March 2021 Edition Vol.13, Issue 3

COVID and Health Disparities in Cancer

By Lynne Lederman, PhD

At the February 2021 virtual meeting hosted by the American Association for Cancer Research (AACR) on COVID and cancer care, John M. Carethers, MD, University of Michigan, Ann Arbor, Michigan, addressed health inequities and disparities in the pandemic.

Dr. Carethers said deaths due to COVID-19 disproportionally affect Blacks and Hispanics, who were more likely than whites to have experienced pay cuts or job loss, and lack of emergency funds. Presentations also focused on financial hardship, mental health, and insurance challenges for individuals with cancer.

Cancer Survivors Suffer Financial Hardship and Mental Health Symptoms

Jessica Y. Islam, PhD, MPH, UNC Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina, presented an analysis of the US COVID Impact Survey (Abstract S10-02).1

According to Dr. Islam, out-of-pocket costs for cancer care heavily outweigh the average monthly household income of adults, even with an employer-sponsored health plan. Many cancer survivors report difficulty paying bills, and some take less medication or skip recommended treatments.

Given this vulnerability, Dr. Islam’s group evaluated financial hardship among cancer survivors during the pandemic. Objectives included comparing financial hardship among cancer survivors with other adults; identifying determinants of financial hardship among cancer survivors; and evaluating the impact of financial hardship on mental health symptoms among cancer survivors.

This study used publicly available data from the COVID-19 Household Impact Survey collected at three-time points (N=10,760): April 20 to 26, May 4 to 10, and May 30 to June 8, 2020. This is a weighted, nationally representative survey of US adults over age 18 years conducted by the National Opinion Research Center (NORC) at the University of Chicago.

Cancer survivors (n=854; 7.6%) were self-identified by selecting “cancer” in response to the questionnaire item “Has a doctor or other health care provider ever told you that you have any of the following?” from a long list of chronic diseases. Financial hardship was defined as choosing any of the following: borrow from a friend or family member; use a payday loan, deposit advance, or overdraft; sell something; or I would not be able to pay for it right now; in response to the questionnaire item “Suppose you have an unexpected expense that costs $400. Based on your current financial situation, how would you pay for this expense?”

Mental health symptoms were assessed using the questionnaire item “In the past 7 days, how often have you felt nervous, anxious, or on edge; felt depressed; felt lonely; felt hopeless about the future.” Response options were: not at all; 1 to 2 days; 3 to 4 days; or 5 to 7 days; the latter 2 options were collapsed due to sample size.

The sample included 65% >60 years; over half were female and married or living with a partner; 75% were non-Hispanic white; about one-third were employed and had a baccalaureate degree; 48% made <$50,000 annually; 56% were on Medicare. About 18% of cancer survivors reported financial hardship, similar to that reported by the general adult population.

Younger adults, those insured through Medicaid, and rural cancer survivors are more likely to report financial hardship during the COVID-19 pandemic. Among cancer survivors, financial hardship is associated with mental health symptoms, including feeling anxious, depressed, lonely, and hopeless about the future (see Table 1).

COVID Impact Survey of Cancer Survivors

Limitations include the inability to determine if financial hardship was specifically due to cancer treatment. Other unknowns include cancer type, stage, and treatment, including type and if ongoing. No follow-up is possible due to the cross-sectional nature of the survey. The small sample size did not allow stratification by race or ethnicity.

Study strengths include the nationally representative nature of the survey, with publicly available data collected over time, and the ability to compare those with and without a cancer diagnosis.

Dr. Islam said, “For future studies, to be able to focus specifically on how financial hardship in the context of the pandemic will affect cancer treatment continuity will be a very important research question.”

Financial Toxicity in Adolescent and Young Adult Cancer Patients and Survivors

Austin Waters, MSPH, Huntsman Cancer Institute, Salt Lake City, Utah, described associations between changes in employment and financial toxicity during the COVID-19 pandemic among adolescents and young adults (AYA) diagnosed with cancer. Participants were part of the Huntsman Intermountain Adolescent and Young Adult (HIAYA) Cancer Care Program, serving Montana, Idaho, Utah, Nevada, and Wyoming, and were 18 years or older at the time of the survey.

A survey distributed via HIAYA to all HIAYA patients (N=709) via email, text, and mail included  demographic and employment domains. Financial toxicity was captured using the 11-item COmprehensive Score for Financial Toxicity (COST). The primary outcome was COST score for the past four weeks dichotomized as high (0 to 21) or low toxicity (22 to 44). Independent variables included changes in employment since March 2020, gender, treatment status, including any cancer therapies received since March 2020, and age at survey. Data collection began in October 2020 and is ongoing.

AYA who were employed at the start of the pandemic (n=223) had a mean age of 29.6 years; 63% were female, 50.4% had received treatment since March 2020, 28.9% reported job loss or reduced hours, and 51.1% reported high financial toxicity.

There was a statistically significant difference in employment status (P<.001) between those reporting low (n=109) versus high (n=114) financial toxicity. For those employed at the beginning of the pandemic, the odds ratio (OR) was 4.61 (95% CI 2.20-9.46) for those with high financial toxicity vs those with no change. Females were statistically significantly more likely to report high financial toxicity than males (P=.004; OR 2.11, 95% CI 1.16-3.86). There were no differences in financial toxicity by treatment status or age at survey.

According to Mr. Waters, a reduction in hours or job loss during the COVID-19 pandemic was associated with increased financial toxicity in an already highly susceptible population. “AYA don’t have solidified careers, and lack financial stability, among other hallmarks of young adulthood,” he said.

Financial toxicity is associated with worse health-related quality of life, symptom burden, treatment adherence, and survival. The COVID-19 pandemic has more severely affected the employment and financial wellbeing of females than males, and these inequities appear to be mirrored in the findings of this study. Mr. Waters said, “While we understand that the COVID-19 pandemic has been financially devastating for many, further attention needs to be paid to populations at high risk for financial hardship.”

The next steps include conducting quantitative inquiries about financial stress among some AYA subgroups susceptible to higher financial hardships, such as females, racial and ethnic minorities, and sexual and gender minorities.

Dr. Carethers commented that one of the most profound results was that females were affected more than males. He said, “To me, this may affect our future if this has some permanence to it.” Mr. Waters said that although men were losing jobs and reducing hours at the same rate as women, they were not reporting the same financial toxicity, suggesting inequities that are built into society in pay ranges and safety nets that just aren’t there for women that are there for men.

Dr. Carethers said that another big finding was cutting hours as a component of employment status. Mr. Waters said that of those who were laid off, many were service workers or in positions that were not available for work-at-home. Others quit their jobs, so it was not all employer-based job loss or hour reduction. He said, “If you are immunocompromised, working in an essential job during a COVID-19 pandemic, it is probably not the best idea, and survivors have identified that.” For now, these losses seem semipermanent. “We will see, but I imagine it will have a long-lasting impact,” Mr. Waters concluded.

COVID and Cancer: Economic and Insurance Challenges

Michael T. Halpern, MD, PhD, MPH, Medical Officer, Healthcare Delivery Research Program, National Cancer Institute (NCI), Bethesda, Maryland, discussed economic and insurance challenges from the COVID-19 pandemic for individuals with cancer. Much of his presentation summarized previously published information about medical care costs and associated financial toxicity for individuals with cancer and raised a number of unanswered questions.

Individuals with cancer who are Black, Hispanic, or from other racial or ethnic minority groups are more likely than are non-Hispanic white individuals to experience financial hardship, as are those who have lower income or are uninsured versus those with higher income and private insurance. Lack of insurance also decreases survival across multiple cancer types. Dr. Halpern said the COVID-19 pandemic may make these challenges even worse due to documented delays in cancer screening, diagnosis, and treatment, job loss, and COVID-19 infections, all of which result in even more financial hardship and increased mortality.

“At this point we know very little about the financial and insurance challenges from COVID-19 infections among individuals with cancer,” Dr. Halpern said, although estimates from the Commonwealth Fund were that by the end of October 2020, the US would have spent approximately $24 billion on inpatient care for COVID-19, and of that, associated patient out-of-pocket costs would total approximately $1 billion. As well, very little is known about financial hardship resulting from end-of-life care for individuals diagnosed with cancer and COVID-19.

Dr. Halpern said that the NCI has recently funded 54 supplement proposals submitted under a Notice of Special Interest (NOT-CA-20-042, NOT-OD-20-097). Five of these include a specific focus on financial hardship or financial impact associated with COVID-19 for individuals with cancer. “I am hopeful that in the near future we will have more information on financial challenges for individuals with cancer that are associated with COVID-19,” he said.

Dr. Halpern concluded that important future questions include how to support cancer patients and survivors to reduce financial challenges from COVID-19 and determine what information policy makers need to address these issues. Approaches could include determining how to collect timely data to inform interventions or approaches to address financial and insurance challenges among individuals with cancer; rapidly develop, test, disseminate, and implement these interventions in diverse healthcare settings, particularly among patients from racial/ethnic minority populations, from low income groups, and from uninsured or underinsured populations; and finally, use telemedicine to help reduce financial and insurance hardship.

During the discussion, Dr. Halpern said another health equity issue is that not all individuals have access to reliable internet and high speed bandwidth so that they can participate in telehealth. “I think that is another crucial issue in terms of looking at these health equity issues,” he said.


  1. COVID Impact Survey, conducted by NORC (National Opinion Research Center) at the University of Chicago for the Data Foundation.

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