Patients undergoing surgery for gynecologic cancer, particularly those without insurance, experience a significant risk for financial toxicity, according to findings published in Gynecologic Oncology.

“Akin to treatment-induced toxicity, the term ‘financial toxicity’ (FT) has been devised to characterize the adverse impact and financial distress experienced by cancer patients,” Ayesha Ng, a medical student at David Geffen School of Medicine at UCLA, and colleagues wrote. “Notably, FT has been linked with increased mortality, treatment non-adherence, and worsened QOL.”

Ng and colleagues conducted a retrospective cohort study using data from the National Inpatient Sample, an all-payer inpatient database, from 2008-2019, identifying all adult patients undergoing hysterectomy and/or oophorectomy. They also analyzed the association of insurance status with clinical and financial outcomes during these hospitalizations.

Patient Characteristics & Insurance Status Impact FT Risk

The study included 462,529 patients. Nearly half of the patients in the study (N=228,508; 49.4%) had government-funded policies; 204,755 (44.3%) had private insurance and 14,805 (3.2%) were uninsured. Compared with patients with insurance, those without insurance were younger (52±11 vs 61±13 years; P<0.001), were more often Black and Hispanic (Black, 14.9% vs 10.2%; Hispanic, 22.1% vs 9.0%; P<0.001), and more frequently in the lowest income quartile (37.0% vs 23.1%; P<0.001). Patients without insurance were less likely to have elective admissions, but more likely to be transferred from outside hospitals.

Cancer types included uterine (uninsured, 50.6%; insured, 56.7%), ovarian (uninsured, 37.6%; insured, 34.7%), and cervical (uninsured, 11.8%; insured, 8.6%; P<0.001). The open operative approach was used more frequently among uninsured patients (open, 82.5% vs 71.0%; laparoscopic, 4.1% vs 6.6%; robotic, 13.4% vs 22.4%; P<0.001). Mortality rates were similar between insured and uninsured groups, but uninsured patients had increased rates of complications, length of stay, and costs.

Ovarian cancer resections were associated with the highest median costs ($17,258; interquartile range, $12,187-$25,491) compared with cervical and uterine cancers.

“Approximately 52.8% of uninsured and 15.4% of insured patients were at risk for FT,” Ng and colleagues wrote. “As costs increased across both cohorts over the 12-year study period, the disparity in FT risk by payer status broadened.”

Following adjustment for risk, perioperative complications were associated with an almost two-fold greater risk for FT among uninsured patients (aOR, 1.75; 95% CI, 1.46-2.09). Among patients with insurance, Black and Hispanic race, public insurance, and the open operative approach were associated with greater odds of FT.

Strategies for Reducing FT in Gynecologic Oncology

While national efforts to reduce healthcare spending have increased access to healthcare and decreased the number of uninsured individuals, cancer care has not become more affordable, according to Ng and colleagues. The finding that uninsured patients with gynecologic cancers experience significantly greater risk for FT compared with insured patients underscores “the importance of more comprehensive health coverage,” they wrote.

The researchers pointed to disparities in the outcomes they observed, including the higher risk for FT among Black and Hispanic individuals. They also noted that patients with Medicare and Medicaid experienced greater odds of FT compared to patients with private insurance.

“Given its profound impact, financial toxicity in gynecologic oncology deserves further investigation,” Ng and team wrote. “Modifications in healthcare legislation and provision of cost mitigation strategies are needed to optimize quality of cancer care while minimizing the financial burden to patients.”