Patients in Hawai’i spent $230M+ on out-of-state cancer care in 2021–2023, study finds

A new study led by researchers at the University of Hawaiʻi Cancer Center found that at least $230 million was spent on cancer care delivered outside Hawaiʻi between 2021 and 2023, highlighting the significant financial impact of geographic isolation on patients and the health care system.

The study, titled “Quantifying financial toxicity from cancer care travel in a geographically isolated U.S. health system,” published in the Journal of Clinical Oncology, analyzed de-identified data from commercial insurance claims filed through Hawaiʻi Medical Service Association (HMSA) by Hawaiʻi residents receiving cancer treatment. HMSA is an independent licensee of the Blue Cross and Blue Shield Association and the largest health insurance provider in Hawaiʻi.

The study found that certain patients—particularly those with complex cancers such as leukemia, lymphoma and brain tumors—were much more likely to require care outside the state. The findings point to opportunities to strengthen local cancer care capacity and reduce the need for patients to travel thousands of miles for treatment, the researchers said.

“Hawaiʻi represents the most geographically isolated health system in the country, located approximately 2,400 miles (3,862 kilometers) from the continental mainland,” the study said. “Although comprehensive oncology services are available within the state, certain high-complexity subspecialty services, advanced therapeutics and clinical trial opportunities may require patients to seek care outside Hawaiʻi. Such out-of-state (OOS) utilization reflects both patient need and structural constraints in oncology capacity.”

“Patients who must leave the islands for specialized cancer care bear enormous burdens: On top of medical bills, they may face travel expenses, time away from work, and the emotional challenge of receiving treatment far from home and the support of their loved ones. For some patients, the enormous cost of out-of-state treatment puts that care out of reach,” said Dr. Hideko Yamauchi, director of clinical affairs at the UH Cancer Center, and the principal investigator for the study.

“By understanding where and why patients seek care elsewhere, we can better identify opportunities to expand access, strengthen specialized services and keep more patients connected to their support networks while receiving treatment.”

“HMSA is proud to work with the UH Cancer Center on research that helps us better understand the health care needs of the people of Hawaiʻi,” said HMSA Chief Executive Officer Mark M. Mugiishi, MD, FACS, and a co-author of the study. “These findings can help guide efforts to improve access to high-quality cancer care closer to home. Whenever possible, patients should be able to receive advanced treatment in Hawaiʻi while staying connected to their families, communities and support systems during one of the most difficult times of their lives.”

‘Financial toxicity’ places strain on patients

The study found that out-of-state cancer care expenditures totaled approximately $58 million in 2021, rose to $94 million in 2022 and reached nearly $79 million in 2023. Total spending exceeded $230 million during the three-year period.

Breast cancer accounted for the largest total amount spent on out-of-state care at $59.5 million, due to its high prevalence, researchers said. It was followed by leukemia ($46.4 million), lymphoma ($21.5 million), prostate cancer ($14.9 million) and pulmonary cancer ($14 million).

However, leukemia exhibited the highest proportion of out-of-state spending for treatment, at 39%, followed by lymphoma (29%), central nervous system tumors (27%), multiple myeloma (21%) and breast cancer (21%).

The study examined only direct medical costs paid through insurance claims with HMSA. It did not include claims with other insurers. It also did not include additional expenses frequently borne by patients and families, such as airfare, lodging, meals, lost income or caregiver time. Previous research has shown that these travel-related burdens can contribute significantly to what experts call “financial toxicity“—the financial strain associated with cancer treatment.

“A concern raised by these findings is that the patients we can see in the data are only the ones who successfully traveled,” Yamauchi said. “The patients we worry about are the ones we cannot see in this data—those who did not travel and faced barriers to accessing specialized care. Understanding that hidden burden is an important next step for research and policy.”

Although Hawaiʻi’s isolation is unique among the states, similar challenges affect rural and underserved communities throughout the U.S., where specialized cancer services may be limited.

Expansion of Hawaiʻi cancer care indicated

“The UH Cancer Center deeply appreciates HMSA—a member of our Hawaiʻi Cancer Consortium—for collaborating on this crucial research. This study demonstrates why continuing to expand cancer care in Hawaiʻi is so important,” said Dr. Naoto T. Ueno, director of the UH Cancer Center, and a co-author of the study.

The findings suggest that increased investments in Hawaiʻi in high-demand specialty services, advanced diagnostics, clinical trials and innovative care models, such as tele-oncology, could help reduce the need for some patients to travel outside the islands for treatment, Ueno said.

The opening in July of the UH Cancer Center’s Ho’ōla Early Phase Clinical Research Center is one example of such an investment.

“The launch of the UH Cancer Center’s new Ho’ōla Early Phase Clinical Research Center represents a major step toward increasing advanced cancer care in Hawaiʻi,” Ueno said. “Ho’ōla EPCRC will give qualifying Hawaiʻi patients the opportunity to receive cutting-edge, first-in-Hawaiʻi Phase I clinical trial treatments here at home, without leaving their families and communities to travel to the U.S. mainland.

“In addition, the UH Cancer Center’s new statewide academic oncology initiative, Ka ‘Umeke Lama, aims to support and grow Hawaiʻi’s oncology workforce, and bring quality cancer care to underserved populations,” Ueno continued. “Our goal is to ensure that Hawaiʻi residents have access to the newest advances in cancer treatment while remaining close to the people who support them most.”

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Lisa Lock

BA art history, MA material culture. Former museum editor, paramedic, and transplant coordinator. Editing for Science X since 2021.

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Andrew Zinin

Master’s in physics with research experience. Long-time science news enthusiast. Plays key role in Science X’s editorial success.

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