A review of cost communication in oncology: Patient attitude, provider acceptance, and outcome assessment

Financial Hardship in Survivorship Care Delivery

Cancer-related financial hardship is highly prevalent and affects individuals in the setting of cancer care delivery across the survivorship trajectory. Mitigating financial hardship requires multi-level solutions at the policy, payer, health-care system, provider, and individual patient levels. At the highest level, strategies for intervention include enacting policies to improve price transparency and expand insurance coverage. Also needed are implementing systematic screening and financial navigation in cancer care delivery; improving cost communication by provider care teams; developing patient-reported measures that incorporate the multiple, complex dimensions of financial hardship, as reflected in the Economic Strain and Resilience in Cancer tool; and advancing electronic medical record infrastructure to manage data on patient financial hardship. For individual patients, activating their social networks, community resources, and employers provides patient-level support resources to enhance coping. The proposed multi-level approach is needed to overcome financial hardship in the setting of high-quality, high-value cancer care delivery.

Parent Preferences for Transparency of Their Child's Hospitalization Costs

Importance

Health care in the US is often expensive for families; however, there is little transparency in the cost of medical services. The extent to which parents want cost transparency in their children's care is not well characterized.

Objective

To explore the preferences and experiences of parents of hospitalized children regarding the discussion and consideration of health care costs in the inpatient care of their children.

Design, Setting, and Participants

This cross-sectional multicenter survey study included 6 geographically diverse university-affiliated US children's hospitals from November 3, 2017, to November 8, 2018. Participants included a convenience sample of English- and Spanish-speaking parents of hospitalized children nearing hospital discharge. Data were analyzed from January 1, 2020, to June 25, 2021.

Main Outcomes and Measures

Parents' preferences and experiences regarding transparency of their child's health care costs. Multivariable linear regression examined associations between clinical and sociodemographic variables with parents' preferences for knowing, discussing, and considering costs in the clinical setting. Factors included family financial difficulties, child's level of chronic disease, insurance payer, deductible, family poverty level, race, ethnicity, parental educational level, and study site.

Results

Of 644 invited participants, 526 (82%) were enrolled (290 [55%] male), of whom 362 (69%) were White individuals, 400 (76%) were non-Hispanic/Latino individuals, and 274 (52%) had children with private insurance. Overall, 397 families (75%) wanted to discuss their child's medical costs, but only 36 (7%) reported having a cost conversation. If cost discussions were to occur, 294 families (56%) would prefer to speak to a financial counselor. Ninety-eight families (19%) worried discussing costs would hurt the quality of their child's care. Families with a medical financial burden unrelated to their hospitalized child had higher mean agreement that their child's physician should consider the family's costs in medical decision-making than families without a medical financial burden (effect size, 0.55 [95% CI, 0.18-0.92]). No variables were consistently associated with cost transparency preferences.

Conclusions and Relevance

Most parents want to discuss their child's costs during an acute hospitalization. Discussions of health care costs may be an important, relatively unexplored component of family-centered care. However, these discussions rarely occur, indicating a tremendous opportunity to engage and support families in this issue.

Society of Behavioral Medicine (SBM) position statement: support increased knowledge and efforts to address the financial burden associated with cancer treatment

Millions of individuals and their families struggle with both treatment-related and out-of-pocket (OOP) economic repercussions of a cancer diagnosis, an effect increasingly referred to as "financial toxicity." In 2014, the Agency for Healthcare Research and Quality (AHRQ) estimated the total U.S. expenditures for cancer at $87.8 billion dollars with patient OOP costs accounting for $3.9 billion dollars (2014). These figures do not take into account indirect costs, such as those from lost earnings. As a result, financial toxicity can extend well beyond the active treatment phase and have a substantial impact on a household's economic reserve and financial resilience well into the future. Of the 9.5 million U.S. adults aged 50 years and older diagnosed with cancer (2000-2012), 42.2% have depleted their assets at 2 years and 38.2% were financially insolvent in 4 years. Bankruptcy rates are 2.65 times higher among cancer survivors than matched controls. A full 70% of Americans want to have conversations about the costs of care with their health care providers, but only 28% report doing so. Delaying or deferring these conversations can have major financial consequences for patients. According to a polling conducted for the Robert Wood Johnson Foundation (RWJF) by Avalere Health, almost 20% of patients report forgoing care when they have questions about costs. A critical element to achieve this is to have accurate cost information, including health care insurance coverage policies. Specifically, while patients and their families look to their health care providers to help them better navigate the cost implication of their treatment choices, most who are willing to undertake this challenging task need to have accessible and comprehensive (including direct and indirect) cost information to facilitate the discussion.

Financial Toxicity in Head and Neck Cancer Patients Treated With Proton Therapy

Cancer-related financial toxicity impacts head and neck cancer patients and survivors. With increasing use of proton therapy as a curative treatment for head and neck cancer, the multifaceted financial and economic implications of proton therapy-dimensions of "financial toxicity"-need to be addressed. Herein, we identify knowledge gaps and potential solutions related to the problem of financial toxicity. To date, while cost-effectiveness analysis has been used to assess the value of proton therapy for head and neck cancer, it may not fully incorporate empiric comparisons of patients' and survivors' lost productivity and disability after treatment. A cost-of-illness framework for evaluation could address this gap, thereby more comprehensively identifying the value of proton therapy and distinctly incorporating a measurable aspect of financial toxicity in evaluation. Overall, financial toxicity burdens remain understudied in head and neck cancer patients from a patient-centered perspective. Systematic, validated, and accurate measurement of financial toxicity in patients receiving proton therapy is needed, especially relative to conventional photon-based strategies. This will enrich the evidence base for optimal selection and rationale for payer coverage of available treatment options for head and neck cancer patients. In the setting of cancer care delivery, a combination of conducting proactive screening for financial toxicity in patients selected for proton therapy, initiating early financial navigation in vulnerable patients, engaging stakeholders, improving oncology provider team cost communication, expanding policies to promote price transparency, and expanding insurance coverage for proton therapy are critical practices to mitigate financial toxicity in head and neck cancer patients.

Are Cost-of-Care Conversations Best Practice? A Qualitative Study of Oncologists' Attitudes and Practice

PURPOSE

Patients' desire for cost conversations exceeds the incidence of such conversations, and many oncologists report avoiding cost conversations despite reporting willingness to have them. Our objective was to examine oncologists' attitudes toward cost conversations and how those attitudes affect practice.

METHODS

An experienced investigator conducted individual interviews with oncologists practicing in Kentucky. Participants were asked about their attitude toward and experience with cost conversations and their advice for discussing cost with patients. Interview transcripts were analyzed by a four-member team using qualitative descriptive analysis to identify themes.

RESULTS

Participants were 32 MDs (male = 68.8%) age 31-77 years who were board-certified in medical oncology (53.1%), surgical oncology (25.0%), or radiation oncology (21.9%). We categorized participants into two groups: (1) those who viewed cost conversations as best practice and reported pursuing such conversations (37.5%) and (2) those who viewed cost conversations as not best practice and reported avoiding them (62.5%). Our analysis revealed three parallel themes for each category: Cost conversation attitudes and practice were based on (1) making good treatment decisions, (2) being a good clinician, and (3) having a good relationship with patients.

CONCLUSION

Not all oncologists view cost conversations as best practice. To improve cost conversation attitudes and practice, cost conversations can be framed as a strategic tool that-when used well-fosters optimal decision making, professionalism, and the therapeutic relationship.

Assessing the pricing and benefits of oncology products: an update

Introduction: Oncology expenditure is outperforming all other health care sectors. In particular, the cost of oncology pharmaceuticals is soaring as it is fueled both by incremental costs and the introduction rate of new products. Due to the particularities of cancer as a disease, a significant multilayer of pressure is exerted toward the reimbursement of new treatments. Nevertheless, if the expenditure increase is left unattended, it may hamper the viability of any health care system worldwide.Areas covered: A literature review of the expenditure on oncology pharmaceuticals and the exploration of the root causes for the increase in expenditure was performed.Expert commentary: The surging oncology expenditure demonstrates a multi-layer causality that encompasses prices, the uncertainty of clinical trials, the specificities of cancer as a disease, and the artificial monopoly of oncology modalities. Moreover, laxity in the regulatory approval of new products was noted. In addition, the study design should be adequately justified. Finally, new reimbursement schemes, that explicitly reward and promote clinically meaningful and measurable outcomes, are also imperative.

Planning for End of Life

BACKGROUND

Oncology provider discussions of treatment options, outcomes of treatment, and end of life planning are essential to care for patients with advanced malignancies. Studies have shown that despite this, many patients do not have adequate care planning, including end of life planning. It is thought that the accessibility of information outside of clinical encounters and individual factors and/or beliefs may influence the patient's perception of disease.

AIMS

The objective of this study was to evaluate if patient understanding of treatment goals matched the provider and if there were areas of discrepancy. If a discrepancy was found, the survey inquired further into more specific aspects.

METHODS

A questionnaire-based survey was performed at a cancer hospital outpatient clinic. 100 consecutive and consenting patients who had stage IV non-curable lung, gastrointestinal (GI), or other cancer were included in the study. Patients must have had at least 2 visits with their oncologist.

RESULTS

40 patients reported their disease might be curable and 60 reported their disease was not curable. Patients who reported their disease was not curable were more likely to be 65 years or older (P-value: 0.055). They were more likely to report that their doctor discussed the possibility of their cancer getting worse (78.3% VS 55%; P-value 0.024), that their doctor discussed end of life plans (58.3% VS 30%; P- value: 0.01), and that they had appointed a health care decision-maker (86.7% VS 62.5%; P-value: 0.01). 65% of patients who thought their disease might be curable reported that their doctor said it might be curable, compared with only 6.7% of patients who thought their disease was not curable (p < 0.001). Or, equivalently, 35% of patients who thought their disease might be curable reported that their doctor's opinion was that it was not curable, compared with 93% of patients who thought their disease was not curable (p < 0.001). Patients who had lung cancer were more likely to believe their cancer was not curable than patients with gastrointestinal or other cancer, though the difference was not statistically significant (p = 0.165). Patients who said their disease might be curable selected as possible reasons that a miracle (50%) or alternative medicine (66.7%) would get rid of the cancer, or said their family wanted them to believe the cancer would go away (16.7%) or that another doctor said it would (4.2%). Patients who said their disease might be curable said they did so due to alternative medications, another doctor, or their family. Restricting to the 70 patients who reported their doctors telling them their disease was not curable, 20% of them still said that they personally felt their disease might be curable. Patients below 65 years of age were more likely to disagree with the doctor in this case (P-value: 0.047).

CONCLUSION

This survey of patients diagnosed with stage IV cancer shows that a significant number of patients had misunderstandings of the treatment and curability of their disease. Findings suggest that a notable proportion kept these beliefs even after being told by treating physicians that their disease is not curable.

Delivery of Financial Navigation Services Within National Cancer Institute-Designated Cancer Centers

Background

Cancer centers have a responsibility to help patients manage the costs of their cancer treatment. This article describes the availability of financial navigation services within the National Cancer Institute (NCI)-designated cancer centers.

Methods

Data were obtained from the NCI Survey of Financial Navigation Services and Research, an online survey administered to NCI-designated cancer centers from July to September 2019. Of the 62 eligible centers, 57 completed all or most of the survey, for a response rate of 90.5%.

Results

Nearly all cancer centers reported providing help with applications for pharmaceutical assistance programs and medical discounts (96.5%), health insurance coverage (91.2%), assistance with nonmedical costs (96.5%), and help understanding medical bills and out-of-pocket costs (85.9%). Although other services were common, in some cases they were only available to certain patients. These services included direct financial assistance with medical and nonmedical costs and referrals to outside organizations for financial assistance. The least common services included medical debt management (63.2%), detailed discussions about the cost of treatment (54.4%), and guidance about legal protections (50.1%). Providing treatment cost transparency to patients was reported as a common challenge: 71.9% of centers agreed or strongly agreed that it is difficult to determine how much a cancer patient's treatment will cost, and 70.2% of oncologists are reluctant to discuss financial issues with patients.

Conclusions

Cancer centers provide many financial services and resources. However, there remains a need to build additional capacity to deliver comprehensive financial navigation services and to understand the extent to which patients are referred and helped by these services.

Identifying a cut-off score for the COST measure to indicate high financial toxicity and low quality of life among cancer patients

PURPOSE

To identify a cut-off score for the COmprehensive Score for financial Toxicity (COST) to predict a clinical implication of a high level of financial toxicity (FT).

METHODS

A total of 640 cancer patients were recruited from three regional hospitals in Hong Kong. They completed a questionnaire comprising the COST measure and the Functional Assessment of Cancer Therapy - General (FACT-G) instrument. The cut-off score for the COST that predicts the lowest quartile of the FACT-G total score was identified by receiver operating characteristic (ROC) analysis. The sample was then stratified by this cut-off score, and characteristics were compared using Fisher's exact, chi-squared or independent sample t-test.

RESULTS

The mean scores were 20.1 ± 8.8 for the COST and 71.6 ± 15.5 for the FACT-G. The ROC analysis suggested that the cut-off of 17.5 yielded an acceptable sensitivity and specificity. Characteristics of patients with a higher level of FT included being younger, having a monthly household income of < 10,000 HKD (approximately 1290 USD), being more likely not employed, having stage IV cancer and receiving targeted and/or immunotherapy. In terms of financial support, a higher proportion of these patients had discussed financial issues with health care professionals and had received financial assistance. In addition, fewer of them were covered by private health insurance.

CONCLUSION

Our findings suggest a cut-off for the COST that can be used to screen for FT in clinical settings. In addition, while a considerable proportion of high-FT patients received targeted therapy, they often received financial assistance. There is a gap between financial hardship and assistance that warrants attention.

Financial worry and psychological distress among cancer survivors in the United States, 2013-2018

BACKGROUND

A growing proportion of cancer survivors experience financial toxicity. However, the psychological burden of cancer costs and associated mental health outcomes require further investigation. We assessed prevalence and predictors of self-reported financial worry and mental health outcomes among cancer survivors.

PATIENTS AND METHODS

Data from the 2013-2018 National Health Interview Survey (NHIS) for adults reporting a cancer diagnosis were used. Multivariable ordinal logistic regressions defined adjusted odds ratios (AORs) of reporting financial worry by relevant sociodemographic variables, and sample weight-adjusted prevalence of financial worry was estimated. The association between financial worry and psychological distress, as defined by the six-item Kessler Psychological Distress Scale was also assessed.

RESULTS

Among 13,361 survey participants (median age 67; 60.0% female), 9567 (71.6%) self-reported financial worry, including worries regarding costs of paying for children's college education (62.7%), maintaining one's standard of living (59.7%), and medical costs due to illness or accident (58.3%). Female sex, younger age, and Asian American race were associated with increased odds of financial worry (P < 0.05 for all). Of 13,218 participants with complete responses to K6 questions, 701 (5.3%) met the threshold for severe psychological distress. Participants endorsing financial worry were more likely to have psychological distress (6.6 vs. 1.2%, AOR 2.89, 95% CI 2.03-4.13, P< 0.001) with each additional worry conferring 23.9% increased likelihood of psychological distress.

CONCLUSIONS

A majority of cancer survivors reported financial worry, which was associated with greater odds of reporting psychological distress. Policies and guidelines are needed to identify and mitigate financial worries and psychologic distress among patients with cancer, with the goal of improving psychological well-being and overall cancer survivorship care.

Protocol for studying the efficiency of ChemoCalc software in helping patients to understand drug treatment costs for breast cancer: A multicenter, open-label, randomized phase 2 study

Survival of patients with breast cancer can be prolonged by treatment with drugs, particularly new molecular-targeted drugs. However, these agents can be expensive and such treatments can be “an economic burden.” In this ongoing trial, we aim to assess the usefulness of ChemoCalc, a software package for calculating drug costs, to help patients understand the financial outlays. In this multicenter, randomized controlled phase 2 trial, 106 patients with advanced breast cancer will be assigned to either the “ChemoCalc” or “Usual Explanation” group. Treatment using ChemoCalc will be discussed with patients in the ChemoCalc group, whereas standard treatments, without using ChemoCalc, will be discussed with patients in the Usual Explanation group. Subsequently, the participants will decide the treatment and complete a five-grade evaluation questionnaire; those in the Usual Explanation group will receive information about ChemoCalc. Investigators will report if patients subsequently decide to change treatments. The primary endpoint will be the scores of two key questions compared between the groups: “Did you understand the cost of treatment in today's discussion?” and “Do you think the cost of treatment is important in choosing a treatment?“. The secondary endpoints will be to compare discrepancies between treatments recommended by physicians and those selected by patients, the time required for discussion, other questionnaire factors, and the relationship between Comprehensive Score for Financial Toxicity tool and treatment selection. This will be the first randomized controlled trial to assess the efficacy of software to help patients understand drug cost estimates and whether it subsequently affects treatment choice. This study will be conducted according to the CONSORT statement. All participants will sign a written consent form. The study protocol was reviewed and approved by the Clinical Research Review Board of Nagasaki University (19070801). The protocol (version 1) was designed and will be conducted in accordance with the Declaration of Helsinki (1964) and the Ethical Guidelines for Medical and Health Research Involving Human Subjects (2017). The findings will be disseminated through scientific and professional conferences, and in peer-reviewed journals.

Trial registration

UMIN Clinical Trials Registry, UMIN000039904. https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000041968

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We aim to verify the efficiency of the drug cost estimation software ChemoCalc

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We will demonstrate whether knowing drug costs will change treatment choice

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We will elucidate whether ChemoCalc will enable patient–physician discussions

Defining the clinician's role in mitigating financial toxicity: an exploratory study

BACKGROUND

Financial toxicity describes the financial burden imposed onto patients by a cancer diagnosis and is a growing concern. Many clinicians do not currently address financial toxicity despite patients' desire for them to do so. Current literature explores physicians' perspectives but does not clearly define an actionable role clinicians can take to address financial toxicity. We sought to fill this gap by first assessing clinicians' perspective on their role in alleviating financial toxicity at our institution. We subsequently aimed to identify current barriers to mitigating financial toxicity and to garner feedback on clinician-oriented interventions to address this growing problem.

METHODS

We developed an 18-item electronic, anonymous survey through Redcap. We invited all oncology clinicians including attending physicians, advance practice providers, and trainees at our institution to participate.

RESULTS

A total of 72 clinicians (30%) completed the survey. The majority agreed that clinicians have a role in addressing cost. The top three barriers to discussing cost with patients were knowledge of out of pocket costs, time, and awareness of resources. Less than half of respondents used an existing comparative cost tool to incorporate cost consciousness into treatment decisions. The most desired intervention was an institutional resource guide. In open-ended comments, the most common barrier described was transparency of out of pocket costs, and the most common solution proposed was a multi-disciplinary approach to addressing financial concerns patient face.

DISCUSSION

Improving price transparency, incorporating existing resources into clinical practice, and streamlining multi-disciplinary support may help overcome barriers to addressing financial toxicity.

Bargain Hunting for Buffered Lidocaine: A Collaborative Discovery of Cost-saving Strategies That Can Improve Patient Care

Buffered lidocaine is a local anesthetic option during percutaneous needle-directed procedures in the breast. At our institution, sodium bicarbonate (the buffer) is dispensed in volumes that frequently lead to medical waste and shortages. In this study, we describe how moving the buffering of lidocaine from the procedure room to our clinical hospital pharmacy results in a reduction in costs and improves satisfaction across the breast radiology department. While cost savings are difficult to tease out in practices that opt for bundled payments, we were able to access pricing and supply data and coordinate with our pharmacy to change our practice. Making these changes saves our practice $26 000 a year and allows us to continue to offer buffered lidocaine even during sodium bicarbonate shortages. This manuscript describes how these changes came about and their economic impact.

Women Who Are Young, Non-White, and with Lower Socioeconomic Status Report Higher Financial Toxicity up to 1 Year After Breast Cancer Surgery: A Mixed-Effects Regression Analysis

PURPOSE

We examined self-reported financial toxicity and out-of-pocket expenses among adult women with breast cancer.

METHODS

Patients spoke English, Spanish, or Mandarin Chinese, were aged 18+ years, had stage I-IIIA breast cancer, and were eligible for breast-conserving and mastectomy surgery. Participants completed surveys about out-of-pocket costs and financial toxicity at 1 week, 12 weeks, and 1 year postsurgery.

RESULTS

Three hundred ninety-five of 448 eligible patients (88.2%) from the parent trial completed surveys. Excluding those reporting zero costs, crude mean ± SD out-of-pocket costs were $1,512 ± $2,074 at 1 week, $2,609 ± $6,369 at 12 weeks, and $3,308 ± $5,000 at 1 year postsurgery. Controlling for surgery, cancer stage, and demographics with surgeon and clinic as random effects, higher out-of-pocket costs were associated with higher financial toxicity 1 week and 12 weeks postsurgery (p < .001). Lower socioeconomic status (SES) was associated with lower out-of-pocket costs at each time point (p = .002-.013). One week postsurgery, participants with lower SES reported financial toxicity scores 1.02 points higher than participants with higher SES (95% confidence interval [CI], 0.08-1.95). Black and non-White/non-Black participants reported financial toxicity scores 1.91 (95% CI, 0.46-3.37) and 2.55 (95% CI, 1.11-3.99) points higher than White participants. Older (65+ years) participants reported financial toxicity scores 2.58 points lower than younger (<65 years) participants (95% CI, -3.41, -1.74). Younger participants reported significantly higher financial toxicity at each time point.

DISCUSSION

Younger age, non-White race, and lower SES were associated with higher financial toxicity regardless of costs. Out-of-pocket costs increased over time and were positively associated with financial toxicity. Future work should reduce the impact of cancer care costs among vulnerable groups.

IMPLICATIONS FOR PRACTICE

This study was one of the first to examine out-of-pocket costs and financial toxicity up to 1 year after breast cancer surgery. Younger age, Black race, race other than Black or White, and lower socioeconomic status were associated with higher financial toxicity. Findings highlight the importance of addressing patients' financial toxicity in several ways, particularly for groups vulnerable to its effects.

Patient-Provider Discussion About Cancer Treatment Costs and Out-of-Pocket Spending: Implications for Shared Decision Making in Cancer Care

OBJECTIVES

Patient-provider discussion about treatment costs has been recognized as a key component of shared clinical decision making in cancer care. This study examined the association of patient-provider cost discussion with out-of-pocket spending among cancer survivors.

METHODS

Using data from the 2016-2017 Medical Expenditure Panel Survey-Experiences with Cancer Survivorship Supplement, cancer survivors in the United States who reported having a detailed discussion about treatment costs were identified. Multivariable generalized linear model with gamma distribution and log-link was fitted to analyze average total out-of-pocket spending between those who had the discussion and those who did not. We also examined whether having the cost discussion is associated with the likelihood of reporting receipt of all cancer care they believed was necessary using a multivariable logistic regression model. All analyses controlled for patient socioeconomic and health-related characteristics.

RESULTS

Among 1525 individuals, representing 14.6 million cancer survivors in the United States (mean age, 65.5 years; 59% women; 80.4% white), only 10.4% (95% confidence interval [CI], 8.7%-12.1%) reported having the detailed cost discussion with their providers during their cancer care. Having a cost discussion was associated with a -33.8% reduction in (95% CI, -38.2% to -29.6%; an absolute difference of -$478) average total out-of-pocket spending. The probability of receiving all necessary patient-reported cancer care was not different between those who had the discussion and those who did not.

CONCLUSION

Detailed patient-provider cost discussions were associated with lower average total out-of-pocket spending. Patients who had detailed cost discussions with providers did not seem to sacrifice the appropriate utilization of necessary cancer treatments.

Assessment of Financial Toxicity Among Older Adults With Advanced Cancer

Importance

Financial toxicity (FT), unintended and unanticipated financial burden experienced by cancer patients undergoing cancer care, is associated with negative consequences and increased risk of mortality. Older patients (≥70 years) with cancer are at risk for FT, yet data are limited on FT and whether oncologists discuss FT with their patients.

Objective

To examine the prevalence of FT in older adults with advanced cancer, its association with health-related quality of life (HRQoL), and cost conversations between oncologists and patients.

Design, Setting, and Participants

This cross-sectional secondary analysis was performed on baseline data from the Improving Communication in Older Cancer Patients and Their Caregivers study, a cluster randomized trial from 31 community oncology practices across the US that was conducted from October 29, 2014, to April 28, 2017. Participants included 536 patients with advanced cancer who answered 3 questions regarding financial toxicity. Data were analyzed from September 1, 2019, to May 1, 2020.

Exposure

Older patients undergoing cancer care treatments.

Main Outcomes and Measures

The main outcome looked at FT and its association with HRQoL. Three questions were used to identify patients 70 years or older experiencing FT. Multivariable linear regression models were used to assess the independent associations of FT with HRQoL. A single audio-recorded clinic transcript was analyzed within 4 weeks of enrollment for patients with FT. The framework method was used to identify frequency and themes related to cost conversations.

Results

This study evaluated 536 patients 70 years or older with advanced cancer. Ninety-eight patients (18.3%) reported FT; mean (SD) age was 76.4 (5.4) years; 59 (60.2%) were female, 14 (14.3%) were Black/African American, 91 (92.9%) were not employed, and 29 (29.6%) had Medicare as their sole insurance coverage. On multivariate regression analyses, FT was associated with higher levels of depression (β = 0.81; 95% CI, 0.15-1.48), anxiety (β = 1.67; 95% CI, 0.74-2.61), and distress (β = 0.73; 95% CI, 0.08-1.39) and lower HRQoL (β = -5.30; 95% CI, -8.92 to -1.69). Among those who reported FT, 49% had a conversation with their health care professional about costs. Most conversations (79%) were initiated by oncologists or patients. Four themes were generated from cost conversations: statements regarding cost of care, ability to afford medical prescriptions, indirect consequences associated with inability to work and provide for family, and cost burden in nontreatment domains.

Conclusions and Relevance

In this study, among older adults with advanced cancer, FT is associated with worse HRQoL. Almost half of conversations among patients reporting FT demonstrated costs are being actively discussed. Resources and interventions are needed to manage FT.

Out-of-Pocket Costs and Perceived Financial Burden Associated with Prostate Cancer Treatment in a Quebec Remote Area: A Cross-Sectional Study

Background: In publicly funded healthcare systems, patients do not pay for medical visits but can experience costs stemming from travel or over-the-counter drugs. We lack information about the extent of this burden in Canadian remote regions. This study aimed to: (1) describe prostate cancer-related out-of-pocket costs and perceived financial burden, and (2) identify factors associated with such a perceived burden among prostate cancer patients living in a remote region of the province of Quebec (Canada). Methods: A cross-sectional study was conducted among 171 prostate cancer patients who consulted at the outpatient clinic of the Centre Hospitalier de Rouyn-Noranda. Results: The majority of patients (83%) had incurred out-of-pocket costs for their cancer care. The mean total cost incurred in the last three months was $517 and 22.3% reported a moderate, considerable or unsustainable burden. Multivariable analysis revealed that having incurred higher cancer-related out-of-pocket costs (OR: 1.001; 95%CI: 1.001-1.002) private drug insurance (vs. public, OR: 5.23; 95%CI: 1.13-24.17) was associated with a greater perceived financial burden. Having better physical health-related quality of life (OR: 0.95; 95%CI: 0.913-0.997), a university education (vs. elementary/high school level, OR: 0.03; 95%CI: 0.00-0.79), and an income between $40,000 and $79,999 (vs. ≤ $39,999, OR: 0.15; 95%CI: 0.03-0.69) were associated with a lower perceived burden. Conclusion: Prostate cancer patients incur out-of-pocket costs even if they were diagnosed many years ago and the perceived burden is significant. Greater attention should be paid to the development of services to help patients manage this burden.

Determinants of Guideline-Discordant Breast Cancer Care

BACKGROUND

Evidence-based breast cancer treatment guidelines recommend the most appropriate course of therapy based on tumor characteristics and extent of disease. Evaluating the multilevel factors associated with guideline discordance is critical to identifying strategies to eliminate breast cancer survival disparities.

METHODS

We identified females diagnosed with a first primary, stage I-III breast cancer between the ages of 20-69 years of age from the population-based Seattle-Puget Sound Surveillance, Epidemiology, and End Results registry. Participants completed a survey about social support, utilization of patient support services, hypothesized barriers to care, and initiation of breast cancer treatment. We used logistic regression to estimate odds ratios and 95% confidence intervals (CI).

RESULTS

Among 1,390 participants, 10% reported guideline-discordant care. In analyses adjusted for patient-level sociodemographic factors, individuals who did not have someone to go with them to appointments or drive them home (OR 1.96; 95% CI, 1.09-3.59) and those who had problems talking to their doctors or their staff (OR 2.03; 95% CI, 1.13-3.64) were more likely to be guideline discordant than those with social support or without such problems, respectively. Use of patient support services was associated with a 43% lower odds of guideline discordance (OR 0.57; 95% CI, 0.36-0.88).

CONCLUSIONS

Although guideline discordance in this cohort of early-stage breast cancer survivors diagnosed <70 years of age was low, instrumental social support, patient support services, and communication with doctors and their staff emerged as potential multilevel intervention targets for improving breast cancer care delivery.

IMPACT

This study supports extending the reach of interventions designed to improve guideline concordance.

Treatment cost and access to care: experiences of young women diagnosed with breast cancer

PURPOSE

Breast cancer is the leading cause of cancer-related deaths in women younger than 40 years. We aim to evaluate cost as a barrier to care among female breast cancer patients diagnosed between 18 to 39 years.

METHODS

In early 2017, we distributed a survey to women diagnosed with breast cancer between the ages of 18 and 39 years, as identified by the central cancer registries of California, Georgia, North Carolina, and Florida. We used multivariable statistics to explore cost-related barriers to receiving breast cancer care for the 830 women that completed the survey.

RESULTS

About half of the women (47.4%) reported spending more on breast cancer care than expected, and almost two-thirds (65.3%) had not discussed costs with their care team. A third of the patients (31.8%) indicated forgoing care due to cost. Factors associated with not receiving anticipated care due to cost included age less than35 years at diagnosis, self-insurance, comorbid conditions, and late-stage diagnosis.

CONCLUSION

Previous studies using breast cancer registry data have not included detailed insurance information and care received by young women. Young women with breast cancer frequently forgo breast cancer care due to cost. Our results highlight the potential for policies that facilitate optimal care for young breast cancer patients which could include the provision of comprehensive insurance coverage.

Conflicting Perspectives on the Value of Neprilysin Inhibition in Heart Failure Revealed During Development of a Decision Aid Focusing on Patient Costs for Sacubitril/Valsartan

BACKGROUND

Despite concerns about rising costs in health care, cost is rarely an issue discussed by patients and clinicians when making treatment decisions in a clinical setting. This study aimed to understand stakeholder perspectives on a patient decision aid (PtDA) meant to help patients with heart failure choose between a generic and relatively low-cost heart failure medication (ACE [angiotensin-converting enzyme] inhibitor or angiotensin II receptor blocker) and a newer, but more expensive, heart failure medication (angiotensin II receptor blocker neprilysin inhibitor).

METHODS AND RESULTS

Feedback on the PtDA was solicited from 26 stakeholders including patients, clinicians, and the manufacturer. Feedback was recorded and discussed among development team members until consensus regarding both the interpretation of the data and the appropriate changes to the PtDA was reached. Stakeholders found the PtDA sufficient in clarifying the different treatment options for heart failure. However, patients, physicians, and the manufacturer had different opinions on the importance of highlighting cost in a PtDA. Patients indicated issues of cost were crucial to the decision while physicians and manufacturers expressed that the cost issue was secondary and should be de-emphasized.

CONCLUSIONS

The stratified perspectives on the role of cost in medical decision-making expressed by our participants underscore the importance and challenge of having clear, frank discussions during clinic visits about treatment cost and perceived value.

Treatment Decision Making and Financial Toxicity in Women With Metastatic Breast Cancer

INTRODUCTION

Oncologists have increasingly been proponents of shared decision making (SDM) to enhance patient outcomes and reduce unnecessary health care spending. However, its effect on patient out-of-pocket costs is unknown. This study investigated the relationship between patient preferences for SDM and financial toxicity (FT) in patients with metastatic breast cancer (MBC).

PATIENTS AND METHODS

This cross-sectional study utilized surveys of women aged ≥ 18 with MBC who received care at two academic hospitals in Alabama from 2017 to 2019. Patients self-reported their SDM preference (Control Preferences Scale) and FT (Comprehensive Score for Financial Toxicity [COST] tool; 11-item scale, with lower scores indicating worse FT). Effect sizes were calculated using the proportion of variance explained (R²) or Cramer's V. Differences in FT by SDM preference were estimated using mixed models clustered by site and treating medical oncologist.

RESULTS

In 95 women with MBC, 44% preferred SDM, 29% preferred provider-driven decision making, and 27% preferred patient-driven decision making. Patients preferring SDM were more often college educated (53% vs. 39%; V = 0.12) with an income greater than $40,000/y (55% vs. 43%; V = 0.18). Overall median COST was 22 (interquartile range, 16-29). After adjusting for patient demographic and clinical characteristics, patients preferring patient-driven decision making trended toward worse FT (COST 17: 95% confidence interval, 12-22) compared to those preferring SDM (COST 19: 95% confidence interval, 15-23) and those preferring provider-driven decision making (COST 22: 95% confidence interval, 17-27).

CONCLUSION

Patients preferring more patient-driven decision making reported worse FT, although differences did not reach statistical significance. Further research is needed to understand this relationship.

Patient-Provider Discussions About Out-of-Pocket Costs of Cancer Care in the U.S

INTRODUCTION

Despite the importance of cost-related discussions in cancer care, little is known about the prevalence or drivers of these discussions in clinical practice. This study estimates the prevalence and examines the correlates of cancer survivors' discussions about out-of-pocket costs of cancer care with providers.

METHODS

The 2016 and 2017 Medical Expenditure Panel Survey Experiences with Cancer Surveys were used to identify 1,550 survivors who responded to the question on discussion about out-of-pocket costs of cancer care. Multivariable multinomial logistic regression examined the correlates of discussions about out-of-pocket costs. Analyses were performed in 2019.

RESULTS

Approximately one quarter of cancer survivors reported having discussed the out-of-pocket costs of cancer care. In multivariable analyses, respondents in the following categories were less likely to report no cost discussion than any cost discussion: black non-Hispanic/other race (RRR=0.67, 95% CI=0.45, 0.98; white non-Hispanic race as reference), no health insurance at diagnosis (RRR=0.51, 95% CI=0.27, 0.95; private health insurance as reference), and any experience of financial hardship (RRR=0.48, 95% CI=0.35, 0.66; no financial hardship as reference).

CONCLUSIONS

Patient-reported discussions about out-of-pocket costs for cancer care are infrequent in the U.S. The findings highlight the needs to improve the understanding of the barriers and facilitators for effective discussions about out-of-pocket costs of cancer care.

Financial Hardship, Healthcare Utilization, and Health Among U.S. Cancer Survivors

INTRODUCTION

This study examined associations of both medical and nonmedical financial hardships with healthcare utilization and self-rated health among cancer survivors.

METHODS

The National Health Interview Survey (2013-2017) was used to identify cancer survivors (aged 18-64 years: n=4,939; aged ≥65 years: n=6,972). A total of 4 levels of medical financial hardship intensities were created with measures from material, psychological, and behavioral domains. A total of 5 levels of nonmedical financial hardship intensities were created with measures in food insecurity and worry about other economic needs (e.g., housing expenses). Generalized ordinal logistic regression examined associations between medical and nonmedical financial hardship intensities and emergency department visits, use of preventive services and cancer screenings, and self-rated health. All analyses were performed in 2019.

RESULTS

In adjusted analyses, cancer survivors with higher medical financial hardship intensity (Level 4 vs Level 1; aged 18-64 years: 42% vs 26.2%, p<0.001; aged ≥65 years: 37.6% vs 24.3%, p=0.001) and higher nonmedical financial hardship intensity (Level 5 vs Level 1; aged 18-64 years: 37.2% vs 27.9%, p=0.011) had more emergency department visits. Moreover, cancer survivors with higher medical financial hardship intensity had lower influenza vaccine (Level 4 vs Level 1; aged 18-64 years: 45.6% vs 52.5%, p=0.036; aged ≥65 years: 64.6% vs 75.6%, p=0.008) and lower breast cancer screening levels (Level 4 vs Level 1; 46.8% vs 61.2%, p=0.001). Similar patterns were found between higher financial hardship intensities and worse self-rated health.

CONCLUSIONS

Higher medical and nonmedical financial hardships are independently associated with more emergency department visits, lower receipt of some preventive services, and worse self-rated health in cancer survivors. With growing healthcare costs, unmet medical and nonmedical financial needs may worsen health disparities among cancer survivors.

How, When, and With Whom Should Cost of Care Conversations Occur? Preferences of Two Distinct Cancer Survivor Groups

PURPOSE

Cost of care (CoC) conversations should occur routinely in oncology practice. However, patient preferences about with whom, when, and how to have these conversations are missing and preferences may vary across patient populations.

METHODS

We performed a secondary qualitative analysis of quotes from interviews with 28 cancer survivors from two health care settings (Kaiser Permanente Washington and O'Neal Comprehensive Cancer Center at University of Alabama at Birmingham [UABCCC]). A targeted approach searched for three constructs: (1) Who should have CoC conversations with patients? (2) When should CoC conversations occur? and (3) How should CoC conversations happen?

RESULTS

Interviewees were similar in age and education, but UABCCC participants had more racial/ethnic minority representation and financial distress. Within each construct, themes were similar across both groups. As to who should have CoC conversations, we found that (1) providers' main role is medical care, not CoC; and (2) care team staff members are a more appropriate choice to address CoC needs. About the question of when, we found that (3) individuals have strong convictions about when and if they want to discuss CoC; and (4) CoC information and resources need to be available when patients are ready. About the question of how, themes were (5) provide estimates of anticipated out-of-pocket costs and insurance coverage; (6) provide reassurance, sympathy, and concrete solutions; and (7) because of their sensitivity, conduct CoC conversations in a comfortable, private space.

CONCLUSION

These findings offer general guidance as to who should conduct CoC conversations and when and how they should occur, with applicability across different patient populations.

Factors Associated With Oncologist Discussions of the Costs of Genomic Testing and Related Treatments

BACKGROUND

Use of genomic testing is increasing in the United States. Testing can be expensive, and not all tests and related treatments are covered by health insurance. Little is known about how often oncologists discuss costs of testing and treatment or about the factors associated with those discussions.

METHODS

We identified 1220 oncologists who reported discussing genomic testing with their cancer patients from the 2017 National Survey of Precision Medicine in Cancer Treatment. Multivariable polytomous logistic regression analyses were used to assess associations between oncologist and practice characteristics and the frequency of cost discussions. All statistical tests were two-sided.

RESULTS

Among oncologists who discussed genomic testing with patients, 50.0% reported often discussing the likely costs of testing and related treatments, 26.3% reported sometimes discussing costs, and 23.7% reported never or rarely discussing costs. In adjusted analyses, oncologists with training in genomic testing or working in practices with electronic medical record alerts for genomic tests were more likely to have cost discussions sometimes (odds ratio [OR] = 2.09, 95% confidence interval [CI] = 1.19 to 3.69) or often (OR = 2.22, 95% CI = 1.30 to 3.79), respectively, compared to rarely or never. Other factors statistically significantly associated with more frequent cost discussions included treating solid tumors (rather than only hematological cancers), using next-generation sequencing gene panel tests, having higher patient volume, and working in practices with higher percentages of patients insured by Medicaid, or self-paid or uninsured.

CONCLUSIONS

Interventions targeting modifiable oncologist and practice factors, such as training in genomic testing and use of electronic medical record alerts, may help improve cost discussions about genomic testing and related treatments.

Cost health literacy as a physician skill-set: the relationship between oncologist reported knowledge and engagement with patients on financial toxicity

INTRODUCTION

Oncologists are increasingly encouraged to communicate with patients about cost; however, they may lack the cost health literacy required to effectively perform this task.

METHODS

We conducted a pilot survey of oncologists in an academic medical center to assess potential factors that may influence provider attitudes and practices related to financial toxicity. We assessed perceived provider knowledge of treatment costs, insurance coverage and co-pays, and financially focused resources. We then evaluated the relationship between perceived knowledge and reported engagement with issues of financial toxicity.

RESULTS

Of 45 respondents (85% response rate), 58% had changed treatment within the past year as a result of patient financial burden. On self-report, 36% discussed out-of-pocket costs with patients, 42% assessed patient financial distress, but only 20% felt they could intervene upon financial toxicity. Self-perceived awareness of cost health literacy concepts were low; only 16% reporting high out-of-pocket cost knowledge, 31-33% high insurance knowledge, and 8% high awareness of financial resources. Report of cost discussion was associated with greater perceived awareness of both out-of-pocket costs and insurance design. However, reported financial distress assessment was only associated with perceived insurance awareness, not perceived cost knowledge. Cost health literacy was not associated with an increased sense of being able to impact on financial toxicity.

CONCLUSION

Oncologists acknowledge deficits in knowledge and skills that may play a role in the discussion and management of financial toxicity. Some cost health literacy competencies appear to correlate with physician involvement with financial toxicity, suggesting that education on this topic may facilitate physician engagement.

Implementing routine communication about costs of cancer treatment: perspectives of providers, patients, and caregivers

OBJECTIVES

Rising costs in oncology care often impact patients and families directly, making communication about costs and financial impacts of treatment crucial. Cost expenditures could offer opportunities for estimation and prediction, affording personalized conversations about financial impact. We sought to explore providers', patients', and caregivers' preferences towards implementing communication about cost, including when, how, and by whom such information might be provided.

METHODS

We conducted semi-structured phone interviews with a diverse population including 12 oncology providers, 12 patients, and 8 patient caregivers (N = 32). The constant comparative method was used to identify mutually agreed upon themes.

RESULTS

Participant groups differed in their concerns surrounding cost communication, namely whether they want to receive this information and how such information might impact provider and patient treatment decisions. All participants agreed that oncology providers should not be leading cost conversations. Patients and caregivers identified social workers or financial advisors as most equipped to communicate about cost. Participants emphasized timely cost conversations, ideally around the time of diagnosis. Participants favored various metrics of financial impact beyond overall costs of care including disability, days lost from work, and out-of-pocket expenses.

CONCLUSION

Cost transparency should be incorporated into usual care; however, there are several challenges to making cost conversations a part of everyday practice. Patients and family members need resources related to cost to aid in decision-making and those delivering cost information should have competency in oncology, financial advisement, and patient-centered care.

Qualitative Study of Factors Affecting Patient, Caregiver and Physician Preferences for Treatment of Myeloma and Indolent Lymphoma

INTRODUCTION

The number of treatment options for myeloma and indolent lymphoma are expanding at an exponential rate, with few direct head-to-head comparisons on which to base efficacy measures. We sought to understand how patients, their caregivers and physicians weigh treatment characteristics in order to come to a decision on which treatment option to pursue.

METHODS

Patients, their caregivers and physicians were recruited and interviewed until data saturation was reached. A qualitative, thematic analysis was done to identify themes important to each stakeholder.

RESULTS

We found that, while all three groups valued efficacy the most, the consideration of other secondary characteristics of the treatment, such as cost, toxicity and logistical issues all differed subtly between the different groups. Patients valued minimising cost and toxicity, even at small trade-offs in efficacy. Caregivers and physicians valued efficacy foremost.

CONCLUSION

Acknowledging and managing these differences is paramount because they influence shared decision-making and may affect patient outcomes in the short term, as well as their more general well-being in the long term.

'…If I don't have that sort of money again, what happens?': adapting a qualitative model to conceptualise the consequences of out-of-pocket expenses for cancer patients in mixed health systems

ObjectiveThe aim of this study was to explore Western Australian cancer patients’ experiences of out-of-pocket expenses (OOPE) during diagnosis and cancer treatment using a phenomenological approach. MethodsSemi-structured interviews were conducted with a purposive convenience sample of 40 Western Australian cancer patients diagnosed with breast, lung, prostate or colorectal cancer. Participants were asked about the impact of their diagnosis, the associated costs and their experience within the health system. Data were analysed using thematic content analysis. ResultsThree key themes influencing participant OOPE experiences were identified: (1) personal circumstances; (2) communication with health providers; and (3) coping strategies. Despite Australia’s public healthcare system, several participants found the costs affected their financial security and resorted to coping strategies including medication rationing and restrictive household budgeting. The key themes had a complex and interrelated effect on patient OOPE experiences and were used to adapt Carrera et al.’s model of economic consequences of cancer treatment on the patient and patient coping to describe these relationships in a mixed healthcare system. ConclusionOrganised efforts must be implemented to mitigate maladaptive coping strategies being used by cancer patients: (1) health providers should seek informed financial consent from patients before commencing treatment; and (2) financial aid and support schemes for cancer patients should be reviewed to ensure they are delivered equitably. What is known on this topic?The financial cost of cancer can have significant adverse effects on cancer patients. Although financial transparency is desired by cancer patients, its implementation in practice is not clear. What does this paper add?This study adapts a conceptual model for the economic consequences of a cancer diagnosis and repurposes it for a mixed public–private health system, providing a framework for understanding downstream consequences of cancer costs and highlighting opportunities for intervention. What are the implications for health practitioners?Health practitioners need to initiate discussions concerning treatment costs earlier with cancer patients. There are several resources and guides available to assist and facilitate financial transparency. Without urgent attention to the financial consequences of cancer treatment and related expenses, we continue to leave patients at risk of resorting to maladaptive coping strategies, such as medication rationing and restrictive household budgeting.

Financial toxicity associated with treatment of localized prostate cancer

Financial toxicity is a broad term to describe the economic consequences and subjective burden resulting from a cancer diagnosis and treatment. As financial toxicity is associated with poor disease outcomes, recognition of this problem and calls for strategies to identify and support those most at risk are increasing. Men with localized prostate cancer face treatment choices including active surveillance, prostatectomy or radiotherapy. The fact that potential patient out-of-pocket costs might influence decision making has rarely been acknowledged and, overall, the risk of financial toxicity for men with localized prostate cancer remains poorly studied. This shortfall requires a work-up in the context of prostate cancer and a multidimensional framework for considering a patient's risk of financial toxicity. The major elements of this framework are direct and indirect costs, patient-specific values, expectations of possible financial burdens, and individual economic circumstances. Current data indicate that total cost patterns probably differ by treatment modality: surgery might have an increased short-term effect, whereas radiotherapy might have an increased long-term risk of financial toxicity. Specific thresholds of patient income levels or out-of-pocket costs that predict risk of financial toxicity are difficult to identify. Compared with other malignancies, prostate cancer might have a lower overall risk of financial toxicity, but persistent post-treatment urinary, bowel or sexual adverse effects are likely to increase this risk.

Kidney cancer survivorship care: Patient experiences in a Canadian setting

INTRODUCTION

The incidence of kidney cancer (KCa) in Canada is rising. Despite this, there is a shortage of research assessing KCa care experiences. This study aims to explore the current experiences of KCa survivors related to treatment and management, information provision, and barriers to care.

METHODS

A cross-sectional, descriptive study of KCa patients was conducted online and through various cancer centers across Canada. English- and French-speaking adults who received a KCa diagnosis and were currently undergoing treatment or had completed treatment in Canada were eligible to participate.

RESULTS

In total, 368 surveys were completed. Ten percent of respondents had not yet received treatment, 29% were receiving treatment, and 56% had completed treatment. Most respondents (72%) had localized KCa (stage 0-3) at diagnosis. Sixty-one percent of respondents reported that their doctors discussed various treatment options with them and 24% reported discussing applicable clinical trials. Most (85%) respondents received information about their KCa and 36% discussed where to get information about their disease and support. The most commonly reported barriers to care were side effects (26%), system delays (26%), not having access to certain treatments (25%), and financial burden (24%). More participants in Central Region and Quebec (p=0.004) and rural/suburban (p=0.014) areas reported lacking access to certain treatments and KCa experts.

CONCLUSIONS

This was the first large-scale study to explore access to care experiences of Canadian KCa survivors. Results show examples of good patient-centered care and provide new practical information that can inform efforts to improve patient-centered care for KCa patients.

Financial Burdens of Cancer Treatment: A Systematic Review of Risk Factors and Outcomes

BACKGROUND

Patients with cancer experience financial toxicity from the costs of treatment, as well as material and psychologic stress related to this burden. A synthesized understanding of predictors and outcomes of the financial burdens associated with cancer care is needed to underpin strategic responses in oncology care. This study systematically reviewed risk factors and outcomes associated with financial burdens related to cancer treatment.

METHODS

MEDLINE, Embase, PubMed, PsychINFO, and the Cochrane Library were searched from study inception through June 2018, and reference lists were scanned from studies of patient-level predictors and outcomes of financial burdens in US patients with cancer (aged ≥18 years). Two reviewers conducted screening, abstraction, and quality assessment. Variables associated with financial burdens were synthesized. When possible, pooled estimates of associations were calculated using random-effects models.

RESULTS

A total of 74 observational studies of financial burdens in 598,751 patients with cancer were identified, among which 49% of patients reported material or psychologic financial burdens (95% CI, 41%-56%). Socioeconomic predictors of worse financial burdens with treatment were lack of health insurance, lower income, unemployment, and younger age at cancer diagnosis. Compared with patients with health insurance, those who were uninsured demonstrated twice the odds of financial burdens (pooled odds ratio [OR], 2.09; 95% CI, 1.33-3.30). Financial burdens were most severe early in cancer treatment, did not differ by disease site, and were associated with worse health-related quality of life (HRQoL) and nearly twice the odds of cancer medication nonadherence (pooled OR, 1.70; 95% CI, 1.13-2.56). Only a single study demonstrated an association with increased mortality. Studies assessing the comparative effectiveness of interventions to mitigate financial burdens in patients with cancer were lacking.

CONCLUSIONS

Evidence showed that financial burdens are common, disproportionately impacting younger and socioeconomically disadvantaged patients with cancer, across disease sites, and are associated with worse treatment adherence and HRQoL. Available evidence helped identify vulnerable patients needing oncology provider engagement and response, but evidence is critically needed on the effectiveness of interventions designed to mitigate financial burden and impact.

Perspectives on the Costs of Cancer Care: A Survey of the American Society of Breast Surgeons

BACKGROUND

Cancer treatment costs are not routinely addressed in shared decisions for breast cancer surgery. Thus, we sought to characterize cost awareness and communication among surgeons treating breast cancer.

METHODS

We conducted a self-administered, confidential electronic survey among members of the American Society of Breast Surgeons from 1 July to 15 September 2018. Questions were based on previously published or validated survey items, and assessed surgeon demographics, cost sensitivity, and communication. Descriptive summaries and cross-tabulations with Chi-square statistics were used, with exact tests where warranted, to assess findings.

RESULTS

Of those surveyed (N = 2293), 598 (25%) responded. Surgeons reported that 'risk of recurrence' (70%), 'appearance of the breast' (50%), and 'risks of surgery' (47%) were the most influential on patients' decisions for breast cancer surgery; 6% cited out-of-pocket costs as significant. Over half (53%) of the surgeons agreed that doctors should consider patient costs when choosing cancer treatment, yet the majority of surgeons (58%) reported 'infrequently' (43%) or 'never' (15%) considering patient costs in medical recommendations. The overwhelming majority (87%) of surgeons believed that patients should have access to the costs of their treatment before making medical decisions. Surgeons treating a higher percentage of Medicaid or uninsured patients were more likely to consistently consider costs (p < 0.001). Participants reported that insufficient knowledge or resources (61%), a perceived inability to help with costs (24%), and inadequate time (22%) impeded cost discussions. Notably, 20% of participants believed that discussing costs might impact the quality of care patients receive.

CONCLUSIONS

Cost transparency remains rare, however in shared decisions for breast cancer surgery, improved cost awareness by surgeons has the potential to reduce financial hardship.

State Mandate Laws for Autism Coverage and High-Deductible Health Plans

OBJECTIVES

Most states have passed insurance mandates requiring health plans to cover services for children with autism spectrum disorder (ASD). Research reveals that these mandates increased treated prevalence, service use, and spending on ASD-related care. As employer-sponsored insurance shifts toward high-deductible health plans (HDHPs), it is important to understand how mandates affect children with ASD in HDHPs relative to traditional, low-deductible plans.

METHODS

Insurance claims for 2008-2012 for children covered by 3 large US insurers (United Healthcare, Aetna, and Humana) available through the Health Care Cost Institute were used to compare the effects of mandates on ASD-related spending for children in HDHPs and traditional health plans.

RESULTS

Relative to children in traditional plans, mandates were associated with higher average monthly spending increases for children in HDHPs. Mandate-attributable spending differences between children enrolled in HDHPs relative to traditional plans were $77 for ASD-specific services (95% confidence interval [CI]: $10 to $144), $125 for outpatient health services (95% CI: $26 to $223), and $144 for all health services (95% CI: $36 to $253). These spending differentials were driven by differences in plan spending and not out-of-pocket (OOP) spending.

CONCLUSIONS

Spending on ASD-related services attributable to autism mandates was higher among children in HDHPs, but higher spending did not translate into a greater OOP burden. For families with consistently high health care expenditures on ASD-related services, high-deductible products may be worth considering in the context of mandate laws. Families in mandate states with children with ASD enrolled in HDHPs were able to increase service use without paying more OOP.

Development of a Framework and Tool to Facilitate Cost-of-Care Conversations With Patients During Prenatal Care

BACKGROUND

Studies show that patients want to engage in cost-of-care conversations and factor costs into the formulation of care plans. Low-income patients are particularly likely to defer care because of costs, suggesting that cost-of-care conversations may be an important factor in health equity. Little guidance is available to clinicians and health systems for how to integrate effective cost-of-care conversations into clinical practice or to address specific cost needs of low-income patients.

OBJECTIVE

To develop a framework and tool to assist cost-of-care conversations with low-income patients during prenatal care.

DESIGN

A qualitative study using human-centered design methods.

SETTING

University medical center-based obstetrics-gynecology (ob-gyn) practice.

PARTICIPANTS

20 pregnant or recently postpartum women, 16 clinicians, and 8 support and executive staff.

RESULTS

Pregnant women accumulate substantial indirect costs that interfere with treatment adherence and stress patients and their relationships. Frequency and duration of appointments are primary drivers of indirect costs; the burden is exacerbated by not knowing these costs in advance and disproportionately affects low-income patients. Working with ob-gyn clinicians, staff, and patients, a paper-based tool was developed to help patients forecast treatment demands and indirect costs, and to help clinicians introduce and standardize cost conversations.

LIMITATIONS

Data were collected from a small number of stakeholders in a single clinical setting that may not be generalizable to other settings. The tool has not been tested for effects on adherence or clinical outcomes.

CONCLUSION

A communication tool that helps pregnant patients understand their care plan and anticipate indirect costs can promote cost-of-care conversations between clinicians and low-income patients.

PRIMARY FUNDING SOURCE

Robert Wood Johnson Foundation.

Perspectives on Conversations About Costs of Cancer Care of Breast Cancer Survivors and Cancer Center Staff: A Qualitative Study

BACKGROUND

Despite recommendations to discuss the cost of care (CoC) with patients with cancer, little formal guidance is available on how to conduct these sensitive conversations in ways that are acceptable to both patients and providers.

OBJECTIVE

To explore the perspectives of patients and medical and nonmedical cancer center staff on CoC conversations.

DESIGN

In individual interviews, participants were asked to discuss the content of, timing of, and ideal person to hold CoC conversations. Interviews were transcribed verbatim. Content was analyzed to identify emerging essential elements.

SETTING

Division of Preventive Medicine, University of Alabama at Birmingham.

PARTICIPANTS

42 women aged 60 to 79 years with a history of breast cancer and 20 cancer center staff (6 physicians, 4 nurses, 5 patient navigators, 3 social workers, and 2 billing specialists).

RESULTS

Both patients and providers identified reassurance and action as essential elements of CoC conversations. Participants expressed the importance of reassurance that recommended medical care would not be affected by affordability challenges. Action was intended as discussions on ways to help patients cover treatment-related costs, such as discussion of payment plans or linkage to financial resources. Optimal timing for CoC conversations was felt to be after an initial consult visit but before treatment started. The person to hold these conversations should be compassionate, helpful, and knowledgeable of the patient's specific situation (for example, treatment plan, insurance coverage) and of the resources available to attain the patient's goals of care.

LIMITATION

Interviews were limited to older breast cancer survivors and staff at 1 institution.

CONCLUSION

Conversations about CoC extend beyond discussing costs and must be sensitive to the vulnerability experienced by patients. These findings can guide training of personnel involved in CoC conversations.

PRIMARY FUNDING SOURCE

Robert Wood Johnson Foundation.

Rural-urban differences in financial burden among cancer survivors: an analysis of a nationally representative survey

PURPOSE

Rural cancer survivors may disproportionately experience financial problems due to their cancer because of greater travel costs, higher uninsured/underinsured rates, and other factors compared to their urban counterparts. Our objective was to examine rural-urban differences in reported financial problems due to cancer using a nationally representative survey.

METHODS

We used data from three iterations of the National Cancer Institute's Health Information and National Trends Survey (2012, 2014, and 2017) to identify participants who had a previous or current cancer diagnosis. Our outcome of interest was self-reported financial problems associated with cancer diagnosis and treatment. Rural-urban status was defined using 2003 Rural-Urban Continuum Codes. We calculated weighted percentages and Wald chi-square statistics to assess rural-urban differences in demographic and cancer characteristics. In multivariable logistic regression models, we examined the association between rural-urban status and other factors and financial problems, reporting the corresponding adjusted predicted probabilities.

FINDINGS

Our sample included 1359 cancer survivors. Rural cancer survivors were more likely to be married, retired, and live in the Midwest or South. Over half (50.5%) of rural cancer survivors reported financial problems due to cancer compared to 38.8% of urban survivors (p = 0.02). This difference was attenuated in multivariable models, 49.3 and 38.7% in rural and urban survivors, respectively (p = 0.06).

CONCLUSIONS

A higher proportion of rural survivors reported financial problems associated with their cancer diagnosis and treatment compared to urban survivors. Future research should aim to elucidate these disparities and interventions should be tested to address the cancer-related financial problems experienced by rural survivors.

Cancer survivorship care plans, financial toxicity, and financial planning alleviating financial distress among cancer survivors

Concomitant with the increasing use of cancer care plans has been an increasing awareness of the potential for oncology care to result in long-term financial burdens and financial toxicity. Cancer survivors can benefit from information on support and resources to help them navigate the challenges after acute cancer treatment. While cancer survivorship plans could be a vehicle for patients to receive information on how to mitigate financial toxicity, cancer survivorship plans have typically not dealt with the financial impact of cancer treatment or follow-up care. Embedding information into cancer survivorship plans on how to reduce or avoid financial toxicity presents an opportunity to address a highly prevalent patient need. Patient-centered qualitative studies are needed to assess the type, format, and level of detail of the information provided.

Long-Term Survivorship Care After Cancer Treatment - Summary of a 2017 National Cancer Policy Forum Workshop

The National Cancer Policy Forum of the National Academies of Sciences, Engineering and Medicine sponsored a workshop on July 24 and 25, 2017 on Long-Term Survivorship after Cancer Treatment. The workshop brought together diverse stakeholders (patients, advocates, academicians, clinicians, research funders, and policymakers) to review progress and ongoing challenges since the Institute of Medicine (IOM)'s seminal report on the subject of adult cancer survivors published in 2006. This commentary profiles the content of the meeting sessions and concludes with recommendations that stem from the workshop discussions. Although there has been progress over the past decade, many of the recommendations from the 2006 report have not been fully implemented. Obstacles related to the routine delivery of standardized physical and psychosocial care services to cancer survivors are substantial, with important gaps in care for patients and caregivers. Innovative care models for cancer survivors have emerged, and changes in accreditation requirements such as the Commission on Cancer's (CoC) requirement for survivorship care planning have put cancer survivorship on the radar. The Center for Medicare & Medicaid Innovation's Oncology Care Model (OCM), which requires psychosocial services and the creation of survivorship care plans for its beneficiary participants, has placed increased emphasis on this service. The OCM, in conjunction with the CoC requirement, is encouraging electronic health record vendors to incorporate survivorship care planning functionality into updated versions of their products. As new models of care emerge, coordination and communication among survivors and their clinicians will be required to implement patient- and community-centered strategies.

Costs of cancer along the care continuum: What we can expect based on recent literature

BACKGROUND

Cancer costs should be discussed by patients and providers, but information is not readily available. Results from recently published studies (in the last 5 years) on direct and indirect cancer costs may help guide these discussions.

METHODS

The authors reviewed studies published between 2013 and 2017 that reported direct health care costs and indirect (productivity losses) costs. The annual mean total and net costs of cancer were summarized for all payers and for survivors only by age (ages 18-64 and ≥65 years), by phase of care (initial [ie, 12 months from diagnosis], continuing, and end-of-life [ie, 12 months before death]), or for recently diagnosed (within 1-2 years of diagnosis) and longer term survivors.

RESULTS

For all payers combined, costs for cancers like breast, prostate, colorectal, and lung cancers were $20,000 to $100,000 in the initial phase, $1000 to $30,000 annually in the continuing phase, and ≥$60,000 in the end-of-life phase. Annual out-of-pocket costs to recently diagnosed survivors were >$1000 for medical care and time costs, approximately $2000 for productivity losses, and from $2500 to >$4000 for employment disability, depending on age. For longer term survivors, the cost of medical care was approximately $1500 for older survivors and $747 for younger survivors, time costs were $831 to $955 for older survivors and $459 to $630 for younger survivors, and productivity losses were approximately $800. Disability among long-term survivors was similar to that among short-term survivors. Limitations of the reviewed studies included older data and under-representation of higher cost cancers.

CONCLUSIONS

Frequently updated cost information for all cancer types is needed to guide discussions of anticipated short-term and long-term cancer-related costs with survivors. Cancer 2018;000:000-000. © 2018 American Cancer Society.

Patient-Clinician Communication Is a Joint Creation: Working Together Toward Well-Being

Oncology clinicians face a monumentally difficult task: to guide patients on what may be the scariest and most unpleasant journey of their lives. They must preserve their patients' hope while at the same time giving them accurate information. And patients with cancer face a monumentally difficult task: navigating a path while confronting an often-terrifying disease. Communication between patients with cancer, their loved ones, and the treating clinicians presents many challenges. We must become better at communicating with each other; patients need easier access to information about their medical condition and their health care; and we must establish relationships that are stronger and more respectful, trusting, and empathic. If we are to deliver patient-centered or whole-person care, we must know who our patients are, what is important to them, and how they derive meaning in their lives. In this review, we discuss ASCO's first Patient-Clinician Communication guideline, the importance and value of patients having direct access to their medical record, and how to address spirituality and/or religion with patients with cancer.

Cost, Value, and Financial Hardship in Cancer Care: Implications for Pediatric Oncology

Cancer care in the United States faces a perfect storm: an aging population and expected increased cancer incidence, growing numbers of cancer survivors with ongoing care needs, and continued scientific advancements, offering extraordinary promise at extraordinary cost. How, then, do we as pediatric oncologists engage in the dialogue about cancer cost considerations? The purpose of this article and its accompanying session presented at the 2018 ASCO Annual Meeting is to introduce concepts of cost, value, and financial hardship. In the first section, we will provide an overview of principles of health economics, including components of cost, time horizon consideration, discounting, and methods to calculate incremental cost-effectiveness among therapeutic approaches. We will then introduce the value framework being debated in adult oncology and offer potential opportunities for its application in pediatric oncology. In the second section, we will describe the integration of the cost-effectiveness paradigm in an ongoing pediatric clinical trial, including design and analytic considerations. In the third section, we will shift away from cost to the health care system to cost to the patient, which is also termed "financial toxicity" or "financial hardship," focusing on the ongoing burden of cost on survivors of childhood cancer. Our goal is to provide our readers with the vocabulary and understanding of this complex and often thorny debate so that they can be active participants and informed advocates for their patients.