Financial Toxicity of Cancer Care: An Analysis of Financial Burden in Three Distinct Health Care Systems.

PURPOSE: The financial toxicity of cancer care is a source of significant distress for patients with cancer. The purpose of this study is to understand factors associated with financial toxicity in three distinct care systems. METHODS: We conducted a cross-sectional survey of patients in three care systems, Stanford Cancer Institute (SCI), VA Palo Alto Health Care System (VAPAHCS), and Santa Clara Valley Medical Center (SCVMC), from October 2017 to May 2019. We assessed demographic factors, employment status, and out-of-pocket costs (OOPCs) and administered the validated COmprehensive Score for financial Toxicity tool. We calculated descriptive statistics and conducted linear regression models to analyze factors associated with financial toxicity. RESULTS: Four hundred forty-four of 578 patients (77%) completed the entire COmprehensive Score for financial Toxicity tool and were included in the analysis. Most respondents at SCI were White, with annual household income (AHI) > $50,000 USD and Medicare insurance. At the VAPAHCS, most were White, with AHI ≤ $50,000 USD and insured by the Veterans Administration. At SCVMC, most were Asian and/or Pacific Islander, with AHI ≤ $25,000 USD and Medicaid insurance. Low AHI (P < .0001), high OOPCs (P = .003), and employment changes as a result of cancer diagnosis (P < .0001) were associated with financial toxicity in the pooled analysis. There was variation in factors associated with financial toxicity by site, with employment changes significant at SCI, OOPCs at SCVMC, and no significant factors at the VAPAHCS. CONCLUSION: Low AHI, high OOPCs, and employment changes contribute to financial toxicity; however, there are variations based on site of care. Future studies should tailor financial toxicity interventions within care delivery systems.

The intersection of school racial composition and student race/ethnicity on adolescent depressive and somatic symptoms.

Schools are one of the strongest socializing forces in the U.S. and wield considerable influence over individuals' social and economic trajectories. Our study investigates how school-level racial composition, measured by the percentage non-Hispanic white students in a school, affects depressive and somatic symptoms among a representative sample of U.S. adolescents, and whether the association differs by race/ethnicity. We analyzed Wave I data from the US National Longitudinal Study of Adolescent Health, resulting in a sample size of 18,419 students attending 132 junior and senior high schools in 1994/5. After controlling for individual and school characteristics, our multilevel analyses indicated that with increasing percentages of white students at their school, black students experienced more depressive symptoms and a higher risk of reporting high levels of somatic symptoms. After including students' perceptions of discrimination and school attachment, the interaction between black student race and school-level racial composition was no longer significant for either outcome. Our findings suggest that attending predominantly-minority schools may buffer black students from discrimination and increase their school attachment, which may reduce their risk of experiencing depressive and somatic symptoms.

Does education matter? Examining racial differences in the association between education and STI diagnosis among black and white young adult females in the U.S.

OBJECTIVES: Education has long been considered a protective factor against sexual risk behaviors and sexually transmitted infections (STIs) among adolescents; however, few have explored this association and determined differences across racial/ethnic groups of young adult females on a national scale. The purpose of this study was to (1) describe the association between education and STI diagnosis among a national sample of black and white young adult females and (2) examine racial differences in this association. METHODS: We used data from the National Longitudinal Study of Adolescent Health (Add Health) to assess the association between education and chlamydia, gonorrhea, and/or trichomoniasis (self-reported and assay-diagnosed) in 2001-2002 using logistic regression analysis. RESULTS: After adjustment for risk behaviors, education was inversely associated with any assay-diagnosed STI, but this association was nonsignificant among black women for self-reported STI. Additionally, black females enrolled in, or who graduated from, college had significantly higher predicted probabilities of having an STI (12.4% self-reported; 13.4% assay-diagnosed) compared with white females who had less than a high school diploma (6.4% self-reported; 2.3% assay-diagnosed). CONCLUSIONS: Educational status was not uniformly protective against STIs for black and white females in this sample. Particularly for young black women, other factors may play a more prominent role in determining STI risk. Social determinants, such as education, should be viewed as important factors associated with STI prevalence, but their differential impact on various racial/ethnic groups should also be considered when addressing the disproportionate rates of STIs in the U.S.