Debt and Bankruptcy During Treatment

The extent of debt accrual or the need to file for bankruptcy due to treatment costs varies widely, but overall, bankruptcy rates among survivors of cancer are low. A systematic review of 45 studies reported that 12% to 62% of patients reported being in debt due to treatment.2 A survey of 4719 cancer survivors aged 18 to 64 years found that 33% had accrued debt and 3% filed for bankruptcy; of those who accrued debt, 55% had at least $10,000 of debt.7 A longitudinal cohort study of patients aged 50 and older that included 9.5 million new cancer diagnoses between 2000 and 2012 found that 42.4% of patients had used all of their financial assets 2 years after diagnosis, with financial insolvency persisting among 38.2% after 4 years.8 Factors associated with financial toxicity included worsening cancer, need for continued treatment, income, female sex, and having Medicaid or uninsured status.

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Effects on Treatment

Financial toxicity can affect treatment adherence, as patients may skip treatments or visits to reduce costs. In a systematic review, 4% to 45% of patients reported not adhering to treatment due to cost.2 Copay assistance is frequently available from drug manufacturers for patients with private insurance, but not for patients with Medicare because of federal regulations.9 This financial assistance can dramatically reduce drug costs, but the copay cards typically expire after a period of time. Other OOP costs accrue as well, such as transportation, hospital or provider bills, and lost work days.

Financial Outcomes of Cancer Survivors

In a cohort study, childhood cancer survivors were more likely than their siblings to have greater OOP medical costs that were at least 10% of their annual income, and a higher percentage of income spent on OOP costs was associated with difficulty paying medical bills; deferring health care, treatment, tests, or follow-up visits; and considering filing for bankruptcy.10

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In a cohort of 6012 women from the Life and Longevity After Cancer ancillary study of the Women’s Health Initiative, 6% of women experienced some financial burden during the mean 9.2 years after a cancer diagnosis.11 Significant debt, including filing for bankruptcy, occurred among 1.8% of women. Factors associated with financial burden included younger age, lower household income, shorter time since diagnosis, African-American race, lack of private health insurance, presence of comorbidities, treatment with chemotherapy, and regional stage of disease at diagnosis.


Financial toxicity is a potential consequence of cancer treatment, particularly among patients diagnosed at an earlier age and those of lower socioeconomic status or who have public health insurance. Importantly, financial toxicity can affect treatment because patients may not adhere to treatment in an effort to lower their OOP costs. Clinicians should be aware of the challenges that patients face in relation to financial toxicity and set up the appropriate processes and procedures to discuss financial factors that are relevant to each patient’s treatment plan.


  1. Financial Toxicity and Cancer Treatment (PDQ)—Health Professional Version. National Cancer Institute. Updated January 30, 2018. Accessed July 20, 2018.
  2. Altice CK, Banegas MP, Tucker-Seeley RD, Yabroff KR. Financial hardships experienced by cancer survivors: a systematic review. J Natl Cancer Inst. 2017;109(2):djw205. doi: 10.1093/jnci/djw205
  3. Gordon LG, Merollini KMD, Lowe A, Chan RJ. A systematic review of financial toxicity among cancer survivors: we can’t pay the co-pay. Patient. 2017;10(3):295-309. doi: 10.1007/s40271-016-0204-x.
  4. Kale HP, Carroll NV. Self-reported financial burden of cancer care and its effect on physical and mental health-related quality of life among US cancer survivors. Cancer. 2016;122(8):283-289. doi: 10.1002/cncr.29808
  5. Abel GA, Albelda R, Khera N, et al. Financial hardship and patient-reported outcomes after hematopoietic cell transplantation. Biol Blood Marrow Transplant. 2016;22(8):1504-1510. doi:10.1016/j.bbmt.2016.05.008
  6. Stone DS, Ganz PA, Pavlish C, Robbins WA. Young adult cancer survivors and work: a systematic review. J Cancer Surviv. 2017;11(6):765-781. doi: 10.1007/s11764-017-0614-3
  7. Banegas MP, Guy GP Jr, de Moor JS, et al. For working-age cancer survivors, medical debt and bankruptcy create financial hardships. Health Aff (Millwood). 2016;35(1):54-61. doi: 10.1377/hlthaff.2015.0830
  8. Gilligan AM, Alberts DS, Roe DJ, Skrepnek GH. Death or debt? National estimates of financial toxicity in persons with newly-diagnosed cancer [published online June 12, 2018]. Am J Med. doi: 10.1016/j.amjmed.2018.05.020
  9. Fonseca R, Hinkel J. Value and cost of myeloma therapy—we can afford it. Am Soc Clin Oncol Educ Book. 2018;38:647-655. doi: 10.1200/EDBK_200869
  10. Nipp RD, Kirchhoff AC, Fair D, et al. Financial burden in survivors of childhood cancer: a report from the childhood cancer survivor study. J Clin Oncol. 2017;35(30):3474-3481. doi: 10.1200/JCO.2016.71.7066
  11. Hastert TA, Young GS, Pennell ML, et al. Financial burden among older, long-term cancer survivors: Results from the LILAC study [published online July 17, 2018]. Cancer Med. doi: 10.1002/cam4.1671