Theresa Hastert, Ph.D. WHI Cancer SIG Call September 19th, 2016 Predictors of Financial Burden in Cancer Survivors: Results from the LILAC Study Theresa Hastert, Ph.D. WHI Cancer SIG Call September 19th, 2016

Co-Authors and Collaborators Electra Paskett (Collaborating LILAC PI) Cecelia DeGraffinreid Michelle Naughton Tasleem Padamsee Michael Pennell Michael Simon Gregory Young Yousuf Zafar

Background Many cancer survivors face serious financial burdens related to cancer diagnosis, treatment, recovery 10-66% depending on population, measures used Lifestyle changes, assets/savings, debt, bankruptcy Financial concerns can impact treatment decisions, future financial health, quality of life, mortality

Objectives Estimate prevalence of cancer-related financial burden among LILAC participants Examine associations between demographic, cancer, and treatment-related variables and comorbid conditions and financial burden

Study Population LILAC participants who completed both Form F340 (baseline) and F370 (follow-up—including financial burden questions) 7,776 completed F340 Excluded 2,193 who did not complete F370 Excluded 48 missing all financial burden questions Excluded 4 in situ melanoma (late add to F340) Total N=5,531

LILAC Financial Burden Questions

Prevalence of Financial Burden Type of Burden N % Denied health insurance 37 0.7 Denied life insurance 85 1.5 Insurance company refused medical insurance claim 145 2.6 Cancer treatment left large debts/bills to pay 83 Trouble getting a mortgage or other loans 7 0.1 Had to get legal assistance to deal with problems related to cancer 16 0.3 Had to declare bankruptcy because of cancer 12 0.2 In general, I do not have enough money to pay for basics (food, housing, etc.) 504 9.1 Any financial burden 801 14.5 Total N=5,531

Demographic Characteristics Financial Burden by Age and Race Demographic Characteristics No Burden N (%) Any Burden OR (95% CI) P Age at diagnosis <50-59 451 (80.7) 108 (19.3) 1.00 <0.001 60-69 1,947 (84.7) 353 (15.3) 0.76 (0.60, 0.96) 70-79+ 2,332 (87.3) 340 (12.7) 0.61 (0.48, 0.77) Race Black/African-American 170 (76.2) 53 (23.8) Non-Hispanic White 4,334 (85.8) 717 (14.2) 0.53 (0.39, 0.73) Other/multiple 217 (87.5) 31 (12.5) 0.46 (0.28, 0.75)

Socioeconomic Characteristics Financial Burden by Education and Income Socioeconomic Characteristics No Burden N (%) Any Burden OR (95% CI) P Education ≤ High school 682 (85.8) 113 (14.2) 1.00 0.21 Some college 1,531 (84.1) 289 (15.9) 1.14 (0.90, 1.44) College grad 1,373 (85.9) 226 (14.1) 0.99 (0.78, 1.27) Grad school 1,114 (86.7) 171 (13.3) 0.93 (0.72, 1.20) Income <$20,000 315 (78.0) 89 (22.0) <0.001 $20,000-34,999 898 (86.5) 140 (13.5) 0.55 (0.41, 0.74) $35,000-49,999 933 (86.6) 144 (13.4) 0.55 (0.41, 0.73) $50,000-75,000 1,107 (85.6) 186 (14.4) 0.59 (0.45, 0.79) $75,000+ 1,248 (86.4) 197 (13.6) 0.56 (0.42, 0.74)

Financial Burden by Cancer Site No Burden N (%) Any Burden OR (95% CI) P Breast 2,853 (85.6) 478 (14.4) 1.00 0.59 Ovary 99 (83.2) 20 (16.8) 1.21 (0.74, 1.97) Endometrial 423 (85.5) 72 (14.5) 1.02 (0.78, 1.33) Colorectal 492 (86.5) 77 (13.5) 0.93 (0.72, 1.21) Lung 200 (82.3) 43 (17.7) 1.28 (0.91, 1.81) Melanoma 287 (83.4) 57 (16.6) 1.19 (0.88, 1.60) Non-Hodgkin’s Lymphoma 279 (87.7) 39 (12.3) 0.83 (0.59, 1.18) Leukemia 15 (13.4) 0.92 (0.53, 1.60)

Financial Burden by Cancer Stage, Treatment Site, Treatment Categories No Burden N (%) Any Burden OR (95% CI) P Stage Localized 3,396 (85.9) 557 (14.1) 1.00 0.14 Regional 949 (83.6) 186 (16.4) 1.19 (1.00, 1.43) Distant 307 (86.2) 49 (13.8) 0.97 (0.71, 1.33) Chemotherapy No 3,321 (86.3) 529 (13.7) 0.01 Yes 1,382 (83.6) 271 (16.4) 1.23 (1.05, 1.44) Radiation 2,384 (85.4) 408 (14.6) 0.83 2,311 (85.6) 389 (14.4) 0.98 (0.85, 1.14) Hormone therapy 2,754 (85.3) 475 (14.7) 0.72 1,943 (85.6) 326 (14.4) 0.97 (0.84, 1.13)

Summary Overall prevalence of financial burden low using LILAC measures Not having enough to cover the basics most common Younger age, African-American race, low income, chemotherapy associated with financial burden

Strengths & Limitations Large cohort of survivors from across U.S. Several cancers Cancer, treatment information Limitations Limited financial burden measures, power May not represent important patient experiences May not be cancer-specific Timing, survival bias 74% 5+ yrs. since dx; issues may be resolved

Next Steps Comorbidity index in LILAC Consider several factors for adjusted analyses Demographics (age, race, marital status) Socioeconomic characteristics (income, education) Insurance at diagnosis Comorbidities Cancer, stage, treatment

Comments/Questions? Thank you. hastertt@karmanos.org