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Unpublished data from an ongoing prospective study examining financial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.