Out-of-Pocket Costs More Stressful Than Cancer in Texas

Nick Mulcahy

July 31, 2015

In a finding that points to the overwhelming impact of out-of-pocket expenses in American cancer care, more than 30% of patients with advanced cancer rated their financial distress to be more severe than their physical, family, and emotional distress, according to a new study from Texas.

Of the 149 study participants, 72 received treatment for advanced cancer at a general public hospital in Houston and 77 received treatment at a private comprehensive cancer center.

Not surprisingly, the poor folks at the public hospital were a lot worse off.

In fact, a novel self-reported survey revealed that the average "intensity" of financial distress in the public hospital patients, measured in a 10-point scale, was more than twice that of private center patients (8 vs 4; P = .0003).

But some degree of financial distress was present in just about all public and private patients (90% vs 86%).

Financial distress was calculated as the percentage of a patient's total family income spent on out-of-pocket cancer costs in the previous month and the related subjective stress.

Median monthly income of the public patients was lower than that of the private patients ($940 vs $3000).

The overall findings are "concerning" because physicians lack the tools to uncover financial distress, according to the study authors, led by Marvin Delgado-Guay, MD, from the University of Texas M.D. Anderson Cancer Center in Houston.

"The vast majority of the instruments aimed at determining symptom distress and quality of life do not include a financial distress item," they write.

Their study was published online July 23 in the Oncologist.

Financial distress was also associated with anxiety, depression, and poor quality of life.

"I am not surprised that such a large proportion of patients consider financial distress to be more unbearable than other forms of distress," said Yousuf Zafar, MD, from the Duke Cancer Institute in Durham, North Carolina, who, along with his colleague Amy Abernethy, MD, coined the phrase "financial toxicity," as reported by Medscape Medical News.

Patients are at risk of suffering in silence.

Dr Zafar said that patients are ill-prepared for the treatment-related financial burden and do not know where to go for help. "As a result, patients are at risk of suffering in silence," he said.

Dr Delgado-Guay's team and Dr Zafar agree that of all stressors a cancer patient faces, financial distress receives the least attention.

What can clinicians do? Perhaps use the Comprehensive Score for Financial Toxicity (COST) — a questionnaire developed at the University of Chicago, as reported by Medscape Medical News — to help "identify possible interventions to ease patient suffering," the study authors say.

The 30% Explained

In their study, patients had breast, colon, lung, or prostate cancers that were recurrent/refractory (treated with more than two lines of chemo), locally advanced, or metastatic.

In addition to the COST questionnaire, which is not a validated tool, patients completed validated questionnaires to assess symptoms, psychosocial distress, and quality of life/functioning.

To assess the relation between money stress and other cancer-related stressors, the study participants responded to a series of statements made by the investigators, such as "I have more financial distress than physical distress."

Financial distress was reported to be more severe/stressful than physical symptom distress by 45 patients (30%), than distress about physical functioning by 46 patients (31%), than social/family distress by 64 patients (43%), and than emotional distress by 55 patients (37%).

All responses were significantly worse for patients treated at a public hospital than at a private center (P < .05).

When patients consistently report a high level of physical, spiritual, and emotional distress, clinicians should explore the possible presence of financial woes. In other words, when ongoing high levels of distress of any kind are present, expect that financial distress is also present, say the authors.

However, they caution against generalizing their findings because only two institutions were involved.

The authors and Dr have disclosed no relevant financial relationships.

Oncologist. Published online July 23, 2015. Abstract


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