Financial toxicity and drivers of delayed care among cancer survivors across the lifespan.

Abstract

1521 Background: Financial toxicity has been increasingly recognized as a cause of poor outcomes among cancer survivors. Cancer survivors have been shown to face greater healthcare access and affordability issues than the general population, and available evidence suggests that adolescent/young adult (AYA) cancer survivors may face especially high financial toxicity. However, existing research is limited by small sample sizes and methodological constraints. Understanding age-specific healthcare barriers could inform targeted interventions to improve outcomes for cancer survivors across the lifespan. Methods: Participants aged 18 and older were enrolled with informed consent in the All of Us Research Program, an NIH database integrating multiple health information sources. Included participants were cancer survivors who had available data for age, sex and other demographics. Cancer diagnoses were identified using ICD and SNOMED codes. Survey data were used to assess outcomes of financial toxicity and drivers of delayed care, as well as covariates of race, ethnicity, income, education, marital and insurance status. As all participants were insured, insurance status was dropped from the final models. Age groups were coded as 18-39, 40-49, 50-64, 65-74 and 75+. Statistical analysis was conducted using logistic regression by age group, adjusted for covariates. Results: 15,637 cancer survivors were included for analysis, including 1,090 participants aged 18-39 and 2,104 participants over age 75. Compared to 18-39 year olds, odds of being unable to afford specialist care decreased with age: [40-49] OR = 0.57 (p = 0.01), [50-64] OR = 0.18 (p < 0.0001), [65-74] OR = 0.07 (p < 0.0001), [75+] OR = 0.006 (p < 0.0001). Results were similar for primary care, with more extreme effect sizes. Causes of delayed care differed by age group. 18-39 year olds were more likely to report elderly caregiving responsibilities and inability to get time off work as drivers of delayed care, while 40-49 year olds were more likely to report difficulties accessing child care as a driver (OR = 5.25, p < 0.0001). Older cancer patients were also more likely than AYAs to report lack of transportation access as a cause of delayed care ([65-74] OR = 2.33, p < 0.0001). Conclusions: To date, this study represents the largest and most comprehensive analysis of healthcare barriers among cancer survivors across the lifespan. Targeted interventions based on the most significant barriers by age group may more effectively improve healthcare access and outcomes for all ages. Our results support that AYA cancer survivors may benefit most from financial support, elderly care resources and medical notes to facilitate time off work. By comparison, expanding childcare support may be most important for increasing access among those aged 40-49. Among older cancer survivors, ensuring reliable transportation presents the greatest opportunity for improving healthcare access.