Abstract
Purpose:
Describe material financial hardship (e.g., using savings, credit card debt), insurance, and access to care experienced by Utah cancer survivors; investigate urban-rural differences in financial hardship.
Methods:
Cancer survivors were surveyed from 2018–2021 about their experiences with financial hardship, access to healthcare, and job lock (insurance preventing employment changes). Weighed percentage responses, univariable and multivariable logistic regression models for these outcomes compared differences in survivors living in rural and urban areas based on Rural-Urban Commuting Area Code.
Results:
The N=1,793 participants were predominantly Non-Hispanic White, female, and 65 or older at time of survey. More urban than rural survivors had a college degree (39.8% vs. 31.0%, p=0.04). Overall, 35% of survivors experienced ≥1 financial hardship. In adjusted analyses, no differences were observed between urban and rural survivors for: material financial hardship, the overall amount of hardship reported, insurance status at survey, access to healthcare, or job lock. Hispanic rural survivors were less likely to report financial hardship than Hispanic urban survivors (Odds Ratio (OR)=0.24, 95%CI=0.08–0.73)). Rural survivors who received chemo/immune therapy as their only treatment were more likely to report at least one instance of financial hardship than urban survivors (OR=2.72, 95%CI=1.08–6.86).
Conclusions:
The relationship between rurality and financial hardship among survivors may be most burdensome for patients whose treatments require travel or specialty medication access.
Implications for Cancer Survivors:
The impact of living rurally on financial difficulties after cancer diagnoses is complex. Features of rurality that may alter financial difficulty after a cancer diagnosis may vary geographically and instead of considering rurality as a stand-alone factor, these features should be investigated independently.
Keywords: Financial hardship, Rurality, Access to care, Insurance coverage
Introduction
Financial hardship due to cancer care costs is a significant issue reported by many cancer patients and survivors.[1, 2] Financial hardship may result in altered behaviors surrounding spending and debt, which can have long-lasting financial ramifications.[3] Material financial hardship is one domain that captures the conditions related to the high out-of-pocket treatment costs faced by many survivors and the lower income that results from work limitations during and after treatment.[4] High levels of material financial hardship result in multiple negative outcomes for cancer survivors, including avoidance of survivorship care and poorer cancer survival.[5]
Rural cancer experiences are a national priority research area for the National Cancer Institute due to the unique sociodemographic complexity and poorer cancer outcomes faced in many rural communities.[6] Populations living in rural areas tend to have limited access to cancer screening and experience higher rates of cancer-related deaths than urban communities.[6–8] Medical non-adherence occurs more frequently in cancer patients and survivors who live in rural areas.[9, 10] Greater distance to health care, lower income, lack of health insurance, and higher prevalence of chronic health conditions prior to cancer diagnosis, have been proposed as contributing factors for many of poorer health outcomes observed in rural cancer survivors.
Research on the association of rurality with financial hardship has found inconsistent results, with some reports indicating no difference between rural and urban survivors,[6–8, 11–13] and others identifying greater financial hardship for survivors living in rural areas.[10, 14] The rural United States is becoming increasingly economically and demographically diverse, which may explain discrepant financial hardship findings.[15] Therefore, studies representing the diversity of rural regions are needed to explore rural survivors’ access to care and factors that may affect their financial growth such as job lock (i.e., insurance worries prohibiting work changes, which could be more common in rural communities), as well as their experiences with material financial hardship.
Utah represents a distinct region, with a population density much lower than the national average; 82% of Utah counties are classified as rural or frontier [16] and of these, 42% qualify as Health Provider Shortage Areas.[16] Utah has seen substantial Hispanic population growth over the past decade in both rural and urban areas.[17] Thus, we used data from a population-based survey of Utah cancer survivors conducted from 2018 to 2021 to examine differences in self-reported material financial hardship, access to health care and insurance, and job lock between cancer survivors living in rural and urban Utah. We also report on demographic and clinical factors associated with differences in material hardship between rural and urban survivors.
Methods
Sample and Eligibility
Eligible subjects were identified through Utah Cancer Registry (UCR) records. UCR is a statewide, population-based registry which collects and maintains information on reportable cancer diagnoses in Utah and has been part of the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) program since 1973 and the Centers for Disease Control and Prevention’s National Program of Cancer Registries since 2017.
Eligibility included cancer survivors currently living in Utah, diagnosed with cancer between 2012–2019, 18 years or older at diagnosis, and approximately 2–5 years from the end of the calendar year of their cancer diagnosis. Eligible subjects were consented and completed the one-time Utah Cancer Survivor Experiences Survey in either English or Spanish.[18] Individuals with a SEER-reportable invasive cancer diagnosis were eligible. To support inference of the survey results to populations with potential health disparities, sampling of subjects within the eligible population was stratified based on an area-level measure of health insurance coverage and on Hispanic ethnicity, as previously described.[18]
Survey procedures
The survey was performed using mixed-model web and paper data collection process for survivors under age 80, and paper-only response for survivors 80 and older. All subjects received a pre-notification letter, then an introductory letter 7–10 days later with a $2 pre-incentive. Up to three mailed reminders were sent to non-respondents in addition to phone call reminders and an opportunity to complete the survey by phone.
Measures
Rural vs. Urban
Each participant was assigned the Rural-Urban Commuting Area Code (RUCA) of their census tract of residence at diagnosis. RUCA codes from 2013 were used. Codes 1, 2, and 3 were considered urban, and codes 4–10 rural.[19]
Material financial hardship, access to care, insurance denial, and job lock
Questions regarding insurance coverage, job lock, and access to care/cost concerns were selected for inclusion in the Utah Cancer Survivor Experiences Survey from the Behavioral Risk Factor Surveillance System (BRFSS) questionnaires and other surveys.[20] Nine questions focused on material financial hardship were selected from previously completed national studies. Respondents were asked about financial coping mechanisms that occurred due to medical expenses in the 12 months prior. Questions included items such as taking money out of savings, spending >10% of income on medical expenses, taking on credit card debt, and filing for bankruptcy. Responses were dichotomized as yes vs. no/not sure for analysis. Each item was analyzed separately. A count of material financial hardships reported was created (0, 1–2, and 3 or more “yes” responses).
Sociodemographic and cancer variables
Survey items included race and ethnicity, educational status, employment status, and current insurance status. Additional variables obtained from UCR records included: survivor’s age, sex, marital status, race, and ethnicity if missing from survey, and health insurance at time of diagnosis. Cancer information came from UCR records including: cancer site, cancer stage, treatment, and time since diagnosis. For the treatment variable, receipt of chemotherapy includes oral chemotherapy and immunotherapy.
Analyses
We summarized sociodemographic, cancer-related, and hardship-related factors as counts with unweighted and weighted percentages. We compared differences between rural survivors versus urban survivors using chi-squared tests. To determine the association between each financial hardship variable and rurality, we estimated both unadjusted and adjusted odds ratios (OR). To do so, we fitted univariable and multivariable logistic regression models for each hardship variable. Multivariable models adjusted for Hispanic ethnicity, age at survey response, education, and years since diagnosis. We reported the 95% confidence intervals of the ORs. Analyses were weighted to account for the sample design, non-response, and age-adjusted to make statistically valid inferences for Utah cancer survivors. Two-sided p-value was used to establish statistical significance in all analyses. All analyses were performed using SAS version 9.4.
Results
Over the four years of the survey, 1,793 survivors of 3,296 sampled for the survey responded (54.4% response rate). Participants were predominantly Non-Hispanic White, female, and 65 or older at time of survey (Table 1).
Table 1:
Demographic and Cancer-Related Factors of Utah Cancer Survivors by Rural vs. Urban Residence, 2018–2021
| Rural (n=273) | Urban (n=1520) | ||||||
|---|---|---|---|---|---|---|---|
|
|
|||||||
| n | Raw % | Weighted %a | n | Raw % | Weighted %a | p-valueb | |
|
| |||||||
| Years since cancer diagnosis | |||||||
| <2 | 29 | 10.7 | 9.3 | 132 | 8.7 | 8.5 | 0.35 |
| 2–4 | 131 | 48.2 | 48.4 | 663 | 43.7 | 43.9 | - |
| 4+ | 112 | 41.2 | 42.3 | 723 | 47.6 | 47.6 | - |
| Age at survey, years | |||||||
| 18–39 | 12 | 4.4 | 6.4 | 87 | 5.7 | 8.0 | 0.54 |
| 40–64 | 114 | 41.8 | 41.5 | 574 | 37.8 | 38.0 | - |
| 65+ | 147 | 53.9 | 52.2 | 859 | 56.5 | 54.0 | - |
| Sex | |||||||
| Female | 146 | 53.5 | 54.5 | 819 | 53.9 | 53.0 | 0.69 |
| Male | 127 | 46.5 | 45.5 | 701 | 46.1 | 47.0 | - |
| Race/Ethnicity | |||||||
| Other race/ethnicity | 2 | 0.7 | 1.5 | 39 | 2.6 | 3.8 | 0.69 |
| Hispanic/Latino | 28 | 10.3 | 8.0 | 201 | 13.2 | 5.8 | - |
| Non-Hispanic White | 243 | 89.0 | 90.5 | 1280 | 84.2 | 90.5 | - |
| Education | |||||||
| High school or less | 73 | 27.3 | 27.5 | 373 | 25.0 | 21.9 | 0.04 |
| Some college | 110 | 41.2 | 41.5 | 560 | 37.5 | 38.2 | - |
| College graduate | 84 | 31.5 | 31.0 | 562 | 37.6 | 39.8 | - |
| Marital Status at Diagnosis | |||||||
| Married/Living as married | 185 | 76.5 | 75.0 | 1017 | 75.6 | 76.1 | 0.76 |
| Single (divorced, single, widowed, separated) | 57 | 23.6 | 25.0 | 328 | 24.4 | 23.9 | - |
| Employment at Survey | |||||||
| Employed full time (30+ hours per week) | 82 | 30.7 | 30.9 | 448 | 30.0 | 31.6 | 0.90 |
| Employed part time (<30 hours per week) | 23 | 8.6 | 7.6 | 132 | 8.8 | 8.9 | - |
| Retired | 126 | 47.2 | 45.1 | 685 | 45.8 | 44.3 | - |
| *Other | 36 | 13.5 | 16.4 | 231 | 15.4 | 15.2 | - |
| Health Insurance at Survey | |||||||
| Uninsured/No record of insurance | 11 | 4.0 | 3.7 | 71 | 4.7 | 4.0 | 0.93 |
| Public | 143 | 52.4 | 52.0 | 826 | 54.3 | 52.5 | - |
| Private | 115 | 42.1 | 43.2 | 608 | 40.0 | 42.7 | - |
| Other | 4 | 1.5 | 1.1 | 15 | 1.0 | 0.7 | - |
| Cancer Site | |||||||
| Breast | 53 | 29.4 | 28.6 | 329 | 32.7 | 30.0 | 0.34 |
| Prostate | 56 | 31.1 | 28.6 | 284 | 28.3 | 26.9 | - |
| Colorectal | 21 | 11.7 | 12.7 | 94 | 9.4 | 10.0 | - |
| Melanoma | 32 | 17.8 | 16.4 | 214 | 21.3 | 23.1 | - |
| Thyroid | 18 | 10.0 | 13.6 | 84 | 8.4 | 10.0 | - |
| Cancer Treatment | |||||||
| No Chemotherapy or Radiation | 148 | 54.2 | 53.9 | 812 | 53.4 | 54.7 | 0.42 |
| Chemotherapy only | 28 | 10.3 | 9.7 | 214 | 14.1 | 13.0 | - |
| Radiation only | 62 | 22.7 | 24.0 | 302 | 19.9 | 20.2 | - |
| Chemotherapy and Radiation | 35 | 12.8 | 12.3 | 192 | 12.6 | 12.1 | - |
| Surgery Received | |||||||
| Yes | 216 | 79.1 | 81.0 | 1145 | 75.3 | 76.2 | 0.09 |
| No | 57 | 20.9 | 19.0 | 375 | 24.7 | 23.8 | - |
| Stage at Diagnosis | |||||||
| Localized | 164 | 70.7 | 71.2 | 873 | 64.7 | 62.9 | 0.15 |
| Regional | 42 | 18.1 | 16.5 | 300 | 22.2 | 23.6 | - |
| Distant | 20 | 8.6 | 8.3 | 145 | 10.8 | 10.4 | - |
| Not staged/Unknown | 6 | 2.6 | 3.9 | 31 | 2.3 | 3.3 | - |
Weighted for sample design, nonresponse and age distribution
P-value from chi-squared test
Other includes unable to work due to illness or disability, caring for home or family, not seeking paid work, student, other
Distributions of age, sex, and race were similar for urban and rural survivors. The only statistically significant difference was education, where rural survivors included a smaller proportion with a college degree, 31.0%, compared to urban survivors, 39.8%.
For insurance coverage, job lock, and access to care/cost concerns, there were no differences between rural and urban survivors in either the univariable model or the multivariable model (Table 2).
Table 2:
Effect of Rural Residency on Utah Cancer Survivors’ Insurance, Job Lock, Access to Care, and Material Financial Hardship, 2018–2021
| Rural (n=273) | Urban (n=1520) | Rural vs Urban Survivors |
||||
|---|---|---|---|---|---|---|
| Unadjusted Odds Ratio | Adjusted Odds Ratiob | |||||
|
| ||||||
| %a | %a | OR | 95% CI | OR | 95% CI | |
|
| ||||||
| Insurance Type and Job Lock | ||||||
|
| ||||||
| Current Insurance | ||||||
| Private | 62.6 | 63.1 | Ref. | - | Ref. | - |
| Public | 35.5 | 34.7 | 1.03 | 0.76 – 1.40 | 1.01 | 0.73 – 1.39 |
| None | 1.9 | 2.2 | 0.85 | 0.28 – 2.63 | 0.70 | 0.22 – 2.28 |
| Insurance paid for most of cancer care | 97.6 | 97.4 | 1.07 | 0.42 – 2.74 | 1.13 | 0.41 – 3.12 |
| Ever denied health insurance | 7.3 | 8.4 | 0.86 | 0.49 – 1.51 | 0.91 | 0.52 – 1.60 |
| Job Lock | ||||||
| Participant stay at a job because of insurance concern | 21.0 | 20.5 | 1.03 | 0.66 – 1.60 | 1.08 | 0.68 – 1.71 |
| Spouse/significant other stay at a job because of insurance concern | 14.3 | 13.3 | 1.09 | 0.61 – 1.95 | 1.15 | 0.64 – 2.09 |
|
| ||||||
| Access to Care/Cost Concerns | ||||||
|
| ||||||
| Have a primary care provider | 88.0 | 91.9 | 0.65 | 0.40 – 1.06 | 0.60 | 0.36 – 1.00 |
| Had a routine check-up within past year | 78.9 | 79.1 | 0.99 | 0.69 – 1.41 | 1.04 | 0.72 – 1.49 |
| Didnť see doctor due to cost within past year | 3.9 | 5.2 | 0.75 | 0.34 – 1.63 | 0.73 | 0.33 – 1.63 |
| Didnť take medication due to cost within past year | 7.5 | 5.8 | 1.32 | 0.68 – 2.55 | 1.33 | 0.68 – 2.59 |
|
| ||||||
| Material Financial Hardship | ||||||
|
| ||||||
| Had to take money out of savings | 30.5 | 30.6 | 1.00 | 0.72 – 1.37 | 0.96 | 0.68 – 1.35 |
| Spent >10% of savings on medical expenses | 21.6 | 19.5 | 1.13 | 0.78 – 1.65 | 1.05 | 0.70 – 1.56 |
| Took a credit card debt | 14 | 14.7 | 0.95 | 0.61 – 1.47 | 0.92 | 0.58 – 1.45 |
| Put off major purchases | 13 | 12.8 | 1.02 | 0.65 – 1.58 | 0.95 | 0.59 – 1.54 |
| Had to borrow money | 7.9 | 9.4 | 0.82 | 0.48 – 1.40 | 0.71 | 0.39 – 1.31 |
| Been unable to pay for necessities like food heat or rent | 6.2 | 6.5 | 0.94 | 0.48 – 1.82 | 0.76 | 0.37 – 1.54 |
| Thought about filing for bankruptcy | 3.7 | 6 | 0.60 | 0.29 – 1.27 | 0.54 | 0.25 – 1.18 |
| Took out a mortgage against your home/took out a loan | 1.4 | 3.1 | 0.45 | 0.13 – 1.51 | 0.37 | 0.11 – 1.29 |
| Filed for bankruptcy | 1.7 | 1.1 | 1.52 | 0.44 – 5.25 | 1.28 | 0.33 – 4.98 |
|
| ||||||
| Sum of Material Hardship | ||||||
| 0 | 58.5 | 60.0 | Ref. | - | Ref. | - |
| 1 or 2 | 26.5 | 25.1 | 1.08 | 0.76 – 1.54 | 1.06 | 0.74 – 1.52 |
| 3 or more | 15.0 | 14.9 | 1.03 | 0.68 – 1.57 | 0.92 | 0.57 – 1.49 |
% reporting “yes” weighted for sample design, nonresponse, and age distribution.
Adjusted for Hispanic ethnicity, continuous age at survey response, education, and years since diagnosis.
Most survivors had insurance coverage and reported that insurance coverage covered their cancer care. Job lock was reported by approximately 20% of both rural and urban survivors. Most had a primary provider, and few reported skipping care due to costs, although >20% of both rural and urban survivors reported that it was more than 12 months since their most recent checkup.
The most common material financial hardship was taking money out of savings (approximately 30% among rural and urban, Table 2; Appendices). When rural vs. urban survivors were compared, there were no statistically significant findings for the nine material hardship items in either the univariate or multivariable models. For the sum of material hardship responses (0, 1–2, or ≥3 hardships), approximately 40% of participants reported at least one hardship, with no significant difference between rural and urban survivors.
We examined the presence or absence of material financial hardship (0 hardships vs. ≥1) among rural and urban survivors by sociodemographic and cancer factors (Table 3).
Table 3:
Utah Cancer Survivors’ Report of Material Financial Hardship and association with Rural vs. Urban Residence according to Demographic and Cancer-Related Factors, 2018–2021
| One or More Material Financial Hardships | ||||||
|---|---|---|---|---|---|---|
|
| ||||||
| Rural | Urban | Unadjusted Odds Ratioa | Adjusted Odds Ratioa,c | |||
|
| ||||||
| %b | %b | OR | 95% CI | OR | 95% CI | |
|
| ||||||
| All cases | 13.9 | 86.1 | 1.07 | 0.79 – 1.44 | 1.01 | 0.73 – 1.40 |
|
| ||||||
| Age | ||||||
| 18–39 | 10.0 | 90.0 | 0.76 | 0.19 – 3.08 | 0.48 | 0.11 – 2.10 |
| 40–64 | 15.4 | 84.6 | 1.11 | 0.69 – 1.77 | 1.10 | 0.68 – 1.77 |
| 65+ | 13.1 | 86.9 | 1.04 | 0.67 – 1.61 | 0.99 | 0.63 – 1.56 |
|
| ||||||
| Ethnicity | ||||||
| Hispanic | 11.9 | 88.1 | 0.34 | 0.11 – 1.04 | 0.24 | 0.08 – 0.73 |
| Non-Hispanic | 14.1 | 85.9 | 1.14 | 0.84 – 1.56 | 1.13 | 0.81 – 1.56 |
|
| ||||||
| Education | ||||||
| High school or less | 16.5 | 83.5 | 0.98 | 0.55 – 1.74 | 0.95 | 0.51 – 1.78 |
| Some college | 13.2 | 86.8 | 0.87 | 0.54 – 1.4 | 0.84 | 0.50 – 1.40 |
| College graduate | 12.6 | 87.4 | 1.34 | 0.79 – 2.28 | 1.30 | 0.75 – 2.25 |
|
| ||||||
| Marital status at diagnosis | ||||||
| Married/Living as Married | 14.2 | 85.8 | 1.16 | 0.81 – 1.66 | 1.15 | 0.77 – 1.70 |
| Single (divorced, single, widowed, separated) | 12.3 | 87.7 | 0.80 | 0.40 – 1.57 | 0.73 | 0.36 – 1.47 |
|
| ||||||
| Employment status at survey | ||||||
| Employed full time (30+ hours per week) | 14.0 | 86.0 | 1.18 | 0.69 – 2.00 | 1.15 | 0.65 – 2.04 |
| Employed part time (<30 hours per week) | 10.6 | 89.4 | 0.79 | 0.29 – 2.19 | 0.74 | 0.28 – 1.98 |
| Retired | 13.2 | 86.8 | 0.97 | 0.61 – 1.56 | 0.93 | 0.57 – 1.52 |
| *Other | 15.8 | 84.2 | 1.23 | 0.53 – 2.85 | 1.19 | 0.46 – 3.07 |
|
| ||||||
| Cancer sites | ||||||
| Breast | 14.3 | 85.7 | 1.20 | 0.61 – 2.36 | 0.88 | 0.40 – 1.95 |
| Prostate | 10.7 | 89.3 | 0.67 | 0.32 – 1.38 | 0.63 | 0.30 – 1.33 |
| Colorectal | 14.4 | 85.6 | 1.12 | 0.33 – 3.86 | 1.77 | 0.37 – 8.38 |
| Melanoma | 6.8 | 93.2 | 0.59 | 0.22 – 1.55 | 0.67 | 0.24 – 1.87 |
| Thyroid | 20.4 | 79.6 | 1.71 | 0.55 – 5.31 | 1.81 | 0.62 – 5.28 |
|
| ||||||
| Adjuvant Treatment | ||||||
| No/None | 13.1 | 86.9 | 1.03 | 0.67 – 1.59 | 1.04 | 0.66 – 1.64 |
| Yes chemotherapy or immunotherapy, No radiation | 16.4 | 83.6 | 2.73 | 1.14 – 6.55 | 2.72 | 1.08 – 6.86 |
| Yes radiation, No chemotherapy or immunotherapy | 13.5 | 86.5 | 0.74 | 0.39 – 1.43 | 0.65 | 0.32 – 1.31 |
| Yes chemotherapy or immunotherapy, Yes radiation | 13.8 | 86.2 | 1.00 | 0.43 – 2.29 | 0.78 | 0.30 – 2.06 |
|
| ||||||
| Stage at diagnosis | ||||||
| Localized | 15.4 | 84.6 | 1.16 | 0.79 – 1.71 | 1.14 | 0.76 – 1.71 |
| Regional | 6.2 | 93.8 | 0.55 | 0.24 – 1.24 | 0.51 | 0.20 – 1.32 |
| Distant | 13.9 | 86.1 | 1.93 | 0.66 – 5.61 | 1.14 | 0.29 – 4.52 |
| Not staged/unknown | 14.2 | 85.8 | 0.89 | 0.14 – 5.79 | - | - |
|
| ||||||
| Years since cancer diagnosis | ||||||
| <2 | 11.4 | 88.6 | 0.57 | 0.23 – 1.43 | 0.66 | 0.26 – 1.69 |
| 2-<4 | 15.8 | 84.2 | 1.13 | 0.74 – 1.74 | 1.07 | 0.66 – 1.72 |
| 4+ | 12.5 | 87.5 | 1.10 | 0.68 – 1.76 | 1.04 | 0.63 – 1.71 |
Odds of 1 or more financial hardship.
Percent reporting one or more material hardship, weighted for to account for sample survey design and non-response.
Adjusted for Hispanic ethnicity, continuous age at survey response, education, and years since diagnosis.
Other includes unable to work due to illness or disability, caring for home or family 9not seeking paid work), student, other
No urban-rural differences in financial hardship were observed in subgroups by age at diagnosis, education, marital status, employment at survey, or by cancer type. Hispanic participants who lived rurally had 76% lower odds (95% CI=0.08–0.73) of financial hardship than their urban counterparts. Rural survivors who received chemotherapy were 2.72 times (95% CI=1.08–6.86) more likely to report a financial hardship compared to urban survivors who received chemotherapy; there were no urban-rural differences among survivors who received other treatment regimens. Models were run with both treatment and stage at diagnosis in the model, as well as with an interaction term between the two variables to examine the relationship between stage at diagnosis and type of treatment (not shown) and found no significance.
Discussion
In this analysis of survey data from recent cancer survivors from Utah, approximately 40% of participants reported at least one experience of material financial hardship during the past year, similar to other cancer survivor studies.[2, 4] However, we found few differences between rural and urban participants regarding material financial hardship or in other measures including insurance coverage, access to care, and job lock. Rural populations in many parts of the U.S. are older and white, and have lower incomes than urban dwellers.[21–23] While our sample reflects the older and largely white cancer survivor population of Utah, one key difference for Utah compared to other rural U.S. communities is that there is little difference among rural and urban populations in Utah regarding income levels,[24] demonstrating the importance of studies that capture the economic diversity of rurality and cancer.
Our estimates of material financial hardship did not differ by rural or urban survivors except in two ways. We saw an increase in self-reported financial hardship among Utah’s rural cancer survivors who were receiving chemotherapy or immunotherapy as the only treatment for their cancer compared to urban survivors receiving the same treatment. As chemotherapy may be used more in late-stage diagnosis, we examined the relationship between stage at diagnosis and chemotherapy usage. No difference in the percentage of patients with distant stage cancer at diagnosis between rural and urban participants was observed. Further the lack of significance observed in models including both stage at diagnosis and treatment, suggest receipt of chemo and immunotherapy alone increased the reported financial hardship in rural survivors. As chemo and immunotherapy regimens often require inpatient stays and/or long duration and intermittent timing of treatments, this may have additional financial impact on rural residents due to the need to travel and lodge away from their home to receive treatment. Additionally, for oral treatments, access to pharmacies that stock specialty cancer therapies may be limited in rural areas and require additional costs for rural patients to access.
Also, in our estimates, Hispanic survivors who lived in rural areas reported less financial hardship than Hispanic survivors living in urban areas. Multiple factors could account for this, including survivor bias (i.e., Hispanic survivors with greater financial burden in rural areas may be less likely to survive to be included in this survey) or from limitations in our measures of financial hardship. The measures we used are based on national surveys and some items assume individuals have access to savings, the ability to take out a loan or mortgage, and the ability to take on credit card debt, which may not be applicable to poorer individuals. Thus, research to expand how financial hardship is captured amongst different populations may be warranted for capturing the full range of financial hardships experienced by rural cancer survivors.
This survey only included individuals diagnosed and living in Utah. Utah has less racial/ethnic diversity than the majority of states.[25] Individuals belonging to non-white racial or Hispanic populations are more likely to experience financial hardship.[2] The present study included recent survivors of all types of cancer reportable to a state cancer registry. As such, it included many survivors who had experienced early-stage cancers, with a smaller proportion undergoing treatments for regional or distant stage cancers. Treatments for regional or distant cancers tend to require more hospital stays and more cost. Like many reports, we defined rurality using census tract-level RUCA code. Several studies have suggested that the current ways researchers calculate rurality may not be representative of rural identity, or may impact the results of studies depending on the way in which it is classified.[26, 27]
In this statewide report, we found that material financial hardship affects many Utah cancer survivors. Rural survivors who receive immunotherapy or chemotherapy as their only course of treatment report more financial hardship than urban survivors with the same treatment regimen. Rural Hispanic survivors were less likely than urban Hispanic survivors to report financial hardship. Yet, overall, there were very few disparities in financial hardship for Utah rural compared to urban survivors. The findings of this study highlight the need for examination of the complex relationship between rurality and financial hardship amongst cancer survivors according to type of treatment and in heterogeneous rural settings.
Supplementary Material
Acknowledgments
We thank Kate Hak and Lori Burke of the Utah Cancer Registry for their efforts to recruit participants and collect data for this study.
Funding
This study was supported by the US Centers for Disease Control and Prevention’s National Program of Cancer Registries, Cooperative Agreement No. NU58DP007131. The Utah Cancer Registry is also supported by the National Cancer Institute’s SEER Program, Contract No. HHSN261201800016I and by the University of Utah and Huntsman Cancer Foundation. This study was also supported in part by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number UM1TR004409.
Footnotes
Competing Interests
Authors have no conflicts of interest, financial or otherwise, to disclose.
Ethics Approval
This study was reviewed by the Utah Department of Health Institutional Review Board, which deemed the project exempt from human subject’s research approval because it was a program evaluation initiative.
Data Availability
The data generated during study survey and/or data sets analyzed during the current study analysis are not publicly available due to privacy restrictions.
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The data generated during study survey and/or data sets analyzed during the current study analysis are not publicly available due to privacy restrictions.