Financial Toxicity: Still Not Discussed With Cancer Patients

Roxanne Nelson, BSN, RN

July 24, 2018

Financial toxicity has become a well-established issue within cancer care, ever since the term was first coined by S. Yousuf Zafar, MD, and Amy Abernethy, MD, from the Duke Cancer Institute in Durham, North Carolina, to describe an "adverse event" increasingly experienced by patients with cancer.

Despite the growing attention to cancer costs and the need for that aspect of care to be addressed in the clinical setting, a new study has found that this topic is not being adequately addressed by oncologists and other clinicians.

The findings were published online July 23 in Cancer.

They come from a survey that included 306 medical oncologists. About half of them reported that someone in their practice often or always discusses financial burden with patients.

Among breast cancer patients who responded that they were worried about finances, almost three quarters said that their physicians and staff did not offer any assistance.

Among patients who wanted to discuss the impact of breast cancer on employment or finances, 55% reported that they had not had a relevant discussion about this with their provider.

"There definitely appears to be growing awareness in the oncology community of financial toxicity and the need for providers to support patients in this regard," said lead author Reshma Jagsi, MD, DPhil, from the Department of Radiation Oncology at the University of Michigan, Ann Arbor.

But it is a big challenge to know how to have these difficult conversations, she told Medscape Medical News.

"A potentially useful intervention strategy involves communication training for oncology providers," said Jagsi, who is also director of the Center for Bioethics and Social Sciences in Medicine.

"These sorts of interventions need to be developed and evaluated in future research if we are to move the needle on this important issue," she added.

A Gap Remains

There is limited evidence as to whether growing attention to financial issues has motivated physicians to more routinely embrace practices that address and attempt to mitigate financial toxicity, the authors note.

Virtually nothing is known concerning the level of physician engagement with patients regarding financial toxicity or patient perceptions about whether or not their needs are being met, they write. This is what motivated them to conduct the survey.

The survey involved 2502 patients with early breast cancer, 370 surgeons, 306 medical oncologists, and 169 radiation oncologists.

Among medical oncologists, 50.9% reported that someone in their practice often or always discusses financial concerns with patients, as did 15.6% of surgeons and 43.2% of radiation oncologists.

Forty percent of medical oncologists also believed that they were quite aware or very aware of the out-of-pocket costs of the tests and treatments that they recommend to patients, as did 27.3% of surgeons and 34.3% of radiation oncologists.

More than half (about 57%) of medical oncologists and radiation oncologists (55.8%) reported that it was quite important or extremely important to save the patient money, as did 35.3% of surgeons.

Many of the patients who participated in the survey reported that they had acquired debt from their treatment. These patients included 27.1% of white, 58.9% of black, 33.5% of Latina, and 28.8% of Asian women. Many patients also reported substantial amounts of lost income and out-of-pocket expenses that they attributed to their disease.

About 14% of all patients reported that the lost income amounted to 10% or more of their household income; 17% of patients reported spending 10% or more of their household income on out-of-pocket medical expenses; and 7% of patients reported spending the same proportion on out-of-pocket nonmedical expenses.

Jagsi and coauthors note that the unmet patient needs for engaging physicians in discussion about financial concerns were common. Of 945 women who expressed concern about finances, 679 (72.8%) indicated that physicians and their staff did not help them. Among 523 patients who wanted to discuss the impact of breast cancer on employment or finances with their clinicians, 283 (55.4%) reported that no relevant discussions took place with their oncologist, primary care providers, social workers, or other professionals.

Awareness that financial toxicity exists isn't enough — we have to arm providers with tools they can use to provide meaningful help when it is needed. Dr Reshma Jagsi

"Awareness that financial toxicity exists isn't enough — we have to arm providers with tools they can use to provide meaningful help when it is needed," said Jagsi.

The study was funded by a grant to the University of Michigan from the National Cancer Institute and was supported by the University of Michigan Cancer Center Biostatistics, Analytics and Bioinformatics shared resource. Dr Jagsi has received grants from the National Cancer Institute, the Doris Duke Charitable Foundation, and Blue Cross Blue Shield of Michigan and has acted as a paid consultant for Amgen for work performed outside of the current study. Coauthors have received research funding from pharmaceutical companies for work performed outside of the current study.

Cancer. Published online July 23, 2018. Abstract

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