Financial toxicity refers to the financial strain that patients experience while accessing health care. Financial toxicity has been widely studied in cancer and, more recently, in ASCVD; however, no studies contrasted these disease sub-populations directly. Because these are the two main causes of mortality in the United States, we set out to explore which disease population reported the highest burden of financial toxicity overall and by its individual components.

We queried the National Health Interview Survey to identify adults with self-reported ASCVD and/or cancer between 2013 and 2018. Our outcome was financial toxicity, defined as having any of the following:

• Difficulty paying medical bills
• Inability to pay medical bills
• High financial distress
• Cost-related medication nonadherence
• Food insecurity
• Delayed/foregone care due to cost

We stratified the analysis by age groups and mutually exclusive disease groupings (neither ASCVD nor cancer, ASCVD only, cancer only, or both). We found financial toxicity in patients younger than 65 to be common across the disease categories:

• Neither ASCVD nor cancer: 38.3% (95% confidence interval [CI], 37.8-38.9%)
• Cancer: 41.0% (95% CI, 39.5-42.6%)
• ASCVD: 54.1% (95% CI, 52.4-55.8%)
• Both ASCVD and cancer: 54.5% (95% CI, 50.3-58.7%)

When compared with patients who reported neither disease, patients with both cancer and ASCVD had increased odds of all the following:

• Any financial toxicity (odds ratio [OR] 1.93; 95% CI, 1.63-2.28)
• Any difficulty paying medical bills (OR 2.27; 95% CI, 1.91-2.70)
• Inability to pay medical bills at all (OR 3.43; 95% CI, 2.83-4.16)
• High financial distress (OR 2.46; 95% CI, 2.08-2.92)
• Cost-related medication nonadherence (OR 4.72; 95% CI, 3.86- 5.78)
• Food insecurity (OR 3.19; 95% CI, 2.65-3.83)
• Foregone/delayed care due to cost (OR 2.51; 95% CI, 2.08-3.03)

In addition, presence of ASCVD, with or without cancer, was associated with increased odds for all financial toxicity measures when compared to individuals with cancer. After adjusting for confounders including variables such as family income and insurance status, the effect sizes were attenuated, but associations remained consistent and statistically significant even when studying the elderly population. These findings further reinforce the notion that presence of ASCVD was a key determinant of the presence and severity of financial toxicity.

Furthermore, in a composite score of number of financial toxicity measures reported at the individual level, the prevalence of having ≥3 was 9% (≈17.2 million) among those with neither disease, 13% (≈25.3 million) among those with cancer, 23% (≈44.5 million) among those with ASCVD, and 30% (≈57.9 million) among those with both (p trend < 0.001). All these results remained similar in the elderly population.

The study results not only confirm previous findings that individuals with a diagnosis of cancer have higher odds of financial toxicity than those without cancer, but also highlight the burden that financial toxicity from ASCVD represents in the overall adult population. The drivers of financial toxicity may be different in these populations; financial toxicity in cancer usually stems from cancer therapy pharmaceutical pricing, whereas ASCVD tends to be related to acute events often requiring hospitalization like myocardial infarctions and/or stroke. With higher prevalence of financial toxicity among patients with ASCVD, it is critical that interventions to mitigate financial toxicity that have been implemented among patients with cancer are evaluated for patients with ASCVD, such as office discussion about financial burden and using the COST (COmprehensive Score for financial Toxicity) as a validated tool to test for financial toxicity.

Clinical Topics: Cardio-Oncology

Keywords: Prevalence, Self Report, Odds Ratio, Confidence Intervals, Food Supply, Insurance Coverage, Income, Hospitalization, Neoplasms, Myocardial Infarction, Costs and Cost Analysis, Medication Adherence, Stroke, Pharmaceutical Preparations, Financial Support

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