{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,13]],"date-time":"2026-10-13T12:56:16Z","timestamp":1791896176899,"version":"4.3.4"},"reference-count":41,"publisher":"Harborside Press, LLC","issue":"10","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,10]]},"abstract":"<jats:p>\n                    <jats:bold>Background:<\/jats:bold>\n                    Medical debt is recognized as a social determinant of health. This study examines associations of county-level medical debt in collections with diagnosis stage and survival among individuals newly diagnosed with cancer in the United States.\n                    <jats:bold>Patients and Methods:<\/jats:bold>\n                    A cohort of individuals aged \u226518 years newly diagnosed with cancer in 2011\u20132019 was identified from the National Cancer Database and followed through December 31, 2019. The county-level share of adults with medical debt in collections was combined with patient-level data. Hierarchical multivariable logistic and Cox proportional hazard models estimated associations of county-level medical debt with cancer diagnosis stage and overall survival, respectively, for all patients and by cancer type, clinical, and socioeconomic subgroups.\n                    <jats:bold>Results:<\/jats:bold>\n                    A total of 7,558,658 individuals with cancer were identified, with median county-level medical debt of 18%, ranging from 0% to 56%. Patients in the highest medical debt quartile had the highest proportion with stage IV disease and lowest 5-year survival rate. After adjusting for other patient- and county-level characteristics, patients living in counties in the highest quartile of medical debt were more likely to be diagnosed with stage IV disease (odds ratio, 1.079; 95% CI, 1.064\u20131.094) and had poorer survival (hazard ratio, 1.072; 95% CI, 1.061\u20131.082) than those living in counties in the lowest quartile of medical debt, with a statistically significant dose\u2013response relationship (\n                    <jats:italic>P<\/jats:italic>\n                    for trend &lt;.001). Patterns were observed across major cancer types and were consistent across socioeconomic and clinical subgroups.\n                    <jats:bold>Conclusions:<\/jats:bold>\n                    County-level medical debt was associated with advanced-stage diagnosis and worse survival among individuals newly diagnosed with cancer. Future research is warranted to evaluate the recent and ongoing US policy changes on medical debt prevalence and their effects on cancer care and outcomes.\n                  <\/jats:p>","DOI":"10.6004\/jnccn.2026.7036","type":"journal-article","created":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T12:31:37Z","timestamp":1787056297000},"source":"Crossref","is-referenced-by-count":0,"title":["County-Level Medical Debt and Its Associations With Cancer Stage and Survival in the United States"],"prefix":"10.6004","volume":"24","author":[{"given":"Xuesong","family":"Han","sequence":"first","affiliation":[{"name":"Surveillance, Prevention, and Health Services Research, American Cancer Society, Atlanta, GA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nuo Nova","family":"Yang","sequence":"additional","affiliation":[{"name":"Surveillance, Prevention, and Health Services Research, American Cancer Society, Atlanta, GA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xin","family":"Hu","sequence":"additional","affiliation":[{"name":"Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA"},{"name":"Winship Cancer Institute, Emory University, Atlanta, GA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Qinjin","family":"Fan","sequence":"additional","affiliation":[{"name":"Surveillance, Prevention, and Health Services Research, American Cancer Society, Atlanta, GA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jingxuan","family":"Zhao","sequence":"additional","affiliation":[{"name":"Surveillance, Prevention, and Health Services Research, American Cancer Society, Atlanta, GA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zhiyuan","family":"Zheng","sequence":"additional","affiliation":[{"name":"Surveillance, Prevention, and Health Services Research, American Cancer Society, Atlanta, GA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kewei Sylvia","family":"Shi","sequence":"additional","affiliation":[{"name":"Surveillance, Prevention, and Health Services Research, American Cancer Society, Atlanta, GA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Breno","family":"Braga","sequence":"additional","affiliation":[{"name":"Urban Institute, Washington, DC"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Changchuan","family":"Jiang","sequence":"additional","affiliation":[{"name":"University of Texas Southwestern Medical Center, Dallas, TX"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"K. 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Lancet Oncol 2024;25:e235."},{"key":"B3","series-title":"J Clin Oncol","first-page":"980","article-title":"Financial insolvency as a risk factor for early mortality among patients with cancer","volume":"34","author":"Ramsey SD","year":"2016","unstructured":"Ramsey SD, Bansal A, Fedorenko CR,  Financial insolvency as a risk factor for early mortality among patients with cancer. J Clin Oncol 2016;34:980\u2013986."},{"key":"B4","series-title":"JAMA Oncol","first-page":"1726","article-title":"Natural language processing-assessed unmet medical and social needs in cancer crowdfunding stories","volume":"10","author":"Zheng Z","year":"2024","unstructured":"Zheng Z, Yu S, Islami F,  Natural language processing-assessed unmet medical and social needs in cancer crowdfunding stories. JAMA Oncol 2024;10:1726\u20131728."},{"key":"B5","series-title":"J Natl Cancer Inst","first-page":"863","article-title":"Association of medical financial hardship and mortality among cancer survivors in the United States","volume":"114","author":"Yabroff KR","year":"2022","unstructured":"Yabroff KR, Han X, Song W,  Association of medical financial hardship and mortality among cancer survivors in the United States. J Natl Cancer Inst 2022;114:863\u2013870."},{"key":"B6","series-title":"J Clin Oncol","first-page":"1001","article-title":"Association of major adverse financial events and later-stage cancer diagnosis in the United States","volume":"42","author":"Warren JL","year":"2024","unstructured":"Warren JL, Mariotto AB, Stevens J,  Association of major adverse financial events and later-stage cancer diagnosis in the United States. J Clin Oncol 2024;42:1001\u20131010."},{"key":"B7","series-title":"JAMA","first-page":"228","article-title":"Medical debt as a social determinant of health","volume":"326","author":"Mendes de Leon CF","year":"2021","unstructured":"Mendes de Leon CF, Griggs JJ. Medical debt as a social determinant of health. JAMA 2021;326:228\u2013229."},{"key":"B8","series-title":"JAMA","first-page":"250","article-title":"Medical debt in the US, 2009\u20132020","volume":"326","author":"Kluender R","year":"2021","unstructured":"Kluender R, Mahoney N, Wong F, Yin W. Medical debt in the US, 2009\u20132020. JAMA 2021;326:250\u2013256."},{"key":"B9","article-title":"Which County Characteristics Predict Medical Debt?","author":"Blavin F","year":"2022","unstructured":"Blavin F, Braga B, Gangopadhyaya A. Which County Characteristics Predict Medical Debt? Urban Institute; 2022."},{"key":"B10","series-title":"JAMA Netw Open","first-page":"e2354766","article-title":"Associations of medical debt with health status, premature death, and mortality in the US","volume":"7","author":"Han X","year":"2024","unstructured":"Han X, Hu X, Zheng Z,  Associations of medical debt with health status, premature death, and mortality in the US. JAMA Netw Open 2024;7:e2354766."},{"key":"B11","series-title":"N Engl J Med","first-page":"871","article-title":"Alleviating medical debt in the United States","volume":"389","author":"Uppal N","year":"2023","unstructured":"Uppal N, Woolhandler S, Himmelstein DU. Alleviating medical debt in the United States. N Engl J Med 2023;389:871\u2013873."},{"key":"B12","series-title":"JAMA Health Forum","first-page":"e243368","article-title":"Medical debt-the canary in the coal mine for health care affordability","volume":"5","author":"Levitt L","year":"2024","unstructured":"Levitt L. Medical debt-the canary in the coal mine for health care affordability. JAMA Health Forum 2024;5:e243368."},{"key":"B13","article-title":"State Protections Against Medical Debt","unstructured":"The Commonwealth Fund. State Protections Against Medical Debt. Accessed October 29, 2024. Available at: https:\/\/www.commonwealthfund.org\/publications\/maps-and-interactives\/state-protections-against-medical-debt"},{"key":"B14","series-title":"Health Aff (Millwood)","first-page":"54","article-title":"For working-age cancer survivors, medical debt and bankruptcy create financial hardships","volume":"35","author":"Banegas MP","year":"2016","unstructured":"Banegas MP, Guy GP, de Moor JS,  For working-age cancer survivors, medical debt and bankruptcy create financial hardships. Health Aff (Millwood) 2016;35:54\u201361."},{"key":"B15","series-title":"Psychooncology","first-page":"2165","article-title":"Financial hardship associated with colorectal cancer survivorship: the role of asset depletion and debt accumulation","volume":"27","author":"Hanly P","year":"2018","unstructured":"Hanly P, Maguire R, Ceilleachair AO, Sharp L. Financial hardship associated with colorectal cancer survivorship: the role of asset depletion and debt accumulation. Psychooncology 2018;27:2165\u20132171."},{"key":"B16","series-title":"Ann Surg Oncol","first-page":"5546","article-title":"The National Cancer Database conforms to the standardized framework for registry and data quality","volume":"31","author":"Palis BE","year":"2024","unstructured":"Palis BE, Janczewski LM, Browner AE,  The National Cancer Database conforms to the standardized framework for registry and data quality. 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J Clin Epidemiol 1992;45:613\u2013619."},{"key":"B20","article-title":"Rural-Urban Continuum Codes","unstructured":"US Department of Agriculture Economic Research Service. Rural-Urban Continuum Codes. Accessed October 22, 2024. Available at: https:\/\/www.ers.usda.gov\/data-products\/rural-urban-continuum-codes\/"},{"key":"B21","article-title":"Social Determinants of Health Database","unstructured":"Agency for Healthcare Research and Quality. Social Determinants of Health Database. Accessed October 22, 2024. Available at: https:\/\/www.ahrq.gov\/sdoh\/data-analytics\/sdoh-data.html"},{"key":"B22","article-title":"Social Deprivation Index (SDI)","unstructured":"Robert Graham Center. Social Deprivation Index (SDI). Accessed October 22, 2024. Available at: https:\/\/www.graham-center.org\/evidence-based-research\/featured-work\/social-deprivation-index"},{"key":"B23","series-title":"J Gen Intern Med","first-page":"1494","article-title":"Prevalence and correlates of medical financial hardship in the USA","volume":"34","author":"Yabroff KR","year":"2019","unstructured":"Yabroff KR, Zhao J, Han X, Zheng Z. Prevalence and correlates of medical financial hardship in the USA. J Gen Intern Med 2019;34:1494\u20131502."},{"key":"B24","series-title":"Med Care Res Rev","first-page":"538","article-title":"The Affordable Care Act Medicaid expansions and personal finance","volume":"76","author":"Caswell KJ","year":"2019","unstructured":"Caswell KJ, Waidmann TA. The Affordable Care Act Medicaid expansions and personal finance. Med Care Res Rev 2019;76:538\u2013571."},{"key":"B25","series-title":"J Public Econ","first-page":"99","article-title":"The effect of the Affordable Care Act Medicaid expansions on financial wellbeing","volume":"163","author":"Hu L","year":"2018","unstructured":"Hu L, Kaestner R, Mazumder B,  The effect of the Affordable Care Act Medicaid expansions on financial wellbeing. J Public Econ 2018;163:99\u2013112."},{"key":"B26","series-title":"J Natl Cancer Inst","first-page":"688","article-title":"Changes in noninsurance and care unaffordability among cancer survivors following the Affordable Care Act","volume":"112","author":"Han X","year":"2020","unstructured":"Han X, Jemal A, Zheng Z,  Changes in noninsurance and care unaffordability among cancer survivors following the Affordable Care Act. 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Ann Intern Med 2025;178:1334\u20131342."},{"key":"B40","series-title":"Ann Surg Oncol","first-page":"1604","article-title":"Incident cases captured in the National Cancer Database compared with those in U.S. population based central cancer registries in 2012-2014","volume":"26","author":"Mallin K","year":"2019","unstructured":"Mallin K, Browner A, Palis B,  Incident cases captured in the National Cancer Database compared with those in U.S. population based central cancer registries in 2012-2014. Ann Surg Oncol 2019;26:1604\u20131612."},{"key":"B41","series-title":"Cityscape","first-page":"9","article-title":"Credit invisibles and the unscored","volume":"18","author":"Brevoort KP","year":"2016","unstructured":"Brevoort KP, Grimm P, Kambara M. Credit invisibles and the unscored. 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