Abstract
IMPORTANCE: Financial toxicity significantly affects individuals with cancer, impacting not only treatment adherence and outcomes but also psychological dimensions such as satisfaction with life (SWL). Identifying mediators of psychological outcomes of financial toxicity, including hopefulness and social support, is critical for informing interventions to mitigate financial toxicity burdens. OBJECTIVE: To examine the association of financial toxicity with hopefulness, social support, and SWL in patients with cancer, and to test the roles of hopefulness and social support in the association between financial toxicity and SWL. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional analysis assessed baseline patient-reported financial toxicity from participants of the prospective, multisite Economic Strain and Resilience in Cancer-II (ENRICh-II) study who enrolled from August 2020 to December 2022. Included patients were adults receiving ambulatory cancer care for various malignant neoplasm types diagnosed in the year prior from academic, community-based, and federally qualified health centers across 6 oncology clinics. Data were primarily analyzed between January and June 2024. EXPOSURE: Financial toxicity was assessed using the ENRICh instrument, which measures global financial toxicity burden and financial toxicity-related material, coping, and psychological distress burden subdomain scores. MAIN OUTCOMES AND MEASURES: The Satisfaction with Life Scale measured life satisfaction. Hypothesized mediators were measured using the State Hope Scale and Medical Outcomes Study Social Support Survey. A bootstrapping approach to multiple mediation was applied, controlling for demographic and clinical covariates. RESULTS: A total of 519 participants were surveyed (mean [SD] age, 52.0 [15.2] years; 349 female [67.2%]; 49 Black [9.4%], 137 Hispanic [26.4%], 278 White [53.6%]). The most common cancers included breast (202 [38.9%]); colon, rectum, and anal (111 [21.4%]); biliary, liver, pancreatic, and stomach (65 [12.5%]); and leukemia, lymphoma, and other hematologic malignant neoplasms (53 [10.2%]). Higher financial toxicity was significantly associated with lower SWL (r = -0.34, P < .001). Hopefulness and social support each partially mediated this association (social support, -0.03 [95% CI, -0.06 to -0.01]; hope, -0.08, [95% CI, -0.12 to -0.03]). The combined multiple mediation path was significant (-0.02 [95% CI, -0.04 to -0.01]). These associations also existed for the material, coping, and psychological distress financial toxicity domains. CONCLUSIONS AND RELEVANCE: In this multisite, cross-sectional study, greater financial toxicity burden was associated with lower life satisfaction; individuals' hopefulness and perceived social support levels-representing dimensions of psychosocial resilience-statistically mediated this association. These results support an approach that would embed strategies to strengthen psychosocial resilience factors, in combination with current financial assistance, to help mitigate the downstream impacts of cancer-related financial toxicity.