 6, 2021. Available at: https://www.kff.org/uninsured/issue-brief/key-facts-about-the-uninsured-population/

    • Search Google Scholar
    • Export Citation
  • 10.

    Altice CK, Banegas MP, Tucker-Seeley RD, et al. Financial hardships experienced by cancer survivors: a systematic review. J Natl Cancer Inst 2016;109:djw205.

  • 11.

    PDQ Adult Treatment Editorial Board. Financial toxicity and cancer treatment (PDQ)-health professional version. Accessed June 23, 2021. Available at: https://www.cancer.gov/about-cancer/managing-care/track-care-costs/financial-toxicity-hp-pdq

    • Search Google Scholar
    • Export Citation
  • 12.

    Weaver KE, Rowland JH, Bellizzi KM, et al. Forgoing medical care because of cost: assessing disparities in healthcare access among cancer survivors living in the United States. Cancer 2010;116:34933504.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13.

    Kent EE, Forsythe LP, Yabroff KR, et al. Are survivors who report cancer-related financial problems more likely to forgo or delay medical care? Cancer 2013;119:37103717.

    • Crossref
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