'Major Step' to Identify 'Financial Toxicity' From Cancer

Nick Mulcahy

July 16, 2014

Financial toxicity is a relatively new term in oncology, first described last year by academic oncologists.

The phrase refers to the way out-of-pocket expenses can drain the wallets of cancer patients, poison quality of life and, in fact, become an adverse event of treatment.

The catchy phrase — and the ensnaring reality it reflects — inspired multiple news reports, which started with Medscape Medical News and spread to more mainstream publications, such as Forbes.

Now a team from 2 institutions in Chicago has developed a tool that could eventually help clinicians identify patients at risk for this adverse effect of cancer treatment.

The 11-item COST (Comprehensive Score for Financial Toxicity) questionnaire is a "first and major step toward measuring how financial distress impacts the lives of patients with cancer," according to the developers, led by Jonas de Souza, MD, from the section of hematology/oncology at the University of Chicago Medicine.

The team used a series of steps, including pilot testing, and 155 patients with advanced cancer to develop COST. They describe the process in a report published online June 20 in Cancer.

An expert not involved in the development of COST believes this is an important moment.

I think it's groundbreaking.

"I think it's groundbreaking," said Yousuf Zafar, MD, from the Duke Cancer Institute in Durham, North Carolina. "It is a validated measure for identifying a risk that we did not even acknowledge a few years ago," he told Medscape Medical News.

Dr. Zafar and his Duke colleague, Amy Abernathy, MD, who coined the phrase, first wrote about financial toxicity last year (Oncologist. 2013;18:381-390), arguing that it is an adverse event with clinical ramifications, including a lower likelihood of drug treatment compliance, as reported at the time by Medscape Medical News.

In the year since, that report became the second most cited article in the history of the journal.

Many community oncologists are already using financial counselors.

Clinicians should be open to the idea of COST or similar tools, said Dr. Zafar. "Many community oncologists are already using financial counselors to screen patients to ensure that they can pay their bills."

A tool such as COST, which captures a patient-reported outcome, could help predict who will run into trouble and could allow for timely intervention, he said.

New Tool Based on Qualitative Data

In developing COST, Dr. de Souza and colleagues analyzed dozens of potential qualitative questions to ensure content validity and to avoid redundancy.

The team finally settled on 11 statements, including I feel financially stressed, I am able to meet my monthly expenses, and my out-of-pocket monthly expenses are more than I thought they would be.

The absence of quantitative information in COST, such as income and drug costs, is acceptable, said Dr. Zafar.

"In our research, we have found that income didn't really matter," he explained, saying that even wealthy people can undergo financial distress because cancer care costs and periods of unemployment can wreak havoc.

"Even small out-of-pocket costs can impact adherence," Dr. Zafar stated.

The median age of the 155 patients involved in the development of COST was 59.5 years, the median household income was $63,500, all had health insurance, and nearly 40% had completed college or higher education.

Sociodemographic variables, such as race, sex, and insurance type, were not significantly associated with financial toxicity, as measured in the COST cohort.

Nonetheless, the researchers report that greater financial distress was seen in patients without private insurance and in nonwhite patients.

However, these results are not important right now, they note. Their development work was powered for "factor analysis" to determine content validity and not to detect associations with sociodemographic variables.

Although the tool needs further validating, the implications of having such a measuring stick are vast nonetheless, Dr. de Souza and colleagues explain.

Among other things, patients at higher risk for financial distress could be triaged into "intervention programs" that include "cost-communication" programs.

Even drug development could be influenced by a tool like COST, the researchers note, "because cost burden may be factored into quality-of-life assessments in clinical trials."

Cancer. Published online June 20, 2014. Abstract


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