ASCVD and Cancer Diagnoses Pose Potentially Deadly Costs to Patients

Financial toxicity is a known concept in oncology but it is “tremendously underrecognized” in cardiology, researchers say.

ASCVD and Cancer Diagnoses Pose Potentially Deadly Costs to Patients

People diagnosed with atherosclerotic cardiovascular disease (ASCVD) in the United States are more likely to report facing financial toxicity, or heavy economic burden, than those diagnosed with cancer. With dual diagnoses, the strains are even greater.

Researchers say the findings, obtained by surveying patients’ about their experiences, “highlight the prevalence of, and urgent need for, effective methods to alleviate financial toxicity for [both] ASCVD and cancer patients.”

Senior author Khurram Nasir, MD, MPH (Houston Methodist, TX), told TCTMD that this is far from the first study to discuss financial strain among patients being treated for cardiovascular disease. For example, in the past few years, his group has documented that some skip their medications or fail to get flu shots. But thus far, there hadn’t been a comparison between cardiology and oncology.

“While medical financial toxicity is an established concept within the oncology circles, extensively studied and published,” and has received attention from groups like the American Society of Clinical Oncology, he said, “it’s extremely understudied among patients with heart disease, strokes, peripheral arterial disease [and] is tremendously underrecognized. As a result, there’s limited awareness among the cardiology community,” who have no set guidelines for how to detect and mitigate economic burdens among ASCVD patients.

Nasir said “there are a lot of things in the cancer world that can easily be applied” in the cardiovascular realm, where patients may incur out-of-pocket expenses for multiple medications and testing over decades.

Cezar A. Iliescu, MD (University of Texas MD Anderson Cancer Center, Houston), stressed that there are some expenses inherent to achieving good outcomes. Yet he agreed that the economic burden is a legitimate concern. “Even a small part of this cost is a huge amount of burden on the patients individually, and I do believe that because of that they may not request care,” said Iliescu, noting that he’s seen patients defer treatment despite symptoms.

“The solution would be to make care cheaper. The question is how,” he added.

Iliescu, a cardio-oncologist, said that there’s growing awareness that people with dual diagnoses of cardiovascular disease and cancer need specialized care. “But we’ve never discussed the cost issue. It has never been addressed, and I think from that perspective this is a new paper [that] will trigger further discussions on the field and on the cost,” he commented to TCTMD.

The study, with lead authors Javier Valero-Elizondo, MD, MPH (Houston Methodist) and Fouad Chouairi, BS (Yale New Haven Hospital, New Haven, CT), was recently published in JACC: CardioOncology.

[It should be] part and parcel of your usual care processes, where cost is brought into consideration. Khurram Nasir

Valero-Elizondo, Chouairi, Nasir, and colleagues pulled details from the National Health Interview Survey (NHIS) on adults with self-reported ASCVD and/or cancer between 2013 and 2018. The data set included 141,826 participants below the age of 65, of whom an estimated 4.5% had cancer, 3.8% had ASCVD, and 0.6% had both. The population tended to be between 40 and 64 years old, insured, and white.

The public health ramifications are large, they point out, as “this translates to 8.9, 7.5, and 1.2 million nonelderly adults” each year.

Financial toxicity, defined as “any difficulty paying medical bills, high financial distress, cost-related medication nonadherence, food insecurity, and/or foregone/delayed care due to cost,” was more common in patients diagnosed with cancer or ASCVD, and especially among those with both, compared with no diagnosis. Comparing the two diseases directly, the ASCVD patients reported more financial strain those did with cancer (54% vs 41%; P < 0.001). Adjusted for potential confounders, each of these the measures remained more prevalent in the ASCVD group.

Financial Toxicity: ASCVD vs Cancer


Adjusted OR

95% CI

Difficulty Paying Medical Bills



Inability to Pay Bills



Cost-Related Medication Nonadherence



Food Insecurity



Forgone/Delayed Care Due to Cost



Nonelderly adults with ASCVD were more apt to report being burdened by at least three of these factors, whether they had heart disease alone (23%) or in combination with cancer (30%), than if they had cancer alone (13%; P < 0.001).

As to what’s driving the differences, the researchers suggest that some of it relates to time. “For example, patients with cancer may have short bursts of high expenditures with chemotherapy, whereas ASCVD incurs a more chronic economic burden related to the costs of drugs, procedures, clinician visits, and hospital stays,” they note. “Additionally, with prolonged survival following the diagnosis of cancer, the cardiac toxicity of some treatments, and better treatment options for ASCVD, the population of patients with simultaneous ASCVD and cancer is growing.”

They acknowledge limitations to their analysis, including the self-reported responses and inability to tease out the effects of a specific catastrophic event versus chronic bills. Moreover, as with any observational study, it’s hard to show causality; for example, people who face food insecurity may cope by making less-than-healthy choices, which could in turn affect disease risk. It’s also possible that cancer was less burdensome simply because existing strategies to mitigate its financial effects have worked.

Nasir cautioned that the current findings need to be confirmed in real-world health systems to understand whether the signals detected in the NHIS data set might guide screening for financial toxicity at a broader level.

For Iliescu, one question is how actual healthcare costs—not perceived burden—differ among ASCVD, cancer, and dual diagnoses. The goal in cardio-oncology has been “to address the cardiovascular issues in the early days, at the moment when the patient gets diagnosed with cancer, rather than getting the patient in the middle of the fight,” he explained. This might stave off complications that require hospitalization, interventions, etcetera, which each drive up costs. It makes sense, said Iliescu, to have a comprehensive cardiovascular evaluation up front, with time to exhaust preventive measures in the outpatient setting.

Cost Brought Into Consideration

Reza Arsanjani, MD, and Nandita Khera, MD, MPH (both from Mayo Clinic Arizona, Phoenix), in an accompanying editorial, say that although financial toxicity isn’t a new concept, the study helpfully compares and describes how cancer and ASCVD can have incremental effects on various economic measures.

“The results of this study are highly relevant to researchers and clinicians in cardiology and oncology,” they write. “The population with both of these diseases will continue to increase due to shared risk factors for cancer and ASCVD, and as overall survival across these diseases continues to improve. There is significant overlap in both disease trajectory and financial difficulties between these diseases.”

According to the editorialists, additional studies should address both direct and indirect costs, such as lost work productivity. Interventions to screen for and address financial toxicity should be developed, with future studies addressing the best ways to integrate and raise awareness of these tools in practice to help minimize financial burdens for patients with CVD and/or cancer.

“Increasing price transparency, better integration of financial advocacy services, and use of value-based insurance design to decrease cost-sharing burden is required at a system level to address this threat to access and quality of care,” the editorialists urge. Finally, integrating financial stewardship and steps for early recognition and management of this problem in our academic curricula will ensure that the future generation of practitioners is more cognizant of this problem that can be devastating for our patients and their families.”

You face paying that bill or dying. And a lot of people choose not to fight, to be honest, because of the burden. Cezar A. Iliescu

For Nasir, change starts with clinicians and healthcare systems talking about financial concerns with their patients, “so it’s part and parcel of your usual care processes, where cost is brought into consideration.” Secondly, he said, professional societies like the American College of Cardiology can get involved by way of continuing medical education, working groups, surveys of their members, and dedicated sessions at their meetings. Ideas that emerge from these efforts can be used, for instance, to develop education programs for patients and establish “financial navigators” to help them through the process.

“We can really reach out across the aisle and see how some of those lessons learned [in oncology] can also be applied to patients with cardiovascular disease,” he urged.

As Iliescu observed: “We’re all going to get older, and probably most of us, if we’re lucky enough, are going to get both diseases at the same time. The question is, what are we going to do [when we’re] in that situation? It’s hard to say. You face paying that bill or dying. And a lot of people choose not to fight, to be honest, because of the burden.”

  • Valero-Elizondo, Chouairi, Iliescu, and the editorialists, Arsanjani and Khera, report no relevant conflicts of interest.
  • Nasir is on the advisory boards of Amgen, Novartis, and The Medicines Company, and his research is partly supported by the Jerold B. Katz Academy of Translational Research.