More Medical Debt Linked to More Deadly Cancers

Higher medical debt burden was associated with a higher incidence of late-stage cancer diagnoses, according to a cross-sectional study of U.S. counties.

Medical debt burden had the biggest impact on late-stage lung cancer diagnoses, with each 10-percentage point increase in county-level medical debt linked to 5.15 additional late-stage cases per 100,000 person-years after adjustment, reported Changchuan Jiang, MD, MPH, of the University of Texas Southwestern Medical Center in Dallas, and colleagues.

Higher medical debt was also tied to additional late-stage cases of the following cancers (P<0.001 for all):

• Colorectal cancer (0.69 per 100,000 person-years)
• Cervical cancer (0.39 per 100,000 person-years)
• Melanoma (0.59 per 100,000 person-years)
• Kidney and renal pelvis cancer (0.38 per 100,000 person-years)
• Bladder cancer (0.24 per 100,000 person-years)
• Head and neck cancer (0.92 per 100,000 person-years)

Similar patterns were observed for overall cancer incidence, they wrote in JAMA Network Open.

These findings were in line with those of another recent study showing that the greatest proportion of cancer patients with a diagnosis of stage IV disease and lower 5-year survival rates was observed in counties with the highest medical debt.

“Our findings have potential implications for policy, practice, and future research,” wrote Jiang and colleagues. “Reducing medical debt and strengthening financial protections may help mitigate barriers to cancer prevention and care.”

“Potential strategies include expanding insurance coverage, reducing out-of-pocket costs, limiting aggressive billing practices, and implementing financial navigation programs,” they added.

In an accompanying editorial, Nicole M. Mott, MD, MSCR, of the University of Colorado in Aurora, and Fumiko Chino, MD, of the University of Texas MD Anderson Cancer Center in Houston, noted that other studies have shown that a large burden of medical debt is associated with reduced cancer screening rates, as well as more deaths from screening-eligible cancers.

“Taken together, these studies suggest a potential pathway whereby patients with medical debt in collections fail to undergo preventive screening or seek evaluation for early cancer symptoms, are subsequently diagnosed at later stages, and ultimately die more frequently from disease,” they wrote. “Regardless of the exact mechanism by which medical debt is associated with increased late-stage cancer incidence, critical interpretation of the findings from [this study] requires viewing medical debt as a marker for structural disadvantage and a potentially modifiable risk factor for delayed care and worse outcomes.”

For this study, Jiang and team used county-level data linking 2016 medical debt with age-adjusted incidence rates from January 2017 through December 2021 for lung, colorectal, cervical, breast, prostate, melanoma, kidney and renal pelvis, bladder, and head and neck cancers — all of which have recommendations for screening or early signs or symptoms. Late stage was defined as regional or distant disease.

Among 2,958 U.S. counties included in the analysis, 61% were rural, and the rest were urban. The mean prevalence of medical debt in collections was 21.1%, and the mean primary care physician density was 0.54 physicians per 1,000 population.

The mean medical debt prevalence was higher in rural versus urban counties (21.5% vs 20.5%, P=0.007) and in counties in the highest versus lowest Social Vulnerability Index quartile (27.4% vs 13.9%, P<0.001).

Compared with counties in the lowest quartile of medical debt burden, those in the highest quartile had a higher incidence of late-stage cancer for most cancer types, including lung cancer (rate ratio [RR] 1.39, 95% CI 1.18-1.64), colorectal cancer (RR 1.14, 95% CI 1.08-1.20), and cervical cancer (RR 1.24, 95% CI 1.14-1.36).

While the study found an association between higher medical debt and most cancers, breast and prostate cancer were exceptions.

Regarding breast cancer, Jiang and colleagues observed a null association (P=0.28) between absolute differences in the incidence rate of late-stage cases and county-level medical debt burden, although there was an absolute increase in the rate of diagnoses (0.22 per 100,000 person-years) for every 10% increase in medical debt.

In the case of prostate cancer, there was actually an inverse association between higher medical debt and diagnosis of late-stage disease, with each 10% increase associated with 0.80 fewer late-stage diagnoses (P<0.001). That trend was similar, but not statistically significant, in the case of all-stage prostate cancer diagnoses (P=0.09).

The authors suggested that the lower incidence of prostate cancer in counties with greater medical debt may reflect lower diagnostic intensity, rather than lower underlying disease burden.

As for the study’s limitations, Jiang and colleagues acknowledged that its design precluded individual-level causal inference, and that county-level findings may not reflect associations at the patient level.