Risk of financial stressors in patients diagnosed with cancer: Lessons from a nation-wide financial navigation program.
Authors: Incudine Andrea , Winder Katharine , Draper Fitzgerald , Thom Bridgette , Ferris Andrea Stern , Basu Roy Upal Kunal 
Published: October 2023

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Background: Financial toxicity associated with a cancer diagnosis can lead to poor outcomes in both non-medical and medical domains. Family Reach, a US-based nonprofit, is dedicated to removing financial barriers between cancer patients and their treatment through comprehensive financial navigation. In this study, we sought to understand the prevalence of medical and non-medical financial stressors in a cohort of patients receiving financial navigation. Methods: Patient application data (provided by patients, caregivers, or case workers) from the Family Reach program from March 2020 - June 2022 were analyzed. Data included patient demographics; clinical and financial attributes; and medical & non-medical financial stressors. Associations between stressors and patient characteristics were assessed using descriptive statistics, multivariable, and univariate tests using SPSS. Results: 10,558 applications from 50 states and D.C. were processed in the study period: 92% had annual household income <$70,000 (US median -$70,784 in 2021).Data were stratified by type of cancer (55% solid vs. 38% hematologic); age (32% pediatric, 32% Adolescents and Young Adults, & 36% adult, defined by NCI as pediatric - 0-14 years, AYA - 15-39 years, and adult – 40+ ); and race/ethnicity [41% non-Hispanic White (W), 22% non-Hispanic Black (B), 16% Hispanic/Latinx (H/L)]. Other race categories (20%) were not analyzed due to small sample sizes (0.9% AI/AN, 4% Asian American, 8% two or more races) Race/ethnicity: 85% B and 84% H/L patients had an annual household income <$50,000, compared to 65% W patients (X2 p<0.05). B and H/L respondents were more likely to belong to single-parent households (59% B, 40% H/L, 30% W, X2 p<0.05). Both groups were at a higher risk of food insecurity (B vs. W, OR=1.8, H/L vs. W, OR=1.9), utility shut-off (B vs. W, OR=1.9, H/L vs. W, OR=1.4), phone shut-off (B vs. W, OR=2.0, H/L vs. W, OR=1.2) and houselessness (B vs. W, OR=1.8, H/L vs. W, OR=1.7), after adjustment for geography. Age of cancer onset: No income differences were observed between pediatric, AYA, & adult patients. Adult (OR=3.2, p<0.05) & AYA (OR=1.9, p<0.05) patients had a higher risk of unpaid medical expenses, as compared to pediatric patients, after adjustment for income & geography. While no significant differences were seen between solid and heme cancers, lung patients were at a higher risk of financial distress from non-medical expenses (e.g., risk of homelessness OR = 1.4, p<0.05) as compared to breast, colon, and prostate combined, after adjustment for income & geography. Conclusions: To our knowledge, this is the first analysis of financial stressors in a national cohort of cancer patients receiving financial navigation. The higher prevalence of financial stressors in patients of color in this self-selected group indicates that interventions addressing cancer need to integrate social determinants of health.