Financial Toxicity and Survival of Patients With Cancer

Roxanne Nelson, RN, BSN

March 17, 2021

Worries about out-of-pocket costs of treatment they are receiving — so-called "financial toxicity" — may harm outcomes for patients with cancer, new research suggests.

The study found that patients with head and neck cancer who were worried about their finances had approximately double the risk of dying when compared to patients without such worries.

The findings were published in Oral Oncology.

"This is the first time that financial worry was shown to impact survival," senior author Anurag Singh, MD, professor of oncology and director of radiation research at Roswell Park Cancer Center, Buffalo, New York, told Medscape Medical News.

"The association we found was very strong, and very concerning," he said. "If you are worried about your finances, your risk of dying is roughly double."

Singh emphasized that the risk of dying was not related to missing treatment due to financial concerns. Although it has been previously reported that as many as a quarter of all patients with cancer choose not to fill a prescription because of cost, this was not the case for the current study population. "Our patients all finished on time and did not skip treatments," he said.

Singh suggests these results could be extrapolated to the larger cancer population, as many cancer types require long treatments, expensive targeted agents, and surgery. "It is possible, and we are studying it in lung, breast, and prostate cancer patients," he said.

The problem of financial toxicity has been widely reported; however, few solutions have emerged, especially those that can be implemented immediately. Singh reports his institution has begun a referral program and plans to publish on this soon. "We have been utilizing financial counselors for our head and neck patients for more than 3 years," he said. "This has stabilized the amount of financial worry during the course of treatment — meaning it didn't get worse while the patient was undergoing treatment."

Financial Worries Linked to Worse Outcomes

In the article, Singh and colleagues explain that they studied patients with head and neck cancer because medical and out-of-pocket expenses are higher for this tumor type compared with other malignancies. Previous studies have shown that patients with head and neck cancer are at risk for worsening quality of life due to financial toxicity, and one study showed that more than two out of three such patients relied on cost-coping strategies, such as selling personal assets or taking credit card loans (J Onc Pract. 2017;13:e310-8).

The team conducted a retrospective review of 284 patients treated at Roswell Park Comprehensive Cancer Center with definitive or postoperative radiation therapy between 2013 and 2017. The median age of patients was 61 years and more than three quarters were men (77.5%).

Of this group, 204 patients (71.8%) received definitive radiation and 80 patients (28.2%) were treated with adjuvant radiation. Chemotherapy was used for 237 patients (83.5%), usually cisplatin, and median follow-up was 39.9 months.

At baseline, 41 (14.4%) patients reported a high level of financial difficulties, and the rate of relapse was higher among these patients.

In the group of patients with financial difficulties, 14 of 41 (33%) patients had a relapse (7 distant, 7 local). Subsequent treatments included none (n = 6, 42.9%), systemic therapy (n = 5, 35.7%), and surgery (n = 3, 21.4%); three patients (21.4%) received immunotherapy at some point during treatment.

In comparison, among patients who reported low financial difficulty at baseline, 50 of 243 patients (20.6%) had a relapse (34 distant, 16 local). Subsequent treatments included none (n = 15, 30%), systemic therapy (n = 25, 50%), and surgery (n = 10, 20%); 14 patients (28%) received immunotherapy at some point during treatment.

The researchers note there was no significant association between financial difficulties and receipt of additional treatments (P = .36) or immunotherapy (P = .62).

However, on multivariable analysis, they found a significant association between financial difficulties and worse overall survival (hazard ratio [HR], 1.75; P = .03) and cancer-specific survival (HR, 2.28; P = .003).

When the team narrowed their focus to 66 patients matched with well-balanced baseline characteristics, the significant association was even more pronounced: a high level of financial difficulties remained associated with worse overall survival (HR, 2.72; P = .04) and cancer-specific survival (HR, 3.75; P = .02).

The team notes that an earlier study by Ramsey and colleagues (J Clin Oncol. 2016;34:980-6) found a higher risk of death among patients with cancer who filed for bankruptcy than those who hadn't. The adjusted mortality among patients with cancer who filed for bankruptcy was nearly double (HR, 1.79; 95% CI, 1.64 - 1.96), and colorectal, prostate, and thyroid cancers had the highest hazard ratios.

Researchers comment that the hazard ratios for overall survival in their current study in the overall and match pair populations (1.75 and 2.72) are consistent with the overall cohort hazard ratio of 1.79 reported by Ramsey and colleagues. "If confirmed in other cohorts, this would suggest that relatively mild financial toxicity at baseline may have the same impact on mortality as an extreme consequence like post-therapy bankruptcy," they comment.

The study was supported by the National Cancer Institute Cancer Center. The authors have declared no disclosures

Oral Oncol. 2021;115:105196. Abstract

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