Financial toxicity in cancer care: origins, impact, and solutions

Abstract Financial toxicity describes the financial burden and distress that can arise for patients, and their family members, as a result of cancer treatment. It includes direct out-of-pocket costs for treatment and indirect costs such as travel, time, and changes to employment that can increase the burden of cancer. While high costs of cancer care have threatened the sustainability of access to care for decades, it is only in the past 10 years that the term “financial toxicity” has been popularized to recognize that the financial burdens of care can be just as important as the physical toxicities traditionally associated with cancer therapy. The past decade has seen a rapid growth in research identifying the prevalence and impact of financial toxicity. Research is now beginning to focus on innovations in screening and care delivery that can mitigate this risk. There is a need to determine the optimal strategy for clinicians and cancer centers to address costs of care in order to minimize financial toxicity, promote access to high value care, and reduce health disparities. We review the evolution of concerns over costs of cancer care, the impact of financial burdens on patients, methods to screen for financial toxicity, proposed solutions, and priorities for future research to identify and address costs that threaten the health and quality of life for many patients with cancer.

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Evolving oncology provider perspectives on care delivery during the COVID-19 pandemic.

Journal of Clinical Oncology ◽

10.1200/jco.2021.39.15_suppl.e18609 ◽

2021 ◽

Vol 39 (15_suppl) ◽

pp. e18609-e18609

Author(s):

Divya Ahuja Parikh ◽

Meera Vimala Ragavan ◽

Sandy Srinivas ◽

Sarah Garrigues ◽

Eben Lloyd Rosenthal ◽

...

Keyword(s):

Cancer Care ◽

Care Delivery ◽

The United States ◽

Advanced Practice ◽

Curative Surgery ◽

Time Points ◽

Patients With Cancer ◽

Provider Perspectives ◽

Significant Difference ◽

The Impact

e18609 Background: The COVID-19 pandemic prompted rapid changes in cancer care delivery. We sought to examine oncology provider perspectives on clinical decisions and care delivery during the pandemic and to compare provider views early versus late in the pandemic. Methods: We invited oncology providers, including attendings, trainees and advanced practice providers, to complete a cross-sectional online survey using a variety of outreach methods including social media (Twitter), email contacts, word of mouth and provider list-serves. We surveyed providers at two time points during the pandemic when the number of COVID-19 cases was rising in the United States, early (March 2020) and late (January 2021). The survey responses were analyzed using descriptive statistics and Chi-squared tests to evaluate differences in early versus late provider responses. Results: A total of 132 providers completed the survey and most were white (n = 73/132, 55%) and younger than 49 years (n = 88/132, 67%). Respondents were attendings in medical, surgical or radiation oncology (n = 61/132, 46%), advanced practice providers (n = 48/132, 36%) and oncology fellows (n = 16/132, 12%) who predominantly practiced in an academic medical center (n = 120/132, 91%). The majority of providers agreed patients with cancer are at higher risk than other patients to be affected by COVID-19 (n = 121/132, 92%). However, there was a significant difference in the proportion of early versus late providers who thought delays in cancer care were needed. Early in the pandemic, providers were more likely to recommend delays in curative surgery or radiation for early-stage cancer (p < 0.001), delays in adjuvant chemotherapy after curative surgery (p = 0.002), or delays in surveillance imaging for metastatic cancer (p < 0.001). The majority of providers early in the pandemic responded that “reducing risk of a complication from a COVID-19 infection to patients with cancer” was the primary reason for recommending delays in care (n = 52/76, 68%). Late in the pandemic, however, providers were more likely to agree that “any practice change would have a negative impact on patient outcomes” (p = 0.003). At both time points, the majority of providers agreed with the need for other care delivery changes, including screening patients for infectious symptoms (n = 128/132, 98%) and the use of telemedicine (n = 114/132, 86%) during the pandemic. Conclusions: We found significant differences in provider perspectives of delays in cancer care early versus late in the pandemic which reflects the swiftly evolving oncology practice during the COVID-19 pandemic. Future studies are needed to determine the impact of changes in treatment and care delivery on outcomes for patients with cancer.

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The HOLA COVID-19 study: Evaluating the impact of caring for patients with COVID-19 on cancer care delivery in Latin America.

Journal of Clinical Oncology ◽

10.1200/jco.2021.39.15_suppl.1537 ◽

2021 ◽

Vol 39 (15_suppl) ◽

pp. 1537-1537

Author(s):

Carolina Bernabe Ramirez ◽

Ana I. Velazquez Manana ◽

Coral Olazagasti ◽

Cristiane Decat Bergerot ◽

Enrique Soto Perez De Celis ◽

...

Keyword(s):

Latin America ◽

Latin American ◽

Cancer Care ◽

Online Survey ◽

Care Delivery ◽

Healthcare Delivery ◽

Significant Proportion ◽

Multiple Choice Questions ◽

Patients With Cancer ◽

The Impact

1537 Background: The severe acute respiratory syndrome 2 (SARS-cov-2) virus causing COVID-19 has brought great challenges to global health services affecting cancer care delivery, outcomes, and increasing the burden in oncology providers (OP). Our study aimed to describe the challenges that OP faced while delivering cancer care in Latin America. Methods: We conducted an international cross-sectional study using an anonymous online survey in Spanish, Portuguese, and English. The questionnaire included 43 multiple choice questions. The sample was stratified by OP who have treated patients with COVID-19 versus those who have not treated patients with COVID-19. Data was analyzed with descriptive statistics and Chi-square tests. Results: A total of 704 OP from 20 Latin American countries completed the survey (77% of 913 who started the survey). Oncologists represented 46% of respondents, followed by 25% surgical-oncologists. Of the respondents, 56% treated patients with COVID-19. A significant proportion of OP reported newly adopting telemedicine during COVID-19 (14% vs 72%, p=0.001). More than half (58%) of OP reported making changes to the treatments they offered to patients with cancer. As shown in the table, caring for patients with COVID-19 significantly influenced practice patterns of OP. Access to specialty services and procedures was significantly reduced: 40% noted significantly decreased or no access to imaging, 20% significantly decreased or no access to biopsies, 65% reported delays in surgical oncology referrals, and 49% in radiation oncology referrals. A vast majority (82%) reported oncologic surgeries were delayed or cancelled, which was heightened among those treating patients with COVID-19 (87% vs 77%, p=0.001). Conclusions: The COVID-19 pandemic has significantly affected the way cancer care is delivered in globally. Although changes to healthcare delivery are necessary as a response to this global crisis, our study highlights the significant disruption and possible undertreatment of patients with cancer in Latin America that results from COVID-19.[Table: see text]

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Financial Toxicity of Cancer Care: An Analysis of Financial Burden in Three Distinct Health Care Systems

JCO Oncology Practice ◽

10.1200/op.20.00890 ◽

2021 ◽

pp. OP.20.00890

Author(s):

Divya A. Parikh ◽

Meera Ragavan ◽

Ritika Dutta ◽

Jeffrey Garnet Edwards ◽

James Dickerson ◽

...

Keyword(s):

Health Care ◽

Cancer Care ◽

Care Delivery ◽

Medical Center ◽

Financial Burden ◽

Financial Toxicity ◽

Cross Sectional Survey ◽

Factors Associated ◽

Care Systems ◽

Comprehensive Score

PURPOSE: The financial toxicity of cancer care is a source of significant distress for patients with cancer. The purpose of this study is to understand factors associated with financial toxicity in three distinct care systems. METHODS: We conducted a cross-sectional survey of patients in three care systems, Stanford Cancer Institute (SCI), VA Palo Alto Health Care System (VAPAHCS), and Santa Clara Valley Medical Center (SCVMC), from October 2017 to May 2019. We assessed demographic factors, employment status, and out-of-pocket costs (OOPCs) and administered the validated COmprehensive Score for financial Toxicity tool. We calculated descriptive statistics and conducted linear regression models to analyze factors associated with financial toxicity. RESULTS: Four hundred forty-four of 578 patients (77%) completed the entire COmprehensive Score for financial Toxicity tool and were included in the analysis. Most respondents at SCI were White, with annual household income (AHI) > $50,000 USD and Medicare insurance. At the VAPAHCS, most were White, with AHI ≤ $50,000 USD and insured by the Veterans Administration. At SCVMC, most were Asian and/or Pacific Islander, with AHI ≤ $25,000 USD and Medicaid insurance. Low AHI ( P < .0001), high OOPCs ( P = .003), and employment changes as a result of cancer diagnosis ( P < .0001) were associated with financial toxicity in the pooled analysis. There was variation in factors associated with financial toxicity by site, with employment changes significant at SCI, OOPCs at SCVMC, and no significant factors at the VAPAHCS. CONCLUSION: Low AHI, high OOPCs, and employment changes contribute to financial toxicity; however, there are variations based on site of care. Future studies should tailor financial toxicity interventions within care delivery systems.

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How Should We Intervene on the Financial Toxicity of Cancer Care? One Shot, Four Perspectives

American Society of Clinical Oncology Educational Book ◽

10.1200/edbk_174893 ◽

2017 ◽

pp. 35-39

Author(s):

S. Yousuf Zafar ◽

Lee N. Newcomer ◽

Justin McCarthy ◽

Shelley Fuld Nasso ◽

Leonard B. Saltz

Keyword(s):

Pharmaceutical Industry ◽

Cancer Care ◽

Cost Sharing ◽

Financial Burden ◽

Patient Advocacy ◽

Financial Toxicity ◽

The Past ◽

Order Of Magnitude ◽

Productive Discussion ◽

Hypothetical Question

The median price of a month of chemotherapy has increased by an order of magnitude during the past 20 years, far exceeding inflation over the same period. Along with rising prices, increases in cost sharing have forced patients to directly shoulder a greater portion of those costs, resulting in undue financial burden and, in some cases, cost-related nonadherence to treatment. What can we do to intervene on treatment-related financial toxicity of patients? No one party can single-handedly solve the problem, and the solution must be multifaceted and creative. A productive discussion of the problem must avoid casting blame and, instead, must look inward for concrete starting points toward improvement in the affordability and value of cancer care. With these points in mind, the authors—representatives from the pharmaceutical industry, insurance providers, oncologists, and patient advocacy—have each been asked to respond with a practical answer to the provocative hypothetical question, “If you could propose one thing, and one thing only, in terms of an action or change by the constituency you represent in this discussion, what would that be?”

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Patient-reported benefit from proposed interventions to reduce financial hardship during cancer treatment.

Journal of Clinical Oncology ◽

10.1200/jco.2020.38.15_suppl.7080 ◽

2020 ◽

Vol 38 (15_suppl) ◽

pp. 7080-7080

Author(s):

Emeline Aviki ◽

Fumiko Chino ◽

Julia Ramirez ◽

Victoria Susana Blinder ◽

Jennifer Jean Mueller ◽

...

Keyword(s):

Cancer Treatment ◽

Cancer Patients ◽

Financial Burden ◽

Gynecologic Cancer ◽

Financial Hardship ◽

Care Providers ◽

Financial Toxicity ◽

The Past ◽

Patient Reported ◽

The Impact

7080 Background: Awareness of cancer patients’ financial toxicity (FT) has increased substantially over the past decade; however, interventions to minimize financial burden remain underdeveloped and understudied. This survey-based study explores patient beliefs on which potential mitigating strategies could improve their financial hardship during cancer treatment. Methods: Interviewer-administered surveys were conducted with consecutive patients in an outpatient, urban, private academic Gynecologic Cancer clinic waiting room for 2 weeks in August 2019. The survey items included patient demographics, disease characteristics, the Comprehensive Score for Financial Toxicity (COST) tool (validated measure of FT with score 0-44; lower scores indicate worse FT), assessment of cost-coping strategies, and patient-reported anticipated benefit from described potential interventions (items that were feasible and relevant to implement in clinic). Results: Of 101 patients who initiated the survey, 87 (86%) completed it and were included in this analysis. The median age was 66 (range, 32-87). Thirty-eight patients (44%) had ovarian, 29 (33%) uterine, 5 (6%) cervical, and 15 (17%) an “other” gynecologic cancer. The median COST score was 32 (range, 6-44). Twenty-nine patients (33%) had COST scores ≤25 and 16 (18%) had COST scores ≤18. The most frequent cost-coping strategy reported was reducing leisure activities (n = 36, 41%) and using savings to pay for medical bills (n = 34, 39%). Six patients (7%) reported not taking a prescribed medication in the past 12 months due to the inability to pay and 0 reported skipping a recommended imaging study. When it came to interventions patients anticipated would improve their current financial hardships, 34 (39%) indicated access to transportation assistance to and from appointments, 31 (36%) said “knowing up front how much I’m going to have to pay for my healthcare”, 29 (33%) indicated “minimizing wait time associated with appointments, which keeps me away from work”, and 22 (25%) indicated “access to free food during/around appointments and treatments”. Only 26 (30%) noted they were not experiencing financial hardship. Conclusions: For an outpatient population of gynecologic cancer patients, several focused, feasible interventions could be implemented to potentially decrease patient FT. Our study can help health care providers in the design of interventions to create meaningful improvements in patient financial burden. Next steps should assess the impact of targeted interventions on patient outcomes.

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Fire, people and ecosystem change in Pleistocene Australia

Australian Journal of Botany ◽

10.1071/bt16138 ◽

2016 ◽

Vol 64 (8) ◽

pp. 643 ◽

Cited By ~ 8

Author(s):

Christopher N. Johnson

Keyword(s):

Fire Regimes ◽

Ecosystem Change ◽

Future Research ◽

Cascading Effects ◽

Continental Scale ◽

The Past ◽

The 1960S ◽

Relationship Of ◽

The Impact ◽

The Relationship

Since the 1960s, Australian scientists have speculated on the impact of human arrival on fire regimes in Australia, and on the relationship of landscape fire to extinction of the Pleistocene megafauna of Australia. These speculations have produced a series of contrasting hypotheses that can now be tested using evidence collected over the past two decades. In the present paper, I summarise those hypotheses and review that evidence. The main conclusions of this are that (1) the effects of people on fire regimes in the Pleistocene were modest at the continental scale, and difficult to distinguish from climatic controls on fire, (2) the arrival of people triggered extinction of Australia’s megafauna, but fire had little or no role in the extinction of those animals, which was probably due primarily to hunting and (3) megafaunal extinction is likely to have caused a cascade of changes that included increased fire, but only in some environments. We do not yet understand what environmental factors controlled the strength and nature of cascading effects of megafaunal extinction. This is an important topic for future research.

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A Cross-Sectional Survey Exploring the Impact of the COVID-19 Pandemic on the Cancer Care of Adolescents and Young Adults

Current Oncology ◽

10.3390/curroncol28040278 ◽

2021 ◽

Vol 28 (4) ◽

pp. 3201-3213

Author(s):

Kaitlyn Howden ◽

Camille Glidden ◽

Razvan G. Romanescu ◽

Andrew Hatala ◽

Ian Scott ◽

...

Keyword(s):

Young Adults ◽

Cancer Treatment ◽

Cancer Care ◽

Negative Impact ◽

Positive Impact ◽

Care Delivery ◽

Adolescents And Young Adults ◽

P Value ◽

Cross Sectional Survey ◽

The Impact

We aimed to describe the negative and positive impacts of changes in cancer care delivery due to COVID-19 pandemic for adolescents and young adults (AYAs) in Canada, as well as the correlates of negative impact and their perspectives on optimization of cancer care. We conducted an online, self-administered survey of AYAs with cancer living in Canada between January and February 2021. Multiple logistic regression was used to identify factors associated with a negative impact on cancer care. Of the 805 participants, 173 (21.5%) experienced a negative impact on their cancer care including delays in diagnostic tests (11.9%), cancer treatment (11.4%), and appointments (11.1%). A prior diagnosis of mental or chronic physical health condition, an annual income of <20,000 CAD, ongoing cancer treatment, and province of residence were independently associated with a negative cancer care impact (p-value < 0.05). The majority (n = 767, 95.2%) stated a positive impact of the changes to cancer care delivery, including the implementation of virtual healthcare visits (n = 601, 74.6%). Pandemic-related changes in cancer care delivery have unfavorably and favorably influenced AYAs with cancer. Interventions to support AYAs who are more vulnerable to the adverse effects of the pandemic, and the thoughtful integration of virtual care into cancer care delivery models is essential.

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Pharmaceutical assistance foundations in the financing of cancer care.

Journal of Clinical Oncology ◽

10.1200/jco.2017.35.8_suppl.8 ◽

2017 ◽

Vol 35 (8_suppl) ◽

pp. 8-8

Author(s):

Aaron Philip Mitchell

Keyword(s):

North Carolina ◽

Cancer Care ◽

Kinase Inhibitors ◽

Care Delivery ◽

Private Insurance ◽

Standard Of Care ◽

Drug Manufacturer ◽

Cancer Drugs ◽

Assistance Programs ◽

Patients With Cancer

8 Background: The rising cost of cancer drugs may make treatment unaffordable for some patients. Patients often rely on drug manufacturer-administered Pharmaceutical Assistance Programs (PAPs) to obtain drugs at reduced or no cost. The overall impact of PAPs on cancer care delivery is unknown. Methods: We identified all patients obtaining cancer drugs across an academically affiliated, integrated health system in the state of North Carolina during 2014. The proportion of patients receiving PAP assistance, and the retail value of the assistance, were quantified for each oncology drug. Cancer drugs were analyzed with respect to route of administration. Results: 215 unique patients submitted a total of 478 successful PAP requests for cancer drugs. The majority of the retail value of drugs obtained was for oral cancer drugs, particularly targeted therapies including tyrosine kinase inhibitors. Among all cancer patients who received medical treatment, 5.5% required PAP assistance, whereas 10.6% receiving an oral agent required PAP assistance (Table). The proportion receiving PAP assistance varied substantially by drug, ranging from <1% of patients (e.g., carboplatin, methotrexate) to 50% of patients (e.g., ponatinib, temsirolimus). Patients obtained a total of $1,556,575 of imatinib and $1,449,633 of dasatinib, which were the two drugs with the highest aggregate retail value. 40% of PAP-utilizing patients were uninsured, 26% had Medicaid coverage, 20% had Medicare coverage, and 14% were commercially insured. Conclusions: A substantial proportion of patients with cancer receive private charitable assistance through PAPs in order to obtain standard-of-care treatments. In particular, a disproportionate share of patients treated with orally-available cancer drugs require PAP assistance. This includes patients with federal and private insurance, suggesting an inability of patients to meet cost-sharing requirements. [Table: see text]

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Financial Toxicity in Cancer Treatment

Psycho-Oncology ◽

10.1093/med/9780190097653.003.0077 ◽

2021 ◽

pp. 616-620

Author(s):

Victoria Blinder ◽

Francesca M. Gany

Keyword(s):

Cancer Treatment ◽

Emotional Distress ◽

Low Income ◽

Financial Distress ◽

Financial Burden ◽

Symptom Burden ◽

Indirect Costs ◽

Young Female ◽

Vulnerable Groups ◽

Financial Toxicity

Financial toxicity is a preventable cancer treatment side effect, encompassing the subjective financial distress and objective financial burden that result from increased spending and decreased earning after diagnosis. The prevalence of financial toxicity has increased with new expensive cancer treatments and insurers gradually shifting costs to patients. Patients with financial toxicity experience increased symptom burden, treatment nonadherence, and cancer-related death. The patients at highest risk are young, female, and nonwhite. For low-income patients, the indirect costs of cancer care can be especially burdensome and include child/elder care, transportation, unpaid work absences or job loss, cancer-related comorbidity treatment costs, and fulfilling dietary requirements. Psychosocial impacts include depression, emotional distress, and reduced quality of life. Patients in palliative care have rated financial distress as more severe than physical, familial, and emotional distress. Interventions and policy changes are needed to ameliorate the effects of financial toxicity, especially for the most vulnerable groups.

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