Background: Financial hardship is a growing challenge for patients with blood cancer who undergo hematopoietic cell transplantation (HCT), and it is associated with poor patient-reported outcomes. In contrast, little is known about the potential impact of patient-reported financial hardship on post-HCT survival.

Methods: We sought to describe the association of financial hardship with survival after HCT in a prospectively assembled cohort of patients from three large transplant centers (n = 325).

Results: There was no association between financial hardship measures assessed at 6 months post-HCT and 1- or 2-year survival after HCT.

Conclusions: Patient-reported financial distress after HCT does not seem to adversely affect post-HCT survival.

Impact: When assessing the effectiveness of interventions to ameliorate familial financial burden among HCT, the focus should be on patient-reported outcomes rather than survival. Cancer Epidemiol Biomarkers Prev; 27(3); 345–7. ©2018 AACR.

Hematopoietic cell transplantation (HCT) is an intensive, medically complex, and potentially life-threatening therapy for many blood cancers, and has a prolonged trajectory of recovery. Although the adverse impact of financial hardship on patient reported outcomes has been illustrated by many studies, data regarding its impact on post-HCT survival is sparse except for the association of extreme financial burden reflected by bankruptcy with increased mortality (1–4). This observational study assessed the association of financial hardship on survival at 1 and 2 years post-HCT.

We mailed a 43-item self-administered questionnaire assessing financial hardship, household income, employment status, and insurance type to 499 HCT patients at 6 months after their HCT at Dana-Farber Cancer Institute (DFCI, Boston, MA), Mayo Clinic Arizona (MCA, Phoenix, AZ), and Roswell Park Cancer Institute (RPCI, Buffalo, NY) from June 2014 to January 2015. Patients provided written informed consent. Study was conducted in accordance with Declaration of Helsinki, and approved by the institutional review boards at the three institutions. The survey methodology, cohort characteristics, and results regarding financial hardship and its impact on patient reported outcomes such as perceived stress and quality of life have been described previously (4). We now describe the impact of financial hardship on 1- and 2-year survival after HCT in this cohort.

Survival analysis was conducted by Kaplan–Meier, and differences in survival curves were assessed with the log-rank test, assuming significant statistical level of 0.05, in the overall cohort as well as allogeneic patient subset. Survival probabilities at 1- and 2-year after HCT were compared in a univariate fashion based on baseline patient characteristics, financial hardship measures, and patient-reported worries.

Among 325 respondents (65.1% response rate), there was no significant difference in survival at 1 or 2 years based on socioeconomic characteristics such as income, education, health insurance type, and employment status. There was also no significant difference in survival based on financial hardship measures individually or combined (defined as unsatisfied with present income, difficulty paying monthly bills, and/or no money at the end of the month). There was a trend toward worse survival in those who reported difficulty paying transit costs for post-HCT care (P = 0.08). Patient worry about being a burden also did emerge as significant predictor for survival (P = 0.01); however, worry specifically about financial or insurance-related questions did not impact survival. Mortality was also associated with transplant type (Table 1). Similar overall null results were seen in an analysis restricted to recipients of allogeneic HCT (Table 2).

Table 1.

Univariate association between survival and baseline sociodemographic variables of study cohort (n = 325)

1-year survival2-year survival
NHR (95% CI)HR (95% CI)
HCT Typea 
 Autologous 172 0.99 (0.95–0.99) 0.94 (0.89–0.97) 
 Allogeneic 153 0.91 (0.85–0.94) 0.83 (0.76–0.88 
Sex 
 Female 130 0.98 (0.94–0.99) 0.91 (0.85–0.95) 
 Male 195 0.93 (0.88–0.96) 0.87 (0.81–0.91) 
Age 
 60 or under 160 0.97 (0.93–0.99) 0.91 (0.85–0.95) 
 Over 60 165 0.93 (0.88–0.96) 0.87 (0.80–0.91) 
Race 
 White 294 0.95 (0.91–0.97) 0.89 (0.84–0.92) 
 Nonwhite 27 1.00 (-) 0.88 (0.66–0.96) 
Insurance type 
 Employer sponsored 198 0.94 (0.89–0.96) 0.86 (0.81–0.90) 
 Government sponsored 99 0.97 (0.91–0.99) 0.94 (0.87–0.97) 
 Self-insured 25 1.00 (-) 0.92 (0.72–0.98) 
Employment status 
 Employed 142 0.96 (0.92–0.98) 0.89 (0.83–0.93) 
 Unemployed 13 1.00 (-) 1.00 (-) 
 Not in the labor force (e.g., retired) 169 0.93 (0.88–0.96) 0.87 (0.81–0.92) 
Marital status 
 Married 234 0.94 (0.90–0.96) 0.88 (0.82–0.91) 
 Not married 89 0.98 (0.91–0.99) 0.92 (0.84–0.96) 
Education 
 BA or higher 169 0.93 (0.88–0.96) 0.87 (0.81–0.92) 
 Less than BA 155 0.97 (0.92–0.99) 0.90 (0.84–0.94) 
Monthly income 
 Low income (less than $3,000) 92 0.96 (0.89–0.98) 0.90 (0.81–0.95) 
 Middle income ($3,000 to $6,999) 139 0.94 (0.89–0.97) 0.85 (0.78–0.90) 
 High income ($7,000 or more) 84 0.95 (0.88–0.98) 0.93 (0.85–0.97) 
1-year survival2-year survival
NHR (95% CI)HR (95% CI)
HCT Typea 
 Autologous 172 0.99 (0.95–0.99) 0.94 (0.89–0.97) 
 Allogeneic 153 0.91 (0.85–0.94) 0.83 (0.76–0.88 
Sex 
 Female 130 0.98 (0.94–0.99) 0.91 (0.85–0.95) 
 Male 195 0.93 (0.88–0.96) 0.87 (0.81–0.91) 
Age 
 60 or under 160 0.97 (0.93–0.99) 0.91 (0.85–0.95) 
 Over 60 165 0.93 (0.88–0.96) 0.87 (0.80–0.91) 
Race 
 White 294 0.95 (0.91–0.97) 0.89 (0.84–0.92) 
 Nonwhite 27 1.00 (-) 0.88 (0.66–0.96) 
Insurance type 
 Employer sponsored 198 0.94 (0.89–0.96) 0.86 (0.81–0.90) 
 Government sponsored 99 0.97 (0.91–0.99) 0.94 (0.87–0.97) 
 Self-insured 25 1.00 (-) 0.92 (0.72–0.98) 
Employment status 
 Employed 142 0.96 (0.92–0.98) 0.89 (0.83–0.93) 
 Unemployed 13 1.00 (-) 1.00 (-) 
 Not in the labor force (e.g., retired) 169 0.93 (0.88–0.96) 0.87 (0.81–0.92) 
Marital status 
 Married 234 0.94 (0.90–0.96) 0.88 (0.82–0.91) 
 Not married 89 0.98 (0.91–0.99) 0.92 (0.84–0.96) 
Education 
 BA or higher 169 0.93 (0.88–0.96) 0.87 (0.81–0.92) 
 Less than BA 155 0.97 (0.92–0.99) 0.90 (0.84–0.94) 
Monthly income 
 Low income (less than $3,000) 92 0.96 (0.89–0.98) 0.90 (0.81–0.95) 
 Middle income ($3,000 to $6,999) 139 0.94 (0.89–0.97) 0.85 (0.78–0.90) 
 High income ($7,000 or more) 84 0.95 (0.88–0.98) 0.93 (0.85–0.97) 

aSignificant at P < 0.05 using log-rank test for equality of survivor functions; survivor function is calculated over full data and evaluated at indicated times.

View Large
Table 2.

Univariate association between survival and financial hardship variables of study cohort (n = 325)

1-year survival2-year survival
NHR (95% CI)HR (95% CI)
Unsatisfied with present income 
 No 164 0.94 (0.89–0.97) 0.90 (0.84–0.93) 
 Yes 158 0.96 (0.92–0.98) 0.88 (0.82–0.93) 
Difficulty paying monthly bills 
 No 186 0.96 (0.92–0.98) 0.91 (0.86–0.95) 
 Yes 136 0.93 (0.88–0.96) 0.86 (0.79–0.91) 
No money at the end of the month 
 No 261 0.94 (0.90–0.96) 0.88 (0.83–0.91) 
 Yes 60 1.00 (-) 0.93 (0.82–0.97) 
“Hardship”b 
 No 141 0.96 (0.92–0.98) 0.91 (0.85–0.95) 
 Yes 182 0.94 (0.89–0.97) 0.87 (0.81–0.91) 
“Extreme hardship”b 
 No 273 0.94 (0.91–0.96) 0.89 (0.84–0.92) 
 Yes 50 1.00 (-) 0.92 (0.79–0.97) 
Post-HCT income decline 
 No 173 0.94 (0.89–0.96) 0.90 (0.84–0.93) 
 Yes 149 0.97 (0.92–0.99) 0.88 (0.82–0.93) 
Difficulty paying for relocation 
 No 262 0.95 (0.92–0.97) 0.89 (0.85–0.93) 
 Yes 60 0.97 (0.87–0.99) 0.88 (0.76–0.94) 
Difficulty paying for transit costs 
 No 191 0.96 (0.92–0.98) 0.92 (0.87–0.95) 
 Yes 131 0.94 (0.88–0.97) 0.85 (0.78–0.90) 
HCT costsc (any one) 
 No 58 0.96 (0.91–0.98) 0.91 (0.85–0.95) 
 Yes 164 0.95 (0.91–0.97) 0.87 (0.81–0.91) 
Worry about being a burden on familya 
 No 180 0.97 (0.93–0.98) 0.93 (0.88–0.96) 
 Yes 138 0.93 (0.88–0.96) 0.84 (0.76–0.89) 
Worry about not having money for necessities 
 No 221 0.95 (0.92–0.97) 0.90 (0.85–0.93) 
 Yes 96 0.97 (0.91–0.99) 0.88 (0.79–0.93) 
Worry about losing/not having health insurance 
 No 229 0.96 (0.92–0.98) 0.89 (0.84–0.92) 
 Yes 89 0.96 (0.88–0.98) 0.90 (0.81–0.94) 
Worry about the cost of health insurance 
 No 207 0.95 (0.91–0.97) 0.87 (0.81–0.91) 
 Yes 110 0.97 (0.92–0.99) 0.93 (0.87–0.97) 
Worry about paying for medical bills 
 No 195 0.96 (0.92–0.98) 0.90 (0.85–0.93) 
 Yes 123 0.95 (0.89–0.98) 0.88 (0.81–0.93) 
1-year survival2-year survival
NHR (95% CI)HR (95% CI)
Unsatisfied with present income 
 No 164 0.94 (0.89–0.97) 0.90 (0.84–0.93) 
 Yes 158 0.96 (0.92–0.98) 0.88 (0.82–0.93) 
Difficulty paying monthly bills 
 No 186 0.96 (0.92–0.98) 0.91 (0.86–0.95) 
 Yes 136 0.93 (0.88–0.96) 0.86 (0.79–0.91) 
No money at the end of the month 
 No 261 0.94 (0.90–0.96) 0.88 (0.83–0.91) 
 Yes 60 1.00 (-) 0.93 (0.82–0.97) 
“Hardship”b 
 No 141 0.96 (0.92–0.98) 0.91 (0.85–0.95) 
 Yes 182 0.94 (0.89–0.97) 0.87 (0.81–0.91) 
“Extreme hardship”b 
 No 273 0.94 (0.91–0.96) 0.89 (0.84–0.92) 
 Yes 50 1.00 (-) 0.92 (0.79–0.97) 
Post-HCT income decline 
 No 173 0.94 (0.89–0.96) 0.90 (0.84–0.93) 
 Yes 149 0.97 (0.92–0.99) 0.88 (0.82–0.93) 
Difficulty paying for relocation 
 No 262 0.95 (0.92–0.97) 0.89 (0.85–0.93) 
 Yes 60 0.97 (0.87–0.99) 0.88 (0.76–0.94) 
Difficulty paying for transit costs 
 No 191 0.96 (0.92–0.98) 0.92 (0.87–0.95) 
 Yes 131 0.94 (0.88–0.97) 0.85 (0.78–0.90) 
HCT costsc (any one) 
 No 58 0.96 (0.91–0.98) 0.91 (0.85–0.95) 
 Yes 164 0.95 (0.91–0.97) 0.87 (0.81–0.91) 
Worry about being a burden on familya 
 No 180 0.97 (0.93–0.98) 0.93 (0.88–0.96) 
 Yes 138 0.93 (0.88–0.96) 0.84 (0.76–0.89) 
Worry about not having money for necessities 
 No 221 0.95 (0.92–0.97) 0.90 (0.85–0.93) 
 Yes 96 0.97 (0.91–0.99) 0.88 (0.79–0.93) 
Worry about losing/not having health insurance 
 No 229 0.96 (0.92–0.98) 0.89 (0.84–0.92) 
 Yes 89 0.96 (0.88–0.98) 0.90 (0.81–0.94) 
Worry about the cost of health insurance 
 No 207 0.95 (0.91–0.97) 0.87 (0.81–0.91) 
 Yes 110 0.97 (0.92–0.99) 0.93 (0.87–0.97) 
Worry about paying for medical bills 
 No 195 0.96 (0.92–0.98) 0.90 (0.85–0.93) 
 Yes 123 0.95 (0.89–0.98) 0.88 (0.81–0.93) 

aSignificant at P < 0.05 using log-rank test for equality of survivor functions; survivor function is calculated over full data and evaluated at indicated times.

b“Hardship” refers to patients reporting any one or two of the three measures of financial difficulty: unsatisfied with present income; difficulty paying monthly bills; and having no money at the end of the month. “Extreme hardship” refers to patients reporting all three measures.

cHCT costs refers to costs due to relocation, transportation, changes in home due to HCT, and services for care for dependents.

View Large

A recent schema for financial hardship has been proposed, consisting of three overlapping domains: material hardship, psychologic impact, and coping behaviors (5). In this large observational study, we examined the impact of each of the individual domains on survival but did not find significant associations. There are multiple potential explanations for our results. Lack of insurance coverage is likely a deterrent for initial HCT referral, making the HCT population a somewhat less vulnerable group regarding poor clinical outcome due to financial burden because of the safety net provided by insurance. Indeed, in our study, all patients were insured. Moreover, a majority of transplant programs have social workers and resource specialists who work diligently to review patient financial status and address difficult issues early (6). In addition, assessment of financial hardship at six months rather than at time points closer to when survival was examined may have influenced our findings. Finally, due to the sizable mortality after HCT from disease as well as transplant complications, it is possible that the impact of financial burden is not apparent at this time but with longer follow-up may emerge as a predictor for worse survival.

While provocative, our findings need to be validated in a larger study with longer follow-up and more frequent periodic assessment of financial hardship. While we did not find an impact on survival, this is only one outcome of interest after HCT. Indeed, we do know that financial hardship leads to poor quality of life and increased perceived stress in our population. While the systems at the transplant centers studied may be working well enough to preventing HCT patients with hardship from experiencing earlier death, there is a gap between supply and demand in terms of personnel and real-time resources for patients with cancer-related financial needs (7). Policy changes at the institutional and federal levels can help expand the infrastructure for financial advocacy services to protect the lived experiences, if not the survival, of these patients, and in doing so honor the societal investment made in the provision of this intensive procedure. Moreover, our data suggest that when assessing the effectiveness of such changes, the focus should be on patient-reported outcomes rather than survival.

R. Soiffer is a member of the board of directors at Kiadis and is a consultant/advisory board member for Merck, GlaxoSmithKline, and Juno. No potential conflicts of interest were disclosed by the other authors.

Conception and design: R. Albelda, T. Hahn, O.O. Odejide, R. Soiffer, G.A. Abel

Development of methodology: N. Khera, R. Albelda, T. Hahn, G.A. Abel

Acquisition of data (provided animals, acquired and managed patients, provided facilities, etc.): N. Khera, R. Albelda, T. Hahn, O.O. Odejide, G.A. Abel

Analysis and interpretation of data (e.g., statistical analysis, biostatistics, computational analysis): N. Khera, R. Albelda, T. Hahn, D.Y. Salas-Coronado, R. Soiffer, G.A. Abel

Writing, review, and/or revision of the manuscript: N. Khera, R. Albelda, T. Hahn, D.Y. Salas-Coronado, O.O. Odejide, R. Soiffer, G.A. Abel

Administrative, technical, or material support (i.e., reporting or organizing data, constructing databases): N. Khera, R. Albelda, T. Hahn, D.Y. Salas-Coronado, R. Soiffer, G.A. Abel

Study supervision: N. Khera, G.A. Abel

This work was supported by grants from the Comprehensive Partnership to Reduce Cancer Health Disparities (U54 CA156732), University of Massachusetts (Boston, MA), and Dana-Farber/Harvard Cancer Center (Boston, MA).

The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked advertisement in accordance with 18 U.S.C. Section 1734 solely to indicate this fact.

1.
Ramsey
 
SD
,
Bansal
 
A
,
Fedorenko
 
CR
,
Blough
 
DK
,
Overstreet
 
KA
,
Shankaran
 
V
, et al 
Financial insolvency as a risk factor for early mortality among patients with cancer
.
J Clin Oncol
 
2016
;
34
:
980
–
6
.
Google Scholar
Crossref
Search ADS
PubMed
 
2.
Hamilton
 
JG
,
Wu
 
LM
,
Austin
 
JE
,
Valdimarsdottir
 
H
,
Basmajian
 
K
,
Vu
 
A
, et al 
Economic survivorship stress is associated with poor health-related quality of life among distressed survivors of hematopoietic stem cell transplantation
.
Psycho-Oncol
 
2013
;
22
:
911
–
21
.
Google Scholar
Crossref
Search ADS
 
3.
Khera
 
N
,
Chang
 
YH
,
Hashmi
 
S
,
Slack
 
J
,
Beebe
 
T
,
Roy
 
V
, et al 
Financial burden in recipients of allogeneic hematopoietic cell transplantation
.
Biol Blood Marrow Transplant
 
2014
;
20
:
1375
–
81
.
Google Scholar
Crossref
Search ADS
PubMed
 
4.
Abel
 
GA
,
Albelda
 
R
,
Khera
 
N
,
Hahn
 
T
,
Salas Coronado
 
DY
,
Odejide
 
OO
, et al 
Financial hardship and patient-reported outcomes after hematopoietic cell transplantation
.
Biol Blood Marrow Transplant
 
2016
;
22
:
1504
–
10
.
Google Scholar
Crossref
Search ADS
PubMed
 
5.
Altice
 
CK
,
Banegas
 
MP
,
Tucker-Seeley
 
RD
,
Yabroff
 
KR
. 
Financial hardships experienced by cancer survivors: a systematic review
.
J Natl Cancer Inst
 
2016
;
109
:
djw205
–
djw205
.
Google Scholar
Crossref
Search ADS
PubMed
 
6.
Kim
 
W
,
McNulty
 
J
,
Chang
 
YH
,
Weise
 
M
,
Hashmi
 
S
,
Ailawadhi
 
S
, et al 
Financial burden after allogeneic hematopoietic cell transplantation: a qualitative analysis from the patient/'s perspective
.
Bone Marrow Transplant
 
2015
;
50
:
1259
–
61
.
Google Scholar
Crossref
Search ADS
PubMed
 
7.
Smith
 
SK
,
Nicolla
 
J
,
Zafar
 
SY
. 
Bridging the gap between financial distress and available resources for patients with cancer: a qualitative study
.
J Oncol Pract
 
2014
;
10
:
e368
–
72
.
Google Scholar
Crossref
Search ADS
PubMed
 
©2018 American Association for Cancer Research.
2018
American Association for Cancer Research.