Determinants and Consequences of Financial Hardship Among Adult Survivors of Childhood Cancer: A Report From the St. Jude Lifetime Cohort Study

Abstract

Background: Financial hardship among survivors of pediatric cancer has been understudied. We investigated determinants and consequences of financial hardship among adult survivors of childhood cancer.

Methods: Financial hardship, determinants, and consequences were examined in 2811 long-term survivors (mean age at evaluation = 31.8 years, years postdiagnosis = 23.6) through the baseline survey and clinical evaluation. Financial hardship was measured by material, psychological, and coping/behavioral domains. Outcomes included health and life insurance affordability, retirement planning, symptoms, and health-related quality of life (HRQOL). Odds ratios (ORs) estimated associations of determinants with financial hardship. Odds ratios and regression coefficients estimated associations of hardship with symptom prevalence and HRQOL, respectively. All statistical tests were two-sided.

Results: Among participants, 22.4% (95% confidence interval [CI] = 20.8% to 24.0%), 51.1% (95% CI = 49.2% to 52.9%), and 33.0% (95% CI = 31.1% to 34.6%) reported material, psychological, and coping/behavioral hardship, respectively. Risk factors across hardship domains included annual household income of $39 999 or less vs $80 000 or more (material OR = 3.04, 95% CI = 2.08 to 4.46, psychological OR = 3.64, 95% CI = 2.76 to 4.80, and coping/behavioral OR = 4.95, 95% CI = 3.57 to 6.86) and below high school attainment vs college graduate or above (material OR = 2.22, 95% CI = 1.45 to 3.42, psychological OR = 1.75, 95% CI = 1.18 to 2.62, and coping/behavioral OR = 2.05, 95% CI = 1.38 to 3.06). Myocardial infarction, peripheral neuropathy, subsequent neoplasm, seizure, stroke, reproductive disorders, amputation, and upper gastrointestinal disease were associated with higher material hardship (all P < .05). Hardship across three domains was associated with somatization, anxiety and depression (all P < .001), suicidal ideation (all P < .05), and difficulty in retirement planning (all P < .001). Survivors with hardship had statistically significantly lower HRQOL (all P < .001), sensation abnormality (all P < .001), and pulmonary (all P < .05) and cardiac (all P < .05) symptoms.

Conclusions: A substantial proportion of adult survivors of childhood cancer experienced financial hardship. Vulnerable sociodemographic status and late effects were associated with hardship. Survivors with financial hardship had an increased risk of symptom prevalence and impaired HRQOL.

Figure 1.

Conceptual framework for investigating financial hardship in adult survivors of childhood cancer. HRQOL = health-related quality of life.

Figure 2.

A consort diagram of study participant enrollment. SJLIFE = St. Jude Lifetime Cohort Study.

Figure 3.

Prevalence of financial hardship in adult survivors of childhood cancer.

Figure 4.

Associations of financial hardship with physical component summary (PCS; upper) and mental component summary (MCS; lower). The horizontal line indicates the norm 50 for the SF-36 PCS and MCS. The means (SD) of PCS and MCS of all participants were 50.1 (9.4) and 49.0 (9.6), respectively. The width of each box represents the interquartile range of PCS/MCS, with the upper line for the 75th percentile value, the middle line for the 50th percentile value, and the lower line for the 25th percentile value; the lines extended vertically from the box (whiskers) indicate the highest and lowest values of the study participants.