Assessment of Financial Toxicity Among Older Adults With Advanced Cancer

"It is not the fault of the health care team - it is the way the system works": a mixed-methods quality improvement study of patients with advanced cancer and family members reveals challenges navigating a fragmented healthcare system and the administrative and financial burdens of care

BACKGROUND

Healthcare fragmentation and lack of care coordination are longstanding problems in cancer care. This study's goal was to provide in-depth understanding of how the organization and fragmentation of healthcare impacts the experiences of patients with advanced cancer and their families, especially near the end-of-life.

METHODS

This mixed-methods quality improvement study took place at a large multi-specialty healthcare organization in Northern California. Electronic health record data was used to identify patients with advanced cancer and their characteristics. Data were collected 10/2019-05/2022 through periodic patient surveys and in-depth interviews with sampled family members, including open-ended questions about overall healthcare experiences. Data were analyzed using inductive thematic analysis.

RESULTS

Overall, 281/482 (58.3%) patients with advanced cancer completed surveys. Surveyed patients' mean age was 68 (SD: 12.8) years, 53% were male, 73% White, 14.2% Asian, 1.4% Black, 3.9% Other; 8.9% Hispanic, and 19.2% were deceased within 12 months. Twenty-four family members completed in-depth interviews: 17/24 (70.8%) were spouses, 62.5% were female and 50% were interviewed after the patient's death. Respondents were generally positive about health care team interactions, but consistently brought up the negative impacts of the organization of healthcare, "It is not the fault of the health care team - it is the way the system works." Three major challenges were identified. (1) Systemic healthcare care fragmentation, including difficulties navigating care across providers and institutions, "It seems like everything is like an isolated incident… there's no overall, big picture viewpoint." (2) Administrative burdens, "In the end I gave up [scheduling care] because I was tired of calling." (3) Financial burdens, "This oncologist wanted to put him on a drug…but it was $4000 a month." Respondents described these challenges leading to worse quality of care, health, and quality of life, and loss of trust in the national healthcare system.

CONCLUSIONS

These findings illustrate how care fragmentation and administrative and financial burdens lead to worse quality care and distrust of healthcare. Better coordination of patient-centered care, and a fundamental restructuring of a highly fragmented national healthcare system are required to meet the needs of patients with complex conditions like advanced cancer and their families.

Adapting, implementing and evaluating a navigation intervention for older people with cancer and their family caregivers in six countries in Europe: the Horizon Europe-funded EU NAVIGATE project

Background

Navigation interventions could support, educate and empower older people with cancer and/or their family caregivers by addressing barriers and ensuring timely access to needed services and resources throughout the continuum of supportive, palliative and end-of-life care.

Objectives

European Union (EU) NAVIGATE is an interdisciplinary and cross-country Horizon Europe-funded project (2022-2027) aiming to evaluate the effectiveness, cost-effectiveness and implementation of a navigation intervention for older people with cancer and their family caregivers in Europe. EU NAVIGATE aims to advance the evidence on cancer patient navigation in Europe.

Design

Adaptation, implementation and evaluation of a navigation intervention with an international pragmatic randomized controlled trial (RCT) and embedded mixed-method process evaluation at its core. A logic model guides dissemination and impact-generating strategies. EU NAVIGATE involves six experienced EU academic partners; one EU national cancer league with their affiliated academic partner; three EU dissemination partners; and a Canadian partner.

Methods

We adapted the Canadian Navigation: Connecting, Advocating, Resourcing, and Engaging (Nav-CARE©) volunteer programme to healthcare contexts in Belgium, Ireland, Italy, the Netherlands, Poland and Portugal following the new ADAPT guidance. Nav-CARE was developed over the past 15 years and supports people with declining health and their families to improve their quality of life and well-being, foster empowerment and facilitate timely and equitable access to healthcare and social services. In EU NAVIGATE, the navigation intervention is being provided by trained and mentored social workers in Poland and by trained and mentored volunteers in the other five countries. Via a pragmatic RCT with process evaluation, we implement and evaluate the navigation intervention to study its impact on older people with cancer and their family caregivers. We also aim to understand its cost-effectiveness, how to optimally implement it in different countries, and its differential effects in patient subgroups. We will also map existing cancer navigation interventions in Europe, the United States and Canada to position EU NAVIGATE within the field of navigation interventions worldwide.

Conclusion

EU NAVIGATE aims to deliver high-quality evidence on a navigation intervention for older people with cancer in Europe and to develop practice and policy recommendations for sustainable implementation of navigation interventions in Europe and beyond.

A Phenomenological Approach to Financial Toxicity: The-Economic-Side Effect of Cancer

The economic burden of chronic diseases such as cancer could negatively impact patients' health and quality of life. The daily management of the disease results in economic needs that patients often face directly, which may lead to real toxicity, just defined as financial toxicity. This study aims to explore cancer patients' experiences, emotions, opinions, and feelings related to the phenomenon of financial toxicity. A phenomenological qualitative descriptive study was conducted through face-to-face interviews with adult oncological patients. The sample (n = 20) was predominantly composed of females (with a meanly 58 years old) with breast cancer and in chemotherapy treatment. The most relevant topics that emerged from the patients' experiences were the impact on work, the distance from the treatment centre, the economic efforts, the impact on the quality of life, and the healthcare workers' support during the healthcare pathway. From the phenomenological analysis of the interviews, three main themes and seven related subthemes emerged. This study provided a phenomenological interpretation of financial toxicity in adult cancer patients and underlines that this issue involves families or caregivers, too. Financial problems appear relevant for those who experience cancer and should be included in a routine assessment by healthcare professionals.

Financial toxicity in early-phase cancer clinical trial participants

BACKGROUND

Little is known about financial toxicity in early-phase clinical trial (EP-CT) participants. This study sought to describe financial toxicity in EP-CT participants and assess associations with patient characteristics and patient-reported outcomes (PROs).

METHODS

Prospectively enrolled EP-CT participants from were followed from April 2021 through January 2023. Participants completed the Comprehensive Score for Financial Toxicity (<26 = financial toxicity) at time of treatment. Quality of life (QOL), symptoms, coping, and resource concerns were surveyed. Associations of financial toxicity with patient characteristics, PROs, and clinical outcomes were explored.

RESULTS

Of 261 eligible patients, 197 completed baseline assessments (75.5%, median age = 63.4 years [31.8-88.6], 57.4% female). Most common cancers were gastrointestinal (33.0%) and breast (20.8%). More than one third (34.0%) of patients reported financial toxicity. Patients with financial toxicity were more likely to be <65 years (70.2% vs 48.5%, p = .004), unemployed (45.5% vs 16.9%, p < .001), not have attended college (53.1% vs 26.4%, p = .002), and have income <$60,000 (59.7% vs 25.4%, p < .001). In adjusted models, patients with financial toxicity reported lower QOL (B = -6.66, p = .004) and acceptance (B = -0.78, p = .002), and increased self-blame (B = 0.87, p < .001). They were more likely to have concerns regarding housing (10.6% vs 2.3%, p = .025), bills (31.8% vs 3.8%, p < .001), food (9.1% vs 0.8%, p = .006), and employment (21.2% vs 1.5%, p < .001). There was no difference in time on trial (hazard ratio, 1.03; p = .860) or survival (hazard ratio, 1.16; p = .496).

CONCLUSIONS

More than one third of EP-CT participants reported financial toxicity. Factors associated with financial toxicity and demonstrated novel associations among financial toxicity with QOL, coping, and resource concerns were identified, highlighting the need to address financial toxicity among this population.

Influence of age on financial toxicity in cancer patients

Objective

The aim of this study was to assess the level of financial toxicity (FT) experienced by the following three age groups of cancer patients in China: young working-aged patients (age < 40 years), middle-aged patients (40-64 years), and older patients (≥ 65 years).

Methods

The data used for this study were collected via a cross-sectional survey conducted in China. FT was assessed using the Comprehensive Score for Financial Toxicity (COST). ANOVA was used to examine the differences in FT status between age groups. Multivariate linear regression models were employed to assess the association between age and FT, adjusted by socioeconomic and other clinical characteristics.

Results

A total of 556 cancer patients completed the survey. Approximately 54.3% of the participants were male and 45.7% were female. The majority (61.5%) were aged 40-64 years, while 27.7% were aged 65 or older. The mean FT scores for young patients (< 40 years), middle-aged patients (40-64 years), and older patients (≥ 65 years) were 16.7, 12.8, and 12.4, respectively. The results of the regression analysis revealed that, without adjusting for background characteristics, young patients had significantly higher mean COST scores. This suggests they experienced lower levels of FT compared to patients in other age groups. Stratified analysis revealed that, for older patients, only educational level and type of insurance scheme were significant factors in predicting the COST score.

Conclusions

This study provides empirical evidence for developing targeted interventions and policies to reduce the FT for patients in different age groups. Given that FT is complicated, a longitudinal study should be conducted to explore the long-term impact of FT on cancer patients' quality of life and well-being.

Long-term patient-reported values following cancer surgery: A global survey study

BACKGROUND AND OBJECTIVES

We evaluated the long-term quality of life (QOL) and priorities of an international cohort of cancer surgery survivors.

METHODS

Patients were surveyed through online support groups. We utilized the Short Form-12 questionnaire to evaluate QOL and a novel survey to assess the relative importance of longevity, experience, and costs.

RESULTS

A total of 592 patients from six continents responded. They were 58 ± 12 years old, 70% female, and 92% White. Patients averaged 37 months from their initial cancer diagnosis, with a maximum survivorship of 46 years. Across 17 disease sites, respondents generally ranked longevity, functional independence, and emotional well-being most important, while treatment experience and costs were ranked least important (W = 33.6%, p < 0.001). However, a subset of respondents ranked costs as significantly important. There were no differences in QOL based on demographics, except patients with higher education and income reported better QOL scores. Despite improvements in QOL throughout survivorship, both physical-QOL (41.1 ± 11.1 at 1 year vs. 42.3 ± 12.6 at 5 years, p = 0.511) and mental-QOL (41.3 ± 13.4 at 1 year vs. 44.6 ± 13.9 at 5 years, p = 0.039) remained below that of the general population (50 ± 10; both p < 0.001).

CONCLUSIONS

Cancer survivors experience enduring physical and mental impairment throughout survivorship. Future efforts should aim to provide sustained support across varied socioeconomic groups, ensuring equitable care and enhancement of QOL postcancer treatment.

Associations Between Rehabilitation Utilization and Out-of-Pocket Costs Among Older Adults With Breast Cancer in the United States

OBJECTIVE

To examine the association between rehabilitation utilization within 12 months of breast cancer diagnosis and out-of-pocket costs in the second year (12-24mo after diagnosis).

DESIGN

Secondary analysis of the 2009-2019 Surveillance, Epidemiology and End Results-Medicare linked database. Individuals who received rehabilitation services were propensity-score matched to individuals who did not receive services. Overall and health care service-specific models were examined using generalized linear models with a gamma distribution.

SETTING

Inpatient and outpatient medical facilities.

PARTICIPANTS

A total of 35,212 individuals diagnosed with nonmetastatic breast cancer and were continuously enrolled in Medicare Fee-For Service (parts A, B, and D) in the 12 months before and 24 months postdiagnosis.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Individual cost responsibility, a proxy for out-of-pocket costs, which was defined as deductibles, coinsurance, and copayments during the second year after diagnosis (12-24mo postdiagnosis).

RESULTS

The mean individual cost responsibility was higher in individuals who used rehabilitation than those who did not ($4013 vs $3783), although it was not a clinically meaningful difference (d=0.06). Individuals who received rehabilitative services had significantly higher costs attributed to individual provider care ($1634 vs $1476), institutional outpatient costs ($886 vs $812), and prescription drugs ($959 vs $906), and significantly lower costs attributed to institutional inpatient costs ($455 vs $504), and durable medical equipment ($81 vs $86).

CONCLUSIONS

Older adults with breast cancer who received rehabilitation services had higher cost responsibility during the second year after diagnosis than those who did not. Future work is needed to examine the relationship between rehabilitation and out-of-pocket costs across longer periods of time and in conjunction with perceived benefit.

Exploring the economic toxicity experiences and coping styles of patients with colorectal cancer fistula in Jiangsu province, China: a qualitative study

OBJECTIVES

In recent years, economic toxicity has significantly affected the physical and mental health as well as the quality of life of patients with colorectal cancer. However, this issue has not garnered adequate attention from healthcare professionals. This study aims to investigate the experiences of economic toxicity and coping strategies among patients with colorectal cancer fistula. The findings are intended to inform the development of suitable and effective intervention programmes to address economic toxicity within this patient population.

DESIGN

A descriptive phenomenological approach was employed in this qualitative research, using a semistructured method for data collection and analysis of interview data. Traditional content analysis methods were applied, encompassing coding, categorisation and theme distillation. Data analysis continued until thematic saturation was achieved, with no new themes emerging.

SETTING

Nanjing Medical University Lianyungang Clinical Medical College.

PARTICIPANTS

A total of 21 patients with colorectal cancer fistula were selected as interview subjects through purposive sampling. The selection took place from May 2022 to May 2023, involving patients during their stay at a tertiary hospital in Lianyungang city, Jiangsu province, China.

RESULTS

In total, three pieces and eight subthemes were distilled: subjective feelings (worries about treatment costs, concerns about uncertainty about the future, worries about daily life), coping styles (coping alone, unwillingness to help, prepurchased insurance, dealing with illness, giving up treatment, inability to afford costs) and needs and aspirations (need for health policies, need for social support).

CONCLUSIONS

Patients with colorectal cancer fistulae experience economic toxicity, leading to significant impairment in both physical and mental health. Despite employing various coping strategies, healthcare professionals must prioritise addressing the economic toxicity issue in patients. Implementing rational and effective interventions can greatly assist patients in effectively managing economic toxicity.

The invisible scars: Unseen financial complications worsen every aspect of long-term health in trauma survivors

BACKGROUND

Trauma survivors are susceptible to experiencing financial toxicity (FT). Studies have shown the negative impact of FT on chronic illness outcomes. However, there is a notable lack of data on FT in the context of trauma. We aimed to better understand prevalence, risk factors, and impact of FT on trauma long-term outcomes.

METHODS

Adult trauma patients with an Injury Severity Score (ISS) ≥9 treated at Level I trauma centers were interviewed 6 months to 14 months after discharge. Financial toxicity was considered positive if patients reported any of the following due to the injury: income loss, lack of care, newly applied/qualified for governmental assistance, new financial problems, or work loss. The Impact of FT on Patient Reported Outcome Measure Index System (PROMIS) health domains was investigated.

RESULTS

Of 577 total patients, 44% (254/567) suffered some form of FT. In the adjusted model, older age (odds ratio [OR], 0.4; 95% confidence interval [95% CI], 0.2-0.81) and stronger social support networks (OR, 0.44; 95% CI, 0.26-0.74) were protective against FT. In contrast, having two or more comorbidities (OR, 1.81; 95% CI, 1.01-3.28), lower education levels (OR, 1.95; 95% CI, 95%, 1.26-3.03), and injury mechanisms, including road accidents (OR, 2.69; 95% CI, 1.51-4.77) and intentional injuries (OR, 4.31; 95% CI, 1.44-12.86) were associated with higher toxicity. No significant relationship was found with ISS, sex, or single-family household. Patients with FT had worse outcomes across all domains of health. There was a negative linear relationship between the severity of FT and worse mental and physical health scores.

CONCLUSION

Financial toxicity is associated with long-term outcomes. Incorporating FT risk assessment into recovery care planning may help to identify patients most in need of mitigative interventions across the trauma care continuum to improve trauma recovery. Further investigations to better understand, define, and address FT in trauma care are warranted.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Geriatric Oncology: A 5-Year Strategic Plan

The increasing rate of the older adult population across the world over the next 20 years along with significant developments in the treatment of oncology will require a more granular understanding of the older adult population with cancer. The ASCO Geriatric Oncology Community of Practice (COP) herein provides an outline for the field along three fundamental pillars: education, research, and implementation, inspired by ASCO's 5-Year Strategic Plan. Fundamental to improving the understanding of geriatric oncology is research that intentionally includes older adults with clinically meaningful data supported by grants across all career stages. The increased knowledge base that is developed should be conveyed among health care providers through core competencies for trainees and continuing education for practicing oncologists. ASCO's infrastructure can serve as a resource for fellowship programs interested in acquiring geriatric oncology content and provide recommendations on developing training pathways for fellows interested in pursuing formalized training in geriatrics. Incorporating geriatric oncology into everyday practice is challenging as each clinical setting has unique operational workflows with barriers that limit implementation of valuable geriatric tools such as Geriatric Assessment. Partnerships among experts in quality improvement from the ASCO Geriatric Oncology COP, the Cancer and Aging Research Group, and ASCO's Quality Training Program can provide one such venue for implementation of geriatric oncology through a structured support mechanism. The field of geriatric oncology must continue to find innovative strategies using existing resources and partnerships to address the pressing needs of the older adult population with cancer to improve patient outcomes.

Physical health-related quality of life trajectories over two years following breast cancer diagnosis in older women: a secondary analysis

PURPOSE

To identify distinct trajectories of physical health-related quality of life (HRQoL) in older women over the first two years following breast cancer diagnosis, and to examine characteristics associated with trajectory group membership.

METHODS

A secondary analysis of a longitudinal study of women diagnosed with stage I-III breast cancer who completed surveys within eight months of diagnosis and six, twelve, and eighteen months later that focuses on a subset of women aged ≥ 65 years (N = 145).Physical HRQoL was assessed using the Physical Component Score (PCS) of the SF-36 Health Survey. Finite mixture modeling identified distinct PCS trajectories. Multivariable logistic regression identified variables predictive of low PCS group membership.

RESULTS

Two distinct patterns of PCS trajectories were identified. The majority (58%) of women had PCS above the age-based SF-36 population norms and improved slightly over time. However, 42% of women had low PCS that remained low over time. In multivariable analyses, older age, difficulty paying for basics, greater number of medical comorbidities, and higher body mass index were associated with low PCS group membership. Cancer treatment and psychosocial variables were not significantly associated.

CONCLUSION

A large subgroup of older women reported very low PCS that did not improve over time. Older age, obesity, multiple comorbidities, and lower socioeconomic status may be risk factors for poorer PCS in women with breast cancer. Incorporating routine comprehensive geriatric assessments that screen for these factors may help providers identify older women at risk for poorer physical HRQoL post breast cancer treatment.

Financial difficulties experienced by patients with gastrointestinal stromal tumours (GIST) in the Netherlands: data from a cross-sectional multicentre study

PURPOSE

This study aims to (1) explore the prevalence of patient-reported financial difficulties among GIST patients, differentiating between those currently undergoing tyrosine kinase inhibitor (TKI) treatment and those who are not; (2) investigate associations between financial difficulties and sociodemographic and clinical characteristics, work, cancer-related concerns, anxiety and depression and (3) study the impact of financial difficulties on health-related quality of life.

METHODS

A cross-sectional study was conducted among Dutch GIST patients diagnosed between 2008 and 2018, who were invited to complete a one-time survey between September 2020 and June 2021. Patients completed nine items of the EORTC item bank regarding financial difficulties, seven work-related questions, the Hospital Anxiety and Depression Scale, Cancer Worry Scale and EORTC QLQ-C30.

RESULTS

In total, 328 GIST patients participated (response rate 63.0%), of which 110 (33.8%) were on TKI treatment. Patients currently treated with TKIs reported significantly more financial difficulties compared to patients not on TKIs (17.3% vs 8.7%, p = 0.03). The odds of experiencing financial difficulties was 18.9 (95% CI 1.7-214.7, p = 0.02) times higher in patients who were less able to work due to their GIST diagnosis. Patients who experienced financial difficulties had significantly lower global quality of life and functioning, and more frequently reported psychological symptoms as compared to patients who did not report financial difficulties.

CONCLUSION

Even in a country where the costs of TKIs and follow-up care are covered by health insurance, financial difficulties can be present in GIST patients, especially in patients on TKI treatment, and may negatively influence the quality of life.

Financial Burden of Hepatocellular Carcinoma Screening in Patients With Cirrhosis

BACKGROUND

The overall value of hepatocellular carcinoma screening is defined by the balance of benefits and harms. Studies have only reported physical harms with none describing financial harms.

METHODS

We conducted a multicenter pragmatic randomized clinical trial of hepatocellular carcinoma screening outreach among 2872 patients with cirrhosis from March 2018 to April 2021. Patients with positive or indeterminate results and matched patients with negative results completed surveys at baseline and at follow-up measuring financial harms via Cancer Self-Administered Questionnaire and financial burden via Comprehensive Score for Financial Toxicity Functional Assessment of Chronic Illness Therapy. Univariable and multivariable longitudinal regression analyses were performed to compare changes in financial harms across groups: true positive, true negative, false positive, and indeterminate. Semistructured interviews were conducted in a subset of patients, sampled by center and test result.

RESULTS

Of 311 patients who completed at least 1 follow-up survey (75% response rate), 37 had true positive, 133 true negative, 64 false positive, and 77 indeterminate results. Financial harms increased in true positive and false positive patients with no significant changes noted among those with true negative or indeterminate results. At follow-up, 21.8% of patients reported moderate-severe financial burden, which was not significantly associated with test results. Semistructured interviews revealed variation in the frequency and severity of financial harms based on test results, with increased harm in those with false positive results.

CONCLUSIONS

Financial harms of hepatocellular carcinoma screening vary by test result and can pose a barrier that must be considered when determining the optimal screening program.

Retirement behavior of cancer survivors: role of health insurance

PURPOSE

Workers who rely on employment for health insurance may be unable to reduce work during and following treatment for a serious health condition, potentially harming their health in retirement. In this study, we examine the influence of retiree and employment-contingent insurance on the retirement and health of workers diagnosed with cancer.

METHODS

This longitudinal cohort study used 2000-2018 Health and Retirement Study data to examine changes in employment, weekly hours worked, and health status measures following a cancer diagnosis. We selected respondents who reported a new cancer diagnosis (n = 354) and a matched, non-cancer sample (n = 1770), restricting both samples to those employed and younger than age 63.

RESULTS

Following a cancer diagnosis, women with retiree health insurance were 18.6 percentage points less likely to work (95% CI: - 36.3 to - 1.0; p < 0.05) relative to women with employer health insurance, but no retiree insurance. Employed women with cancer but without employment-contingent health insurance increased weekly hours worked by 34% relative to similar non-cancer controls. Men and women with a cancer diagnosis and without employment-contingent health or retiree insurance were also less likely to work (p < 0.05). Among those who stopped working, respondents with cancer and employment-contingent health insurance reported better health status than respondents without employment-contingent health insurance.

CONCLUSIONS

Cancer survivors with employer and retiree health insurance leave the workforce earlier and report better health status when they stop working than those without equivalent insurance.

IMPLICATIONS FOR CANCER SURVIVORS

Policies to support health insurance outside of employment may allow cancer survivors to retire earlier and may have positive health benefits.

Financial Toxicity in Radiation Oncology: Impact for Our Patients and for Practicing Radiation Oncologists

With rising costs of diagnosis, treatment, and survivorship, financial burdens on patients with cancer and negative effects from high costs, called financial toxicity (FT), are growing. Research suggests that FT may be experienced by more than half of working-age cancer survivors and a similar proportion may incur debt or avoid recommended prescription medications due to treatment costs. As FT can lead to worse physical, psychological, financial, and survival outcomes, there is a discrete need to identify research gaps around this issue that constrain the development and implementation of effective screening and innovative care delivery interventions. Prior research, including within a radiation oncology-specific context, has sought to identify the scope of FT among patients with cancer, develop assessment tools to evaluate patient risk, quantify financial sacrifices, and qualify care compromises that occur when cancer care is unaffordable. FT is a multifactorial problem and potential solutions should be pursued at all levels of the health care system (patient-provider, institutional, and systemic) with specific regard for patients' individual/local contexts. Solutions may include selecting alternative treatment schedules, discussing financial concerns with patients, providing financial navigation services, low-cost transportation options, and system-wide health policy shifts. This review summarizes existing FT research, describes tools developed to measure FT, and suggests areas for intervention and study to help improve FT and outcomes for radiation oncology patients.

Access to Financial Assistance Programs and Their Impact on Overall Spending on Oral Anticancer Medications at an Integrated Specialty Pharmacy

PURPOSE

Financial assistance (FA) programs are increasingly used to help patients afford oral anticancer medications (OAMs), but access to such programs and their impact on out-of-pocket (OOP) spending has not been well explored. This study aimed to (1) characterize the impact of receipt of FA on both OOP spending and likelihood of catastrophic spending on OAMs and (2) evaluate racial/ethnic disparities in access to FA programs.

METHODS

Patients with a cancer diagnosis prescribed an OAM anytime between January 1, 2021, and December 31, 2021 were included in this retrospective, single-center study at an integrated specialty pharmacy affiliated with a tertiary academic cancer center. Fixed-effect regression models were used to characterize the impact of receipt of FA on overall spending and likelihood of catastrophic spending on OAMs, as well as explore the association of race/ethnicity with receipt of FA.

RESULTS

Across 1,186 patients prescribed an OAM, 37% received FA. Receipt of FA was associated with lower annual spending on OAMs (β = -$1,236 US dollars [USD; 95% CI, -$1,841 to -$658], P < .001) but not reduced risk of catastrophic spending (odds ratio [OR], 0.442 [95% CI, 0.755 to 3.199], P = .23). Non-White patients (OR, 0.60 [95% CI, 0.43 to 0.85], P = .004) and patients who spoke English as a second language (OR, 0.46 [95% CI, 0.23 to 0.90], P = .02) were less likely to receive FA compared with White and English-speaking patients, respectively.

CONCLUSION

FA programs can mitigate high OOP spending but not for patients who spend at catastrophic levels. There are racial/ethnic and language disparities in access to such programs. Future studies should evaluate access to FA programs across diverse delivery settings.

Describing financial toxicity among cancer patients in different income countries: a systematic review and meta-analysis

Background

There is limited evidence of financial toxicity (FT) among cancer patients from countries of various income levels. Hence, this study aimed to determine the prevalence of objective and subjective FT and their measurements in relation to cancer treatment.

Methods

PubMed, Science Direct, Scopus, and CINAHL databases were searched to find studies that examined FT. There was no limit on the design or setting of the study. Random-effects meta-analysis was utilized to obtain the pooled prevalence of objective FT.

Results

Out of 244 identified studies during the initial screening, only 64 studies were included in this review. The catastrophic health expenditure (CHE) method was often used in the included studies to determine the objective FT. The pooled prevalence of CHE was 47% (95% CI: 24.0-70.0) in middle- and high-income countries, and the highest percentage was noted in low-income countries (74.4%). A total of 30 studies focused on subjective FT, of which 9 used the Comprehensive Score for FT (COST) tool and reported median scores ranging between 17.0 and 31.9.

Conclusion

This study shows that cancer patients from various income-group countries experienced a significant financial burden during their treatment. It is imperative to conduct further studies on interventions and policies that can lower FT caused by cancer treatment.

A Phenomenological Qualitative Exploration of Mind-Body Therapy Use and Effectiveness Among Young, Middle, and Older Adult Cancer Survivors

BACKGROUND

Having been diagnosed with and treated for cancer can have negative psychosocial repercussions that may differ across the lifespan. Mind-body therapies (MBTs), such as tai-chi/qigong (TCQ) or mindfulness-based cancer recovery (MBCR), have shown promise in decreasing negative psychosocial outcomes in cancer survivors, but few studies have explored potential differences in MBT use and effectiveness across age groups.

METHODS

A descriptive phenomenological qualitative design was used. Participants included young (18-39), middle (40-64), and older (65+) adult cancer survivors who were diagnosed with any type of cancer and had participated in Mindfulness-Based Cancer Recovery (MBCR) or Tai Chi/Qigong (TCQ) MBTs. Semi-structured qualitative interviews explored participants' experiences in MBTs and these were analyzed using descriptive phenomenological analysis.

RESULTS

Among the interviews (n = 18), young (n = 6), middle-aged (n = 8), and older (n = 4) adults participated. 5 themes emerged: influences in joining the program, unique lifestyles, positive class experiences, use of media, and program impacts. Though all age groups benefitted from MBT participation, variations between age groups with respect to the benefits received and motivations for joining the program were observed.

DISCUSSION

MBTs had beneficial physical and mental health effects on survivors of all age groups. These benefits were particularly connected to the ongoing life stresses common to each age cohort, such as relief from work and family roles for young adults or support during retirement transition for older adults. Hence, access to MBT programs may be beneficial as part of the survivorship plan for patients and the recruitment strategies or content can be adapted by MBT providers to better target and support age-specific groups. More research is required with a larger sample.

Financial Toxicity among Patients with Breast Cancer during the COVID-19 Pandemic in the United States

This study reported the prevalence of financial distress (financial toxicity (FT)) and COVID-19-related economic stress in patients with breast cancer (BC). Patients with BC were recruited from the Ciitizen platform, Breastcancer.org, and patient advocacy groups between 30 March and 6 July 2021. FT was assessed with the COmprehensive Score for financial Toxicity (COST) instrument. COVID-19-related economic stress was assessed with the COVID-19 Stress Scale. Among the 669 patients, the mean age was 51.6 years; 9.4% reported a COVID-19 diagnosis. The prevalence rates of mild and moderate/severe FT were 36.8% and 22.4%, respectively. FT was more prevalent in patients with metastatic versus early BC (p < 0.001). The factors associated with FT included income ≤ USD 49,999 (adjusted odds ratio (adj OR) 6.271, p < 0.0001) and USD 50,000-USD 149,999 (adj OR 2.722, p < 0.0001); aged <50 years (adj OR 3.061, p = 0.0012) and 50-64 years (adj OR 3.444, p = 0.0002); living alone (adj OR 1.603, p = 0.0476); and greater depression severity (adj OR 1.155, p < 0.0001). Black patients (adj OR 2.165, p = 0.0133), patients with income ≤ USD 49,999 (adj OR 1.921, p = 0.0432), or greater depression severity (adj OR 1.090, p < 0.0001) were more likely to experience COVID-19-related economic stress. FT was common in patients with BC, particularly metastatic disease, during COVID-19. Multiple factors, especially lower income and greater depression severity were associated with financial difficulties during COVID-19.

Evaluation of financial toxicity and associated factors in female patients with breast cancer: a systematic review and meta-analysis

PURPOSE

These systematic review and meta-analysis were conducted to discuss the financial toxicity (FT) level among breast cancer (BC) patients and the associated demographic and economic factors.

METHODS

A systematic review and meta-analysis of single means were used by following the Joanna Briggs Institute guidelines and PRISMA guidance. Untransformed means (MRAW) were used to estimate the confidence interval for individual studies, while I2 and tau2 statistics were used to examine heterogeneity among pooled studies. Electronic databases were PubMed, CINAHL, Web of Science, Scopus, Cochrane Library, Ovid MEDLINE(R), Science Direct, and Turkish databases were used to find relevant studies published in the last 15 years (between 2008 and 2023).

RESULTS

A total of 50 studies were reviewed in the systematic review, and 11 were included in the overall and subgroup meta-analyses. The majority of reviewed studies were from the USA (38 studies), while there were four studies from China and eight studies from other countries having different types of health systems. The overall estimated FT level based on 11 pooled studies was 23.19, meaning mild level FT in the range of four categories (no FT score > 25, mild FT score 14-25, moderate FT score 1-13, and severe FT score equal to 0), with a 95% CI of 20.66-25.72. The results of subgroup meta-analyses showed that the estimated FT levels were higher among those patients who were single, with lower education levels, stage 3 patients, younger, lower income, unemployed, and living in other countries compared to those who were married, more educated, and stages 1 and 2 patients, more aged, more income, employed, and patients in the USA.

CONCLUSION

The cost-effectiveness of the treatment strategies of BC depends on the continuity of care. However, FT is one of the leading factors causing BC patients to use the required care irregularly, and it has a negative effect on adherence to treatment. So, removing the economic barriers by taking appropriate measures to decrease FT will increase the efficiency of already allocated resources to BC treatments and improve the health outcomes of BC patients.

Cost and utilization of healthcare services for persons with diabetes

AIMS

Describe and compare healthcare costs and utilization for insured persons with type 1 diabetes (T1D), type 2 diabetes (T2D), and without diabetes in the United States.

METHODS

Using a nationally representative healthcare claims database, we identified matched persons with T1D, T2D, and without diabetes using a propensity score quasi-randomization technique. In each year between 2009 and 2018, we report costs (total and out-of-pocket) and utilization for all healthcare services and those specific to medications, diabetes-related supplies, visits to providers, hospitalizations, and emergency department visits.

RESULTS

In 2018, we found out-of-pocket costs and total costs were highest for persons with T1D (out-of-pocket: $2,037.2, total: $25,652.0), followed by T2D (out-of-pocket: $1,543.3, total: $22,408.1), and without diabetes (out-of-pocket: $1,122.7, total: $14,220.6). From 2009 to 2018, out-of-pocket costs were increasing for persons with T1D(+6.5 %) but decreasing for T2D (-7.5 %) and without diabetes (-2.3 %). Medication costs made up the largest proportion of out-of-pocket costs regardless of diabetes status (T1D: 51.4 %, T2D: 55.4 %,without diabetes: 51.1 %).

CONCLUSIONS

Given the substantial out-of-pocket costs for people with diabetes, especially for those with T1D, providers should screen all persons with diabetes for financial toxicity (i.e., wide-ranging problems stemming from healthcare costs). In addition, policies that aim to lower out-of-pocket costs of cost-effective diabetes related healthcare are needed with a particular focus on medications.

Heterogeneity of financial toxicity and associated risk factors for older cancer survivors in China

In China, older cancer survivors may show heterogeneity in financial toxicity (FT). We aimed to identify FT profiles among older Chinese cancer survivors and examine the association between FT profiles and individual characteristics. We used a latent profile analysis to categorize participants and a multinomial logistic regression to examine the associations. We identified three distinct FT profiles: high, moderate, and low. Participants aged 65-69 years, with a monthly household income ≥ 5,000 CNY and a high school education or above were more likely to be classified into the moderate than high FT profile, a monthly household income ≥ 5,000 CNY increased the likelihood of being in the low FT profile and living alone negatively affected the odds of being in the low FT profile. The findings identified heterogeneity in FT among this population, may help identify high-risk groups, and may enable early intervention.

The costs and inequities of precision medicine for patients with prostate cancer: A call to action

Financial toxicity is a growing problem in the delivery of cancer care and contributes to inequities in outcomes across the cancer care continuum. Racial/ethnic inequities in prostate cancer, the most common cancer diagnosed in men, are well described, and threaten to widen in the era of precision oncology given the numerous structural barriers to accessing novel diagnostic studies and treatments, particularly for Black men. Gaps in insurance coverage and cost sharing are 2 such structural barriers that can perpetuate inequities in screening, diagnostic workup, guideline-concordant treatment, symptom management, survivorship, and access to clinical trials. Mitigating these barriers will be key to achieving equity in prostate cancer care, and will require a multi-pronged approach from policymakers, health systems, and individual providers. This narrative review will describe the current state of financial toxicity in prostate cancer care and its role in perpetuating racial inequities in the era of precision oncology.

The impact of COVID-19 on mortality, length of stay, and cost of care among patients with gastrointestinal malignancies: A propensity score-matched analysis

BACKGROUND

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the coronavirus 19 (COVID-19) pandemic have had a lasting impact on the care of cancer patients. The impact on patients with gastrointestinal (GI) malignancies remains incompletely understood. We aimed to assess the impact of COVID-19 on mortality, length of stay (LOS), and cost of care among patients with GI malignancies, and identify differences in outcomes based on primary tumor site.

METHODS

We analyzed discharge encounters collected from the National Inpatient Sample (NIS) between March 2020 and December 2020 using propensity score matching (PSM) and COVID-19 as the treatment effect.

RESULTS

Of the 87,684 patient discharges with GI malignancies, 1892 were positive for COVID-19 (C+) and eligible for matching in the PSM model. Following PSM analysis, C+ with GI tumors demonstrated increased incidence of mortality compared to their COVID-19-negative (C-) counterparts (21.3% vs. 11.9%, p < 0.001). C+ patients with colorectal cancer (CRC) had significantly higher mortality compared to those who were C- (40% vs. 24%; p = 0.035). In addition, C+ patients with GI tumors had a longer mean LOS (9.4 days vs. 6.9 days; p < 0.001) and increased cost of care ($26,048.29 vs. $21,625.2; p = 0.001) compared to C- patients. C+ patients also had higher odds of mortality secondary to myocardial infarction relative to C- patients (OR = 3.54, p = 0.001).

CONCLUSIONS

C+ patients with GI tumors face approximately double the odds of mortality, increased LOS, and increased cost of care compared to their C- counterparts. Outcome disparities were most pronounced among patients with CRC.

Frailty and medical financial hardship among older adults with cancer in the United States

Background

Little is known about the association between frailty level and medical financial hardship among older adults with cancer. This study aims to describe the prevalence of frailty and to identify its association with medical financial hardship among older cancer survivors in the United States.

Methods

The National Health Interview Survey (NHIS; 2019-2020) was used to identify older cancer survivors (n = 3,919). Both the five-item (Fatigue, Resistance, Ambulation, Illnesses, and Low weight-for-height) FRAIL and the three-domain (Material, Psychological, and Behavioral) medical financial hardship questions were constructed based on the NHIS questionnaire. Multivariable logistic models were used to identify the frailty level associated with financial hardship and its intensity.

Results

A total of 1,583 (40.3%) older individuals with cancer were robust, 1,421 (35.9%) were pre-frail, and 915 (23.8%) were frail. Compared with robust cancer survivors in adjusted analyses, frail cancer survivors were more likely to report issues with material domain (odds ratio (OR) = 3.19, 95%CI: 2.16-4.69; p < 0.001), psychological domain (OR = 1.47, 95%CI: 1.15-1.88; p < 0.001), or behavioral domain (ORs ranged from 2.19 to 2.90, all with p < 0.050), and greater intensities of financial hardship.

Conclusion

Both pre-frail and frailty statuses are common in the elderly cancer survivor population, and frail cancer survivors are vulnerable to three-domain financial hardships as compared with robust cancer survivors. Ongoing attention to frailty highlights the healthy aging of older survivors, and efforts to targeted interventions should address geriatric vulnerabilities during cancer survivorship.

The Role of Financial Difficulties as a Mediator between Physical Symptoms and Depression in Advanced Cancer Patients

Financial difficulties experienced by cancer patients negatively impact the mental health of the patients. The objective of this study was to examine the mediating role of financial difficulties between physical symptoms and depression in patients with advanced cancer. A prospective, cross-sectional design was adopted in the study. The data were collected from 861 participants with advanced cancer in 15 different tertiary hospitals in Spain. The participants' socio-demographic characteristics were collected using a standardized self-report form. Hierarchical linear regression models were used to explore the mediating role of financial difficulties. In the results, 24% of patients reported a high level of financial difficulties. Physical symptoms were positively associated with financial difficulties and depression (β = 0.46 and β = 0.43, respectively), and financial difficulties was positively associated with depression (β = 0.26). Additionally, financial difficulties played a role in explaining the relationship between physical symptoms and depression, showing a standardized regression coefficient of 0.43 which decreased to 0.39 after the financial difficulties were controlled. Healthcare professionals should consider the importance of providing financial resources and emotional support to help patients and their families cope with the financial burden associated with cancer treatment and its symptoms.

Management of Prostate Cancer in Older Adults

The majority of men with prostate cancer are diagnosed when they are older than 65 years; however, clinical trial participants are disproportionately younger and more fit than the real-world population treated in typical clinical practices. It is, therefore, unknown whether the optimal approach to prostate cancer treatment is the same for older men as it is for younger and/or more fit men. Short screening tools can be used to efficiently assess frailty, functional status, life expectancy, and treatment toxicity risk. These risk assessment tools allow for targeted interventions to increase a patient's reserve and improve treatment tolerance, potentially allowing more men to experience the benefit of the significant recent treatment advances in prostate cancer. Treatment plans should also take into consideration each patient's individual goals and values considered within their overall health and social context to reduce barriers to care. In this review, we will discuss evidence-based risk assessment and decision tools for older men with prostate cancer, highlight intervention strategies to improve treatment tolerance, and contextualize these tools within the current treatment landscape for prostate cancer.

Financial Toxicity in Cancer Care: Implications for Clinical Care and Potential Practice Solutions

Patients with cancer face an array of financial consequences as a result of their diagnosis and treatment, collectively referred to as financial toxicity (FT). In the past 10 years, the body of literature on this subject has grown tremendously, with a recent focus on interventions and mitigation strategies. In this review, we will briefly summarize the FT literature, focusing on the contributing factors and downstream consequences on patient outcomes. In addition, we will put FT into context with our emerging understanding of the role of social determinants of health and provide a framework for understanding FT across the cancer care continuum. We will then discuss the role of the oncology community in addressing FT and outline potential strategies that oncologists and health systems can implement to reduce this undue burden on patients with cancer and their families.

Is Financial Toxicity Captured in Assessments of Quality of Life In Oncology Randomized Clinical Trials?

BACKGROUND

Financial difficulties in relation with diagnosis and treatment of patients with cancer affects their quality-of-life (QoL). We aim to characterize how financial toxicity was captured in oncology randomized clinical trials (RCTs), and to estimate how often the study-drug or other expenses were covered by sponsors.

METHODS

This was a cross-sectional analysis of articles published in six high impact journals (The New England Journal of Medicine, The Lancet, JAMA, The Lancet Oncology, Journal of Clinical Oncology, and JAMA Oncology). Selected articles needed to report on a RCT published between January 2018 and December 2019, study an anti-cancer drug, and have reported QoL results. We abstracted the QoL questionnaires used; whether the survey was directly assessing financial difficulties; whether a difference in financial toxicity was reported between arms; and whether the sponsor supplied the study-drug or covered other expenses.

RESULTS

For all 73 studies that met inclusion criteria, 34 studies (47%) utilized QoL questionnaires without direct assessment of financial difficulties. The study drug was provided by the sponsor in at least 51 trials (70%), provided according to local rules in 3 trials (4%), and undeterminated in the remaining 19 trials (26%). We found 2 trials (3%) with payments or compensation to enrolled patients.

CONCLUSION

This cross-sectional study found 47% of articles reporting on QoL in oncology RCTs did not use QoL questionnaires directly assessing financial toxicity. Additionnaly, the study drug was supplied by the sponsor in most trials. Financial toxicity occurs in real-life settings when patients have to pay for the drugs and other medical expenses. QoL assessments from oncology RCTs lack generalizability to real-world settings, due to limited querying of financial toxicity.

POLICY SUMMARY

Real-world evidence could be demanded by regulators as post-requirement studies to ensure QoL results observed in trials will replicate in patients treated outside investigational trials.

Relationship between income and concerns about physical changes and help-seeking by older adult cancer survivors: a secondary analysis

OBJECTIVE

Globally, the number of older adults surviving cancer is anticipated to grow rapidly over the next decades. Cancer and its treatment can leave survivors with a myriad of challenges including physical changes which impact independence and quality of life. This project explored the relationship of income level with concerns and help-seeking for physical changes following treatment in older Canadian survivors of cancer.

METHODS

A Canada-wide survey of community-dwelling survivors of cancer explored their experiences with survivorship care one to three years following completion of treatment. A secondary trend analysis examined the relationship of income with older adults' level of concern and help-seeking experiences regarding physical consequences they attributed to their cancer treatment.

RESULTS

In total, 7,975 people aged 65 years and older who survived cancer responded to the survey, of whom 5,891 (73.9%) indicated annual household income. Prostate (31.3%), colorectal (22.7%) and breast (21.8%) cancer accounted for the majority of respondents. Of those who reported household income data, over 90% wrote about the impact of physical changes following treatment, their concerns about the changes, and whether they sought help for their concerns. The most frequently identified physical challenge was fatigue (63.7%). Older survivors with low annual household incomes of less than $CA25,000 reported the highest levels of concern about multiple physical symptoms. 25% or more of the survey respondents across all income levels reported difficulty finding assistance for their concerns about the physical challenges, especially in their local communities.

CONCLUSION

Older survivors of cancer can experience a range of physical changes, amenable to intervention by physical therapy, yet experience challenges obtaining relevant help. Those with low income are more severely affected, even within a universal healthcare system. Financial assessment and tailored follow-up are recommended.

Financial toxicity in cancer patients undergoing radiotherapy in a universal health care system - a prospective multicenter study of 1075 patients

PURPOSE

To establish and confirm prevalence as well as risk factors of financial toxicity in a large national cohort of cancer patients undergoing radiotherapy in a universal health care system.

METHODS

We conducted a prospective cross-sectional study offering a patient-reported questionnaire to all eligible cancer patients treated with radiotherapy in 11 centers in Germany during 60 consecutive days. The four-point subjective financial distress question of the EORTC QLQ-C30 was used as a surrogate for financial toxicity. Confirmatory hypothesis testing evaluated the primary study outcomes: overall prevalence of financial toxicity and its association with predefined risk factors. P-values <.05 were considered statistically significant.

RESULTS

Of 2341 eligible patients, 1075 (46%) participated. The prevalence of subjective financial distress (=any grade higher than not present) was 41% (438/1075) exceeding the hypothesized range of 26.04-36.31%. Subjective financial distress was felt "A little" by 26% (280/1075), "Quite a bit" by 11% (113/1075) and "Very much" by 4% (45/1075) of the patients. Lower household income, lower global health status/ quality of life, higher direct costs and higher loss of income significantly predicted higher subjective financial distress per ordinal regression and confirmed these risk factors. Higher psychosocial distress and lower patient satisfaction were significantly associated with higher subjective financial distress in an exploratory ordinal regression model.

CONCLUSION

The overall prevalence of financial toxicity was higher than anticipated, although reported at low or moderate degrees by most affected patients. As we confirmed risk factors associated with financial toxicity, patients at risk should be addressed early for potential support.

Association between financial toxicity and health-related quality of life of patients with gynecologic cancer

OBJECTIVES

Patients often struggle with their financial situation during cancer treatment due to treatment-related costs or loss of income. This resulting negative effect is called financial toxicity, which is a known as a side effect of cancer care. This study aimed to evaluate the association between financial toxicity and health-related quality of life among patients with gynecologic cancer using validated questionnaires.

METHODS

In this multicenter study, patients with gynecologic cancer receiving anti-cancer drug treatment for > 2 months were recruited. Patients answered the COmprehensive Score for Financial Toxicity (COST) tool, EORTC-QLQ-C30, disease-specific tools (EORTC-QLQ-OV28/CX24/EN24), and EQ-5D-5L. Spearman's rank correlation coefficient was used to determine associations.

RESULTS

Between April 2019 and July 2021, 109 cancer patients completed the COST questionnaire. The mean COST score was 19.82. Strong associations were observed between financial difficulty (r = - 0.616) in the EORTC-QLQ-C30 and body image (r = 0.738) in the EORTC-QLQ-CX24, while weak associations were noted between the global health status/quality of life (r = 0.207), EQ-5D-5L index score (r = 0.252), and several function and symptom scale scores with the COST score.

CONCLUSIONS

Greater financial toxicity was associated with worse health-related quality of life scores, such as financial difficulty in gynecologic cancer patients and body image in cervical cancer patients as strong associations, and weakly associated with general health-related quality of life scores and several function/symptom scales.

Care needs of older patients with advanced cancer

PURPOSE OF REVIEW

This review summarized current research evidence examining care needs of older patients with advanced cancer in dealing with disease, treatment, and treatment-related side effects. It also identified gaps and directions for future research and practice.

RECENT FINDINGS

Older patients with advanced cancer need support from health professionals, family, friends, and other social network members in the management of physical symptoms and functioning, psychosocial and spiritual care, information provision, and practical resolution of daily problems. As older patients are affected by aging-related factors, they usually have unique patterns of care needs compared with younger patients.

SUMMARY

Currently, insufficient research evidence hinders a comprehensive understanding of care needs of older patients with advanced cancer, as well as potential influencing factors. Future efforts are needed to develop more sophisticated assessment methods and interventions to better understand and address care needs of older patients with advanced cancer.

Evaluation of parking-related financial toxicity associated with cancer treatments in Western Canada

INTRODUCTION/BACKGROUND

Patients and their caregivers incur numerous out-of-pocket costs while receiving oncologic treatments. These expenses are often overlooked by clinicians, even in countries with publicly funded healthcare systems. Parking fees are one such category of expenses that contribute to financial toxicity in cancer care. Patients with cancer often have protracted treatment courses, especially if they are receiving external beam radiation therapy. It is not clear if cancer center parking fees influence city-specific indices such as city-specific cost of living. The aim of this study was to evaluate cancer center parking fees in Western Canada and to elucidate any correlation between daily cost of parking and the city-specific indices.

METHODS

This was a cross sectional study conducted from February 1st, 2022, to March 1st, 2022. An online search was undertaken to obtain the publicly available parking information for the regional and community cancer centers in the provinces of British Columbia, Alberta, Manitoba, and Saskatchewan. Telephone calls were made with parking offices or switchboards to obtain this information for the cancer centers that did not have online information on parking. Cancer center address transit scores, median city household income, and city-specific cost of living scores were obtained online for the cities where the cancer centers were located. Pearson correlation and a zero-inflated negative binomial model were used for statistical analysis.

RESULTS

Data was collected from 115 community and regional cancer centers distributed across the 4 provinces. The median hourly parking fee across all provinces was 2.00 Canadian Dollars (CAD) (Interquartile range (IQR), 0-4.25), whereas the median daily cost of parking was 9.50 CAD (IQR, 0-13.13). The median cancer center address transit score was 41.00 (IQR, 12.00-50.50). There was a statistically significant (p=0.029) positive correlation between the daily cost of parking and city cost of living. The correlation coefficient between the two variables was 0.412. Furthermore, there was a statistically significant (p<0.001) positive correlation between daily cost of parking and cancer center address transit score. The correlation coefficient between the two variables was 0.676. In addition, there was a strong negative correlation between the cancer center address transit score and the presence of free parking with a correlation coefficient of -0.613 (p<0.001). There was a nonsignificant (p=0.88) negative correlation between cost of living and the presence of free parking with a correlation coefficient of -0.028.

DISCUSSION

The results of this study demonstrate that daily cost of parking for community and regional cancer centers in Western Canada significantly influences city-specific cost of living and cancer center address transit scores to a varying degree. This demonstrates that the influence of parking fees on patients with cancer is multilayered with significant direct and indirect effects. This can contribute to loss of wage and added financial burden on patients and their caregivers in higher-cost provinces. The presence of free parking at community and regional cancer centers had a statistically significant negative correlation with the cancer center address transit score. This suggests that cities with more free parking also have less robust public transit systems. Conversely, the presence of an extensive public transit system leads to a lower likelihood of free parking being available at cancer centers.

CONCLUSION

The presence of a strong public healthcare system does not necessarily address all aspects of cancer-related financial toxicity. There is strong evidence of both positive and negative correlations between city specific indices and cancer center parking fees in Western Canada. Policy makers and stakeholders should be cognizant of this interplay between the various city specific indices and parking fees for patients with cancer. Policies on provincial and federal levels should be implemented to address this increasingly problematic burden on oncologic patients.

External Validation of Risk Factors for Unplanned Hospitalization in Older Adults With Advanced Cancer Receiving Chemotherapy

BACKGROUND

Older adults (age ≥65 years) receiving chemotherapy are at risk for hospitalization. Predictors of unplanned hospitalization among older adults receiving chemotherapy for cancer were recently published using data from a study conducted by the Cancer and Aging Research Group (CARG). Our study aimed to externally validate these predictors in an independent cohort including older adults with advanced cancer receiving chemotherapy.

METHODS

This validation cohort included patients (n=369) from the GAP70+ trial usual care arm. Enrolled patients were aged ≥70 years with incurable cancer and were starting a new line of chemotherapy. Previously identified risk factors proposed by the CARG study were ≥3 comorbidities, albumin level <3.5 g/dL, creatinine clearance <60 mL/min, gastrointestinal cancer, ≥5 medications, requiring assistance with activities of daily activities (ADLs), and having someone available to take them to the doctor (ie, presence of social support). The primary outcome was unplanned hospitalization within 3 months of treatment initiation. Multivariable logistic regression was applied including the 7 identified risk factors. Discriminative ability of the fitted model was performed by calculating the area under the receiver operating characteristic (AUC) curve.

RESULTS

Mean age of the cohort was 77 years, 45% of patients were women, and 29% experienced unplanned hospitalization within the first 3 months of treatment. The proportions of hospitalized patients with 0-3, 4-5, and 6-7 identified risk factors were 24%, 28%, and 47%, respectively (P=.04). Impaired ADLs (odds ratio, 1.76; 95% CI, 1.04-2.99) and albumin level <3.5 g/dL (odds ratio, 2.23; 95% CI, 1.37-3.62) were significantly associated with increased odds of unplanned hospitalization. The AUC of the model, including the 7 identified risk factors, was 0.65 (95% CI, 0.59-0.71).

CONCLUSIONS

The presence of a higher number of risk factors was associated with increased odds of unplanned hospitalization. This association was largely driven by impairment in ADLs and low albumin level. Validated predictors of unplanned hospitalization can help with counseling and shared decision-making with patients and their caregivers.

CLINICALTRIALS

gov identifier: NCT02054741.

Communication of costs and financial burdens between cancer patients and healthcare providers: a qualitative systematic review and meta-synthesis

OBJECTIVES

The aim of this study was to synthesize qualitative research regarding communication of costs and financial burdens between patients and healthcare providers to provide evidence for the subsequent development of intervention programs.

METHODS

Studies published prior to 11 February 2023 were collected from electronic databases, including PubMed/MEDLINE, MEDLINE (Ovid), Web of Science, EMBASE (Ovid), CINAHL (EBSCO), and ProQuest. A checklist for qualitative research drawn from the Joanna Briggs Institute Reviewer's Manual was applied to assess the quality of the included studies. Meta-aggregation was performed to synthesize the findings of the included studies.

RESULTS

Four synthesized findings were derived from 15 studies: cost communication offered more benefits than drawbacks, and most patients were willing to engage in cost communication; cost communication has been implemented in clinical practice but continued to face shortcomings and barriers; an expected cost communication should take into account timing, location, personnel, personality, and content; healthcare providers required education, information, tools, standardized processes, and policy and organizational support to increase their ability to deliver cost communication.

CONCLUSIONS

Cost communication can help optimize decision-making and reduce the risk of financial difficulties, as has been widely recognized by patients and healthcare providers. However, a complete clinical practice plan to facilitate cost communication has not yet been created.

The Association Between Cost-Related Non-Adherence Behaviors and Diabetes Outcomes

BACKGROUND

We examined the impact of various comorbid conditions on diabetes and condition-specific cost-related nonadherence (CRN), and HbA1c in adults with diabetes.

METHODS

This was a cross-sectional analysis of participants with diabetes and poor glycemic control in an ongoing trial (n = 600). We computed prevalence of condition-specific CRN, prevalence of specific types of diabetes-related CRN by comorbid condition, prevalence of specific types of condition-specific CRN within each comorbidity, and the association between condition-specific and diabetes-related CRN and HbA1c for each comorbid condition.

RESULTS

Fifty-eight percent (n = 350) of participants reported diabetes-related CRN. Diabetes-related CRN rates were highest in those with liver problems (63%), anemia (61%), respiratory diseases (60%), and hyperlipidemia (60%). Condition-specific CRN rates were high in those with respiratory diseases (44%), back pain (41%), and depression (40%). Participants with cancer and kidney diseases reported the lowest rates of diabetes-related and condition-specific CRN. Delaying getting diabetes prescriptions filled was the most commonly reported form of diabetes-related CRN across all comorbid conditions and was the highest in those with liver problems (47%), anemia (46%), and respiratory diseases (45%). In adjusted models, those with back pain (beta-coefficient, 0.45; 95%CI 0.02-0.88; P = .04) and hyperlipidemia (beta-coefficient, 0.50; 95%CI 0.11-0.88; P = .01) who reported both diabetes-related and condition-specific CRN had higher HbA1c.

CONCLUSIONS

CRN in patients with diabetes is higher than in other comorbid conditions and is associated with poor diabetes control. These findings may be driven by higher out-of-pocket costs for medications to manage diabetes, lack of symptoms associated with poor diabetes control, or other factors, with implications for both clinicians and health insurance programs.

Financial Toxicity Among Patients With Breast Cancer Worldwide: A Systematic Review and Meta-analysis

Importance

Financial toxicity (FT) is the negative impact of cost of care on financial well-being. Patients with breast cancer are at risk for incurring high out-of-pocket costs given the long-term need for multidisciplinary care and expensive treatments.

Objective

To quantify the FT rate of patients with breast cancer and identify particularly vulnerable patient populations nationally and internationally.

Data Sources

A systematic review and meta-analysis were conducted. Four databases-Embase, PubMed, Global Index Medicus, and Global Health (EBSCO)-were queried from inception to February 2021. Data analysis was performed from March to December 2022.

Study Selection

A comprehensive database search was performed for full-text, English-language articles reporting FT among patients with breast cancer. Two independent reviewers conducted study screening and selection; 462 articles underwent full-text review.

Data Extraction and Synthesis

A standardized data extraction tool was developed and validated by 2 independent authors; study quality was also assessed. Variables assessed included race, income, insurance status, education status, employment, urban or rural status, and cancer stage and treatment. Pooled estimates of FT rates and their 95% CIs were obtained using the random-effects model.

Main Outcomes and Measures

FT was the primary outcome and was evaluated using quantitative FT measures, including rate of patients experiencing FT, and qualitative FT measures, including patient-reported outcome measures or patient-reported severity and interviews. The rates of patients in high-income, middle-income, and low-income countries who incurred FT according to out-of-pocket cost, income, or patient-reported impact of expenditures during breast cancer diagnosis and treatment were reported as a meta-analysis.

Results

Of the 11 086 articles retrieved, 34 were included in the study. Most studies were from high-income countries (24 studies), and the rest were from low- and middle-income countries (10 studies). The sample size of included studies ranged from 5 to 2445 people. There was significant heterogeneity in the definition of FT. FT rate was pooled from 18 articles. The pooled FT rate was 35.3% (95% CI, 27.3%-44.4%) in high-income countries and 78.8% (95% CI, 60.4%-90.0%) in low- and middle-income countries.

Conclusions and Relevance

Substantial FT is associated with breast cancer treatment worldwide. Although the FT rate was higher in low- and middle-income countries, more than 30% of patients in high-income countries also incurred FT. Policies designed to offset the burden of direct medical and nonmedical costs are required to improve the financial health of vulnerable patients with breast cancer.

Impact of a Comprehensive Financial Resource on Financial Toxicity in a National, Multiethnic Sample of Adult, Adolescent/Young Adult, and Pediatric Patients With Cancer

PURPOSE

Financial toxicity is a well-recognized problem for patients with cancer. However, a crucial gap remains in describing and implementing mitigation strategies. We conducted a national survey of a multiethnic adolescent/pediatric and adult patient population served by Family Reach, a nonprofit organization focused on removing financial barriers to cancer care, to evaluate the impact of a comprehensive financial resource on patient-reported financial toxicity.

METHODS

An electronic survey was administered to characterize patients' current financial health and the impact of Family Reach's resources on financial toxicity. The survey was e-mailed to all patients or caregivers who received resources from Family Reach between January 1, 2020, and June 30, 2020. Factors associated with higher financial stress and higher potential impact of resources on financial burden were evaluated through separate multivariate regression models. Qualitative responses were analyzed using manual coding and thematic analysis.

RESULTS

Three hundred thirty socioeconomically and racially diverse respondents (overall response rate 40%; 46% non-Hispanic White; 48% with incomes below the federal poverty line) completed the survey and were included in the analysis. More than half of respondents reported high financial stress in the previous week. Hispanic ethnicity, Black race, and low annual household income were associated with higher financial toxicity. A greater amount of financial assistance was associated with a higher confidence rating that resources provided would decrease financial stress. In open-ended comments, respondents highlighted the impact of the COVID-19 pandemic and resulting job loss on financial toxicity, the importance of financial navigation, the benefits of financial assistance, and anxiety about long-term financial health.

CONCLUSION

A comprehensive financial resource, particularly financial assistance, alleviated financial toxicity in a multiethnic national sample of patients with cancer. Ongoing work is critical to address sustainable funding sources and financial navigation to support patients during treatment and survivorship.

Financial Hardship and Quality of Life Among Patients With Advanced Cancer Receiving Outpatient Palliative Care: A Pilot Study

BACKGROUND

Patients with advanced cancer are increasingly experiencing financial hardship (FH) and associated negative health outcomes.

OBJECTIVE

The aims of this study were to describe FH and explore its relationship to quality of life (QOL) in patients with advanced cancer receiving outpatient palliative care (PC).

METHODS

Validated questionnaires assessed FH, QOL dimensions, symptom burden, and sociodemographic and clinical characteristics. Descriptive statistics characterized the sample and described FH. Pearson correlation and linear regression assessed relationships between FH and QOL.

RESULTS

The average participant (n = 78) age was 56.6 (SD, 12.2) years. Most were female (56.4%), White (50%) or Black (46.2%), and had a range of education, partner statuses, and cancer diagnoses. Median time since cancer diagnosis was 35.5 months (interquartile range, 9-57.3 months). Highest mean symptom burden scores were for pain (2.5 [SD, 1.0]) and fatigue (2.0 [SD, 1.1]), on a 0- to 3-point scale (higher score representing worse symptom burden). The median COST (COmphrehensive Score for financial Toxicity) score was 15.0 (interquartile range, 9.0-23.0). Most (70%) had some (n = 43) or extreme (n = 9) difficulty paying for basic needs. Greater than 28% (n = 21) incurred cancer-related debt. Multivariate models indicated that FH negatively affected role limitations due to physical health ( P = .008), pain ( P = .003), and emotional well-being ( P = .017) QOL dimensions.

CONCLUSIONS

Financial hardship, QOL, and symptom burden scores demonstrate need for continued support for and research among patients with advanced cancer. Data support links between FH and important QOL dimensions. Larger, longitudinal studies are needed to understand how FH affects QOL in patients with advanced cancer.

IMPLICATIONS FOR PRACTICE

Proactive financial assessment and interventions are needed to support patients with advanced cancer experiencing the cumulative effects of cancer and its treatment.

Defining the Role of the Modern Oncology Provider in Mitigating Financial Toxicity

Financial toxicity, the cumulative financial hardships resulting from cancer diagnosis and treatment, is a growing problem in the United States. With the proliferation of costly novel therapeutics and improved cancer survival, financial toxicity will remain a major issue in cancer care delivery. Frontline oncology providers serve as gatekeepers in the medical system and, as such, could play essential roles in recognizing and addressing financial toxicity. Providers and health systems could help mitigate financial toxicity through routine financial toxicity screening, financial navigation, and advocacy. Specific strategies include developing and implementing financial screening instruments that can be integrated in electronic medical records and establishing team-based financial navigation programs to help patients with out-of-pocket medical costs, nonmedical spending, and insurance optimization. Finally, providers should continue to advocate for policies and legislation that decrease cost and promote value-based care. In this review, we examine opportunities for provider engagement in these areas and highlight gaps for future research.

The development and validation of a patient-reported outcome measure to assess financial hardship among older cancer survivors in China: hardship and recovery with distress survey

Background

Financial hardship has been described as a patient's economic experiencefollowing cancer-related treatment. Standardized patient-reported outcome measures(PROM) to assess this distress has not been well-studied, especially among older cancer survivors.

Objective

The aim of this study was to develop and validate PROM for assessing the financial hardship of older cancer survivors in China.

Methods

Items were generated using qualitative interviews and literature review. Items were screened based on Delphi expert consultation and patients' opinions. Item response theory (IRT) and classical test theory (CTT) were used to help reduce items. Retained items formed a pilot instrument that was subjected to psychometric testing. A cut-off score for the new instrument for predicting poor quality of life was identified by receiver operating characteristic (ROC) analysis.

Results

Qualitative interviews and literature review generated 135 items, which were reduced to 60 items because of redundancy. Following Delphi expert consultation and patients' evaluation, 24 items with high importance were extracted. Sixteen items were selected due to satisfactory statistical analysis based on CTT and IRT. Ten items were retained and comprised 2 domains after loadings in exploratory factor analysis (EFA). Internal consistency was satisfactory (α = 0.838). Test-retest reliability was good (intraclass correlation, 0.909). The ROC analysis suggested that the cut-off of 18.5 yielded an acceptable sensitivity and specificity.

Conclusions

The PROM for Hardship and Recovery with Distress Survey (HARDS) consists of 10 items that specifically reflect the experiences of financial hardship among older Chinese cancer survivors, and it also showed good reliability and validity in clinical settings.

Predictors of Financial Toxicity in Patients Receiving Concurrent Radiation Therapy and Chemotherapy

Purpose

Financial toxicity (FT) is a significant concern for patients with cancer. We reviewed prospectively collected data to explore associations with FT among patients undergoing concurrent, definitive chemoradiation therapy (CRT) within a diverse, urban, academic radiation oncology department.

Methods and Materials

Patients received CRT in 1 of 3 prospective trials. FT was evaluated before CRT (baseline) and then weekly using the European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire Core-30 questionnaire. Patients were classified as experiencing FT if they answered ≥2 on a Likert scale question (1-4 points) asking if they experienced FT. Rate of change of FT was calculated using linear regression; worsening FT was defined as increase ≥1 point per month. χ², t tests, and logistic regression were used to assess predictors of FT.

Results

Among 233 patients, patients attended an average of 9 outpatient and 4 radiology appointments over the 47 days between diagnosis and starting CRT. At baseline, 52% of patients reported experiencing FT. Advanced T stage (odds ratio, 2.47; P = .002) was associated with baseline FT in multivariate analysis. The mean rate of FT change was 0.23 Likert scale points per month. In total, 26% of patients demonstrated worsening FT during CRT. FT at baseline was not associated with worsening FT (P = .98). Hospitalization during treatment was associated with worsening FT (odds ratio, 2.30; P = .019) in multivariate analysis.

Conclusions

Most patients reported FT before CRT. These results suggest that FT should be assessed (and, potentially, addressed) before starting definitive treatment because it develops early in a patient's cancer journey. Reducing hospitalizations may mitigate worsening FT. Further research is warranted to design interventions to reduce FT and avoid hospitalizations.

Cost-effectiveness of Response-Adapted De-escalation of Immunotherapy in Advanced Melanoma

Importance

Combination immunotherapy with nivolumab and ipilimumab has markedly improved outcomes for patients with advanced melanoma. However, these therapies pose a considerable financial burden to both patients and the health care system. The ADAPT-IT trial demonstrated comparable progression-free and overall survival for patients with response-adapted ipilimumab discontinuation compared with standard of care (SOC).

Objective

To determine the cost-effectiveness of ipilimumab discontinuation for patients with interim imaging-confirmed tumor response in the treatment of advanced melanoma.

Design, Setting, and Participants

This cost-effectiveness analysis was performed using data from the ADAPT-IT (follow-up of 33 months) and CheckMate 067 (follow-up of 6.5 years) trials, as well as published literature over the ADAPT-IT trial duration of 33 months. The analysis was performed in a US setting from a US-payer perspective, and the willingness-to-pay (WTP) threshold was set at $100 000/quality-adjusted life-year (QALY). A total of 355 patients with previously untreated melanoma (unresectable stage III or IV metastatic melanoma) were included.

Exposure

Response-adapted ipilimumab discontinuation compared with SOC therapy.

Main Outcomes and Measures

The primary outcomes of the CheckMate trial were overall survival and progression-free survival, while that of ADAPT-IT was objective response. This informed a decision model to estimate lifetime costs and QALYs associated with both strategies. Incremental cost, effectiveness, and cost-effectiveness ratio were assessed. Sensitivity and scenario analyses were performed to account for variability in trials and input parameters.

Results

Of the 355 patients included in the analysis, 41 patients were from the ADAPT-IT trial (median age, 65 years; 28 [68%] male) and 314 patients from the CheckMate 067 trial (median age, 61 years; 206 [66%] male). Response-adapted treatment was the cost-effective option in 94.0% of scenarios based on Monte Carlo simulations, with a dominant incremental cost-effectiveness ratio and an incremental net monetary benefit of $28 849 compared with SOC therapy. Cost savings were estimated at $19 891 per patient compared with SOC. In scenario analyses, current SOC was only considered as a cost-effective option under best survival assumptions and if the willingness-to-pay threshold exceeded $630 000/QALY.

Conclusions and Relevance

This economic evaluation demonstrated that response-adapted treatment de-escalation in patients with advanced melanoma may lead to considerable savings in health care costs and could represent the most cost-effective strategy across various resource settings. Future trials should aim to provide further evidence on noninferiority.

Quality of life in home-dwelling cancer patients aged 80 years and older: a systematic review

OBJECTIVE

Quality of Life (QoL) in elderly cancer patients is a topic that has been little explored. This systematic review aims to identify, assess, and report the literature on QoL in home-dwelling cancer patients aged 80 years and older and what QoL instruments have been used.

METHODS

We systematically searched the databases of Medline, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), PsykINFO, Scopus, Epistemonikos and Cinahl to identify studies of any design measuring QoL among home-dwelling cancer patients aged 80 years and older. We screened the titles and abstracts according to a predefined set of inclusion criteria. Data were systematically extracted into a predesigned data charting form, and descriptively analyzed. The included studies were assessed according to the Critical Appraisal Skills Programme (CASP) checklists, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement (PRISMA) checklist was used to ensure rigor in conducting our investigations and reporting our findings. This systematic review was registered in PROSPERO (CRD42021240170).

RESULTS

We included three studies that specifically analyze QoL outcomes in the subgroup of home-dwelling cancer patients aged 80 years and older, with a total of 833 participants having various cancer diagnoses. 193 of the participants included in these three studies were aged 80 years or more. Different generic and cancer-specific QoL instruments as well as different aims and outcomes were studied. All three studies used a diagnosis-specific instrument, but none of them used an age-specific instrument. Despite heterogeneity in cancer diagnoses, instruments used, and outcomes studied, QoL in home-dwelling cancer patients aged over 80 years old seems to be correlated with age, physical function, comorbidity, living alone, needing at-home care services, being in a poor financial situation and having a small social network.

CONCLUSION

Our systematic review revealed only three studies exploring QoL and its determinants in the specific subgroup of home-dwelling cancer patients aged 80 years and over. A gap in the knowledge base has been identified. Future studies of this increasingly important and challenging patient group must be emphasized. Subgroup analyses by age must be performed, and valid age and diagnosis specific QoL instruments must be used to generate evidence in this segment of the population.

Spirituality and financial toxicity among Hispanic breast cancer survivors in New Jersey

OBJECTIVE

Cancer survivors often incur significant out-of-pocket costs; this can result in financial toxicity, defined as the adverse financial impact of cancer due to direct or indirect costs related to the disease. There has been little research on whether spirituality is associated with the experience of financial toxicity. In this study, we tested the hypothesis that spirituality would be inversely associated with financial toxicity.

METHODS

We evaluated these associations in a cross-sectional study of Hispanic breast cancer survivors (n = 102) identified through the New Jersey State Cancer Registry. Participants completed the FACIT-Sp-12, which has two spirituality subscales (meaning/peace; faith). Financial toxicity was assessed using the 11-item COST measure; lower scores suggest worse toxicity. In multivariable linear regression analyses, we examined the associations between spirituality scores and financial toxicity, adjusting for age, race, education, household income, and insurance status.

RESULTS

The spirituality total score (β = 0.49, 95% confidence interval (CI): 0.17, 0.8), meaning/peace subscale score (β = 0.71, 95% CI: 0.12, 1.31), and faith (β = 0.71, 95% CI: 0.2, 1.21) subscale score were all inversely associated with financial toxicity.

CONCLUSIONS

Spirituality may be an important factor in ameliorating the detrimental effects of financial toxicity among Hispanic breast cancer survivors and should be considered in interventions for financial toxicity in this population.

Navigating financial toxicity in patients with cancer: A multidisciplinary management approach

Approximately one-half of individuals with cancer face personal economic burdens associated with the disease and its treatment, a problem known as financial toxicity (FT). FT more frequently affects socioeconomically vulnerable individuals and leads to subsequent adverse economic and health outcomes. Whereas multilevel systemic factors at the policy, payer, and provider levels drive FT, there are also accompanying intervenable patient-level factors that exacerbate FT in the setting of clinical care delivery. The primary strategy to intervene on FT at the patient level is financial navigation. Financial navigation uses comprehensive assessment of patients' risk factors for FT, guidance toward support resources, and referrals to assist patient financial needs during cancer care. Social workers or nurse navigators most frequently lead financial navigation. Oncologists and clinical provider teams are multidisciplinary partners who can support optimal FT management in the context of their clinical roles. Oncologists and clinical provider teams can proactively assess patient concerns about the financial hardship and employment effects of disease and treatment. They can respond by streamlining clinical treatment and care delivery planning and incorporating FT concerns into comprehensive goals of care discussions and coordinated symptom and psychosocial care. By understanding how age and life stage, socioeconomic, and cultural factors modify FT trajectory, oncologists and multidisciplinary health care teams can be engaged and informative in patient-centered, tailored FT management. The case presentations in this report provide a practical context to summarize authors' recommendations for patient-level FT management, supported by a review of key supporting evidence and a discussion of challenges to mitigating FT in oncology care. CA Cancer J Clin. 2022;72:437-453.