“I felt super lucky:” Luck and administrative burden in cancer-related financial hardship.

198 Background: Financial hardship after cancer diagnosis is common and leads to earlier mortality and worse quality of life. This qualitative study sought to identify causal and protective factors for financial hardship as part of a larger study to refine a theoretical model and measure of financial hardship. Methods: We recruited female breast cancer survivors at a large comprehensive cancer center. Participants completed a semi-structured interview focused on their reflections of cancer diagnosis and active treatment. Interviews assessed multiple dimensions of financial hardship (coping, impacts, worry/anxiety, depression) and contributing, protective, and contextual factors. We conducted framework qualitative analysis of interview transcripts. Results: We interviewed eighteen women with breast cancer (100% early or regional stage; 77% White; mean age 57; time since diagnosis 3-24 years). Participants reported varying levels of financial hardship during diagnosis and treatment. Financial coping behaviors ranged from minor rebudgeting, to skipping or delaying healthcare, to major decisions about family structure (e.g. having children; marriage or divorce). Even successful financial coping induced stress (“it was just really painful”) because of administrative and time burden: hypervigilance to bills and finances; waiting in phone queues; negotiating with insurance companies and employers; liaising between employer, insurance company, and care team; and learning about, gathering documents, and applying for benefits (e.g. FMLA; disability). Employment and generous health insurance were protective, but out-of-network care and coverage denials tempered this protection and introduced stress. Worry about employment or insurance loss and the administrative burdens required to financially cope also created stress. Other protective factors were largely described as good luck, such as understanding bosses, flexible work arrangements, multiple household incomes, assistance from family and friends, or avoidance of more severe hardship (“we were fortunate we didn't lose our home"). Easily accessible health insurance was also described as good luck. Conclusions: Administrative and time burden required for financial coping behaviors can induce distress for women with breast cancer, even if successful in mitigating financial hardship. Luck emerged as a prominent protective factor. Luck and its relationship to structural factors that generate inequity may have ethical and policy implications for addressing cancer-related financial hardship and is worthy of further study.