Assess whether county-level medical debt prevalence was associated with cancer incidence, particularly late-stage incidence, across US counties.
Approach:
Design and data: County-level analysis of 2,958 US counties, relating medical debt in collections in 2016 to age-adjusted cancer incidence from 2017 to 2021.
Measures and analysis: Researchers evaluated all-stage and late-stage incidence for nine cancers. Late-stage disease was regional or distant. Models adjusted for metropolitan status, primary care physician density, and social vulnerability, with state-level random effects and county…
Key Findings:
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.
Smaller increases per 10-percentage-point rise in debt prevalence were observed for late-stage head and neck, colorectal, melanoma, cervical, kidney and renal pelvis, and bladder cancers.
Compared with counties in the lowest debt quartile, those in the highest quartile had 39% higher late-stage lung, 14% higher colorectal, and 24% higher cervical cancer incidence.
Late-stage breast cancer incidence was not associated with debt in the primary analysis; higher debt was associated with lower recorded late-stage prostate cancer incidence.
Mean medical debt prevalence was 21% across included counties and was higher in counties with greater social vulnerability.
Interpretation:
The authors described medical debt as a possible area-level marker of structural and financial barriers associated with cancer detection and population-level cancer outcomes. They noted that barriers to lung cancer screening and follow-up, as well as socioeconomic and behavioral risk factors, may help explain the larger absolute association for lung cancer.
Limitations:
The ecological, cross-sectional design does not establish causation or patient-level relationships; researchers could not determine whether people with medical debt were those diagnosed with cancer.
Residual confounding, within-county disparities, and differences in data availability across cancer types may have affected results.
The measure captured debt in collections but not debt amounts or medical expenses financed through credit cards or home refinancing unless those debts entered collections.
Conclusion:
The researchers called for longitudinal studies using individual-level risk factors and health care use to clarify the relationship between medical debt and cancer stage at diagnosis.
