Association of financial hardship and survival in working-age patients following cancer diagnosis in Taiwan

Abstract

Background: Extreme income or asset loss as severe form of financial hardship (FH) has been linked to worse survival outcomes in cancer patients. This study aimed to assess the incidence, risk factors, and impact of severe financial hardship (SFH) on survival among working-age cancer patients in Taiwan's universal healthcare system, using an objective measure for SFH.

Methods: This study analyzed linked national longitudinal data for patients aged 20-63 years diagnosed with cancer between 2007 and 2018. Severe financial hardship was defined as household net income falling below the poverty threshold post-diagnosis. Propensity score matching (1:4) was used to balance baseline characteristics between SFH and non-SFH groups. Cox proportional hazard models were used to estimate the hazard ratio (HR) of outcomes.

Results: Among 400 229 working-age cancer patients, the incidence of SFH was 4.7 per 1000 person-years (95% confidence interval [CI], 4.6-4.9) over a mean follow-up of 5.7 ± 4.3 years. Severe financial hardship was associated with younger age, male sex, advanced stage, and intensive treatments. Patients with SFH within 1 year of diagnosis had significantly lower survival, with an adjusted HR of 1.64 (95% CI, 1.56-1.72) for all-cause mortality compared to those without SFH. Notably, early stage patients with SFH faced a higher relative mortality risk than advanced-stage patients.

Conclusions: Severe financial hardship substantially increases mortality among cancer patients in Taiwan, highlighting gaps in financial protection. Addressing SFH through implementing targeted policies and enhancing support mechanisms is essential to improve survival outcomes and reduce disparities in cancer care.

Keywords: cancer; financial hardship; financial toxicity; survival.

Figure 1.

Patient selection process. SFH indicated transition to low-income household after cancer diagnosis. Abbreviations: NHI, National Health Insurance; SFH, severe financial hardship.

Figure 2.

Cumulative incidence of SFH after first cancer diagnosis (N = 400 299). CI, confidence interval; p-y, person-years.

Figure 3.

Overall survival and cancer-related survival among working-age patients with and without SFH. (A) Overall survival; (B) Cancer-related survival. The log-rank test was used to compare survival probabilities. Conditional Cox regression analysis was employed to estimate HRs of SFH for mortality risk. The analysis was adjusted for age group, sex, socioeconomic status, cancer site, AJCC stage, types of cancer treatment, modified CCI, and year of diagnosis. CI, confidence interval; p-y, person-years; aHR, adjusted hazard ratio; SFH, severe financial hardship.

Figure 4.

Adjusted HR of all-cause and cancer-related mortality in different subgroups of working-age patients with cancer with or without SFH. aHR, adjusted hazard ratio; CI, confidence interval; SES, socioeconomic status; SFH, severe financial hardship.