'Financial Toxicity': Still a Pressing Concern for Patients With Cancer

Roxanne Nelson, BSN, RN

August 10, 2017

Financial toxicity has become a well-established "side effect" of cancer care, with many patients experiencing varying levels of distress related to the cost of their care.

A new analysis now shows that over a third of patients with cancer who have health insurance are facing out-of-pocket costs that are higher than they anticipated. Not surprisingly, those experiencing the highest economic burden were the most distressed.

Within this cohort, 39% of patients experienced a higher than expected financial burden and 16% reported high or overwhelming financial distress.

Those who experienced the highest level of distress were patients who were underinsured and who were spending nearly a third of their income for costs related to their cancer treatment.

"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," say the authors, led by Fumiko Chino, MD, from the Duke University Medical Center, Durham, North Carolina.

"This suggests that unpreparedness for treatment-related expenses may impact future cost-conscious decision making. Interventions to improve patient health care cost literacy might impact decision making," they write.

The findings were published August 10 in a research letter in JAMA Oncology.

The High Cost of Care

The term "financial toxicity" was coined by Amy Abernethy, MD, from the Duke Cancer Institute, and colleagues, to describe an "adverse event" that is being increasingly experienced by patients with cancer.

"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," they wrote in 2013.

At the time, they noted several reasons underlying the high economic burden faced by patients with cancer. One was the cost of treatment itself, which had become increasingly more expensive than in days past.

The cost of private insurance premiums jumped by 170% from 1999 to 2011 — far outpacing the average increase in wages. Prescription drug copayments also radically changed with the introduction of tiered formularies that passed more cost to the patient. As an example, from 2000 to 2012, the proportion of individuals with a drug plan containing three tiers increased from 27% to 63%.

Other papers and researchers have looked at the effect of cost on both patients and survivors.

For example, a 2015 study conducted among patients with multiple myeloma showed that a substantial proportion 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.

All of the patients had health insurance, but nearly half had tapped into their savings to pay for their treatment. In addition, almost 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.

In a 2016 survey of nearly 700 survivors of childhood cancer, investigators found that 23% of respondents reported one or two instances of forgoing needed healthcare because of the costs involved, and 31% reported at least three instances.

"The sad story of all of this is that the ones with chronic health conditions are the ones who need care the most, and they are the ones most likely to skip some of their needed healthcare," lead author, Douglas Fair, MD, a pediatric oncologist from the University of Utah in Salt Lake City, told Medscape Medical News at the time. "This may be because they also have more social morbidities. They may not have a job or not have insurance because they don't have a job, so again, they are socioeconomically vulnerable."

Distress Despite Being Insured

In the current study, Dr Chino and colleagues conducted a cross-sectional survey to look at financial distress and cost expectations among patients who were undergoing cancer therapy. The 300 adult patients were receiving treatment at a comprehensive cancer center and at three affiliated rural oncology clinics.

The cohort comprised 300 patients, and all but 3 had some type of insurance coverage: 168 with private insurance, 107 with Medicare, and 22 with Medicaid.

Within this group, 49 patients (16%) reported that they were experiencing high or overwhelming financial distress. The median relative cost of care (defined as monthly out-of-pocket costs divided by income) was 11% for the entire cohort but 31% for those with the greatest level of distress.

In comparison, the median relative cost of care was only 10% for patients with no, low, or average financial distress.

In an unadjusted analysis, factors associated with an unexpected burden included being nonwhite, unemployed/not retired, unmarried, and younger and having lower household income, higher costs, colorectal/breast cancer, a lower quality of life, and higher financial distress.

In an adjusted analysis, experiencing higher than expected financial burden was associated with high or overwhelming financial distress (odds ratio, 4.78; P < .01), as well as a reduced willingness to pay for treatment (odds ratio, 0.48; P = .03).

"Future studies should test interventions for cost mitigation through shared decision making," the author conclude.

Coauthor Dr Zafar was supported by the American Cancer Society and by institutional support from the Duke Cancer Institute. The authors have disclosed no relevant financial relationships.

JAMA Oncol. Published online August 10, 2017. Abstract  

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