Financial toxicity among cancer patients with limited English proficiency.

Abstract

30 Background: Financial toxicity (FT), the financial burden and distress associated with cancer care, is linked to worse quality of life, decreased treatment adherence, and increased mortality. Patients with limited English proficiency (LEP) may be particularly vulnerable because of socioeconomic disadvantage and language-related barriers to navigating healthcare and financial systems. We evaluated differences in FT prevalence and engagement with the financial assistance pathway among LEP and non-LEP cancer patients and assessed whether LEP was independently associated with FT. Methods: We conducted a retrospective review of a quality improvement project from March 2023 to December 2024, among patients within 1 year of cancer diagnosis and who had received chemotherapy, radiation, or surgery within the prior 4 months, receiving outpatient care in breast, gynecologic, gastrointestinal, and thoracic oncology clinics who underwent routine FT screening. Screening included patient response to the FACIT-COST instrument and health-related social risk measures assessing food, housing, medication, and transportation insecurity. FT was defined as COST score <16, unmet essential need, or borrowing/loans related to cancer care. Demographic, clinical, insurance, screening, and patient financial services intervention data were compared between LEP and non-LEP patients. Multivariable logistic regression evaluated the association between LEP and FT while adjusting for age, race, insurance status, disease stage, oncology service, and recent cancer treatment. Results: Among 10,118 patients sent the FT screener, 800 (7.9%) had LEP and 9,318 were non-LEP. FT was more common among LEP patients than non-LEP patients (67% vs 38%), with lower median COST scores (17 vs 25). FT screening completion was lower among LEP patients (47% vs 66%) (all p<0.001). LEP patients were older (median age 66 vs 61 years), more frequently Asian (48% vs 10%) or Hispanic (31% vs 9%), and more frequently insured through Medicaid (59% vs 9%) than non-LEP patients. Among patients with a positive FT screen who were referred to patient financial services, outreach rates were similar between LEP and non-LEP patients (55% vs 49%, p=0.3). In multivariable logistic regression, LEP remained independently associated with FT (aOR 1.93, 95% CI 1.45–2.57, p<0.001). Conclusions: LEP patients experienced substantially higher rates of financial toxicity and lower screening completion than non-LEP patients. Although engagement with later stages of the financial assistance pathway was similar once referrals were initiated, attrition was observed in both groups. LEP remained independently associated with FT after adjustment for demographic, insurance, and clinical factors. Multilingual, language-concordant, and proactive approaches to FT screening and financial navigation may improve equitable delivery of oncology care.