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.