The role of financial security in loneliness or sadness among Medicare-enrolled cancer survivors during the COVID-19 pandemic

Abstract

Introduction

This study aims to estimate the relative decreased rate of financial security and increased rate of loneliness or sadness during the COVID-19 pandemic and investigate the association between financial security and loneliness or sadness among Medicare beneficiaries with a cancer history.

Material and Methods

We examined population-based, cross-sectional data from the Medicare Current Beneficiary Survey COVID-19 Winter 2021 survey. The study cohort included 1,632 Medicare beneficiaries (aged ≥65 years) with self-reported cancer history. The outcome was feelings of loneliness or sadness, and the independent variable was financial security during the 2020–2021 winter surge of COVID-19. We conducted weighted descriptive statistics, a cross-tabulation analysis, and multivariable logistic regression analyses.

Results

Overall, 18.8% of cancer survivors reported increased feelings of loneliness or sadness and 11.2% reported decreased financial security during the 2020–2021 winter surge of COVID-19. Cancer survivors who reported decreased financial security had 93% higher odds of increased feelings of loneliness or sadness compared to those who reported feeling more or about the same financial security (Adjusted odds ratio [AOR] = 1.93; 95% Confidence Interval [CI] 1.25–3.01; p <0.004).

Discussion

Decreased financial security and increased feelings of loneliness or sadness were prevalent among cancer survivors. Additional screenings and interventions beyond what are currently available are needed to ease the socioeconomic vulnerabilities experienced by cancer survivors.

1. Introduction

Cancer is the second leading cause of death in the US [1]. It is projected that around 1.9 million new cancer cases and 609,360 cancer deaths will occur in the US by the end of 2022 [1]. However, with advances in cancer diagnosis, early detection, and the use of targeted cancer treatments, the number of cancer survivors is increasing. As of January 2022, >18 million individuals are living with a history of cancer diagnosis, and this number is expected to expand to 22.2 million by 2030 [2,3]. Moreover, the number of cancer survivors who live five or more years after diagnosis is projected to increase by 33% over next decade [4].

Living longer with a cancer history often predisposes survivors to long-term harmful impacts of cancer treatment which may deteriorate survivors' health and overall well-being [5,6]. It is well documented that cancer treatments are costly in the US, resulting in high medical expenses and out-of-pocket costs that put survivors at increased risk of financial hardship [[7], [8], [9], [10], [11]]. In fact, research shows that up to 73% of cancer survivors face financial hardship attributed in part to their cancer diagnosis, treatment-related loss of employment or hours worked, partially paid or unpaid sick leaves, and increased out-of-pocket medical spending [12]. A recent study showed that Medicare beneficiaries with four major diseases (cardiovascular disease, cancer, diabetes, and chronic lung disease) have much higher out-of-pocket healthcare expenditure than anyone without those four conditions. Specifically, those with cancer history were 13% more likely to spend higher than 20% of their annual income on out-of-pocket expenditures compared to those without any of those four conditions [13]. The ever rising cost of cancer treatment, inadequate coverage by most health insurance plans, and personal financial commitments (e.g., loans, mortgages, childcare fees) are compounding sources of financial hardship experienced by many survivors [7,8]. In fact, up to 62% of cancer survivors suffer from debt because of their cancer treatment, and up to 45% report non-adherence to medications because of cost [14]. The COVID-19 pandemic further exacerbated financial hardships among cancer survivors [15,16] such as employment income loss. A recent study found that during the pandemic, a third of cancer survivors (31%) struggled to pay for their healthcare needs and 57% struggled to afford non-healthcare needs, despite having health insurance coverage [17]. Indeed, in many cases, financial hardship necessitates cost-saving behaviors, which can compromise survivorship care and health outcomes [18,19].

We used the conceptual model developed by Hawkley and colleagues (2020) to guide this study [20]. The model illustrates temporal causal relationships among financial shock, loneliness, mediators, and covariates. According to this model, levels of loneliness increase for older adults who experienced income loss. In fact, adults who lost 75% of their income were significantly lonelier than those who did not have such loss. Additionally, individuals with poor health are more likely to experience financial hardship and poor health itself is also a risk factor for loneliness. Furthermore, individuals who experience financial hardship may also experience poor social connectedness, which is another risk factor for loneliness [20].

Over the past three years, the COVID-19 pandemic had a significant negative social impact on cancer survivors due to public health restrictions (e.g., stay-at-home orders, shielding, limited in-person social interactions), which contributed to poor social connectedness, social isolation, loneliness, increased anxiety and depression, and poor sleep [[21], [22], [23]]. In fact, a recent study showed that one in two adults (53%) with a history of a cancer diagnosis reported loneliness and a pervasive sense of social isolation during the pandemic [24]. Similarly, a study conducted with ovarian cancer survivors reported self-reported loneliness of 43% among study participants [25]. In addition, during the pandemic, cancer survivors faced tremendous uncertainties about their health conditions due to sudden disruption in cancer care, including canceled or delayed appointments, along with the fear of having a cancer recurrence and/or COVID infection [26]. Roughly half of older breast cancer survivors experienced disruption in cancer care during the first six months of the COVID-19 [27]. Another recent study found that cancer survivors were more likely to report feeling lonely than adults without cancer history and those with limited social interaction were even more likely to feel lonely [28]. Such findings are concerning because loneliness is an independent contributor to morbidity and mortality in older adults independent of social isolation [29]. Specifically, individuals who feel lonely have up to 26% increased risk of all-cause mortality [29]. Loneliness has also been found to be as harmful as smoking 15 cigarettes a day among both cancer and non-cancer population groups [30]. We may surmise from emerging literature that the COVID-19 pandemic heightened financial and social vulnerabilities experienced by cancer survivors. Currently, limited research exists examining the link between financial security and loneliness or sadness in this population. We, therefore, used a nationally representative sample of US Medicare beneficiaries (aged ≥65 years) with cancer history to (1) estimate the relative decreased rate of financial security and increased rate of loneliness or sadness and (2) investigate the association between financial security and loneliness or sadness among cancer survivors during the during the 2020–2021 winter surge of the COVID-19 pandemic.

2. Materials and Methods

2.1. Study Data and Sample

The study used cross-sectional data from the Medicare Current Beneficiary Survey (MCBS) COVID-19 Winter 2021 Community Supplement Public Use File. The MCBS is a multi-purpose longitudinal survey of Medicare beneficiaries aged ≥65 and beneficiaries with certain conditions aged <64 residing in the US. It is funded by the Centers for Medicare and Medicaid Services (CMS) Office of Enterprise Data and Analytics (OEDA) [31]. The 2021 MCBS COVID-19 survey was a cross-sectional phone survey of Medicare community-dwelling beneficiaries conducted between March 1 and April 25, 2021. The survey collected COVID-19-related data such as testing, vaccination, social distancing, preventive health behaviors, deferred medical care, as well as social, financial, and emotional well-being. The sample size of the survey was 11,107 individuals weighted to be representative of 57,387,274 Medicare beneficiaries, with an overall response rate of 79.6%. Detailed information about the 2021 MCBS COVID-19 survey is available at the CMS MCBS website [31].

The present study included a nationally representative sample of community-dwelling Medicare beneficiaries aged ≥65 years with self-reported cancer history (other than skin cancer). The survey was completed either by Medicare beneficiaries or through proxy respondents. We excluded observations completed by proxy respondents (n = 1,352), those younger than 64 years old (n = 1506), those without cancer history (n = 6,495), and those with missing values on study variables (n = 122). This yielded a study sample of 1,632 cancer survivors aged ≥65 years, representing 8,415,427 Medicare beneficiaries with a history of cancer (Fig. 1 ). The data that we used for this study is publicly available and de-identified. Therefore, our study did not require institutional review board approval according to the Code of Federal Regulations part 46.102.

Fig. 1.

Flow Chart displaying sample selection.

2.2. Measures

2.2.1. Outcome Variable

The outcome variable was self-reported feelings of loneliness or sadness during the past six months. Participants were asked to respond to one question measuring loneliness or sadness: “Since [reference date]…have you felt more lonely or sad, less lonely or sad, or about the same?” with responses of (1) more lonely or sad, (2) less lonely or sad, and (3) about the same. The reference date used for the 2021 MCBS COVID-19 survey was November 1, 2020. For the present study, we categorized loneliness or sadness as a binary variable by combining categories “less lonely or sad” and “about the same” into one category as 0 = less/about the same lonely or sad and 1 = more lonely or sad. Prior studies leveraging MCBS COVID-19 data also used similar categories for loneliness and sadness [32].

2.2.2. Independent Variable

The key independent variable was self-reported financial security during the past six months. Participants were asked the following question: “Since [reference date]…have you felt more financially secure, less financially secure, or about the same?” with response options of (1) more financially secure, (2) less financially secure, and (3) about the same. We created a binary variable for financial security by combining categories “more financially secure” and “about the same” to create categories 0 = more/about the same financially secure and 1 = less financially secure.

2.2.3. Covariates

The self-reported socio-demographic covariates included in the analysis were: age (65–74 years, ≥ 75 years), sex (male, female), race and ethnicity (non-Hispanic Black, Hispanic, non-Hispanic White, and Other [American Indian or Alaska Native, Asian, Native Hawaiian or other Pacific Islander, two or more races, unknown races]), annual household income (<$25,000 and ≥ $25,000), having access to the internet (yes, no), US census regions (Northeast, Midwest, South, West), metropolitan status (metropolitan, non-metropolitan), and Medicare and Medicaid dual eligibility status (non-dual, full eligible, partial eligible, and qualified Medicare beneficiary [QMB] eligible only). We also included living alone status (yes, no) and social connectedness, which was defined as feeling less socially connected to family and friends over the past six months (between November 1, 2020 and April 25, 2021). We also included chronic health conditions (Alzheimer's disease/dementia, depression, heart conditions, hypertension, stroke emphysema/asthma/COPD, diabetes, hypercholesterolemia, osteoporosis). We categorized chronic health conditions as 0 = not having any condition, 1 = having one condition, 2 = two conditions, and 3 = three or more conditions.

2.3. Statistical Analyses

Data analyses were conducted on weighted data using Stata, version 17.0 (StataCorp LLC). The MCBS uses a multi-stage cluster sampling design, and the variance estimation method of balanced repeated replication (BRR) using Fay's adjustment of 0.3 is recommended, which was used in our data analyses. We also applied recommended sample weights to account for the complex survey design of the MCBS. First, we report unweighted frequencies of sample characteristics. Then, we conducted weighted descriptive statistics, proportions, and 95% confidence intervals (CI), a cross-tabulation analysis, and a Wald χ² test to describe the characteristics of the study sample and examine the characteristics by financial security. We used a weighted multivariable logistic regression model to investigate the association between financial security and feelings of loneliness or sadness by adjusting for covariates. We report unadjusted and adjusted odds ratios with their corresponding 95% CI for study variables. Associations were examined in a two-sided test at the 5% significance level.

3. Results

3.1. Sample Characteristics

Table 1 presents the sample characteristics. Overall, 57.6% of the sample were female, 7.0% self-reported as Hispanic, 6.4% as non-Hispanic Black, 81.2% as non-Hispanic White, and 21.7% reported an annual household income of <$25,000. Over half of the participants (51.6%) reported the presence of multiple co-morbidities (≥3 chronic health conditions), and 22.5% reported a history of depression. About 18.5% reported living alone, and 42.6% reported decreased social connectedness to family and friends. Nearly one-fifth of participants (18.8%) reported increased feelings of loneliness or sadness, and 11.2% reported decreased financial security during the past six months. Cancer survivors who reported increased feelings of loneliness or sadness were more likely to be female, self-report as Hispanic and non-Hispanic White, and live in West and Midwest regions (Table 1). In addition, cancer survivors who felt more lonely or sad were more likely to report a history of depression, decreased social connectedness, and decreased financial security (all p <0.05).

Table 1.

Differences in characteristics of study participants by feelings of loneliness or sadness.

Characteristics	Unweighted frequencies N = 1632	Weighted % (95% CI) Weighted n = 8,415,427	Less/same lonely or sad	More lonely or sad	p-value
Age					0.888
65–74	629	55.9 (53.4–58.3)	55.8 (53.1–58.5)	56.2 (50.9–61.3)
≥75	1003	44.1 (41.7–46.6)	44.2 (41.5–47.0)	43.8 (38.7–49.1)
Sex					<0.001
Male	707	42.4 (39.8–45.1)	46.8 (43.6–50.0)	23.5 (18.5–29.4)
Female	925	57.6 (54.9–60.2)	53.2 (50.1–56.4)	76.5 (70.7–81.5)
Race and Ethnicity					0.002
Non-Hispanic Black	96	6.4 (4.8–8.4)	7.2 (5.4–9.5)	3.1 (1.3–7.2)
Hispanic	129	7.0 (5.7–8.6)	6.3 (4.9–8.1)	9.9 (6.2–15.2)
Non-Hispanic White	1332	81.2 (78.6–83.5)	80.4 (77.5–83.1)	84.2 (78.3–88.7)
Other	75	5.4 (4.2–7.1)	6.1 (4.6–8.0)	2.8 (1.4–5.6)
Income					0.918
<$25,000	400	21.7 (19.4–24.3)	21.8 (19.1–24.8)	21.5 (17.1–26.7)
≥$25,000	1232	78.3 (75.7–80.6)	78.2 (75.2–80.9)	78.5 (73.3–82.9)
Medicare-Medicaid dual eligibility					0.659
Nondual	1480	91.9 (90.1–93.4)	91.7 (89.5–93.6)	92.6 (88.8–95.1)
Fully dual eligible	80	4.4 (3.3–5.8)	4.4 (3.1–6.1)	4.3 (2.3–7.9)
Partial	39	1.9 (1.4–2.6)	2.1 (1.5–2.9)	1.2 (0.48–3.2)
QMB eligible only	33	1.8 (1.1–3.0)	1.8 (1.0–3.1)	1.9 (0.84–4.1)
Residing Area					0.305
Metro	1294	82.0 (79.2–84.4)	81.4 (78.5–84.0)	84.2 (78.4–88.7)
Non-metro	338	18.0 (15.6–20.8)	18.6 (16.0–21.5)	15.8 (11.3–21.7)
US census regions					0.031
West	356	22.7 (20.7–24.9)	22.2 (20.0–24.6)	25.0 (19.1–32.0)
Northeast	322	20.0 (17.4–22.8)	19.8 (16.9–23.1)	20.8 (15.6–27.3)
Midwest	342	19.8 (17.7–22.1)	18.6 (16.4–21.1)	24.9 (19.6–31.0)
South	612	37.5 (34.6–40.5)	39.4 (36.1–42.7)	29.3 (23.5–36.0)
Living alone status					0.958
No	1283	81.5 (79.1–83.7)	81.5 (78.8–84.0)	81.4 (76.6–85.4)
Yes	349	18.5 (16.3–20.9)	18.5 (16.1–21.1)	18.6 (14.6–23.4)
Internet access
Yes	1346	86.6 (84.4–88.6)	86.2 (83.5–88.6)	88.3 (84.0–91.5)
No	286	13.4 (11.4–15.7)	13.8 (11.5–16.5)	11.7 (8.5–16.0)
Comorbid conditions					0.113
None	82	6.3 (4.9–8.0)	6.7 (5.2–8.7)	4.3 (4.9–8.0)
1	258	17.1 (14.9–19.6)	16.7 (14.4–19.2)	19.2 (14.9–19.6)
2	396	25.0 (22.5–27.6)	26.0 (23.3–28.8)	20.7 (22.5–27.6)
≥3	895	51.6 (47.8–55.3)	50.6 (46.6–54.6)	55.8 (47.8–55.3)
Depression history					<0.001
Yes	350	22.5 (20.1–25.0)	19.1 (16.5–22.0)	36.8 (31.0–43.1)
No	1282	77.5 (75.1–79.9)	80.9 (78.0–83.5)	63.2 (57.0–69.0)
Social connectedness					<0.001
Less connected	658	42.6 (39.4–45.9)	37.1 (33.9–40.5)	66.3 (60.9–71.4)
More/same connected	974	57.4 (54.1–60.6)	62.9 (59.5–66.1)	33.7 (28.6–39.1)
Financial security					<0.001
More/same security	1469	88.8 (86.8–90.5)	90.7 (88.9–92.2)	80.4 (74.6–85.2)
Less security	163	11.2 (9.5–13.2)	9.3 (7.8–11.1)	19.6 (14.8–25.5)
Loneliness or sadness
Less/same lonely or sad	1469	81.2 (78.7–83.6)	NA	NA
More lonely or sad	163	18.8 (16.5–21.4)	NA	NA

Abbreviations: CI, Confidence Interval; QMB, Qualified Medicare Beneficiary NA, Not Applicable p-values are based on a Wald χ2 test.

3.2. Financial Security among Cancer Survivors

As presented in Table 2 , the proportion of cancer survivors who reported decreased financial security during the last six months was higher among younger groups (13.7% vs. 8.1%, p = 0.002), females (13.7% vs. 7.9%, p <0.001) and those with lower income compared to higher income participants (18.8% vs. 9.1%, p <0.001). In addition, cancer survivors with three or more co-morbidities had a higher rate of reporting decreased financial security (14.3%) compared to participants with no co-morbidity (8.8%, p <0.001). In addition, the proportion of decreased financial security was higher among cancer survivors who reported an increased feeling of loneliness or sadness (19.6% vs. 9.3%, p <0.001).

Table 2.

Financial security among Medicare beneficiaries with cancer history.

Characteristics	More/same financial security	Less financial security
	Weighted % (95% CI)	Weighted % (95% CI)	p-value
Age			0.002
65–74	86.3 (83.2–90.0)	13.7 (11.0–16.8)
≥75	91.9 (89.7–93.6)	8.1 (6.4–10.3)
Sex			<0.001
Male	92.1 (89.8–93.9)	7.9 (6.1–10.2)
Female	86.3 (83.5–88.8)	13.7 (11.3–16.5)
Race and Ethnicity
Non-Hispanic Black	89.7 (87.8–91.4)	10.3 (8.6–12.2)	0.205
Hispanic	82.6 (71.0–90.2)	17.4 (9.8–29.0)
Non-Hispanic White	89.7 (89.8–91.4)	10.3 (8.6–12.2)
Other	91.8 (82.5–96.4)	8.2 (3.6–17.5)
Income			<0.001
<$25,000	81.2 (76.2–85.3)	18.8 (14.7–23.8)
≥$25,000	90.9 (88.7–92.7)	9.1 (7.3–11.3)
Medicare-Medicaid dual eligibility			0.054
Nondual	89.8 (87.8–91.6)	10.2 (8.5–12.2)
Fully dual eligible	74.2 (59.2–85.0)	25.8 (15.0–44.8)
Partial	87.4 (70.8–95.2)	12.6 (4.8–29.2)
QMB eligible only	71.2 (50.1–85.9)	28.8 (14.1–49.9)
Residing Area			0.607
Metro	88.6 (86.3–90.5)	11.4 (9.5–13.7)
Non-metro	89.7 (85.2–93.0)	10.3 (7.1–14.8)
US census regions
West	87.6 (81.4–91.9)	12.4 (8.1–18.6)	0.710
Northeast	90.3 (87.0–92.8)	9.7 (7.2–13.0)
Midwest	89.4 (84.1–93.1)	10.6 (6.9–15.9)
South	88.4 (85.8–90.5)	11.6 (9.5–14.2)
Living alone status			0.920
No	88.7 (86.4–90.7)	11.3 (9.3–13.6)
Yes	89.0 (83.3–92.9)	11 (7.1–16.7)
Internet access			0.02
Yes	89.7 (87.5–91.6)	10.3 (8.4–12.5)
No	82.6 (76.8–87.2)	17.4 (12.8–23.2)
Comorbid conditions			0.002
None	91.1 (73.2–97.5)	8.9 (2.5–26.8)
1	90.8 (85.0–94.6)	9.2 (5.4–15.0)
2	93.0 (90.1–95.2)	7.0 (4.9–9.9)
≥3	85.7 (82.8–88.2)	14.3 (11.8–17.2)
Depression history			<0.001
Yes	78.8(73.6–83.3)	21.2(16.7–26.4)
No	91.6 (89.8–93.2)	8.4(6.8–10.2)
Social connectedness			0.075
Less connected	86.7 (83.4–89.5)	13.3 (10.5–16.6)
More/same connected	90.3 (87.8–92.3)	9.7 (7.7–12.3)
Loneliness or sadness			<0.001
Less/same lonely or sad	90.7 (88.9–92.2)	9.3 (7.8–11.1)
More lonely or sad	80.4 (74.6–85.2)	19.6 (14.8–25.4)

Abbreviations: CI, Confidence Interval; NA, Not Applicable, QMB, Qualified Medicare Beneficiary p-values are based on a Wald χ2 test.

3.3. Association between Financial Security and Loneliness or Sadness

Table 3 shows the results from unadjusted and multivariable logistic regression analyses. In the unadjusted model, cancer survivors who reported decreased financial security had much higher odds of reporting increased feelings of loneliness or sadness compared to those who reported feeling more or about the same financial security (AOR = 2.38, 95% CI 1.63–3.48, p <0.001). This relationship was significant in adjusted model as well. Cancer survivors who reported decreased financial security had 93% higher odds of increased feelings of loneliness or sadness compared to those who reported feeling more or about the same financial security (AOR = 1.93, 95% CI 1.25–3.01, p = 0.004). Compared with males, females had twice the odds of reporting increased feelings of loneliness or sadness during the past six months (AOR = 2.56, 95% CI 1.75–3.75, p <0.001). In addition, cancer survivors who reported decreased social connectedness to family members and friends had three times the odds of feeling more lonely or sad compared with those who reported more or about the same social connectedness (AOR = 3.21, 95% CI 2.45–4.22, p <0.001). The odds of increased feelings of loneliness or sadness were also higher for those who reported a history of depression compared to those without a depression history (AOR = 2.00, 95% CI 1.38–2.88, p <0.001).

Table 3.

Relationship between financial security and feelings of loneliness or sadness in Medicare beneficiaries with cancer history.

Characteristics	Unadjusted OR (95% CI)	p-value	AOR (95% CI)	p-value
Financial security
More/same financial security	1		1
Less financial security	2.38 (1.63–3.48)	<0.001	1.93 (1.25–3.01)	0.004
Sex
Male	1		1
Female	2.86 (2.03–4.04)	<0.001	2.56 (1.75–3.75)	<0.001
Age
65–74	1		1
≥75	0.98 (0.77–1.25)	0.889	1.24 (0.93–1.65)	0.144
Race and Ethnicity
Non-Hispanic White	1		1
Non-Hispanic Black	0.42 (0.16–1.07)	0.069	0.48 (0.17–1.33)	0.155
Hispanic	1.45 (0.81–2.72)	0.194	1.64 (0.81–3.32)	0.171
Other	0.44 (0.19–1.04)	0.062	0.53 (0.23–1.22)	0.137
Income
<$25,000	0.98 (0.70–1.39)	0.919	0.96 (0.62–1.49)	0.854
≥$25,000	1		1
Medicare-Medicaid dual eligibility
Non-dual	1		1
Fully dual eligible	0.98 (0.44–2.22)	0.967	0.64 (0.25–1.65)	0.351
Partial	0.59 (0.19–1.80)	0.350	0.81 (0.21–3.15)	0.753
QMB eligible only	1.05 (0.43–2.54)	0.916	0.96 (0.38–2.44)	0.935
Residing Area
Metro	1		1
Non-metro	0.82 (0.55–1.22)	0.329	0.90 (0.62–1.31)	0.582
US census regions
West	1		1
Northeast	0.94 (0.56–1.58)	0.802	0.97 (0.55–1.73)	0.924
Midwest	1.19 (0.76–1.86)	0.453	1.12 (0.66–1.89)	0.674
South	0.66 (0.43–1.03)	0.067	0.68 (0.43–1.10)	0.117
Living alone status
No	1		1
Yes	1.01 (0.73–1.40)	0.958	0.91 (0.60–1.38)	0.644
Internet access
No	1		1
Yes	1.21 (0.78–1.87)	0.398	1.11 (0.69–1.83)	0.693
Social connectedness
More/same connected	1		1
Less connected	3.34 (2.63–4.22)	<0.001	3.21 (2.45–4.22)	<0.001
Comorbid conditions
0	1		1
1	1.82 (0.73–4.58)	0.198	2.18 (0.74–6.45)	0.16
2	1.26 (0.51–3.14)	0.610	1.56 (0.55–4.42)	0.40
≥3	1.75 (0.76–4.06)	0.189	2.02 (0.73–5.54)	0.17
Depression history
No	1		1
Yes	2.47 (1.78–3.42)	<0.001	2.00 (1.38–2.88)	<0.001

Abbreviations: AOR, Adjusted Odds ratio; CI, Confidence Interval; QMB, Qualified Medicare Beneficiary.

4. Discussion

In this paper, we used a population-based, nationally representative sample of Medicare beneficiaries with a cancer history (aged ≥65 years) to examine financial security and loneliness or sadness during the 2020–2021 winter surge of the COVID-19 pandemic. Our findings show an increase in loneliness or sadness and a decrease in financial security among older cancer survivors during this period. Specifically, an estimated 1.5 million cancer survivors (18.8%) reported increased feelings of loneliness or sadness, and about one million (11.2%) reported decreased financial security over the past six months. These findings are not unique to our study. Previous studies have reported even higher rates of loneliness or sadness among patients with cancer compared to our study. A recent study reported 27% of older adults (aged ≥65) with cancer diagnosis experienced loneliness [33]. Direct comparisons with this study, however, are limited due to active cancer treatment in their study population. Similarly, another study found that 53% of study participants with a cancer diagnosis were in the “lonely” group [24], yet, the patient population enrolled in this study was younger compared to our study population.

Our study findings also showed that cancer survivors who reported decreased financial security were more likely to report increased feelings of loneliness or sadness. A recent study conducted in the US during the pandemic with 1861 older adults (aged ≥50) found that people with higher financial hardship have a statistically significant higher probability of suffering from loneliness (β =0.28, p <0.001) [34]. Estimates from another study conducted during the earlier phase of the pandemic with 971 individuals with chronic health conditions (diabetes, heart diseases, hypertension, psychiatric disorders, HIV, cancer, and asthma) showed that participants with financial uncertainties have higher chances of suffering from loneliness [35]. Since many older cancer survivors experienced significant levels of loneliness and financial insecurity during the pandemic, it is clear that additional screenings and interventions beyond what is currently available are needed to ease the socioeconomic vulnerabilities experienced by this population.

Our findings further reveal that loneliness or sadness was more pervasive in female cancer survivors. Previous studies have reported similar sex differences in feelings of loneliness or sadness. For instance, Clifton and colleagues (2022) found higher rates of loneliness among older females (age ≥ 65) with active cancer compared to older males [33]. Another study conducted among the general population during the pandemic reported similar trends [36]. Our findings, along with those of other studies, present strong evidence that women are more vulnerable to loneliness or sadness. This may be explained in part by differences between men and women in valuing social relationships. Men are likely more appreciative of the instrumental elements of social relationships, such as shared activities and interests. In contrast, women likely value more affective elements in relationships, such as intimacy, closeness, and mutual social support. These were severely compromised by protection measures during the pandemic. The long-term impact of COVID-19 and related public health restrictions are yet to be fully explored. It is, however, increasingly evident that routine screening not only for common symptoms but also for loneliness is warranted, especially among female cancer survivors.

Moreover, our study findings showed that cancer survivors with a depression history and those who reported decreased social connectedness to family members or friends reported increased feelings of loneliness or sadness. Similar observations were reported previously. One study comparing social network data before and after the COVID-19 pandemic found that individuals with close social ties and with frequent interactions with their social ties had a lower increase in loneliness during the pandemic [37]. Another study analyzing mental health symptoms during the COVID-19 pandemic discovered that cancer survivors who had limited social interactions were more likely to report mental health symptoms, including feelings of nervousness, anxiety, and loneliness [28]. The general picture emerging from recent studies provides evidence that the pandemic contributed to increased social isolation along with the worsening of psychological symptoms in this population. Developing strategies to provide peer support and connect cancer survivors who experience poor social connectedness may help to improve overall social well-being and reduce loneliness among cancer survivors.

Our findings also yielded age and sex differences with respect to financial security. Decreased financial security was more prevalent among cancer survivors aged 65–74 compared to those 75+ years old. Income variation by age among the US population is well-documented [38,39]. Financial burden is high for people with a history of cancer, and this is commonly attributed to high treatment expenditure, loss of work days, and multiple disease-related commitments, which significantly lower income [40]. Females in our study experienced lower financial security compared to their male counterparts. Possible reasons for this sex discrepancy might include lower median income levels, lower pensions, and limited social security benefits available to women compared to men in the US [41]. These are further exacerbated by sex inequalities in pay. For example, men were more financially affluent in 2020, with women only earning 84% of what men earned [42]. Other potential contributors include reduced work hours and frequent career breaks taken by women to meet caregiving responsibilities [41]. Further research is needed to meet the challenge of addressing sex inequalities in perceived financial security.

Our results revealed reduced financial security among cancer survivors with multiple co-morbidities (≥3). This finding is consistent with previous research showing that Medicare beneficiaries with cancer history and comorbid conditions had increased odds of financial burden [43]. This is not surprising given that the presence of multiple co-morbidities is linked to increased out-of-pocket treatment expenses [44,45], lower productivity, increased absenteeism, lower rates of labor market participation, reduced hours of work [46], and employment change [47] Patients with cancer and co-morbidities are also more likely to face workplace discrimination than those without co-morbidities [48]. In this way, chronic conditions exacerbate cancer-related financial hardship, magnifying the detrimental effects of the latter on health. This underlines the importance of systemic and multilevel interventions to provide targeted financial support to cancer survivors with multiple co-morbidities following the pandemic.

4.1. Limitations

This study has several limitations. First, our dataset was limited to Medicare beneficiaries aged ≥65 with a history of cancer diagnosis. Therefore, the results are not generalizable beyond this population. In addition, the cross-sectional data of our study limits the causal inference. Future studies using prospective longitudinal follow-up designs are thus needed to explore the causal impact of financial security on loneliness or sadness. Additionally, loneliness or sadness was combined as a single outcome and was measured using one item in this study. Further research should consider using validated and reliable loneliness scales to provide deeper insight into the multifaceted aspects of loneliness and sadness among cancer survivors. Several variables were also missing from the dataset that may be associated with loneliness or sadness and financial security (e.g., type of cancer, treatment regimen, treatment status, time since diagnosis). Lastly, study variables were self-reported, which is subject to reporting bias.

5. Conclusion

In conclusion, increased feelings of loneliness or sadness and decreased financial security were prevalent among older cancer survivors during the COVID-19 pandemic. Increasing cost-related health literacy, encouragement from oncologists for cost-related discussion, and policy reformation are some of the strategies that may improve financial security among cancer survivors [49]. In addition, our findings highlight the importance of accounting for loneliness or sadness in the routine screening of cancer survivors, particularly in conjunction with referral pathways for psychosocial and mental health support services. In addition, an important insight from this study is that financial security significantly impacts feelings of loneliness or sadness. Thus, systemic, and multilevel interventions are needed to improve the financial protection of cancer survivors and ease socioeconomic vulnerabilities experienced by this population. Addressing financial security may ameliorate loneliness or sadness among older cancer survivors.

Availability of Data and Materials

The data that support the findings of this study are openly available in Centers for Medicare & Medicaid Services at https://www.cms.gov/Research-Statistics-Data-and-Systems/Downloadable-Public-Use-Files/MCBS-Public-Use-File

Funding Statement

Dr. Hermine Poghosyan is partially funded by National Institute of Health/ National Cancer Institute R01CA258269. Dr. Stella Arakelyan's role in the project was funded by the National Institute for Health and Care Research (NIHR) under its Artificial Intelligence for Multiple and Long-Term Conditions Programme (NIHR202639). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

Patient Consent Statement

Not applicable as we conducted secondary data analysis of publicly available data.

Author Contributions

Hermine Poghosyan: statistical analyses. All co-authors participated in the conceptualization of the study, the interpretation of study findings, writing the original draft, reviewing and editing revisions, and they approved the final article.

Declaration of Competing Interest

None.