Impact of COVID-19 Economic Repercussions on Cancer Survivors
In late March, a record 6.6 million people filed for unemployment in the United States, while some models anticipate the unemployment rate to rise up to 32% for the second quarter of 2020.31,32Cancer survivors that will be affected by this may be at a higher risk for financial burden than the general population and more severe financial toxicity than would normally be expected.33,34 Indeed it is predicted that low-wage and self-employed workers will face the greatest risk of immediate financial burdens.35 Cancer survivors with low income at baseline, loss of wages, or perceived social isolation already face higher levels of financial toxicity than their counterparts.33,34 These are all factors that may be exacerbated by necessary public health measures such as physical distancing. Thus low-earning or socially isolated cancer survivors may represent some of the highest risk groups for increased financial toxicity during the pandemic compared to the general population and other cancer survivors.
Survivors employed in services that cannot be offered from home may be disproportionately affected and forced into temporary unemployment. Unpublished data from an ongoing prospective study examining financial toxicity in HNC survivors at our institution suggests that this may constitute up to 61.6% (45/73) of patients with squamous cell carcinoma (SCC) of the upper aerodigestive system. In a previous cross-sectional investigation of insured patients who completed primary treatment for SCC of the oral cavity, oropharynx, or larynx/hypopharynx, we found differences in financial toxicity by primary site, with worst financial toxicity in larynx/hypopharynx patients. This finding illuminates potential site-specific factors, e.g. workplace discrimination or inability to return to work, that may contribute to increased risk.36 Of all working-age cancer survivors (45% of people diagnosed with cancer),37 just 54% report working full time.38 This number will certainly be affected in the short-term, but these effects may linger long after acute pandemic control measures have been lifted. An increased proportion of cancer survivors may potentially suffer long-term cancer-associated job loss as a result of economic repercussions on the job market; a potentially less supportive and accommodating work environment;39 decreased functional status;40 and loss of productivity which cancer survivors already experience at greater levels than patients without a cancer history.41
Employment provides sense of self-fulfillment and return to normalcy, social interaction, financial compensation, as well as critical health care benefits. Despite changes under the Affordable Care Act (ACA), employer-sponsored health insurance coverage remains the dominant source of insurance in the US with close to half of all those covered in the US receiving insurance from an employer.42 Long-term cancer survivors report higher rates of “job lock,” i.e. a perceived need to stay at a specific job to maintain health insurance, compared with similar workers with no cancer history.43,44Low-income workers who lose their jobs in the wake of the pandemic may have few coverage options depending on where they live. As of early 2020, 14 states had not expanded their Medicaid programs as allowed by the ACA, and many low-income adults in these states fall into a “coverage gap” given they do not qualify for Medicaid but their incomes are too low to qualify for subsidized private insurance.45 The prevalence of financial toxicity is not limited to low-income individuals, though. In previously published work from our group, we found that among Medicare and private beneficiaries, groups conventionally perceived as well-insured and less likely to face many of the socioeconomic barriers encountered by traditional Medicaid patients, financial toxicity remains a major concern.36 Middle-income cancer survivors who previously qualified for employer-provided insurance and do not qualify for Medicaid may be gravely affected by the ongoing unemployment crisis. While the ACA created insurance Marketplaces to provide private coverage options, most of these plans have high-deductibles, and middle-income patients may not be able to afford required premiums and cost-sharing.46-48 With loss of employment and their employment health benefits, they may be “priced out” and face a bleak choice between less than optimal treatment and financial ruin. This echoes predictions from 2008 noting that “at least 25,000 patients with cancer undergoing treatment in 2009 [would] lose coverage as a result of the recession”.49 A preliminary report estimates that 1.55 million newly unemployed persons will lose health insurance coverage due to the pandemic.50 The study does not stratify this estimate per disease, but it is safe to say that cancer survivors will certainly be among those affected.
Multiple studies have suggested that cancer-related financial strain may be linked to decreased self-reported HRQOL, thereby contributing to a greater mortality risk.2,3,5-8 This is at least in part attributable to maladaptive coping strategies such as treatment non-adherence.51 In attempts to remedy increasing costs, patients limit use of medications, miss clinical appointments, borrow money, take credit card loans or have family members work additional hours.51-54 One study found a link between the 2008 economic recession and a decreased rate of cancer treatment,55 implying that during economic hardships, patients may be less likely to seek cancer care due to financial constraints. Moreover, attainment of basic necessities may be disproportionately affected in cancer survivors who have reported greater levels of food insecurity (worrying about whether food would run out, food spoiling, and the inability to afford balanced meals) compared to individuals without a cancer history.56 These coping strategies may be amplified during the COVID-19 pandemic with the potential for devastating consequences on health and health outcomes, including cancer progression and death. A longitudinal analysis of data from 75 countries has in fact demonstrated that sharp unemployment rises such as that from 2008 to 2010 were significantly associated with an increase in all-cancer mortality and all specific cancers except lung cancer in women.57 The study further estimated an excess of about 260,000 cancer-related deaths associated with the 2008 to 2010 economic crisis.57 History informs us that we must examine these issues urgently as we grapple with the economic repercussions and resulting health consequences on cancer survivors.