1. Nalley, Catlin

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A study recently presented at the 2021 ASCO Quality Care Symposium found that, compared to individuals who reported adherence, cost-related prescription nonadherence was associated with higher health care cost responsibility in cancer survivors (Abstract 4). The researchers also observed that prescription adherence decisions could be more cost-sensitive for those living in rural versus urban areas.

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"As many speakers at the symposium have already touched on, cancer-related financial hardship is a prevalent issue," noted study author Courtney Williams, DrPh, MPH, a Cancer Prevention Fellow in the Office of the Associate Director of the Healthcare Delivery Research Program of the National Cancer Institute. "It's estimated that more than half of U.S. cancer survivors experience at least one domain of financial hardship due to their cancer treatment and survivorship year.


"And a common coping behavior attributed to cancer-related financial hardship is medication nonadherence," she continued, noting that this can include skipping the recommended doses of medications, splitting pills, or not filling prescribed medications. "This often leads to unmet therapeutic goals and potential emergency department use, which further increases health care spending and exacerbates potentially existing financial hardship."


Previous research, Williams explained, has also shown that individuals living with cancer in rural areas report financial problems due to their cancer more often when compared to those in urban areas. "[This could be] due to resource constraints at the policy, system, and individual level," she noted. "And these constraints may differentially impact medication adherence.


"However, little is known about the direct patient costs, which lead to prescription nonadherence among older cancer survivors and if there are potentially differences between those survivors living in rural and urban areas," Williams said.


Study Methodology, Results

To address this knowledge gap, Williams and colleagues initiated the current study. The main objective was to quantify and compare patient health care costs for older cancer survivors who did and did not report cost-related prescription nonadherence, overall and by rural/urban residence.


This retrospective cohort study used data from the Surveillance, Epidemiology, and End Results Program; Medicare claims; and the Consumer Assessment of Healthcare Providers and Systems survey linked data resource (SEER-CAHPS). Patients included in the study were Medicare fee-for-service beneficiaries with prostate, breast, colorectal, gynecologic, and lung cancer diagnosed between 2008 and 2015.


Overall, the study included 9,137 cancer survivors with a median age of 76. Fourteen percent had less than a high school diploma, 15 percent had ever been dual eligible for both Medicare and Medicaid, and 60 percent had one or more non-cancer comorbidity. Most of the individuals were prostate cancer survivors (40%). Additionally, Williams reported that the majority of the cancer survivors in this study had a localized, or regional, diagnosis and the median time from their cancer diagnosis to the time they took the survey was 7 years.


Among this sample of more than 9,000 cancer survivors, approximately one out of every 10 reported cost-related prescription nonadherence in the previous 6 months, according to Williams.


The researchers observed that the prevalence of cost-related nonadherence was similar by patient characteristics. The median cost responsibility in the year prior to the survey was $1,988 for patients reporting nonadherence and $1,455 for those reporting adherence. In adjusted models, patients reporting nonadherence had $628 higher patient cost responsibility in the year prior compared to those who reported adherence, according to the study authors.


"When stratifying our sample by rural or urban residents, we saw that one in five cancer survivors were considered rural dwelling," said Williams. "We also saw similar proportions of adherence within residence group. About 1 in 10 cancer survivors reported cost-related prescription nonadherence regardless of if they lived in an urban or rural setting."


An examination within residence groups found that rural-dwelling survivors had similar cost responsibilities in comparison to those reporting prescription nonadherence and adherence. Conversely, Williams highlighted that urban-dwelling survivors reporting nonadherence had a $696 higher cost responsibility in the year prior compared to those reporting adherence.


Study Implications

Overall, the researchers observed that about one in 10 long-term cancer survivors reported cost-related prescription nonadherence in the previous 6 months, which was associated with about a $600 higher health care cost responsibility in the previous year compared to those reporting adherence, Williams summarized.


"We also saw similar cost responsibilities when comparing rural-dwelling survivors reporting adherence and nonadherence. This could suggest that adherence decisions may not depend fully on direct health care costs," she noted. "And instead, these decisions may also be linked to indirect health care costs associated with health care access issues, like personal transportation to receive care or limited accessibility to pharmacies, specialists, or survivorship care in rural areas.


"And because of this," Williams concluded, "understanding how to address both direct health care costs and potential cost-related barriers to care for urban- and rural-dwelling, older cancer survivors could potentially aid and increase prescription adherence and, ultimately, better help outcomes for long-term cancer survivors."


Catlin Nalley is a contributing writer.