Sara Khor: Well, thank you. My name is Sara Khor. I'm an economist at Spring Health and the work I'm talking about today really is a collaborative effort with colleagues from the University of Washington as well as from the Fred Hutchinson Cancer Center. So most cancer financial toxicity research asks what cancer diagnosis and treatment do to patients financially. In other words, financial hardship is often seen as a toxic downstream effect of a cancer diagnosis and the subsequent cancer care. What we're asking in this study is a more upstream question, right? Could financial hardship before diagnosis shape cancer diagnosis itself? Specifically, is pre-diagnosis financial hardship influencing the stage at which cancer is diagnosed? And this question kind of positions financial hardship as an upstream determinant of health and potential driver of cancer detection. And this is important because stage of diagnosis drives so much of what happens next. Things like prognosis, treatment intensity, patient burden, and of course, eventually downstream financial hardship on patients. And so if pre-diagnosis financial hardship truly affects stage of diagnosis, then part of the cancer disparity that is related to financial hardship may be developing before patients ever enter oncology care.
And we also wanted to understand whether this association was strongest in cancer where early detection depends on screening or routine exams, because that helps identify where intervention may be possible. So we linked three data sources, the SEER Cancer Registry data, the credit report data from a major credit reporting agency in the US, TransUnion, and health plan enrollment and insurance claims data. So the cohort included around 50,000 adults with stage one to four solid tumors diagnosed between 2014 and 2017. We defined for the study financial hardship as having at least one adverse credit event in the two years before cancer diagnosis, including events like third party collection, charge-offs, delinquent mortgage payments, tax liens, and more severe events like foreclosures, repossessions, and bankruptcies. A primary outcome was late-stage cancer diagnosis defined as stage three or four.
All right, so first we found that about 30% of cancer patients experienced some form of financial hardship before diagnosis. And overall, patients with pre-diagnosis financial hardship had a 14% higher risk of being diagnosed with late-stage cancer compared to those without hardship. So even after adjusting for things like age, sex, race, insurance, area deprivation and rurality. We also saw a dose response pattern. The more hardship domains a patient experience, the greater their risk of late-stage diagnosis. And when we stratified by screening category, the association was strongest where there were earlier detection opportunities. Among cancers with organized screening programs, cancers like prostate cancer or breast cancer, financial hardship was associated with a 25% higher risk of late-stage diagnosis and among cancers detectable by routine physical exams like melanoma, the risk was 44% higher. In cancers without routine screening, we did not see a significant overall association.
And so this pattern suggests that financial hardship may matter most when early detection depends on patients being able to access and complete screening or routine exams. And then to further explore mechanisms, we then looked at breast cancer as an example. So in that group, about 70% of the increased risk of late-stage diagnosis that was associated with financial hardship was explained by non-receipt of screening mammography. So the key takeaway is that financial hardship may not only be a consequence of cancer, it may also be an upstream risk factor that shapes who gets diagnosed late, which makes it a potentially actionable upstream target.
So the pattern we saw was strongest in cancers where early detection depends on screening or routine exams, suggesting that financial strain may disrupt access to those opportunities. And even when screening itself is covered by insurance, patients may still face barriers like time off work, transportation, fear of follow-up costs, cognitive stress and limited cognitive bandwidth. So the practical implication is to think about earlier lower burden interventions, identify hardship earlier, reducing logistical barriers to screening and to subsequent follow-up and recognizing that financial distress is also a mental health burden that may require support. That's all I have. Thank you.
Daniel Joyce: Thanks so much. Really, really exciting and really inventive work, honestly. I mean, much has been written about financial toxicity and how expensive cancer is and how those expenses negatively harm patients and then lead to non-adherence, which then leads to worse outcomes. But I love this outlook because it's like preventative medicine and how little we often think in medical research in general about how can we prevent all these things from happening in the first place. It's great to explore new treatments in cancer care and understand how we can make the effects of cancer less bad for our patients, but what if we can prevent the cancer in the first place and why aren't we spending more time looking at that instead? And this is like the financial hardship version of that. So I love it. I think one of the tough parts is, is that to really screen for this, you have to have a touch point with the person to understand where they're at in life.
And so how do we do that? How do we assess every American on the planet for, or every person on the planet for financial hardship? This focusing on a very specific part of Washington in your work, how do we get those touchpoints? And what do those touchpoints look like in the population to understand, okay, you're this age, you're at this financial hardship. Have you thought about screening for important cancers here and let me help you get access to that? Because it seems like it's really an access issue, correct?
Sara Khor: Yeah. Yeah, absolutely. And I mean, this is a hard question. How do we screen? Where do we screen, right? And I think I have two thoughts to that. One is of course there's the gateway of our healthcare system. There's the primary care, but this is assuming that patients interact with primary care regularly. But if they do, that is one potential area we can screen. There is area where, I mean, we can potentially have outreach, community outreach, right, that can go to the community itself. We can screen through things that are already maybe in the community like mobile vans that are already maybe out there and tack on questions that also ask about struggles with financial strain. And I think that's one way, that's more of a individual level screening. And I think there is also some potential to using data like this, like the study to identify maybe geographical hotspots, maybe neighborhoods where financial strains are really a big problem and maybe we can put more resources in those neighborhoods, put more screening vans in those neighborhoods, care navigators and so on to really help with the access issues.
Daniel Joyce: Yeah, great points. I do think there's a challenge too. In your study, you looked at the two years prior to their cancer diagnosis for these financial hardship indicators, which the indicator you use for financial hardship was kind of extreme stuff in my opinion of like, "Oh, things are going bad financially for this person if these things are happening." But it seems to me that there's probably a continuum there of financial hardship and there's probably a tipping point where you get the most bang for your buck, but you might have to catch it before any of these catastrophic things happen. So do you have any future work or ideas to kind of figure out, okay, where do we catch them in this financial hardship continuum perhaps before? Just because you found that hardship two years before their diagnosis, which was then late-stage, might have helped to catch it 10 years ago-
Sara Khor: Even earlier.
Daniel Joyce: When you could have screened for it and prevented that late-stage. So how do we catch them earlier before they've even experienced that financial hardship event?
Sara Khor: Yeah. One of the interesting thing that we found and we did a sub-study to look at less severe financial hardship and we actually look at just credit card overdue and even then that itself, which is pretty, compared to things like foreclosure and bankruptcy really less severe, we still see a strong signal. So I think first it's saying that you don't have to be experiencing these extreme events to already have an impact in cancer staging. And your other question about, well, can we have maybe some ongoing screening that is earlier on to catch maybe onset of financial hardship before it has any downstream effects? I think that would be hard, right, using credit type data for screening purposes and that itself has its own challenges with trusts and with transparency and it goes in the...
But it's a question that we also ask. What can we supplement with patient centered questions that can happen again on the clinic level. When patients interact with the system for the first time, can we start asking patients? So instead of using maybe these more objective credit type data to ask patients on a patient level, a more patient centered way to capture those early events. Yeah.
Daniel Joyce: Yeah. It's a great point. If we can get them at any contact with the healthcare system, if they have an ER visit when they're 30 for a broken bone or something, if there's an opportunity there to do an objective instrument like the cost questionnaire or something like that and that could then funnel them to resources that facilitate screening practices for cancer, I think a lot of that could be super helpful. And I think right now we don't capitalize on that enough, on taking advantage of every healthcare interaction to help set that patient up for better healthcare down the line.
Sara Khor: Right.
Daniel Joyce: One thing I think about is the psychology behind all of this of kind of, okay, you're experiencing financial hardship, what is going on in the brain of that person that makes them not want to access healthcare? And I can relate to it. I mean, I am very fortunate in life as a physician and have expendable income to pay on healthcare if I need to, but we were just on vacation in Florida last week. My daughter, who's one year old had gunk coming out of her eye and we thought, "Oh, should we go in and get her checked out? Maybe we need antibiotics." And I got to be honest, just like a $75 copay for an urgent care was enough for me to be like, "I don't know if I really want to do this." We ended up going, ended up paying. But the point is, is that I get the fear of having to pay.
I get the fear of also not knowing what those payments will be. Even that visit, we didn't know what the cost was going to be until at the end of the visit when we checked out at the desk and then they told us. Do you think there's a role for price transparency? And I know this is super complex in how to do this, but if you could tell a patient, "Hey, screening is this much for you. And even at the worst case scenario, let's say you have cancer, you get a treatment, this is what it's going to cost you to go through that process versus if we find nothing." Do you think that would help or do you think it's just too complex to even give that information to patients?
Sara Khor: I absolutely think that it would help and it is important, right, for the healthcare system to be transparent with downstream costs so then they can factor it in as a piece of information at the decision time point. And I do think that fear of downstream costs is a major factor that these patients experience when or give them hesitation in seeking care or enough to discourage them to recognize symptoms or wanting to seek care. Yeah. So I do think there is a role for transparency, price transparency. Yeah.
Daniel Joyce: Yeah. And probably some role in us as physicians who do screening in that we talk about risks and benefits of all the treatment options we give to our patients and I think it's becoming more and more accepted by us that financial toxicity is a toxicity of treatment we should be talking with our patients about when we're having those shared decision-making conversations, but it probably fits for screening too. And when you're having that discussion about, do you get the PSA checked? Well, here are the pros and cons, here's what might happen. We might find clinically insignificant cancer and what that can mean for you and the cost implications of that for the patient because I do think some patients will look at that and it will influence whether they get that PSA checked or not.
And just knowing that seems like it would be of value because if you could identify those patients in those moments who you're having that conversation with and they're like, "Ah, too much for me. I'm not going to get the screening." Well, there's your financial toxicity screener right there. You've identified your patient who needs to get in those financial assistance resources.
Sara Khor: Right.
Daniel Joyce: And improve their care that way.
Sara Khor: Yeah, absolutely. And I think the last point that you made is very important. It's not so much of then discouraging them from seeking care, but rather identify who might be hesitating and linking them up to resources. And I think that's the key. Yeah.
Daniel Joyce: Do you see any policy efforts addressing this right now, this idea of financial hardship in screening, or where can we do better from a policy side of things?
Sara Khor: Yeah. And this is something I think a lot about. I think there are a few things. I think there is the financial screening part that we talked a bit about. I think from a... There's also this huge logistic burden that is barrier for these patients. Right. So when you think about somebody who's experiencing financial toxicity or financial hardship, they are handling multiple things in their life. There's a lot going on. There's debt rolling up. They might be worried about taking extra time off to go check things out and managing maybe multi-step follow-up procedures are complicated when you're already so overload, like the cognitive overburden and the mental stress that is related to being in financial hardship. And I think if there is a way we can pinpoint where these bottlenecks might be, maybe instead of a five-step workup, diagnostic workup, if we can reduce it to two, right, have things automatically scheduled so then patients don't have to make that extra call to the specialist or don't have to come in that extra time.
Can we streamline processes to reduce really this logistical burden? And I think that is where the health system could potentially make a difference. Can we reduce wait time? All these logistical barriers and again, maybe not all logistical barriers have the same effect. Can we identify at least a couple that would have the biggest help, things like that and yeah.
Daniel Joyce: Really great points. I think that efficiency in care probably benefits patients a lot, but it probably benefits the healthcare system also and utilizing less wasteful spending. And so there's a win-win there from a policy side of things, I think, for both patients and healthcare systems. All right, I'll leave you with this question. I always like to bring it back to people like me, I guess, because I'm selfish and I view life through my own lens, but like I'm a practicing urologist, a urologic oncologist. What is the main takeaway you want me to get from this work and how can I see my practice a little bit differently because of it?
Sara Khor: Yeah. So I think first is again, that main takeaway, that financial hardship is an upstream, can be an upstream factor, not just a downstream consequence of cancer, but it can happen before a cancer was diagnosed and actually affect when cancer is diagnosed. I think that's something to think about. And I think as a urologist, I would think patients are coming in probably already screened or at least coming in with symptoms and how can we improve the workup? How can we identify those bottlenecks, identify maybe one or two or how can we start asking these financial hardship questions in the clinic and then identify these logistical barriers and potentially help patients streamline the process. Yeah, that would be my current thoughts.
Daniel Joyce: I love it. I love it. And I think it's such an admirable goal and again, just really fantastic work, really creative and important look on financial hardship in patients' lives. It's been a joy to talk to you. Thank you for taking the time and I look forward to what's next from you.
Sara Khor: Thank you. It's my pleasure. Thank you again for having me.