A new study from the University of Hawaiʻi Cancer Center found that patients spent at least $230 million on cancer care delivered outside the state between 2021 and 2023. The research, published in the Journal of Clinical Oncology, highlights the financial burden of geographic isolation on both patients and the health care system.
Researchers analyzed de-identified commercial insurance claims from Hawaiʻi Medical Service Association (HMSA), the largest health insurer in the state.
The analysis focused on residents receiving oncology treatment outside the state.
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It found that certain individuals — those with complex malignancies like leukemia, lymphoma, and brain tumors — were far more likely to need out-of-state care.
These results point to gaps in local oncology capacity, researchers said.
Why some individuals must leave the islands
“Hawaiʻi represents the most geographically isolated health system in the country, located approximately 2,400 miles from the continental mainland,” the report states. It acknowledges that full oncology services exist in the state, but “certain high-complexity subspecialty services, advanced therapeutics and clinical trial opportunities may require individuals to seek care outside the islands.”
Dr. Hideko Yamauchi, the report’s principal investigator and director of clinical affairs at the center, said individuals who must travel face 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,” Yamauchi said. “For some individuals, the enormous cost of treatment outside the state puts that care out of reach.”
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The report did not include non-medical costs like airfare, lodging, or lost income — meaning the true financial toll is likely higher.
Spending rose and fell over three years
Oncology care expenditures outside the state totaled roughly $58 million in 2021, then jumped to $94 million in 2022, before dropping to nearly $79 million in 2023.
Breast malignancies accounted for the largest total out-of-state spending at $59.5 million, driven by their high prevalence. Leukemia followed at $46.4 million, lymphoma at $21.5 million, prostate malignancies at $14.9 million, and lung malignancies at $14 million.
But when looking at the proportion of spending for each malignancy type, leukemia had the highest share at 39%. Lymphoma followed at 29%, central nervous system tumors at 27%, and breast malignancies at 21%. Multiple myeloma also accounted for a similar share.
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The hidden burden of those who never travel
Yamauchi raised a concern that the data only captures individuals who successfully traveled. “Understanding that hidden burden is an important next step for research and policy.”
The report’s authors note that similar challenges affect rural and underserved communities across the U.S., where specialized oncology services may be limited.
Efforts to expand local care
HMSA CEO Mark M. Mugiishi, also a co-author, said these results can “help guide efforts to improve access to high-quality oncology care closer to home.”
