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Financial worry and psychological distress among cancer survivors in the United States, 2013—2018

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Abstract

Background

A growing proportion of cancer survivors experience financial toxicity. However, the psychological burden of cancer costs and associated mental health outcomes require further investigation. We assessed prevalence and predictors of self-reported financial worry and mental health outcomes among cancer survivors.

Patients and methods

Data from the 2013–2018 National Health Interview Survey (NHIS) for adults reporting a cancer diagnosis were used. Multivariable ordinal logistic regressions defined adjusted odds ratios (AORs) of reporting financial worry by relevant sociodemographic variables, and sample weight-adjusted prevalence of financial worry was estimated. The association between financial worry and psychological distress, as defined by the six-item Kessler Psychological Distress Scale was also assessed.

Results

Among 13,361 survey participants (median age 67; 60.0% female), 9567 (71.6%) self-reported financial worry, including worries regarding costs of paying for children’s college education (62.7%), maintaining one’s standard of living (59.7%), and medical costs due to illness or accident (58.3%). Female sex, younger age, and Asian American race were associated with increased odds of financial worry (P < 0.05 for all). Of 13,218 participants with complete responses to K6 questions, 701 (5.3%) met the threshold for severe psychological distress. Participants endorsing financial worry were more likely to have psychological distress (6.6 vs. 1.2%, AOR 2.89, 95% CI 2.03–4.13, P< 0.001) with each additional worry conferring 23.9% increased likelihood of psychological distress.

Conclusions

A majority of cancer survivors reported financial worry, which was associated with greater odds of reporting psychological distress. Policies and guidelines are needed to identify and mitigate financial worries and psychologic distress among patients with cancer, with the goal of improving psychological well-being and overall cancer survivorship care.

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Data Availability

Raw data are publicly available from NHIS/IPUMS (http://ipums.org).

Code availability

Stata SE/15.1 was used. Code is available upon request from the first and/or corresponding authors.

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Acknowledgments

The authors would like to thank Marie Gabrielle Dee, Gabriel B. Borja, and Carolyn H. Cong for assistance with proofreading the manuscript.

Funding

B.A.M. receives funding from the Prostate Cancer Foundation and (PCF), the Department of Defense, the American Society for Radiation Oncology (ASTRO), and the Sylvester Comprehensive Cancer Center outside the submitted work. P.L.N. receives support from Bayer, Astellas, Ferring, Dendreon, Blue Earth, Genome Dx, Augmenix, Boston Scientific, Janssen, Myovant Sciences, and Cota Healthcare outside the submitted work. V.M. reported receiving a grant from the Conquer Cancer Foundation outside the submitted work.

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Authors and Affiliations

  1. Harvard Medical School, Boston, MA, USA

    Edward Christopher Dee, Ryan D. Nipp, Zizi Yu & Santino S. Butler

  2. Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA, USA

    Edward Christopher Dee, Vinayak Muralidhar, Santino S. Butler & Paul L. Nguyen

  3. Department of Medical Oncology, Massachusetts General Hospital, Boston, MA, USA

    Ryan D. Nipp

  4. Department of Radiation Oncology, Miller School of Medicine, University of Miami, Miami, FL, USA

    Brandon A. Mahal

  5. Office of Community Outreach and Engagement, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, USA

    Brandon A. Mahal

  6. Department of Radiation Oncology, University of Texas Southwestern, Dallas, TX, USA

    Nina N. Sanford

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Contributions

ECD: conceptualization, data curation, formal analysis, investigation, methodology, validation, visualization, writing—original draft, and writing—review and editing

RDN: conceptualization, investigation, methodology, supervision, validation, visualization, and writing—review and editing

VM: conceptualization, data curation, formal analysis, investigation, methodology, project administration, supervision, validation, visualization, writing—original draft, and writing—review and editing

ZY: conceptualization, data curation, formal analysis, investigation, methodology, validation, visualization, and writing—review and editing

SSB: conceptualization, data curation, investigation, methodology, validation, visualization, and writing—review and editing

BAM: conceptualization, investigation, methodology, supervision, validation, visualization, and writing—review and editing

PLN: conceptualization, investigation, methodology, supervision, validation, visualization, and writing—review and editing

NNS: conceptualization, data curation, formal analysis, investigation, methodology, project administration, resources, software, supervision, validation, visualization, writing—original draft, and writing—review and editing

Corresponding author

Correspondence to Nina N. Sanford.

Ethics declarations

Conflict of interest

All other authors have no relevant financial or non-financial interests to disclose.

Ethics approval

The Dana-Farber/Harvard Cancer Center and University of Texas Southwestern Medical Center institutional review boards deemed the study to be exempt given the use of public de-identified data.

Consent to participate

Data used are de-identified and publicly available by the National Center for Health Statistics (NCHS), the survey’s managing agency (https://www.cdc.gov/nchs/nhis/participants/yourprivacy.htm). Therefore, consent to participate was not gathered by the authors of this study.

Consent for publication

Data used are de-identified and publicly available by the National Center for Health Statistics (NCHS), the survey’s managing agency (https://www.cdc.gov/nchs/nhis/participants/yourprivacy.htm). Therefore, consent for publication was not gathered by the authors of this study.

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Supplementary Information

Supplementary Table 1

Survey questions used to assess financial worry (DOCX 93 kb)

Supplementary Table 2

Multivariable adjusted odds ratios (AORs) for individual sources of financial worry among participants reporting a cancer diagnosis from the National Health Interview Survey (NHIS) from 2013 to 2018 (DOCX 200 kb)

Supplementary Table 3

Multivariable adjusted odds of reporting individual Kessler 6 symptoms in the past 30 days by increasing financial worry score (N=13,218). The multivariable model was also controlled for year of interview, region of residence, age, sex, sexual orientation, marital status, citizenship status, race/ethnicity, educational attainment, socioeconomic status, self-reported health status, alcohol use, tobacco use, health insurance coverage, and time since diagnosis. (DOCX 14 kb)

Supplementary Table 4

Results of ordinal regression defining multivariable adjusted odds of increasing financial worry by baseline characteristics among 149,904 participants without a history of cancer diagnosis from the National Health Interview Survey (NHIS) between 2013 and 2018. (DOCX 14 kb)

Supplementary Table 5

Logistic regression-defined adjusted odds of severe psychologic distress (Kessler 6 ≥13) for patients with (N=13,218) and without (N=148,648) a history of cancer from the National Health Interview Survey (NHIS) between 2013 and 2018, adjusting for age, sex, year, race/ethnicity, region of residence, sexual orientation, marital status, citizenship status, highest educational attainment, socioeconomic status, overall health status, alcohol use status, smoking status, and healthcare insurance coverage status. For patients with a history of cancer, the regression also adjusted for years since diagnosis. (DOCX 13 kb)

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Dee, E.C., Nipp, R.D., Muralidhar, V. et al. Financial worry and psychological distress among cancer survivors in the United States, 2013—2018. Support Care Cancer 29, 5523–5535 (2021). https://doi.org/10.1007/s00520-021-06084-1

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