Background: The prevalence of cancer survivorship is increasing. In this study, we provide contemporary population-based estimates and projections of the overall and site-specific cancerattributable medical care costs in the United States.Methods: We identified survivors aged ≥65 years diagnosed with cancer between 2000 and 2012 from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database and used 2007 to 2013 claims to estimate costs by cancer site, phases of care, and stage at diagnosis. Annualized average cancer-attributable costs for medical care (Medicare Parts A and B) and oral prescription drugs (Medicare Part D) were estimated by subtracting costs between patients with cancer and matched controls. Costs are reported in 2019 U.S. dollars. We combined phase-specific attributable costs with prevalence projections to estimate national costs from 2015 through 2030.

Background The American Cancer Society, Centers for Disease Control and Prevention, National Cancer Institute, and North American Association of Central Cancer Registries collaborate to provide annual updates on cancer incidence and mortality and trends by cancer type, sex, age group, and racial/ethnic group in the United States. In this report, we also examine trends in stage-specific survival for melanoma of the skin (melanoma). Methods Incidence data for all cancers from 2001 through 2017 and survival data for melanoma cases diagnosed during 2001–2014 and followed up through 2016 were obtained from the Centers for Disease Control and Prevention- and National Cancer Institute-funded population-based cancer registry programs compiled by the North American Association of Central Cancer Registries. Data on cancer deaths from 2001 through 2018 were obtained from the National Center for Health Statistics’ National Vital Statistics System. Trends in age-standardized incidence and death rates and 2-year relative survival were estimated by joinpoint analysis, and trends in incidence and mortality were expressed as average annual percent change (AAPC) during the most recent 5 years (2013–2017 for incidence and 2014–2018 for mortality). Results Overall cancer incidence rates (per 100,000 population) for all ages during 2013–2017 were 487.4 among males and 422.4 among females. During this period, incidence rates remained stable among males but slightly increased in females (AAPC = 0.2%; 95% confidence interval [CI] = 0.1% to 0.2%). Overall cancer death rates (per 100,000 population) during 2014–2018 were 185.5 among males and 133.5 among females. During this period, overall death rates decreased in both males (AAPC = −2.2%; 95% CI = −2.5% to − 1.9%) and females (AAPC = −1.7%; 95% CI = −2.1% to − 1.4%); death rates decreased for 11 of the 19 most common cancers among males and for 14 of the 20 most common cancers among females, but increased for 5 cancers in each sex. During 2014–2018, the declines in death rates accelerated for lung cancer and melanoma, slowed down for colorectal and female breast cancers, and leveled off for prostate cancer. Among children younger than age 15 years and adolescents and young adults aged 15–39 years, cancer death rates continued to decrease in contrast to the increasing incidence rates. Two-year relative survival for distant-stage skin melanoma was stable for those diagnosed during 2001–2009 but increased by 3.1% (95% CI = 2.8% to 3.5%) per year for those diagnosed during 2009–2014, with comparable trends among males and females. Conclusions Cancer death rates in the United States continue to decline overall and for many cancer types, with the decline accelerated for lung cancer and melanoma. For several other major cancers, however, death rates continue to increase or previous declines in rates have slowed or ceased. Moreover, overall incidence rates continue to increase among females, children, and adolescents and young adults. These findings inform efforts related to prevention, early detection, and treatment and for broad and equitable implementation of effective interventions, especially among under-resourced populations.

Background The novel human coronavirus disease 2019 (COVID-19) pandemic has claimed more than 600,000 lives worldwide, causing tremendous public health, social, and economic damages. While the risk factors of COVID-19 are still under investigation, environmental factors, such as urban air pollution, may play an important role in increasing population susceptibility to COVID-19 pathogenesis. Methods We conducted a cross-sectional nationwide study using zero-inflated negative binomial models to estimate the association between long-term (2010-2016) county-level exposures to NO 2 , PM 2.5 and O 3 and county-level COVID-19 case-fatality and mortality rates in the US. We used both single and multipollutant models and controlled for spatial trends and a comprehensive set of potential confounders, including state-level test positive rate, county-level healthcare capacity, phase-of-epidemic, population mobility, population density, sociodemographics, socioeconomic status, race and ethnicity, behavioral risk factors, and meteorology. Results 3,659,828 COVID-19 cases and 138,552 deaths were reported in 3,076 US counties from January 22, 2020 to July 17, 2020, with an overall observed case-fatality rate of 3.8%. County-level average NO 2 concentrations were positively associated with both COVID-19 case-fatality rate and mortality rate in single-, bi-, and tri-pollutant models. When adjusted for co-pollutants, per inter-quartile range (IQR) increase in NO 2 (4.6 ppb), COVID-19 case-fatality rate and mortality rate were associated with an increase of 11.3% (95% CI 4.9% to 18.2%) and 16.2% (95% CI 8.7% to 24.0%), respectively. We did not observe significant associations between COVID-19 case-fatality rate and long-term exposure to PM 2.5 or O 3 , although per IQR increase in PM 2.5 (2.6 ug/m 3 ) was marginally associated with 14.9% (95% CI: 0.0% to 31.9%) increase in COVID-19 mortality rate when adjusted for co-pollutants. Discussion Long-term exposure to NO 2 , which largely arises from urban combustion sources such as traffic, may enhance susceptibility to severe COVID-19 outcomes, independent of long-term PM 2.5 and O 3 exposure. The results support targeted public health actions to protect residents from COVID-19 in heavily polluted regions with historically high NO 2 levels. Continuation of current efforts to lower traffic emissions and ambient air pollution may be an important component of reducing population-level risk of COVID-19 case-fatality and mortality.

BACKGROUND: High patient out-of-pocket (OOP) spending for medical care is associated with medical debt, distress about household finances, and forgoing medical care because of cost in the USA. OBJECTIVE: To examine the national prevalence of medical financial hardship domains: (1) material conditions from increased OOP expenses (e.g., medical debt), (2) psychological responses (e.g., distress), and (3) coping behaviors (e.g., forgoing care); and factors associated with financial hardship. DESIGN AND PARTICIPANTS: We identified adults aged 18-64 years (N = 68,828) and ≥ 65 years (N = 24,614) from the 2015-2017 National Health Interview Survey. Multivariable analyses of nationally representative crosssectional survey data were stratified by age group, 18-64 years and ≥ 65 years. MAIN MEASURES: Prevalence of material, psychological, and behavioral hardship and hardship intensity. KEY RESULTS: Approximately 137.1 million (95% CI 132.7-141.5) adults reported any medical financial hardship in the past year. Hardship is more common for material, psychological and behavioral domains in adults aged 18-64 years (28.9%, 46.9%, and 21.2%, respectively) than in adults aged ≥ 65 years (15.3%, 28.4%, and 12.7%, respectively; all p < .001). Lower educational attainment and more health conditions were strongly associated with hardship intensity in multivariable analyses in both age groups (p < .001). In the younger group, the uninsured were more likely to report multiple domains of hardship (52.8%), compared to those with some public (26.5%) or private insurance (23.2%) (p < .001). In the older group, individuals with Medicare only were more likely to report hardship in multiple domains (17.1%) compared to those with Medicare and public (12.1%) or Medicare and private coverage (10.1%) (p < .001). CONCLUSIONS: Medical financial hardship is common in the USA, especially in adults aged 18-64 years and those without health insurance coverage. With trends towards higher patient cost-sharing and increasing health care costs, risks of hardship may increase in the future.

Background: With rising costs of cancer care, this study aims to estimate the prevalence of, and factors associated with, medical financial hardship intensity and financial sacrifices due to cancer in the United States.Methods: We identified 963 cancer survivors from the 2016 Medical Expenditures Panel Survey -Experiences with Cancer. Medical financial hardship due to cancer was measured in material (e.g., filed for bankruptcy), psychological (e.g., worry about paying bills and finances), and behavioral (e.g., delaying or forgoing care due to cost) domains. Nonmedical financial sacrifices included changes in spending and use of savings. Multivariable logistic models were used to identify characteristics associated with hardship intensity and sacrifices stratified by age group (18-64 or 65þ years).Results: Among cancer survivors ages 18 to 64 years, 53.6%, 28.4%, and 11.4% reported at least one, two, or all three domains of hardship, respectively. Among survivors ages 65þ years, corresponding percentages were 42.0%, 12.7%, and 4.0%, respectively. Moreover, financial sacrifices due to cancer were more common in survivors ages 18 to 64 years (54.2%) than in survivors 65þ years (38.4%; P < 0.001). Factors significantly associated with hardship intensity in multivariable analyses included low income and educational attainment, racial/ethnic minority, comorbidity, lack of private insurance coverage, extended employment change, and recent cancer treatment. Most were also significantly associated with financial sacrifices.Conclusions: Medical financial hardship and financial sacrifices are substantial among cancer survivors in the United States, particularly for younger survivors.Impact: Efforts to mitigate financial hardship for cancer survivors are warranted, especially for those at high risk.

Background:The novel human coronavirus disease 2019 pandemic has claimed more than 240,000 lives worldwide, causing tremendous public health, social, and economic damages. While the risk factors of COVID-19 are still under investigation, environmental factors, such as urban air pollution, may play an important role in increasing population susceptibility to COVID-19 pathogenesis. Methods:We conducted a cross-sectional nationwide study using zero-inflated negative binomial models to estimate the association between long-term (2010-2016) county-level exposures to NO 2 , PM 2.5 and O 3 and county-level COVID-19 case-fatality and mortality rates in the US. We used both single and multipollutant models and controlled for spatial trends and a comprehensive set of potential confounders, including state-level test positive rate, county-level healthcare capacity, phase-of-epidemic, population mobility, sociodemographic, socioeconomic status, behavior risk factors, and meteorological factors.Results: 1,027,799 COVID-19 cases and 58,489 deaths were reported in 3,122 US counties from January 22, 2020 to April 29, 2020, with an overall observed case-fatality rate of 5.8%. Spatial variations were observed for both COVID-19 death outcomes and long-term ambient air pollutant levels. County-level average NO 2 concentrations were positively associated with both COVID-19 case-fatality rate and mortality rate in single-, bi-, and tri-pollutant models (p-values<0.05). Per inter-quartile range (IQR) increase in NO 2 (4.6 ppb), COVID-19 case-fatality rate and mortality rate were associated with an increase of 7.1% (95% CI 1.2% to 13.4%) and 11.2% (95% CI 3.4% to 19.5%), respectively. We did not observe significant associations between long-term exposures to PM 2.5 or O 3 and COVID-19 death outcomes (p-values>0.05), although per IQR increase in PM 2.5 (3.4 ug/m 3 ) was marginally associated with 10.8% (95% CI: -1.1% to 24.1%) increase in COVID-19 mortality rate. Discussions and Conclusions:Long-term exposure to NO 2 , which largely arises from urban combustion sources such as traffic, may enhance susceptibility to severe COVID-19 outcomes, independent of longterm PM 2.5 and O 3 exposure. The results support targeted public health actions to protect residents from COVID-19 in heavily polluted regions with historically high NO 2 levels. Moreover, continuation of current efforts to lower traffic emissions and ambient air pollution levels may be an important component of reducing population-level risk of COVID-19 deaths.

Rising costs of cancer care have led to increased concerns about medical financial hardship for cancer survivors and their families in the United States. In this commentary, we provide an overview of research describing medical financial hardship and introduce a conceptual framework for identifying risk factors and research gaps at the patient and family, provider and care team, health care system, employer, and state and national policy levels. We then use this framework to highlight measurement and data infrastructure gaps related to hardship, summarize existing interventions to minimize hardship, and identify opportunities for future intervention efforts.

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