Patients with Cancer at Risk for Bankruptcy

Caroline Helwick

August 2011, Vol 2, No 5 - ASCO Annual Meeting

Scott D. Ramsey, MD, PhD

Chicago, IL—Nearly 2% of patients with cancermay file for personal bankruptcy 5 years after their diagnosis, according to researchers from Fred Hutchinson Cancer Research Center in Seattle who presented their data at the 2011 American Society of Clinical Oncology (ASCO) Annual Meeting.

“We found that bankruptcy is a particular risk for patients with cancer,” said Scott D. Ramsey, MD, PhD, Professor of Medicine, Fred Hutch inson Cancer Re search Center, University of Wash ington School of Medicine, and Director, Cancer Prevention Clinic, Seattle Cancer Care Alliance.

Dr Ramsey and colleagues studied data for >230,000 patients with cancer showing that rates varied widely across cancer types, that younger patients aged <44 years were particularly at risk, and that bankruptcies increased over time. Bankruptcy rates averaged 0.5% at 1 year but rose to 1.9% at 5 years post – diagnosis. In comparison, the bankruptcy rate in the general population of western Washington State was only 0.28%.

Using the Surveillance, Epidemi – ology and End Results registry, the researchers identified 231,799 adults with newly diagnosed first primary cancers between 1995 and 2009 living in western Washington State. They linked these to bankruptcy filings (Chapters 7 and 13) in federal bank rates of bankruptcy after cancer.

“We found that persons filing for bankruptcy tended to be younger, female, and nonwhite, and to be diagnosed with local or regional disease rather than distant disease,” Dr Ramsey said. “Also, across all cancers we studied, young patients were at particular risk. We think this is likely due to the fact that young people have lower incomes, fewer assets, and less access to insurance.”

The 5 cancers with the highest association with bankruptcy at 5 years were:

  • Lung cancer, 7.7%
  • Thyroid cancer, 4.8%
  • Leukemia/lymphoma, 3.6%
  • Uterine cancer, 3.2%
  • Colorectal cancer, 3.1%.

The next 3 top cancers were mela – noma, 3.0%; breast cancer, 2.9%; and prostate cancer, 1.7%.

“We were puzzled that thyroid [cancer] was one of the most common,” Dr Ramsey said. “We think it’s because this is a cancer that occurs often in young women who may have fewer assets, lower income, and perhaps less insurance coverage, because they may be less likely to be employed. Thyroid cancer treatment is fairly straight – forward, but treatment actually costs more than one would think. A course of radioactive iodine is about $40,000, so this could be a factor as well.”

The 5-Year Postdiagnosis Trend

For the 231,799 patients investigated, after mean follow-up of 4.3 years, 4805 (2.1%) filed for bankruptcy. Median time to bankruptcy was 2.5 years.

Rates of bankruptcy filings generally began to rise 1 year after diagnosis and peaked before the Bankruptcy Abuse Prevention and Consumer Protection Act of 2005. Rates then declined sharply, before climbing again after 2007 in conjunction with the recent “financial crisis.” For all patients, regardless of the cancer, rates steadily climbed to 5 years postdiagnosis.

“The bankruptcy laws of 2005 influenced the timing of bankruptcy filings. There was a huge spike prior to enactment, followed by a very large decline, then a big increase after the financial crisis,” Dr Ramsey said.

Uncertainties regarding the potential impact of the bankruptcy law led to a rush to file. For example, one of the law’s features is a “means test” that can disqualify some individuals from bankruptcy protection. Many lawyers, therefore, counseled patients who felt they were at risk to file before implementation of the law.

“After the law was passed and experience with the procedures was gained, lawyers realized the barriers were not as great as they had assumed. As the legal community became comfortable, there was a rebound in filing, which was accelerated by the financial crisis,” he added.

Young Age A Risk Factor

Across all cancer types, a strong trend was evident for increased rates in younger populations, in a multivariate model adjusted for cofactors. The hazard ratios (HRs) by age, in this non-Medicare population, are shown in the Table.

In the multivariate model, other factors were shown to be influential:

  • Enforcement of new bankruptcy laws in 2005: HR, 0.31-0.42
  • Female sex versus male: HR, 0.75 (lung)
  • Regional stage of disease at diagnosis versus local stage: HR, 1.32-1.77
  • Married versus nonmarried: HR, 0.61 (breast cancer).