Affluent, Insured, and Worried About Cancer Costs

8 in 10 Patients Want Cost Review Prior to Treatment

Nick Mulcahy

September 26, 2018

The cost of early stage breast cancer therapy is a concern that influences treatment decisions for many women, even when they have insurance and higher income than most Americans, a new survey suggests.

The 607 survey participants all had a history of breast cancer or ductal carcinoma in situ (stage 0-III). The majority had private insurance (70%) or Medicare (25%) and a higher annual household income (≥ $74,000) than the general US population.

Despite this relatively empowered socioeconomic status among participants, nearly half (43%) reported considering costs when making treatment decisions. Furthermore, 40% wanted their physicians to think about costs when making medical recommendations.

The survey participants also overwhelmingly reported that they wanted to understand costs prior to treatment (79%), report the study authors, led by Rachel Adams Greenup, MD, MPH, of Duke University Medical Center in Durham, North Carolina.

The study revealed this rarely happened, with 78% of the women saying that costs were never discussed with their caregivers.

The new data are due to be presented at the American Society of Clinical Oncology (ASCO) Quality Care Symposium, September 28-29, in Phoenix, Arizona.

"In an era of rising cancer treatment costs, we don't routinely discuss the financial implications of cancer care with women embarking on treatment," said Greenup in a meeting press statement.

In an era of rising cancer treatment costs, we don't routinely discuss the financial implications of cancer care    Rachel Adams Greenup, MD

Many breast cancer treatment options are comparable in efficacy but have different costs, she said, adding that information about costs could facilitate better decision making.

Details of the Survey

The study participants — who were participants in the Army of Women or the Sisters Network, which are national organizations for women after breast cancer — completed an 88-question electronic survey. The survey focused on their experiences with breast cancer treatment costs and preferences for cost information.

The group was relatively young (median age at diagnosis, 49.6 years) and median time from diagnosis was 6.7 years.

Median reported out-of-pocket (OOP) costs were $3500. However, 25% had OOP costs ≥ $8000, 10% had OOP costs ≥ $18,000, and 5% had OOP costs ≥ $30,000.

The survey also asked women to characterize their financial burden as none, slight, somewhat, significant, and catastrophic. A total of 15.5% chose significant or catastrophic to describe their financial burden.

In view of the survey population's demographics (insured, educated, and white), it is likely that other American women have an even greater risk of financial harm, according to ASCO.

In the study, women were more likely to report financial harm if they had bilateral mastectomy vs lumpectomy (odds ratio [OR], 1.9; P = 0.03), greater stage at diagnosis (stage 3 vs 0; OR, 3.9; P < 0.01), and discussed costs during the clinical encounter (OR, 2.3; P < 0.01).

Women who reported discussing costs were more likely to be stage 2 or 3 (56% vs 40%; P = 0.02), less likely to be depressed (24% vs 30%; P = 0.03), and had less insurance coverage (trend P = 0.02) compared with those who did not.

The researchers reported that decreased risk of financial harm was associated with older age (OR, 0.95; P < 0.01), increasing household income (overall P < 0.001), better insurance coverage (OR, 0.5; P < 0.001), and longer time since diagnosis (OR, 0.65; P < 0.001).

Greenup believes that knowing the price of treatments might be a clinical boon. "Cost transparency could improve the quality of treatment decisions patients make and has the potential to reduce the risk of financial harm," she said in a Duke press statement.

Research Into Costs Yields Insights

In recent years, Duke University has been at the forefront of research related to cancer costs, related financial harms, and the topic of cost transparency.

The now ubiquitous term financial toxicity was coined in 2013 by Amy Abernethy, MD, PhD, who was a medical oncologist at the Duke Cancer Institute at the time. The term describes an "adverse event" increasingly experienced by patients with cancer, she and a colleague explained.

Last year, Duke researchers reported that over a third of patients with cancer who have health insurance are facing out-of-pocket costs that are higher than they anticipated.

Other researchers have documented that oncologists have not fully taken up the subject of cancer treatment costs in the clinic. For example, earlier this year a survey that included 306 medical oncologists as well as patients found that cancer costs are not being adequately addressed by oncologists and other clinicians, as reported by Medscape Medical News.

Oncologists could potentially help control overall cancer costs if they learned the costs of the drugs they prescribe, a former insurance executive said at this year's National Comprehensive Cancer Network annual meeting.

Drugs account for 45% to 50% of the total cost of cancer care in the United States, and opportunities abound for cost reductions, said Lee Newcomer, MD, MHA, who recently retired as senior vice president, oncology and genetics, UnitedHealthcare.

He cited the example of bone-modifying agents for patients with metastatic breast cancer: the bisphosphonate zoledronic acid ($200/year) has equivalent efficacy to the monoclonal antibody denosumab ($25,900/year).

Multiple study authors have reported financial ties with Pfizer.

ASCO Quality Care Symposium. Phoenix, Arizona; September 29, 2018. Abstract 32.

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