Higher county-level medical debt in collections was associated with higher incidence rates of late-stage cancer across 7 cancer types in a national analysis of 2,958 US counties.
Researchers examined the association between medical debt in collections in 2016 and age-adjusted cancer incidence from 2017 to 2021 using county-level data. Medical debt prevalence was measured as the percentage of individuals with credit bureau records who had debt in collections, using data from the Urban Institute Debt in America project. Cancer incidence data came from the Centers for Disease Control and Prevention State Cancer Profiles. Of 3,143 US counties, 185 were excluded because medical debt data were unavailable.
The outcomes were age-adjusted all-stage and late-stage cancer incidence rates per 100,000 person-years. Late-stage disease was defined as regional or distant disease. Researchers evaluated 9 cancers with screening recommendations or recognizable early signs or symptoms: lung, colorectal, cervical, breast, prostate, melanoma, kidney and renal pelvis, bladder, and head and neck cancers. Models were adjusted for metropolitan status, primary care physician density, and the Social Vulnerability Index, with state-level random effects and weighting by county population.
Each 10-percentage-point increase in medical debt prevalence was associated with 5.15 additional late-stage lung cancer cases per 100,000 person-years after adjustment. Smaller increases were observed for late-stage head and neck cancer (0.92 additional cases), colorectal cancer (0.69), melanoma (0.59), cervical cancer (0.39), kidney and renal pelvis cancer (0.38), and bladder cancer (0.24) per 100,000 person-years.
The association was also evident across debt quartiles. Counties in the highest medical debt quartile had 39% higher late-stage lung cancer incidence than those in the lowest quartile. Late-stage colorectal cancer incidence was 14% higher, and cervical cancer incidence was 24% higher. The researchers suggested that barriers to annual lung cancer screening and follow-up, alongside socioeconomic and behavioral risk factors, may help explain the larger absolute association observed for lung cancer.
Associations were generally consistent in sex-stratified analyses, although the estimated changes in cancer incidence were larger among males. Results were also similar in sensitivity analyses using alternative socioeconomic adjustments and available county-level screening rates for colorectal, breast, and cervical cancers.
The associations did not extend uniformly across all cancer types. Late-stage breast cancer incidence was not associated with medical debt in the primary analysis, although an association emerged in sensitivity analyses. For prostate cancer, higher medical debt was associated with lower recorded late-stage incidence. The prostate cancer finding could reflect lower prostate-specific antigen testing and diagnostic intensity or understaging in communities with fewer resources rather than a lower underlying disease burden.
Across the included counties, a mean of 21% of individuals with credit bureau records had medical debt in collections, with prevalence ranging from 1% to 52%. Debt burden was higher in more socially vulnerable communities: counties in the highest quartile of the Social Vulnerability Index had a mean medical debt prevalence of 27%, compared with 14% in the lowest quartile.
The study's ecological and cross-sectional design precluded causal or patient-level conclusions. Researchers could not determine whether residents with medical debt were the same patients who received cancer diagnoses, and residual confounding by unmeasured socioeconomic factors, health care resources, and state policies was possible. County averages may also have obscured disparities within counties, while differences in data availability across cancer types may have affected comparisons between them. Researchers also lacked information about the amount of debt or its burden relative to household finances, and the collections-based measure did not capture medical expenses financed through credit cards or home refinancing, even if those debts subsequently entered collections.
The researchers called for longitudinal studies incorporating individual-level risk factors and health care use to clarify the relationship between medical debt and cancer stage at diagnosis. “These findings suggest that medical debt may be an area-level marker of structural and financial barriers associated with cancer detection and cancer outcomes at the population level,” wrote first author Jiazhang Xing, MD, of Sinai Hospital of Baltimore, and colleagues.
Hu reported grants from government, nonprofit, and industry sources outside the submitted work. Yabroff reported honoraria from the American Society of Clinical Oncology. Jiang reported grants from the American Cancer Society and ASCO Conquer Cancer Foundation and personal fees from Johnson & Johnson. No other disclosures were reported.
Source: JAMA Network Open
