Myeloma Patients, Even Well-Off Ones, Vulnerable to Financial Toxicity

Roxanne Nelson RN, BSN

September 25, 2015

"Financial toxicity" is prevalent in patients with multiple myeloma, even those with health insurance, new research indicates.

A small study of 100 patients found that a substantial proportion of them were struggling or sacrificing to pay for their treatment, and had to resort to a variety of strategies to cover the cost of their care.

Nearly half of those surveyed, all of whom had insurance, had tapped into their savings to pay for their treatment. Nearly three quarters (71%) reported having at least a minor financial burden, and 36% had applied for financial assistance. In addition, 10 patients had to stop their treatment altogether.

The study was published online in Lancet Haematology.

The ever-rising costs of treatment, coupled with increasing, out-of-pocket expenses for patients, has led to a new term in cancer care — "financial toxicity," coined 2 years ago by oncologist Amy Abernethy, MD, from the Duke Cancer Institute in Durham, North Carolina. She and her colleague reported that "out-of-pocket expenses related to treatment are akin to physical toxicity, in that costs can diminish quality of life and impede delivery of the highest quality care."

In the current paper, lead author Scott Huntington, MD, who was with the division of hematology/oncology at the University of Pennsylvania, Philadelphia, at the time the study was conducted and is now a faculty member at Yale University, noted that the high-cost novel therapies are integral to myeloma treatment in the United States and place the general myeloma population at risk for financial burden.

"Our pilot study population was well insured and had a number of factors potentially protective against financial burden — including a higher household income and education level compared to the US population at large," he told Medscape Medical News.

But it is unclear if these results can be extrapolated to the larger population of myeloma patients. "As a pilot study, our single institution setting may limit the generalizability of our findings," Dr Huntington said. "Future multi-center studies may be useful to define the impact of financial toxicity on clinical outcomes and aid early identification of patients at greatest risk."

While cancer patients in general are being hard hit, the authors hypothesized that myeloma patients may be particularly vulnerable to financial toxicity because of prevalent use of high-cost novel agents and prolonged treatment duration, including long-term maintenance therapies. "We hope our study adds to the conversation surrounding treatment-related financial toxicity, a growing problem for patients dealing with cancer," he explained.

Multiple Payment Strategies Used

In this study, Dr Huntington and his colleagues conducted a cross-sectional survey of individuals who were receiving at least 3 months of ongoing treatment for multiple myeloma at a single tertiary academic medical center in the US. The survey was derived from previously reported studies and included the 11-item COST (Comprehensive Score for Financial Toxicity), and insurance and treatment data were obtained from patients' electronic health records.

Overall, they found that financial toxicity was common and the COST score was strongly associated with patient-level factors and the use of strategies to cope with high treatment costs.

The median household income of the cohort was between $60,000 and $79,999 per year, and 70 (70%) of 100 patients reported at least some college education. At the time of the survey, all patients had health insurance, and when stratified by median COST score, patients with scores of 23 or less (higher financial toxicity) were more likely to be women, black, not married, and have lower household incomes per year than were individuals with scores of greater than 23 (P < ∙05).

More than half of the participants (59%) reported that treatment costs for myeloma were higher than expected, and 55% reported that they had reduced spending on basic goods.

Nearly two thirds (64%) stated that they had decreased spending on leisure activities since their cancer diagnosis.

The use of savings to pay for treatment was common in this cohort (46%), 21% said that they had borrowed money, and 17% reported that there were delays in their treatment because of cost.

Thirty-six percent of patients said that they had applied for financial copayment assistance, including six persons with household incomes of over $100,000 per year.

Patients with COST scores lower than the median (increased financial toxicity) were more likely to report reduced spending on basic goods and leisure activities, use of savings for cancer care, borrowing money to pay for treatment, a delay in treatment initiation for financial reasons, and stopping myeloma treatment because of cost than were those with scores of greater than the median (all P < ∙01).

Traditionally, oncologists did not discuss cost with patients when prescribing treatment, but now it seems that needs to be part of the conversation, Dr Huntington pointed out. "Encouraging cost and value-based discussions between patients and providers may be a necessary first step in addressing treatment-related financial toxicity."

"However, structural healthcare reforms are likely needed to ensure our system not only rewards treatment innovation, but also secures equitable and affordable cancer care for all," he added. “Without reforms in the United States, the impact of financial toxicity and implicit rationing is likely to grow, jeopardizing access to promising cancer treatment."

The study was funded by the Perelman School of Medicine at the University of Pennsylvania. Several of the coauthors have relationships with industry.

Lancet Haematol. Published Online September 17, 2015.

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