| dc.description.abstract | Cancer is the second major cause of death in the US which exerts significant morbidity, mortality and economic burden. In this dissertation I focused on the financial toxicity of cancer. I conducted three studies examining the out-of-pocket (OOP) costs and underinsurance among insured all-cancer, skin cancer and hepatocellular carcinoma patients. Since identification of financially vulnerable groups is important, the predictors of OOP and underinsurance were also investigated.
In the first study, insured cancer patients were identified (n(total) = 6280, n(non-elderly) = 2738 and n(elderly) = 3542) from Medical Expenditure Panel Survey (MEPS) data. Nearly 13% were underinsured, with a higher proportion of elderly patients (16.4%) than non-elderly patients (8.8%). Nearly all (98%) patients had some OOP expenditures, with mean adjusted OOP per person per year of $1623 overall, $1552 for non-elderly and $1669 for elderly patients. Higher expenditure patterns were observed in older adults, females, non-Hispanic whites, patients with a college degree and patients with higher income compared to respective counterparts, for both elderly and non-elderly cohorts.
In the second study, similar study design was adopted for skin cancer patients (n(total) = 1825, n(NMSC) = 1566 and n(melanoma) = 259) using MEPS data. Adjusted mean total OOP for all skin cancer patients and only NMSC patients were $1766 and $1763, respectively, and the probability of underinsurance were 13.1% and 13.2%, respectively. In the analysis of significant predictors, 60-64 years age group, females, people with some college education or a college degree and people with high income demonstrated higher all-cause total OOP expenditure compared to their respective counterparts. Weighted descriptive analyses was repeated stratifying the sample by skin cancer type.
The third study used Surveillance, Epidemiology, and End Results (SEER)-Medicare data to examine the estimates and predictors of OOP incurred by HCC patients (n(total) = 9942, n(satisfying_Milan_criteria) = 2905 and n(not_satisfying_Milan_criteria) = 7037). Adjusted mean per person per month (PPPM) OOP for the full sample, cohort satisfying and cohort not satisfying the Milan criteria were $903, $797 and $949, respectively. Among the covariates, race/ethnicity, Metro/non-metro status, NCI comorbidity index, stage at diagnosis, cirrhosis duration and presence of ascites were significant predictors of PPPM OOP costs.
Excessive OOP burden that results in financial toxicity may impact the life of a cancer patient in several ways. Consequences of excess OOP includes foregoing basic necessities, experiencing excessive psychological stress and forgoing necessary medical care. Insured patients are not immune to the detrimental effects of financial toxicities of cancer. In this dissertation I have examined the OOP expenditure and underinsurance affecting cancer patients to get a better understanding of the financial toxicity. The three studies presented here investigate these issues in three different scenarios, namely all-cancer, skin cancer and hepatocellular carcinoma. The outcomes of these studies will fill the gap in current cancer OOP costs related knowledge and will help patients, physicians and policy makers make well-informed decisions. | en |
