Association of modifiable factors with financial burden and health literacy among patients with cancer.
Authors: Yanez Betina , Peipert John , Garcia Sofia F. , Mai Quan H. , Lancki Nicola , Buitrago Diana , Taub Chloe J. , Jensen Roxanne E. , Smith Justin Dean , Penedo Frank J. , Cella David , Kircher Sheetal Mehta 
Published: June 2022

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Background: Cancer patients are at a higher risk of financial burden compared to those with other chronic illnesses and those without cancer. Additionally, cancer patients with low health literacy are at risk for poor health outcomes and poor self-management. Aside from factors such as education and insurance, there is limited information on the role of modifiable factors in predicting financial burden and health literacy. The aim of this study was to identify risk factors associated with financial burden and health literacy among cancer patients. Methods: Participants were 2,260 adult, English- or Spanish-speaking patients who were recruited from an NCI-designated cancer center in the Chicagoland area as part of a trial on symptom management. Participants completed measures on depressive symptoms and anxiety using the Patient-Reported Outcomes Measurement Information System (PROMIS). Financial burden was assessed using a Comprehensive Score for Financial Toxicity (COST FACIT) item (FT12) and health literacy was assessed by the Single Item Literacy Screener (SILS). Additional information on insurance and cancer diagnosis were extracted from medical records. The area deprivation index (ADI) was calculated using national percentile rankings for the patient’s block group. All patient-reported outcomes were assessed at study baseline. Cross-sectional logistic regression models were fit with the FT12 item [dichotomized as high (somewhat/quite a bit/very much) vs. low (not at all/a little bit) financial burden] and SILS [dichotomized as high (quite a bit/extremely) vs. low (not at all/a little bit/somewhat) health literacy] as separate outcomes. The primary covariates of interest were anxiety and depressive symptoms T-scores (dichotomized reflect normal limits vs. elevated distress). Analyses were adjusted for socio-demographic and clinical characteristics. Results: After adjusting for covariates, significant associations of greater financial burden were PROMIS depression [odds ratio (OR): 1.63 (95% CI: 1.22-2.19)] and PROMIS anxiety (OR: 1.60; 95% CI: 1.22-2.10). In addition, higher ADI score, lower education, unemployment, and low health literacy were significantly associated with greater financial burden. PROMIS depression (OR: 2.15; 95% CI: 1.38-3.40) was associated with low heath literacy, along with disability/leave of absence, Medicare/Medicaid/uninsured and lower education. Conclusions: Modifiable factors are associated with financial burden and health literacy. These results support the systematic screening for financial burden and health literacy in addition emotional well-being. Interventions targeting the modifiable factors elucidated in this study may further efforts to provide quality and equitable comprehensive cancer care. Future work should evaluate the potential causal pathways between depression, health literacy, and financial burden.