Do cancer survivors change their prescription drug use for financial reasons? Findings from a nationally representative sample in the United States

Patterns of medication adherence in a multi-ethnic cohort of prevalent statin users diagnosed with breast, prostate, or colorectal cancer

PURPOSE

To investigate the implications of a cancer diagnosis on medication adherence for pre-existing comorbid conditions, we explored statin adherence patterns prior to and following a new diagnosis of breast, colorectal, or prostate cancer among a multi-ethnic cohort.

METHODS

We identified adults enrolled at Kaiser Permanente Northern California who were prevalent statin medication users, newly diagnosed with breast, colorectal, or prostate cancer between 2000 and 2012. Statin adherence was measured using the proportion of days covered (PDC) during the 2-year pre-cancer diagnosis and the 2-year post-cancer diagnosis. Adherence patterns were assessed using generalized estimating equations, for all cancers combined and stratified by cancer type and race/ethnicity, adjusted for demographic, clinical, and tumor characteristics.

RESULTS

Among 10,177 cancer patients, statin adherence decreased from pre- to post-cancer diagnosis (adjusted odds ratio (OR_adj):0.91, 95% confidence interval (95% CI):0.88-0.94). Statin adherence decreased from pre- to post-cancer diagnosis among breast (OR_adj:0.94, 95% CI:0.90-0.99) and colorectal (OR_adj:0.79, 95% CI:0.74-0.85) cancer patients. No difference in adherence was observed among prostate cancer patients (OR_adj:1.01, 95% CI:0.97-1.05). Prior to cancer diagnosis, adherence to statins was generally higher among non-Hispanic whites and multi-race patients than other groups. However, statin adherence after diagnosis decreased only among these two populations (OR_adj:0.85, 95% CI:0.85-0.92 and OR_adj:0.86, 95% CI:0.76-0.97), respectively.

CONCLUSIONS

We found substantial variation in statin medication adherence following diagnosis by cancer type and race/ethnicity among a large cohort of prevalent statin users in an integrated health care setting.

IMPLICATIONS FOR CANCER SURVIVORS

Improving our understanding of comorbidity management and polypharmacy across diverse cancer patient populations is warranted to develop tailored interventions that improve medication adherence and reduce disparities in health outcomes.

Identifying and Understanding Barriers and Facilitators to Medication Adherence Among Marshallese Adults in Arkansas

Background: Significant health disparities are present in Marshallese adults residing in the United States, most notably a high incidence of type 2 diabetes and other chronic conditions. There is limited research on medication adherence in the Marshallese population. Objective: This study explored perceptions of and experiences with medication adherence among Marshallese adults residing in Arkansas, with the aim of identifying and better understanding barriers and facilitators to medication adherence. Methods: Eligible participants were Marshallese adults taking at least one medication for a chronic health condition. Each participant completed a brief survey and semistructured interview conducted in Marshallese by a bilingual Marshallese staff member. Interviews were recorded, transcribed, and translated from Marshallese to English. Qualitative data were coded for a priori and emergent themes. Results: A total of 40 participants were included in the study. The most common contributing factor for nonadherence was forgetting to take medication (82%). A majority of participants (70%) reported difficulty paying for medicine, 45% reported at least one form of cost-related nonadherence, and 40% engaged in more than one cost-related nonadherence practice. Family support and medication pill boxes were identified as facilitators for medication adherence. The majority of the participants (76.9%) stated that they understood the role of a pharmacist. Participants consistently desired more education on their medications from pharmacy providers. Conclusion: This is the first study to explore barriers and facilitators to medication adherence among Marshallese patients. The findings can be used to develop methods to improve medication adherence among Marshallese.

Addressing Financial Barriers to Patient Participation in Clinical Trials: ASCO Policy Statement

Research conducted through clinical trials is essential for evaluating new treatment modalities, establishing new standards of cancer care, and ultimately improving and prolonging the lives of patients with cancer. However, participation in trials has been low, and this is attributable to various factors including patient financial barriers. Such financial barriers include the rising cost of cancer care; a lack of transparency in coverage policy; and the perception of ethical, compliance, or institutional impediments to patient financial support. ASCO convened a roundtable discussion with a variety of stakeholders to define the scope of the problem, as well as to identify clinical practice and policy solutions applicable at the institutional and system-wide levels. This statement summarizes key discussions from the ASCO Roundtable, as well as findings from the literature, and provides ASCO's recommendations for overcoming financial barriers that may otherwise prevent participation in clinical trials. These recommendations broadly address the following key areas: (1) improving the policy environment for coverage of clinical trials; (2) facilitating transparency among providers, patients, and payers for trial-related out-of-pocket costs; (3) refuting the specter of inducement to enable targeted financial support for patients; and (4) improving the available data on costs of cancer clinical trials.

Total and out-of-pocket expenditures among women with metastatic breast cancer in low-deductible versus high-deductible health plans

PURPOSE

High-deductible health plan (HDHP) enrollment is expanding rapidly and might substantially increase out-of-pocket (OOP) payment burden. We examined trends in total and OOP health service expenditures overall and by insurance coverage type among women with metastatic breast cancer.

METHODS

We used a longitudinal time series design to examine measures among 5364 women with metastatic breast cancer insured by a large US health insurer from 2004 to 2011. We measured outcomes during the 12 months after a first identified metastatic breast cancer diagnosis and required women to have at least 6 months of prior enrollment. We plotted enrollment measures and adjusted total and OOP spending. We fit trend lines using linear autoregressive models.

RESULTS

Between 2004 and 2011, the percentage of women with metastatic breast cancer enrolled in employer-mandated HDHPs increased from 8 to 23% while the percentage enrolled in employer-mandated low-deductible plans (LDHPs) decreased from 69 to 37%. Over the same time period, estimated annual inflation-adjusted total health service spending among women with metastatic breast cancer whose employers only offered HDHPs or LDHPS increased from $96,899 to $104,688 (increase of $1197 per year; 95% confidence interval [CI]: $47,$2,348). Corresponding OOP spending values among these women with employer-mandated deductible levels were $4,496 and $5,151 ($91 per year trend; 95% CI -$13,$195). From 2004-2011, women in HDHPs and LDHPs had unchanged annual OOP spending, estimated at of $6642 (95% CI $6,268,$7016) and $4,247 (95% CI $3956,$4538), respectively. Thus, women in HDHPs experienced 55% (44%, 66%) more OOP spending than women in LDHP.

CONCLUSIONS

OOP spending among women with metastatic breast cancer and employer-mandated deductible levels was 55% higher among HDHP than LDHP members, and employer-mandated HDHP enrollment increased substantially from 2004 to 2011. Stakeholders and policymakers should design health plans that protect financially vulnerable cancer patients from high OOP costs.

Financial toxicity and implications for cancer care in the era of molecular and immune therapies

Molecular and immune therapies have revolutionized cancer treatment and improved patient outcomes and survival. However, the pricing of these drugs has become an issue as the cost of cancer care continues to rise significantly. Cost sharing policies have increased out-of-pocket expenses for patients, leading to poorer financial well-being, quality of life, psychosocial health, and treatment adherence. In this review, we briefly examine some factors affecting the pricing of these new targeted therapies; the effects of financial toxicity on patients; and highlight potential health policy and patient-provider level interventions to address these issues.

Is Cancer History Associated With Assets, Debt, and Net Worth in the United States?

Background

Financial hardships experienced by cancer survivors have become a prominent public health issue in the United States. Few studies of financial hardship have assessed financial holdings, including assets, debts, and their values, associated with a cancer history.

Methods

Using the 2008-2011 Medical Expenditure Panel Survey, we identified 1603 cancer survivors and 34 915 individuals age 18-64 years without a cancer history to assess associations between self-reported cancer history and assets, debts, and net worth. Distributions of self-reported asset and debt ownership, their values, and net worth were compared for adults with and without a cancer history with chi-square statistics. Multivariable ordered probit regression analysis was conducted to assess the association between cancer history and net worth using a two-sided Wald test. All analyses were stratified by age group (18-34, 35-44, 45-54, and 55-64 years). Statistical tests were two-sided.

Results

Among those age 45-54 years, cancer survivors had a lower proportion of home ownership than individuals without a cancer history (59.0% vs 67.1%, P = .0014) and were statistically significantly more likely to have negative net worth (≤-$3000) and less likely to have positive net worth (≥$3000). Cancer survivors were more likely to have debt than individuals without a cancer history, especially among those age 18-34 years (41.3% vs 27.1%, P < .001).

Conclusions

Cancer history is associated with lower asset ownership, more debt, and lower net worth, especially in survivors age 45-54 years. Longitudinal studies of financial holdings will be important to inform development of interventions to reduce financial hardship.

Polypharmacy and patterns of prescription medication use among cancer survivors

BACKGROUND

The population of cancer survivors is rapidly growing in the United States. Long-term and late effects of cancer, combined with the ongoing management of other chronic conditions, make survivors particularly vulnerable to polypharmacy and its adverse effects. In the current study, the authors examined patterns of prescription medication use and polypharmacy in a population-based sample of cancer survivors.

METHODS

Using data from the Medical Expenditure Panel Survey (MEPS), the authors matched cancer survivors (5216 survivors) with noncancer controls (19,588 controls) by age, sex, and survey year. Polypharmacy was defined as ≥5 unique medications. The authors estimated the percentage of respondents prescribed medications within therapeutic classes and total prescription expenditures.

RESULTS

A higher percentage of cancer survivors were prescribed ≥5 unique medications (64.0%; 95% confidence interval [95% CI], 62.3%-65.8%) compared with noncancer controls (51.5%; 95% CI, 50.4%-52.6%), including drugs with abuse potential. Across all therapeutic classes, a higher percentage of newly (≤1 year since diagnosis) and previously (>1 years since diagnosis) diagnosed survivors were prescribed medications compared with controls, with large differences observed with regard to central nervous system agents (65.8% [95% CI, 62.3%-69.3%] vs 57.4% [95% CI, 55.3%-59.5%] vs 46.0% [95% CI, 45.0%-46.9%]). Specifically, nearly 10% of survivors were prescribed benzodiazepines and/or opioids compared with approximately 5% of controls. Survivors had more than double the prescription expenditures (median of $1633 vs $784 among controls). Findings persisted across age and comorbidity categories.

CONCLUSIONS

Cancer survivors were prescribed a higher number of unique medications, including drugs with abuse potential, thereby increasing their risk of adverse drug events, financial toxicity, poor adherence, and drug-drug interactions. Cancer 2018;124:2850-2857. © 2018 American Cancer Society.

Exploring barriers to the receipt of necessary medical care among cancer survivors under age 65 years

PURPOSE

With increasing cancer care costs and greater patient cost-sharing in the USA, understanding access to medical care among cancer survivors is imperative. This study aims to identify financial, psychosocial, and cancer-related barriers to the receipt of medical care, tests, or treatments deemed necessary by the doctor or patient for cancer among cancer survivors age < 65 years.

METHODS

We used data on 4321 cancer survivors aged 18-64 years who completed the 2012 LIVESTRONG Survey. Multivariable logistic regression was used to identify risk factors associated with the receipt of necessary medical care, including sociodemographic, financial hardship, debt amount, caregiver status, and cancer-related variables.

RESULTS

Approximately 28% of cancer survivors were within 1 year, and 43% between 1 and 5 years, since their last treatment at the time of survey. Nearly 9% of cancer survivors reported not receiving necessary medical care. Compared to survivors without financial hardship, the likelihood of not receiving necessary medical care significantly increased as the amount of debt increased among those with financial hardship (RRFinancial hardship w/< $10,000 debt = 1.94, 95% CI 1.55-2.42, and RR RRFinancial hardship w/≥ $10,000 debt = 3.41, 95% CI 2.69-4.33, p < 0.001). Survivors who reported lack of a caregiver, being uninsured, and not receiving help understanding medical bills were significantly more likely to not receive necessary medical care.

CONCLUSION

We identified key financial and insurance risk factors that may serve as significant barriers to the receipt of necessary medical care among cancer survivors age < 65 in the USA IMPLICATIONS FOR CANCER SURVIVORS: The majority of cancer survivors reported receiving medical care either they or their doctors deemed necessary. However, identifying potentially modifiable barriers to receipt of necessary medical cancer care among cancer survivors age < 65 is imperative for developing interventions to ensure equitable access to care and reducing cancer disparities.

Setting the stage for universal financial distress screening in routine cancer care

Financial burden from cancer treatment is increasingly being recognized as a threat to optimal access, quality, and outcomes of cancer care for patients. Although research in the area is moving at a fast pace, multiple questions remain unanswered, such as how to practically integrate the assessment and management of financial burden into routine health care delivery for patients with cancer. Although psychological distress screening for patients undergoing cancer treatment now is commonplace, the authors raise the provocative idea of universal screening for financial distress to identify and assist vulnerable groups of patients. Herein, the authors outline the arguments to support screening for financial burden in addition to psychological distress, examining it as an independent patient-reported outcome for all patients with cancer at various time points during their treatment. The authors describe the proximal and downstream impact of such a strategy and reflect on some challenges and potential solutions to help integrate this concept into routine cancer care delivery. Cancer 2017;123:4092-4096. © 2017 American Cancer Society.