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Peer-reviewedCC BY 4.0JAMA Network Open

Medical Debt and Advanced Cancer Stage at Diagnosis

  • Jiazhang Xing1
  • Xuesong Han2
  • Xin Hu3
  • Lingbin Meng4
  • Lang Qu1
  • Ryan D. Nipp5
  • K. Robin Yabroff2
  • Changchuan Jiang6
6 affiliations
  1. 1Department of Medicine, Sinai Hospital of Baltimore, Baltimore, Maryland
  2. 2Department of Surveillance, Prevention and Health Services Research, American Cancer Society, Atlanta, Georgia
  3. 3Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia
  4. 4Department of Medical Oncology, The Ohio State University Wexner Medical Center, Columbus
  5. 5Department of Internal Medicine, Section of Hematology/Oncology, University of Oklahoma Health and Stephenson Cancer Center, Oklahoma City
  6. 6Division of Hematology and Oncology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
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Abstract

Importance: Medical debt affects millions of US residents and has been associated with higher cancer mortality. Whether medical debt burden is associated with incidence of advanced stage cancer, a key determinant of survival, remains unclear.

Objective: To examine the association between medical debt and cancer incidence in the US.

Design, Setting, and Participants: This cross-sectional study used ecological county-level data linking 2016 medical debt with age-adjusted incidence rates of 9 cancers from January 1, 2017, to December 31, 2021. The study included 2958 US counties with available data on medical debt in collections and cancer incidence rates. Population-based data were obtained and analyzed from January 11, 2025, to February 15, 2026.

Exposure: Percentage of residents with any medical debt in collections in 2016.

Main Outcomes and Measures: Age-adjusted all-stage and late-stage (regional or distant) cancer incidence rates per 100 000 person-years from 2017 to 2021. Multivariable models adjusted for urban-rural status, Social Vulnerability Index (SVI), primary care physician density, and states were used to estimate differences in age-adjusted incidence rates of cancer associated with county-level medical debt burden.

Results: Among the 2958 US counties included in the analysis, 1154 (39.0%) were urban and 1804 (61.0%) were rural. The mean (SD) prevalence of medical debt in collections was 21.1% (9.6%), with a mean (SD) primary care physician density of 0.54 (0.35) physicians per 1000 population. The prevalence of medical debt ranged from 1.2% to 51.8%. The mean (SD) medical debt prevalence was higher in rural than urban counties (21.5% [10.0%] vs 20.5% [8.9%]; P = .007) and in counties in the highest vs lowest SVI quartile (27.4% [9.0%] vs 13.9% [6.9%]; P < .001). After adjustment, each 10percentage point increase in county-level medical debt was associated with a higher incidence of late-stage lung cancer (5.15 [95% CI, 4.62-5.68] additional cases per 100 000 person-years), colorectal cancer (0.69 [95% CI, 0.44-0.94] additional cases per 100 000 person-years), cervical cancer (0.39 [95% CI, 0.23-0.55] additional cases per 100 000 person-years), melanoma (0.59 [95% CI, 0.48-0.70] additional cases per 100 000 person-years), kidney and renal pelvis cancer (0.38 [95% CI, 0.27-0.49] additional cases per 100 000 person-years), bladder cancer (0.24 [95% CI, 0.16-0.32] additional cases per 100 000 person-years), and head and neck cancer (0.92 [95% CI, 0.77-1.07] additional cases per 100 000 person-years). Similar patterns were observed for overall cancer incidence.

Conclusions and Relevance: In this cross-sectional study of US counties, higher medical debt burden was associated with higher incidence rates of late-stage and overall cancer across multiple cancer types. These findings suggest that medical debt may reflect structural and financial barriers associated with cancer diagnosis and outcomes at the population level.

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Cite

BibTeXRIS
BibTeX
@article{xing2026medical,
  title = {{Medical Debt and Advanced Cancer Stage at Diagnosis}},
  author = {Jiazhang Xing and Xuesong Han and Xin Hu and Lingbin Meng and Lang Qu and Ryan D. Nipp and K. Robin Yabroff and Changchuan Jiang},
  journal = {JAMA Network Open},
  year = {2026},
  month = oct,
  doi = {10.1001/jamanetworkopen.2026.37508},
  url = {https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2854693},
  note = {CC BY 4.0},
}
RIS
TY  - JOUR
TI  - Medical Debt and Advanced Cancer Stage at Diagnosis
AU  - Jiazhang Xing
AU  - Xuesong Han
AU  - Xin Hu
AU  - Lingbin Meng
AU  - Lang Qu
AU  - Ryan D. Nipp
AU  - K. Robin Yabroff
AU  - Changchuan Jiang
PY  - 2026
DA  - 2026/10/01
JO  - JAMA Network Open
DO  - 10.1001/jamanetworkopen.2026.37508
UR  - https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2854693
AB  - Importance: Medical debt affects millions of US residents and has been associated with higher cancer mortality. Whether medical debt burden is associated with incidence of advanced stage cancer, a key determinant of survival, remains unclear.  Objective: To examine the association between medical debt and cancer incidence in the US.  Design, Setting, and Participants: This cross-sectional study used ecological county-level data linking 2016 medical debt with age-adjusted incidence rates of 9 cancers from January 1, 2017, to December 31, 2021. The study included 2958 US counties with available data on medical debt in collections and cancer incidence rates. Population-based data were obtained and analyzed from January 11, 2025, to February 15, 2026.  Exposure: Percentage of residents with any medical debt in collections in 2016.  Main Outcomes and Measures: Age-adjusted all-stage and late-stage (regional or distant) cancer incidence rates per 100 000 person-years from 2017 to 2021. Multivariable models adjusted for urban-rural status, Social Vulnerability Index (SVI), primary care physician density, and states were used to estimate differences in age-adjusted incidence rates of cancer associated with county-level medical debt burden.  Results: Among the 2958 US counties included in the analysis, 1154 (39.0%) were urban and 1804 (61.0%) were rural. The mean (SD) prevalence of medical debt in collections was 21.1% (9.6%), with a mean (SD) primary care physician density of 0.54 (0.35) physicians per 1000 population. The prevalence of medical debt ranged from 1.2% to 51.8%. The mean (SD) medical debt prevalence was higher in rural than urban counties (21.5% [10.0%] vs 20.5% [8.9%]; P = .007) and in counties in the highest vs lowest SVI quartile (27.4% [9.0%] vs 13.9% [6.9%]; P < .001). After adjustment, each 10percentage point increase in county-level medical debt was associated with a higher incidence of late-stage lung cancer (5.15 [95% CI, 4.62-5.68] additional cases per 100 000 person-years), colorectal cancer (0.69 [95% CI, 0.44-0.94] additional cases per 100 000 person-years), cervical cancer (0.39 [95% CI, 0.23-0.55] additional cases per 100 000 person-years), melanoma (0.59 [95% CI, 0.48-0.70] additional cases per 100 000 person-years), kidney and renal pelvis cancer (0.38 [95% CI, 0.27-0.49] additional cases per 100 000 person-years), bladder cancer (0.24 [95% CI, 0.16-0.32] additional cases per 100 000 person-years), and head and neck cancer (0.92 [95% CI, 0.77-1.07] additional cases per 100 000 person-years). Similar patterns were observed for overall cancer incidence.  Conclusions and Relevance: In this cross-sectional study of US counties, higher medical debt burden was associated with higher incidence rates of late-stage and overall cancer across multiple cancer types. These findings suggest that medical debt may reflect structural and financial barriers associated with cancer diagnosis and outcomes at the population level.
SN  - 2574-3805
ER  -