Rural-urban differences in financial burden among cancer survivors: an analysis of a nationally representative survey

  • Whitney E. ZahndEmail author
  • Melinda M. Davis
  • Jason S. Rotter
  • Robin C. Vanderpool
  • Cynthia K. Perry
  • Jackilen Shannon
  • Linda K. Ko
  • Stephanie B. Wheeler
  • Cassie L. Odahowski
  • Paige E. Farris
  • Jan M. Eberth
Original Article



Rural cancer survivors may disproportionately experience financial problems due to their cancer because of greater travel costs, higher uninsured/underinsured rates, and other factors compared to their urban counterparts. Our objective was to examine rural-urban differences in reported financial problems due to cancer using a nationally representative survey.


We used data from three iterations of the National Cancer Institute’s Health Information and National Trends Survey (2012, 2014, and 2017) to identify participants who had a previous or current cancer diagnosis. Our outcome of interest was self-reported financial problems associated with cancer diagnosis and treatment. Rural-urban status was defined using 2003 Rural-Urban Continuum Codes. We calculated weighted percentages and Wald chi-square statistics to assess rural-urban differences in demographic and cancer characteristics. In multivariable logistic regression models, we examined the association between rural-urban status and other factors and financial problems, reporting the corresponding adjusted predicted probabilities.


Our sample included 1359 cancer survivors. Rural cancer survivors were more likely to be married, retired, and live in the Midwest or South. Over half (50.5%) of rural cancer survivors reported financial problems due to cancer compared to 38.8% of urban survivors (p = 0.02). This difference was attenuated in multivariable models, 49.3 and 38.7% in rural and urban survivors, respectively (p = 0.06).


A higher proportion of rural survivors reported financial problems associated with their cancer diagnosis and treatment compared to urban survivors. Future research should aim to elucidate these disparities and interventions should be tested to address the cancer-related financial problems experienced by rural survivors.


Cancer survivorship Financial toxicity Rural health Health disparities Survey research 



This study used secondary data from the National Cancer Institute. The “Data Terms of Use” does not allow for release of data by data users. However, these data are publicly available from the National Cancer Institute and available for download on their website upon acknowledgement of the “Data Terms of Use.”

Funding information

This publication was supported, in part, by the Cancer Prevention and Control Research Network, funded by the Centers for Disease Control and Prevention and the National Cancer Institute (3 U48 DP005000-01S2, University of South Carolina PI: Friedman, Authors: Zahnd, Odahowski, and Eberth; 3 U48 DP005006-01S3, Oregon Health & Science University PI: Shannon and Winters-Stone, Authors: Davis, Perry, Farris, Shannon; 3 U48 DP005014-01S2, University of Kentucky PI: Vanderpool, Author: Vanderpool; 3 U48 DP005013-01S1A3, University of Washington PI: Hannon, Author: Ko; and 3 U48 DP005017-01S8, University of North Carolina PI: Wheeler, Authors: Wheeler and Rotter). Melinda Davis was supported in part by an NCI K07 award (1K07CA211971-01A1). Linda Ko was supported in part by a grant from the Clinical and Translational Science Awards program (UL1 TR002319). This study was also supported by the Federal Office of Rural Health Policy (FORHP), Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services (HHS) under cooperative agreement [5 U1CRH30539-03-00; Eberth, Zahnd, Odahowski].

Compliance with ethical standards

Conflicts of interest

The authors declare they have no conflicts of interest.


The information, conclusions, and opinions expressed in this brief are those of the authors and no endorsement by FORHP, HRSA, CDC, NIH, or HHS is intended or should be inferred.

Supplementary material

520_2019_4742_MOESM1_ESM.docx (19 kb)
ESM 1 (DOCX 19 kb)


  1. 1.
    Miller KD, Siegel RL, Lin CC, Mariotto AB, Kramer JL, Rowland JH (2016) Cancer treatment and survivorship statistics, 2016. CA Cancer J Clin 66(4):271–289. CrossRefGoogle Scholar
  2. 2.
    Yabroff KR, Lund J, Kepka D, Mariotto A (2011) Economic burden of cancer in the US: estimates, projections, and future research. Cancer Epidemiol Biomark Prev 20(10):2006–2014. CrossRefGoogle Scholar
  3. 3.
    Kent EE, Forsythe LP, Yabroff KR, Weaver KE, de Moor JS, Rodriguez JL (2013) Are survivors who report cancer-related financial problems more likely to forgo or delay medical care? Cancer 119(20):3710–3717. CrossRefGoogle Scholar
  4. 4.
    Yabroff KR, Dowling EC, Guy GP Jr, Banegas MP, Davidoff A, Han X et al (2016) Financial hardship associated with cancer in the United States: findings from a population-based sample of adult cancer survivors. J Clin Oncol 34(3):259–267. CrossRefGoogle Scholar
  5. 5.
    Yabroff KR, Zhao J, Zheng Z, Rai A, Han X (2018) Medical financial hardship among cancer survivors in the United States: what do we know? What do we need to know? Cancer Epidemiol Biomark Prev 27:1389–1397CrossRefGoogle Scholar
  6. 6.
    Wheeler SB, Spencer JC, Pinheiro LC, Carey LA, Olshan AF, Reeder-Haynes KE (2018) Financial impact of breast cancer in black versus white women. J Clin Oncol (36(17)):1695–1701.
  7. 7.
    Palmer NR, Geiger AM, Lu L, Case LD, Weaver KE (2013) Impact of rural residence on forgoing healthcare after cancer because of cost. Cancer Epidemiol Biomark Prev 22(10):1668–1676. CrossRefGoogle Scholar
  8. 8.
    Charlton M, Schlichting J, Chioreso C, Ward M, Vikas P (2015) Challenges of rural cancer care in the United States. Oncology (Williston Park) 29(9):633–640Google Scholar
  9. 9.
    McDougall JA, Banegas MP, Wiggins CL, Chiu VK, Rajput A, Kinney AY (2018) Rural disparities in treatment-related financial hardship and adherence to surveillance colonoscopy in diverse colorectal cancer survivors. Cancer Epidemiol Biomark Prev 27(11):1275–1282. CrossRefGoogle Scholar
  10. 10.
    Mathews M, West R, Buehler S (2009) How important are out-of-pocket costs to rural patients’ cancer care decisions? Can J Rural Med 14(2):54–60Google Scholar
  11. 11.
    Whitney RL, Bell JF, Reed SC, Lash R, Bold RJ, Kim KK et al (2016) Predictors of financial difficulties and work modifications among cancer survivors in the United States. J Cancer Surviv 10(2):241–250CrossRefGoogle Scholar
  12. 12.
    WeStat (2017) Health Information National Trends Survey 5 (HINTS 5) Cycle 1 Methodology Report July 2017. Accessed 1 October 2018
  13. 13.
    National Cancer Institute (2018) HINTS Public Use Dataset. Available at Accessed on 1 August 2018
  14. 14.
    Czajka JL and Beyler A. Declining response rates in federal surveys: trends and implications. Accessed 23 Sept 2018
  15. 15.
    United States Department of Agriculture (2016). Rural Urban Continuum Codes. Accessed 1 Aug 2018
  16. 16.
    Greenberg AJ, Haney D, Blake KD, Moser RP, Hesse BW (2018) Differences in access to and use of electronic personal health information between rural and urban residents in the United States. J Rural Health 34 Suppl 1:s30-s8 doi 10.1111/jrh.12228:s30–s38CrossRefGoogle Scholar
  17. 17.
    National Cancer Institute (2017) Analytics recommendations for HINTS 5, Cycle 1 Data November, 2017. Accessed 1 October 2018
  18. 18.
    van Buuren S (2007) Multiple imputation of discrete and continuous data by fully conditional specification. Stat Methods Med Res 16(3):219–242. CrossRefGoogle Scholar
  19. 19.
    Lee KJ, Carlin JB (2012) Recovery of information from multiple imputation: a simulation study. Emerg Themes Epidemiol 13(9(1)):3. CrossRefGoogle Scholar
  20. 20.
    Graubard BI, Korn EL (1999) Predictive margins with survey data. Biometrics 55(2):652–659CrossRefGoogle Scholar
  21. 21.
    SAS Institute Inc. (2009) SAS/STAT ® 9.2 User’s Guide SEC. SAS Institute Inc, NC, p 2018Google Scholar
  22. 22.
    Probst JC, Moore CG, Glover SH, Samuels ME (2004) Person and place: the compounding effects of race/ethnicity and rurality on health. Am J Public Health 94(10):1695–1703CrossRefGoogle Scholar
  23. 23.
    Jagsi R, Ward KC, Abrahamse PH, Wallner LP, Kurian AW, Hamilton AS et al (2018) Unmet need for clinician engagement regarding financial toxicity after diagnosis of breast cancer. Cancer 124(18):3668–3676. CrossRefGoogle Scholar
  24. 24.
    Shih YT, Chien CR (2017) A review of cost communication in oncology: patient attitude, provider acceptance, and outcome assessment. Cancer 123(6):928–939. CrossRefGoogle Scholar
  25. 25.
    Meropol NJ, Schrag D, Smith TJ, Mulvey TM, Langdon RM Jr, Blum D et al (2009) American Society of Clinical Oncology guidance statement: the cost of cancer care. J Clin Oncol 27(23):3868–3874. CrossRefGoogle Scholar
  26. 26.
    Shankaran V, Leahy T, Steelquist J, Watabayashi K, Linden H, Ramsey S et al (2018) Pilot feasibility study of an oncology financial navigation program. J Oncol Pract 14:e122–e129CrossRefGoogle Scholar
  27. 27.
    Zullig LL, Wolf S, Vlastelica L, Shankaran V, Zafar SY (2017) The role of patient financial assistance programs in reducing costs for cancer patients. J Manag Care Spec Pharm 23:407–411Google Scholar
  28. 28.
    Zafar SY, Chino F, Ubel PA, Rushing C, Samsa G, Altomare I et al (2015) The utility of cost discussions between patients with cancer and oncologists. Am J Manag Care 21(9):607–615Google Scholar
  29. 29.
    Butow PN, Phillips F, Schweder J, White K, Underhill C, Goldstein D (2012) Psychosocial well-being and supportive care needs of cancer patients living in urban and rural/regional areas: a systematic review. Support Care Cancer 20(1):1–22. CrossRefGoogle Scholar
  30. 30.
    Vanderpool RC, Nichols H, Hoffler EF, Swanberg JE (2017) Cancer and employment issues: perspectives from cancer patient navigators. J Cancer Educ 32(3):460–466. CrossRefGoogle Scholar
  31. 31.
    Palomino H, Peacher D, Ko E, Woodruff SI, Watson M (2017) Barriers and challenges of cancer patients and their experience with patient navigators in the rural US/Mexico border region. J Cancer Educ 32(1):112–118. CrossRefGoogle Scholar
  32. 32.
    Inrig SJ, Higashi RT, Tiro JA, Argenbright KE, Lee SJ (2017) Assessing local capacity to expand rural breast cancer screening and patient navigation: an iterative mixed-method tool. Eval Program Plann 61:113–124. CrossRefGoogle Scholar
  33. 33.
    Gordon LG, Merollini KMD, Lowe A, Chan RJ (2017) A systematic review of financial toxicity among cancer survivors: we can’t pay the co-pay. Patient 10(3):295–309. CrossRefGoogle Scholar
  34. 34.
    Mariotto AB, Yabroff KR, Shao Y, Feuer EJ, Brown ML (2011) Projections of the cost of cancer care in the United States: 2010-2020. J Natl Cancer Inst 103(2):117–128. CrossRefGoogle Scholar
  35. 35.
    Shih YT, Smielauskas F, Geynisman DM, Kelly RJ, Smith TJ (2015) Trends in the cost and use of targeted cancer therapies for the privately insured nonelderly: 2001 to 2011. J Clin Oncol 33(19):2190–2196CrossRefGoogle Scholar
  36. 36.
    Tran G, Zafar SY (2018) Financial toxicity and implications for cancer care in the era of molecular and immune therapies. Ann Transl Med 6(9):166CrossRefGoogle Scholar
  37. 37.
    Srinivasan S, Moser RP, Willis G, Riley W, Alexander M, Berrigan D et al (2015) Small is essential: importance of subpopulation research in cancer control. Am J Public Health 105(Suppl 3):S371–S373. CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Whitney E. Zahnd
    • 1
    • 2
    Email author
  • Melinda M. Davis
    • 3
    • 4
    • 5
  • Jason S. Rotter
    • 6
  • Robin C. Vanderpool
    • 7
  • Cynthia K. Perry
    • 8
  • Jackilen Shannon
    • 5
  • Linda K. Ko
    • 9
    • 10
  • Stephanie B. Wheeler
    • 6
  • Cassie L. Odahowski
    • 1
    • 11
  • Paige E. Farris
    • 5
  • Jan M. Eberth
    • 1
    • 11
    • 12
  1. 1.Rural and Minority Health Research Center, Arnold School of Public HealthUniversity of South CarolinaColumbiaUSA
  2. 2.Department of Health Services Policy and Management, Arnold School of Public HealthUniversity of South CarolinaColumbiaUSA
  3. 3.Oregon Rural Practice-based Research Network, School of MedicineOregon Health & Science UniversityPortlandUSA
  4. 4.Department of Family Medicine, School of MedicineOregon Health & Science UniversityPortlandUSA
  5. 5.OHSU-PSU School of Public HealthOregon Health & Science UniversityPortlandUSA
  6. 6.Department of Health Policy and Management, Gillings School of Global Public HealthUniversity of North Carolina at Chapel HillChapel HillUSA
  7. 7.Department of Health, Behavior & Society, College of Public HealthUniversity of KentuckyLexingtonUSA
  8. 8.School of NursingOregon Health & Science UniversityPortlandUSA
  9. 9.Division of Public Health SciencesFred Hutchinson Cancer Research CenterSeattleUSA
  10. 10.Department of Health ServicesUniversity of WashingtonSeattleUSA
  11. 11.Department of Epidemiology and Biostatistics, Arnold School of Public HealthUniversity of South CarolinaColumbiaUSA
  12. 12.Cancer Prevention and Control ProgramUniversity of South CarolinaColumbiaUSA

Personalised recommendations