Patient–Provider Discussions About Out-of-Pocket Costs of Cancer Care in the U.S.


      Despite the importance of cost-related discussions in cancer care, little is known about the prevalence or drivers of these discussions in clinical practice. This study estimates the prevalence and examines the correlates of cancer survivors’ discussions about out-of-pocket costs of cancer care with providers.


      The 2016 and 2017 Medical Expenditure Panel Survey Experiences with Cancer Surveys were used to identify 1,550 survivors who responded to the question on discussion about out-of-pocket costs of cancer care. Multivariable multinomial logistic regression examined the correlates of discussions about out-of-pocket costs. Analyses were performed in 2019.


      Approximately one quarter of cancer survivors reported having discussed the out-of-pocket costs of cancer care. In multivariable analyses, respondents in the following categories were less likely to report no cost discussion than any cost discussion: black non-Hispanic/other race (RRR=0.67, 95% CI=0.45, 0.98; white non-Hispanic race as reference), no health insurance at diagnosis (RRR=0.51, 95% CI=0.27, 0.95; private health insurance as reference), and any experience of financial hardship (RRR=0.48, 95% CI=0.35, 0.66; no financial hardship as reference).


      Patient-reported discussions about out-of-pocket costs for cancer care are infrequent in the U.S. The findings highlight the needs to improve the understanding of the barriers and facilitators for effective discussions about out-of-pocket costs of cancer care.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Preventive Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • American Society of Clinical Oncology
        The state of cancer care in America, 2017: a report by the American Society of Clinical Oncology.
        J Oncol Pract. 2017; 13: e353-e394
      1. Kaiser Family Foundation. Payments for cost sharing increasing rapidly over Published October 5, 2017. Accessed March 8, 2019.

        • Zheng Z
        • Jemal A
        • Han X
        • et al.
        Medical financial hardship among cancer survivors in the United States.
        Cancer. 2019; 125: 1737-1747
        • Cutler DM
        • Everett W
        Thinking outside the pillbox–medication adherence as a priority for health care reform.
        N Engl J Med. 2010; 362: 1553-1555
        • Neugut AI
        • Subar M
        • Wilde ET
        • et al.
        Association between prescription co-payment amount and compliance with adjuvant hormonal therapy in women with early-stage breast cancer.
        J Clin Oncol. 2011; 29: 2534-2542
        • Zafar SY
        • Peppercorn JM
        • Schrag D
        • et al.
        The financial toxicity of cancer treatment: a pilot study assessing out-of-pocket expenses and the insured cancer patient's experience.
        Oncologist. 2013; 18: 381-390
        • Ramsey S
        • Blough D
        • Kirchhoff A
        • et al.
        Washington State cancer patients found to be at greater risk for bankruptcy than people without a cancer diagnosis.
        Health Aff (Millwood). 2013; 32: 1143-1152
        • Ramsey SD
        • Bansal A
        • Fedorenko CR
        • et al.
        Financial insolvency as a risk factor for early mortality among patients with cancer.
        J Clin Oncol. 2016; 34: 980-986
        • Meropol NJ
        • Schrag D
        • Smith TJ
        • et al.
        American Society of Clinical Oncology guidance statement: the cost of cancer care.
        J Clin Oncol. 2009; 27: 3868-3874
        • Zafar SY
        • McNeil RB
        • Thomas CM
        • Lathan CS
        • Ayanian JZ
        • Provenzale D
        Population-based assessment of cancer survivors’ financial burden and quality of life: a prospective cohort study.
        J Oncol Pract. 2015; 11: 145-150
        • Bullock AJ
        • Hofstatter EW
        • Yushak ML
        • Buss MK
        Understanding patients’ attitudes toward communication about the cost of cancer care.
        J Oncol Pract. 2012; 8: e50-e58
        • Irwin B
        • Kimmick G
        • Altomare I
        • et al.
        Patient experience and attitudes toward addressing the cost of breast cancer care.
        Oncologist. 2014; 19: 1135-1140
        • Kelly RJ
        • Forde PM
        • Elnahal SM
        • Forastiere AA
        • Rosner GL
        • Smith TJ
        Patients and physicians can discuss costs of cancer treatment in the clinic.
        J Oncol Pract. 2015; 11: 308-312
        • Shih YT
        • Chien CR
        A review of cost communication in oncology: patient attitude, provider acceptance, and outcome assessment.
        Cancer. 2017; 123: 928-939
      2. Agency for Healthcare Research and Quality, Centers for Disease Control and Prevention, HHS. Your experiences with cancer. Rockville, MD: Agency for Healthcare Research and Quality; Published 2018. Accessed November 2019.

        • Agency for Healthcare Research and Quality
        MEPS HC-192 2016 full year consolidated data file.
        Agency for Healthcare Research and Quality, Center for Financing, Access, and Cost Trends, Rockville, MDPublished 2018
        • Agency for Healthcare Research and Quality
        MEPS HC-201 2017 full year consolidated data file.
        Agency for Healthcare Research and Quality, Center for Financing, Access, and Cost Trends, Rockville, MDPublished 2019 (Accessed November 2019)
        • Guy Jr, GP
        • DU Ekwueme
        • Yabroff KR
        • et al.
        Economic burden of cancer survivorship among adults in the United States.
        J Clin Oncol. 2013; 31: 3749-3757
        • Yabroff KR
        • Guy Jr, GP
        • Ekwueme DU
        • et al.
        Annual patient time costs associated with medical care among cancer survivors in the United States.
        Med Care. 2014; 52: 594-601
        • Han X
        • Zhao J
        • Zheng Z
        • de Moor JS
        • Virgo KS
        • Yabroff KR
        Medical financial hardship intensity and financial sacrifices associated with cancer in the United States.
        Cancer Epidemiol Biomarkers Prev. 2020; 29: 308-317
        • President's Cancer Panel
        Promoting value, affordability, and innovation in cancer drug treatment. A report to the president of the United States from the President's Cancer Panel.
        President's Cancer Panel, Bethesda, MDPublished 2018
        • Zafar SY
        • Chino F
        • Ubel PA
        • et al.
        The utility of cost discussions between patients with cancer and oncologists.
        Am J Manag Care. 2015; 21: 607-615
        • Hunter WG
        • Zafar SY
        • Hesson A
        • et al.
        Discussing health care expenses in the oncology clinic: analysis of cost conversations in outpatient encounters.
        J Oncol Pract. 2017; 13: e944-e956
        • Hamel LM
        • Penner LA
        • Eggly S
        • et al.
        Do patients and oncologists discuss the cost of cancer treatment? An observational study of clinical interactions between African American patients and their oncologists.
        J Oncol Pract. 2017; 13: e249-e258
        • Cohen RA
        • Zammitti EP
        High-deductible health plans and financial barriers to medical care: early release of estimates from the National Health Interview Survey, 2016.
        National Center for Health Statistics, Hyattsville, MDPublished 2017 (Accessed October 2019)
        • Altomare I
        • Irwin B
        • Zafar SY
        • et al.
        Physician experience and attitudes toward addressing the cost of cancer care.
        J Oncol Pract. 2016; 12 (e281–248)
        • Schrag D
        • Hanger M
        Medical oncologists’ views on communicating with patients about chemotherapy costs: a pilot survey.
        J Clin Oncol. 2007; 25: 233-237
        • Bestvina CM
        • Zullig LL
        • Rushing C
        • et al.
        Patient-oncologist cost communication, financial distress, and medication adherence.
        J Oncol Pract. 2014; 10: 162-167
        • Meisenberg BR
        • Varner A
        • Ellis E
        • et al.
        Patient attitudes regarding the cost of illness in cancer care.
        Oncologist. 2015; 20: 1199-1204
        • Ubel PA
        • Zhang CJ
        • Hesson A
        • et al.
        Study of physician and patient communication identifies missed opportunities to help reduce patients’ out-of-pocket spending.
        Health Aff (Millwood). 2016; 35: 654-661
        • Foster JA
        • Salinas GD
        • Mansell D
        • Williamson JC
        • Casebeer LL
        How does older age influence oncologists’ cancer management.
        Oncologist. 2010; 15: 584-592
        • Finkelstein EA
        • Tangka FK
        • Trogdon JG
        • Sabatino SA
        • Richardson LC
        The personal financial burden of cancer for the working-aged population.
        Am J Manag Care. 2009; 15: 801-806
        • Short PF
        • Moran JR
        • Punekar R
        Medical expenditures of adult cancer survivors aged <65 years in the United States.
        Cancer. 2011; 117: 2791-2800
        • Hunter WG
        • Zhang CZ
        • Hesson A
        • et al.
        What strategies do physicians and patients discuss to reduce out-of-pocket costs? Analysis of cost-saving strategies in 1,755 outpatient clinic visits.
        Med Decis Making. 2016; 36: 900-910