Financial trouble often arrives quietly, like a distant storm warning most people don't notice until the maelstrom is overhead. A missed bill here, a debt sent to a collection agency there; easy to brush off when there are bigger things to worry about, like a cancer diagnosis. But according to a new study from the Public Health Sciences Division at the Fred Hutch Cancer Center, these early financial warning signs may be connected to what happens months later, in a person's final stretch of illness. Patients who experienced one of these financial setbacks in the two years before their illness reached its final stages were more likely to end up in the emergency room repeatedly, more likely to receive care in a hospital rather than at home, and faced thousands of dollars more in health care costs along the way.
The study, led by Dr. Veena Shankaran and published in JAMA Network Open, is among the first to use objective financial records to examine how money troubles connect to the kind of care cancer patients receive in their final months. “This is the first study, to our knowledge, to directly show a relationship between financial status and health care use and costs for cancer patients at the end of life, in a large population of patients,” said Dr. Shankaran. The team drew on a novel linkage between cancer registry data, insurance claims, and consumer credit records; an approach that allowed them to go beyond patient surveys and look at financial hardship objectively, at scale.
Previous Fred Hutch research has shown that people with cancer are more than twice as likely to file for bankruptcy, and nearly twice as likely to experience what researchers call an “adverse financial event,” compared with people who don’t have cancer. But most of that earlier work focused on financial hardship as an outcome caused by cancer. This study flips the question: once someone is already dealing with financial strain, what happens to the care they receive as their illness progresses?
To find out, the research team linked cancer registry data from Western Washington with insurance claims and consumer credit records from TransUnion, one of the three major credit bureaus. They followed more than 10,800 patients with stage I through IV solid tumors who died between 2013 and 2019, looking specifically at whether patients had experienced a new “adverse financial event”–things like a bill sent to collections, a charge-off, a tax lien, a missed mortgage payment, or a foreclosure–in the two years before death.
About 9% of patients in the study experienced one of these financial setbacks in the final two years of life. The most common was having a bill sent to a third-party collection agency. Compared with patients who didn’t have a new financial setback, those who did were 41% more likely to have multiple emergency room or hospital visits in their last three months of life, and 50% more likely to die in a hospital rather than at home, in hospice, or in a nursing facility. The financial difference was just as stark. Patients who experienced a new financial setback had average health care costs of about $35,000 in their last three months of life, compared to about $31,000 for those who didn’t, a gap of roughly $4,000. Over the last six months of life, that gap widened to nearly $5,800.
The study can’t say for certain why financial strain and intense end-of-life care go together, but the researchers have some informed guesses. A patient struggling financially might not be able to afford a home caregiver, might skip co-payments for medications that manage symptoms, or might have trouble getting to clinic appointments where doctors discuss treatment goals and pain management. Without that kind of support at home, a medical crisis is more likely to end with a call to 911 and a hospital admission rather than being managed in place. Financial strain may also be a signal of other unmet needs, difficulty affording food, housing, or transportation, that researchers know are connected to higher use of emergency rooms and hospitals more broadly. “These findings point to yet another dimension of cancer care that is impacted by financial hardship,” said Dr. Shankaran. “Going forward, we want to try and better understand the reasons why patients who experience adverse financial events face more intense end-of-life care, and target interventions to help address financial barriers to patient-centered end-of-life care.”
End-of-life care is already one of the most expensive periods in the health care timeline, with roughly a quarter of all Medicare spending occurring in patients’ final year of life. If financial hardship is contributing to more hospital-based, higher-cost care at the end of life, that suggests a potential opportunity: helping patients manage financial stress earlier in their cancer journey might not only ease their burden, but could also help more people spend their final days where they want to be, and possibly reduce costs for the health care system overall.
Fred Hutch researchers are already exploring this idea through an ongoing study called CREDIT, which is testing whether connecting patients with advanced cancer to financial navigation services can improve their care and reduce unnecessary emergency room and hospital use. Findings from that research, paired with this new study, could help build the case for making financial support a standard part of cancer care, a tool that could change how, and where, people experience the end of life.
Fred Hutch/University of Washington/Seattle Children’s Cancer Consortium Members Drs. Veena Shankaran and Scott Ramsey contributed to this research.
This research was supported by the Kathryn Butler Foundation and the Texas4000 Foundation.
Shankaran, V., Li, L., Khor, S., Yu, K., Kwendakwema, C. N., Fedorenko, C., Kreizenbeck, K., Khan, H. M., Kestner, S., Wright, W., & Ramsey, S. 2026. Financial Hardship, End-of-Life Health Care Use, and Costs in Patients With Cancer. JAMA Network Open. doi: 10.1001/jamanetworkopen.2026.7923
Science Spotlight writer Darya Moosavi is a postdoctoral research fellow within Johanna Lampe's research group at Fred Hutch. Darya studies the nuanced connections between diet, gut epithelium, and gut microbiome in relation to colorectal cancer using high-dimensional approaches.