Financial Toxicity Prevalent in Older Cancer Patients

Roxanne Nelson, BSN, RN

September 24, 2018

About one in five older cancer patients report experiencing financial toxicity, according to researchers from the University of Rochester in New York.

In a large cohort of more than 500 patients aged 70 years and older, 18% stated they were experiencing financial problems related to the cost of their treatment and that this was taking a toll on their care, quality of life, and mental well-being.

Compared with those not experiencing financial issues, patients reporting financial toxicity had a higher prevalence of severe anxiety (18% vs 7%) and depression (27% vs 21%), as well as a poorer quality of life (41% vs 22%).

The study also found that many older patients report delaying taking medication and/or are unable to afford their basic needs, explained lead author Asad Arastu, MSc, a medical student at the University of Rochester.

"Patients said that they were unable to afford medication and also had problems like the need to take time off work, not being able to afford gas, and cost concerns in other domains," he told Medscape Medical News. "There are a lot of missed opportunities, as patients have these concerns and they are not being discussed."

The findings will be presented at the American Society of Clinical Oncology (ASCO) Quality Care Symposium 2018. The study is a secondary analysis of baseline data from a geriatric assessment intervention study that was conducted across 31 practice sites.

Well-Established "Side Effect" of Cancer Therapy 

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.

However, financial toxicity is a subjective measure without a standard definition, Arastu commented. In order to measure the impact of financial toxicity on cancer patients in their study, the team developed an easy-to-use screening measure for cancer patients based on the current literature.

Patients were categorized as experiencing financial toxicity if they answered yes to any of three questions:

  1. Have you ever delayed medications because of cost?

  2. Have you ever had insufficient income in a typical month for food or housing?

  3. Have you ever had insufficient income in a typical month for other basic needs?

"The three questions are practical and easy for oncologists to use," said Arastu, noting that measurement and assessment tools can often be cumbersome and time consuming for both the patient and physician to fill out.

Senior author Supriya Gupta Mohile, MD, the Wehrheim professor of medicine at the Wilmot Cancer Institute, University of Rochester Medical Center, agrees and said the study has changed her own practice.

"I traditionally didn't ask my patients about their finances," she told Medscape Medical News. "With older patients, there is this perception that they have Medicare and may be okay. This study really impressed upon me how important it was to ask these simple questions about their income or if they can cover their basic needs."

"It is very easy to do, to ask these questions, and I have changed my own practice since we did this research," Mohile emphasized.

I've been surprised by my own assumptions and biases.    Dr Supriya Gupta Mohile a

She explained that the patients were very receptive and it only takes a few minutes of her time. It has also changed her perception that you can't judge a patient's financial status by just their appearance. "I've been surprised by my own assumptions and biases — that I may have assumed that they were well-off or okay and then have been surprised by what they told me," she said. "Or I find out that they are not taking their medicine correctly or missing things they need to do — and found out only because I've asked these questions. It really has opened up an opportunity to have these discussions and make referrals for the patient."

Greater Severity of Mental Health Issues

Patients were categorized as experiencing financial toxicity if they reported delaying medications because of cost, insufficient income in a typical month for food and housing, or insufficient income in a typical month for other basic needs.

Additionally, patients also completed the Generalized Anxiety Disorder-7 (GAD7, score 0–21) questionnaire to evaluate anxiety, Geriatric Depression Scale (GDS, score 0–15) to assess depression, and Functional Assessment of Cancer Therapy-Generation (FACT-G, score 0–108), to measure overall quality of life.

The 542 patients included in the study ranged in age from 70 to 96 years (mean age 77 years; 49% women).

The team found that 18% (n = 98) met the criteria for financial toxicity. In addition, those in the group experiencing financial toxicity scored 1.76-points higher (P < .01) on the GAD7 (indicating greater anxiety severity), 0.76-points higher (P = .02) on the GDS (indicating greater depression severity), and 5.16-points lower (P < .01) on the FACT-G (indicating lower quality of life).

"This is an important topic, and by creating these questions, we hope capture any patients who are experiencing financial toxicity, as well as equipping oncologists with the interventions and information they may need," Mohile commented.

Addressing financial toxicity is also part of larger healthcare "system error," she added, and that there is ongoing research into improving cancer care delivery.

Different Kind of Research

Commenting on the study, William Dale, MD, PhD, chair, Supportive Care Medicine at the City of Hope, Duarte, California, pointed out that the analysis is unique as it is focused completely on an older population. "It is assumed that the majority should have some form of insurance, but this speaks to trade-offs the patients may be making to pay for their care," he said.

This study is also different from other research, which focuses on drug pricing, Dale noted.

"This is patient-reported and about what they are struggling with — whether they are trying to pay for their cancer medicines or associated medications, such as for pain, or even medications that they were already taking prior to their cancer diagnosis," he said. "They may be trying to decide between medications — which is more important — and cutting back on basic needs, such as food."

This is a different kind of financial toxicity, Dale added. "We need to see how they get through their day and try to help them figure out how to pay for everything."

The study also showed that those experiencing financial toxicity were more likely to feel anxious and depressed and have a poorer quality of life. "We can't prove that's the cause, and these issues can be co-associated with cancer, " he said. "But it's safe to say that financial issues may play a role."

No funding source for the study was reported. Mohile has reported having a consulting or advisory role with Seattle Genetics. Arastu has reported no relevant financial relationships.

ASCO Quality Care Symposium. Phoenix, Arizona; September 28, 2018. Abstract 87.

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