title: Financial Insolvency as a Risk Factor for Early Mortality Among Patients With Cancer.
abstract: OBJECTIVE
  Patients with cancer are more likely to file for bankruptcy than the general population, but the impact of severe financial distress on health outcomes among patients with cancer is not known.
  
  
  METHODS
  We linked Western Washington SEER Cancer Registry records with federal bankruptcy records for the region. By using propensity score matching to account for differences in several demographic and clinical factors between patients who did and did not file for bankruptcy, we then fit Cox proportional hazards models to examine the relationship between bankruptcy filing and survival.
  
  
  RESULTS
  Between 1995 and 2009, 231,596 persons were diagnosed with cancer. Patients who filed for bankruptcy (n = 4,728) were more likely to be younger, female, and nonwhite, to have local- or regional- (v distant-) stage disease at diagnosis, and have received treatment. After propensity score matching, 3,841 patients remained in each group (bankruptcy v no bankruptcy). In the matched sample, mean age was 53.0 years, 54% were men, mean income was $49,000, and majorities were white (86%), married (60%), and urban (91%) and had local- or regional-stage disease at diagnosis (84%). Both groups received similar initial treatments. The adjusted hazard ratio for mortality among patients with cancer who filed for bankruptcy versus those who did not was 1.79 (95% CI, 1.64 to 1.96). Hazard ratios varied by cancer type: colorectal, prostate, and thyroid cancers had the highest hazard ratios. Excluding patients with distant-stage disease from the models did not have an effect on results.
  
  
  CONCLUSIONS
  Severe financial distress requiring bankruptcy protection after cancer diagnosis appears to be a risk factor for mortality. Further research is needed to understand the process by which extreme financial distress influences survival after cancer diagnosis and to find strategies that could mitigate this risk.
authors.affiliation: Scott D. Ramsey, Aasthaa Bansal, Catherine R. Fedorenko, and Polly Newcomb, Fred Hutchinson Cancer Research Center; Aasthaa Bansal, University of Washington; Veena Shankaran, University of Washington School of Medicine; Karen A. Overstreet, US Bankruptcy Court, Western District of Washington, Seattle, WA; and David K. Blough, Bechtel, Schenectady, NY. sramsey@fredhutch.org.
authors.forename: Scott D
authors.initials: SD
authors.lastname: Ramsey
authors.affiliation: Scott D. Ramsey, Aasthaa Bansal, Catherine R. Fedorenko, and Polly Newcomb, Fred Hutchinson Cancer Research Center; Aasthaa Bansal, University of Washington; Veena Shankaran, University of Washington School of Medicine; Karen A. Overstreet, US Bankruptcy Court, Western District of Washington, Seattle, WA; and David K. Blough, Bechtel, Schenectady, NY.
authors.forename: Aasthaa
authors.initials: A
authors.lastname: Bansal
authors.affiliation: Scott D. Ramsey, Aasthaa Bansal, Catherine R. Fedorenko, and Polly Newcomb, Fred Hutchinson Cancer Research Center; Aasthaa Bansal, University of Washington; Veena Shankaran, University of Washington School of Medicine; Karen A. Overstreet, US Bankruptcy Court, Western District of Washington, Seattle, WA; and David K. Blough, Bechtel, Schenectady, NY.
authors.forename: Catherine R
authors.initials: CR
authors.lastname: Fedorenko
authors.affiliation: Scott D. Ramsey, Aasthaa Bansal, Catherine R. Fedorenko, and Polly Newcomb, Fred Hutchinson Cancer Research Center; Aasthaa Bansal, University of Washington; Veena Shankaran, University of Washington School of Medicine; Karen A. Overstreet, US Bankruptcy Court, Western District of Washington, Seattle, WA; and David K. Blough, Bechtel, Schenectady, NY.
authors.forename: David K
authors.initials: DK
authors.lastname: Blough
authors.affiliation: Scott D. Ramsey, Aasthaa Bansal, Catherine R. Fedorenko, and Polly Newcomb, Fred Hutchinson Cancer Research Center; Aasthaa Bansal, University of Washington; Veena Shankaran, University of Washington School of Medicine; Karen A. Overstreet, US Bankruptcy Court, Western District of Washington, Seattle, WA; and David K. Blough, Bechtel, Schenectady, NY.
authors.forename: Karen A
authors.initials: KA
authors.lastname: Overstreet
authors.affiliation: Scott D. Ramsey, Aasthaa Bansal, Catherine R. Fedorenko, and Polly Newcomb, Fred Hutchinson Cancer Research Center; Aasthaa Bansal, University of Washington; Veena Shankaran, University of Washington School of Medicine; Karen A. Overstreet, US Bankruptcy Court, Western District of Washington, Seattle, WA; and David K. Blough, Bechtel, Schenectady, NY.
authors.forename: Veena
authors.initials: V
authors.lastname: Shankaran
authors.affiliation: Scott D. Ramsey, Aasthaa Bansal, Catherine R. Fedorenko, and Polly Newcomb, Fred Hutchinson Cancer Research Center; Aasthaa Bansal, University of Washington; Veena Shankaran, University of Washington School of Medicine; Karen A. Overstreet, US Bankruptcy Court, Western District of Washington, Seattle, WA; and David K. Blough, Bechtel, Schenectady, NY.
authors.forename: Polly
authors.initials: P
authors.lastname: Newcomb
mesh_terms: D016361:Bankruptcy / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000191:economics / Q000401:mortality* / Q000523:psychology / Q000628:therapy; D016016:Proportional Hazards Models; D012307:Risk Factors; D018426:SEER Program; D013315:Stress, Psychological / Q000191:economics / Q000209:etiology / Q000523:psychology; D014861:Washington / Q000453:epidemiology
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