County-Level Medical Debt Tied to Later-Stage Cancer Diagnosis, Worse Survival

Patients with cancer living in US counties with the highest share of residents carrying medical debt in collections were more likely to be diagnosed with stage IV disease and had worse overall survival (OS) than those in counties with the lowest debt burden, according to a study published in the Journal of the National Comprehensive Cancer Network (JNCCN).¹ The analysis, led by researchers at the American Cancer Society (ACS), linked National Cancer Database (NCDB) records for more than 7.5 million adults newly diagnosed with cancer between 2011 and 2019 to county-level medical debt data.

What did the study find about cancer stage at diagnosis?

Among patients living in counties with the lowest share of adults with medical debt in collections (0%-12.0%), 38.8% were diagnosed with stage I disease and 19.2% with stage IV disease. In counties with the highest share of medical debt (23.1%-56.0%), 34.4% of patients were diagnosed at stage I, while 21.2% were diagnosed at stage IV. After adjusting for patient- and county-level characteristics, living in the highest medical debt quartile was associated with lower odds of a stage I diagnosis (OR, 0.951; 95% CI, 0.940-0.962) and higher odds of a stage IV diagnosis (OR, 1.079; 95% CI, 1.064-1.094) compared with the lowest quartile (P for trend <.001).

A dose-response relationship between higher county-level medical debt and higher odds of stage IV diagnosis was observed for 15 of 17 major cancer types in unadjusted analyses. It remained statistically significant after adjustment for prostate, lung, thyroid, bladder, and oral cavity and pharynx cancers. The dose-response relationship was consistent across all subgroups when stratified by sociodemographic factors.

How did medical debt affect survival outcomes?

Patients in the lowest medical debt quartile had the best 5-year survival, at 66.3%, compared with 63.4%, 61.2%, and 58.6% for the second, third, and fourth quartiles, respectively. In sociodemographic- and clinically-adjusted models, patients living in counties with the highest medical debt had a 7% increased risk of death compared with those in counties with the lowest medical debt (HR, 1.072; 95% CI, 1.061-1.082; P for trend <.001). The association held across major cancer types and across subgroups defined by age, race and ethnicity, insurance status, and metropolitan status.

How was the study designed?

Researchers combined NCDB records for adults 18 years and older newly diagnosed with a first primary cancer between 2011 and 2019 in the US. Patients with stage 0 diagnosis, missing stage information, missing medical debt data, missing key covariates, or missing diagnosis and last contact dates were excluded from the study population. After criteria were applied, 6,841,646 patients were included in the analysis.

County-level medical debt data was gathered using the Urban Institute Credit Bureau Panel from 2011 to 2019. Medical debt in collections was identified when the debt was either sent to a third-party collections agency or assigned to a creditor’s internal collections department; original creditors were medical providers. The debt in collections was typically at least 180 days past due.

The median county-level medical debt in collections was 18% (range, 0%-56%), with the highest burden concentrated in Southern and nonmetropolitan counties. Hierarchical multivariable logistic and Cox proportional hazards models estimated associations between medical debt quartiles and stage at diagnosis and OS. This adjusted for diagnosis year, age, sex, race and ethnicity, insurance status, comorbidity score, metropolitan status, county-level social deprivation, medically underserved area designation, and state of residence, with a random effect for county.

What do the findings mean for cancer care policy?

“Our findings are critically important as residents of areas with high shares of medical debt could face multiple barriers to cancer screening and other preventive services, timely assessment of early signs of cancer, and effective cancer treatments after diagnosis, ultimately affecting cancer diagnosis and outcomes,” stated Xuesong Han, PhD, scientific director of health services research at the ACS and lead author of the study, in a news release on the findings.² “There is a real need for policies and programs, either directly preventing and reducing medical debt, or structurally promoting economic development and financial resilience in vulnerable communities, to help increase access to affordable care and help people suffering from all types of disease.”

References

1. Han X, Yang NN, Hu X, et al. County-level medical debt and its associations with cancer stage and survival in the United States. J Natl Compr Canc Netw. Published online August 18, 2026. doi:10.6004/jnccn.2026.7036
2. County-level medical debt linked to advanced-stage cancers and worse survival among newly diagnosed US adults. News release. American Cancer Society. August 18, 2026. Accessed August 21, 2026. https://tinyurl.com/kmd92mfn