{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,8]],"date-time":"2026-10-08T16:22:55Z","timestamp":1791476575755,"version":"4.3.4"},"reference-count":26,"publisher":"Wiley","issue":"12","license":[{"start":{"date-parts":[[2026,6,15]],"date-time":"2026-06-15T00:00:00Z","timestamp":1781481600000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2026,6,15]],"date-time":"2026-06-15T00:00:00Z","timestamp":1781481600000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["acsjournals.onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Cancer"],"published-print":{"date-parts":[[2026,6,15]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>Out\u2010of\u2010pocket (OOP) cost is routinely captured by payers and health systems and may help identify individuals at risk of cost\u2010related care avoidance. This study aimed to evaluate the relationship between OOP cost burden relative to household income (OOP:HHI) and cost\u2010related care avoidance and to assess whether this relationship differs by cancer history.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>A retrospective cross\u2010sectional study was conducted leveraging data from multiple survey waves of the Understanding America Study (2015\u20132024). Adults aged \u226518 years with data on OOP health care expenditure, household income, and cost\u2010related care avoidance were included. Mixed\u2010effects logistic models with random intercepts were used to assess associations between OOP:HHI and care avoidance, adjusting for respondent characteristics. Effect modification by cancer history was examined. Classification performance of OOP:HHI alone versus multivariable models was evaluated using receiver operating characteristic curves.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>The analysis included 21,299 responses from 10,811 respondents, of which 2180 responses were from 1052 respondents with cancer history. Higher OOP:HHI was independently associated with increased odds of cost\u2010related care avoidance (adjusted odds ratio per 1% increase\u00a0=\u00a01.03; 95% CI, 1.02\u20131.04) with similar trends in both cancer and noncancer subgroups. OOP:HHI alone showed modest discrimination, whereas multivariable models demonstrated excellent performance in identifying respondents who indicated care avoidance.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Higher OOP cost burden was associated with cost\u2010related care avoidance regardless of cancer history, but cost burden alone was insufficient for\u00a0risk identification. Integrating OOP costs with routinely available patient characteristics may better identify individuals at risk of care avoidance for targeted interventions to mitigate financial toxicity.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1002\/cncr.70495","type":"journal-article","created":{"date-parts":[[2026,6,15]],"date-time":"2026-06-15T09:16:30Z","timestamp":1781514990000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Comparing the association between out\u2010of\u2010pocket cost burden and cost\u2010related care avoidance among individuals with and without a history of cancer"],"prefix":"10.1002","volume":"132","author":[{"ORCID":"https:\/\/orcid.org\/0009-0009-7649-3896","authenticated-orcid":false,"given":"Xi","family":"Liang","sequence":"first","affiliation":[{"name":"Department of Pharmacotherapy College of Pharmacy University of Utah  Salt Lake City Utah USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5247-0010","authenticated-orcid":false,"given":"Djin","family":"Tay","sequence":"additional","affiliation":[{"name":"College of Nursing University of Utah  Salt Lake City Utah USA"},{"name":"Cancer Control and Population Sciences Program Huntsman Cancer Institute  Salt Lake City Utah USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yu","family":"Ke","sequence":"additional","affiliation":[{"name":"Division of Supportive and Palliative Care National Cancer Centre Singapore  Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ding Quan","family":"Ng","sequence":"additional","affiliation":[{"name":"School of Pharmacy &amp; Pharmaceutical Sciences University of California Irvine  Irvine California USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chanthawat","family":"Patikorn","sequence":"additional","affiliation":[{"name":"Department of Social and Administrative Pharmacy Faculty of Pharmaceutical Sciences Chulalongkorn University  Bangkok Thailand"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3193-6800","authenticated-orcid":false,"given":"Carl","family":"Asche","sequence":"additional","affiliation":[{"name":"Department of Pharmacotherapy College of Pharmacy University of Utah  Salt Lake City Utah USA"},{"name":"Cancer Control and Population Sciences Program Huntsman Cancer Institute  Salt Lake City Utah USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nathorn","family":"Chaiyakunapruk","sequence":"additional","affiliation":[{"name":"Department of Pharmacotherapy College of Pharmacy University of Utah  Salt Lake City Utah USA"},{"name":"Department of Social and Administrative Pharmacy Faculty of Pharmaceutical Sciences Chulalongkorn University  Bangkok Thailand"},{"name":"IDEAS Center, Veterans Affairs Salt Lake City Healthcare System  Salt Lake City Utah USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anne C.","family":"Kirchhoff","sequence":"additional","affiliation":[{"name":"Cancer Control and Population Sciences Program Huntsman Cancer Institute  Salt Lake City Utah USA"},{"name":"Division of Pediatric Hematology and Oncology Department of Pediatrics School of Medicine University of Utah  Salt Lake City Utah USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0248-7046","authenticated-orcid":false,"given":"Raymond Javan","family":"Chan","sequence":"additional","affiliation":[{"name":"Caring Futures Institute College of Nursing and Health Sciences Flinders University  Adelaide South Australia Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4391-4219","authenticated-orcid":false,"given":"Alexandre","family":"Chan","sequence":"additional","affiliation":[{"name":"School of Pharmacy &amp; Pharmaceutical Sciences University of California Irvine  Irvine California USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2452-0556","authenticated-orcid":false,"given":"Chia Jie","family":"Tan","sequence":"additional","affiliation":[{"name":"Department of Pharmacotherapy College of Pharmacy University of Utah  Salt Lake City Utah USA"},{"name":"Cancer Control and Population Sciences Program Huntsman Cancer Institute  Salt Lake City Utah USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,6,15]]},"reference":[{"key":"e_1_2_13_2_1","doi-asserted-by":"publisher","DOI":"10.1038\/s41572\u2010022\u201000341\u20101"},{"key":"e_1_2_13_3_1","doi-asserted-by":"publisher","DOI":"10.1093\/jnci\/djh255"},{"key":"e_1_2_13_4_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jpainsymman.2018.12.003"},{"key":"e_1_2_13_5_1","doi-asserted-by":"publisher","DOI":"10.1007\/s11764\u2010021\u201001097\u20105"},{"key":"e_1_2_13_6_1","doi-asserted-by":"publisher","DOI":"10.1136\/bmjgh\u20102024\u2010017133"},{"key":"e_1_2_13_7_1","doi-asserted-by":"publisher","DOI":"10.1002\/cam4.70879"},{"key":"e_1_2_13_8_1","doi-asserted-by":"publisher","DOI":"10.1200\/OP.23.00680"},{"key":"e_1_2_13_9_1","doi-asserted-by":"publisher","DOI":"10.3390\/cancers13112516"},{"key":"e_1_2_13_10_1","doi-asserted-by":"publisher","DOI":"10.1097\/NCC.0000000000000926"},{"key":"e_1_2_13_11_1","doi-asserted-by":"publisher","DOI":"10.1186\/s12962\u2010023\u201000457\u20105"},{"key":"e_1_2_13_12_1","doi-asserted-by":"publisher","DOI":"10.1186\/s12939\u2010018\u20100749\u20105"},{"key":"e_1_2_13_13_1","doi-asserted-by":"publisher","DOI":"10.1200\/OP.2025.21.10_suppl.10"},{"key":"e_1_2_13_14_1","doi-asserted-by":"publisher","DOI":"10.1136\/bmjopen\u20102024\u2010088183"},{"key":"e_1_2_13_15_1","unstructured":"Institute NC.Survivorship Terms. 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