An Intersectional Analysis of Behavioral Financial Hardship and Healthcare Utilization among LGBTQ+ Cancer Survivors

Austin R Waters; Stephanie B Wheeler; Jeremey Fine; Christabel K Cheung; Kelly R Tan; Donald L Rosenstein; Mya L Roberson; Erin E Kent

doi:10.1093/jnci/djae350

An Intersectional Analysis of Behavioral Financial Hardship and Healthcare Utilization among LGBTQ+ Cancer Survivors

J Natl Cancer Inst. 2025 Jan 2:djae350. doi: 10.1093/jnci/djae350. Online ahead of print.

Authors

Austin R Waters^{1

2}, Stephanie B Wheeler^{1

2}, Jeremey Fine¹, Christabel K Cheung^{3

4}, Kelly R Tan^{5

6}, Donald L Rosenstein^{2

7

8}, Mya L Roberson^{1

2}, Erin E Kent^{1

2}

Affiliations

¹ Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
² Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
³ School of Social Work, University of Maryland, Baltimore, MD, USA.
⁴ University of Maryland Greenebaume Comprehensive Cancer Center, Baltimore, MD, USA.
⁵ Department of Health and Community Systems, School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA.
⁶ Hillman Comprehensive Cancer Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
⁷ Department of Psychiatry, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
⁸ Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

PMID: 39745895
DOI: 10.1093/jnci/djae350

Abstract

Background: lesbian, gay, bisexual, transgender, queer, or another non-heterosexual or cisgender identity (LGBTQ+) cancer survivors experience high financial hardship. However, structural drivers of inequities do not impact all LGBTQ+ individuals equally. Using All of Us data, we conducted an intersectional analysis of behavioral financial hardship among LGBTQ+ cancer survivors.

Methods: LGBTQ+ inequities in behavioral financial hardship (ie, cost-related foregone care, delayed care, and medication alterations) and non-cost-related delayed care were estimated using All of Us Data. Multivariable logit models were used to generate predicted probabilities, average marginal effects (AME), and 95% confidence intervals. Models were then used to estimate inequities when disaggregating LGBTQ+ status and combing LGBTQ+ status with age, race, ethnicity, and treatment status.

Results: This analysis included N = 36,217 cancer survivors (6.6%, n = 2,399 LGBTQ+). In multivariable models, LGBTQ+ identity was associated with higher probabilities of and significant AME for all types of behavioral financial hardship (foregone care 31.1% vs. 19.4%; delayed care 22.6% vs. 15.6%; medication alterations 19.2% vs. 11.9%) and non-cost delayed care (14.3% vs. 7.2%). Within the disaggregated analysis, cisgender bisexual and another/multiple orientation women and gender minority survivors had the highest predicted probabilities of all outcomes. In intersectional analyses, survivors who were aged 18-39 and LGBTQ+, Black and LGBTQ+, or Hispanic/Latine and LGBTQ+ had the highest predicted probabilities of all outcomes.

Conclusions: LGBTQ+ cancer survivors experience significantly more behavioral financial hardship and non-cost-related delayed care then non-LGBTQ+ cancer survivors. Interventions at the individual, system, and policy level are needed to address LGBTQ+ inequities in financial hardship.