Electronic Theses and Dissertations

Date of Award


Document Type


Degree Name

Ph.D. in Pharmaceutical Sciences

First Advisor

Yi Yang

Second Advisor

Marie Barnard

Third Advisor

John Bentley


University of Mississippi

Relational Format



The term ‘financial toxicity’ (FT) has been used to describe cancer-related financial hardship and psychological distress experienced by cancer survivors. FT can be detrimental to the health and wellbeing of cancer survivors due to its multifarious adverse effects.

This dissertation strives to advance extant knowledge on cancer-related FT research by investigating three key questions: 1. How have the trends in the direct total and out-of-pocket (OOP) healthcare expenditures, and OOP financial burden of US cancer survivors aged 18-64 years evolved between 2008 – 2019? 2. What are the self-reported HIL levels among adult cancer survivors aged 27-64 years in the US, and which demographic, socioeconomic, and health insurance-related factors influence HIL among cancer survivors? 3. How does FT impact the health-related quality of life (HRQoL) of cancer survivors aged 27-64 years in the US, and does coping mediate this association? To investigate question 1, a trend analysis was conducted using data from the Medical Expenditure Panel Survey (MEPS) for the period 2008-2019. To investigate questions 2 and 3, data were collected from a national convenience sample of cancer survivors using a web-based survey.

Findings from the three studies in this dissertation provide evidence on the impact of cancer-related FT to key healthcare stakeholders including health policy makers, healthcare providers, and cancer survivors and their families. As national healthcare spending grows over time, an increasing portion of healthcare costs is being shifted to consumers. For cancer survivors, a greater proportion of household income is being spent on health care resulting in material financial hardship. Further, as the health insurance landscape becomes more complex and dynamic, cancer survivors may not have adequate health insurance literacy (HIL) to navigate health insurance effectively increasing the risk of high OOP costs and delayed access to care. A complex interplay of rising healthcare costs combined with systemic health insurance and financial challenges, and lack of resources to navigate these challenges was associated with increased perceived FT among working-age cancer survivors and evoked the use of maladaptive coping mechanisms. This financial stress process was found to negatively impact all domains of cancer survivors’ HRQoL.



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