Out-of-pocket costs and burden among rural breast cancer survivors

"It was kind of a nightmare, it really was:" financial toxicity among rural women cancer survivors

PURPOSE

The purpose of this study was to examine how rural women cancer survivors experience and manage financial toxicity.

METHODS

A qualitative descriptive design was used to explore experiences of financial toxicity among rural women who received cancer treatment. We conducted qualitative interviews with 36 socioeconomically diverse rural women cancer survivors.

RESULTS

Participants were categorized into three groups: (1) survivors who struggled to afford basic living expenses but did not take on medical debt; (2) survivors who took on medical debt but were able to meet their basic needs; and (3) survivors who reported no financial toxicity. The groups differed by financial and job security and insurance type. We describe each group and, for the first two groups, the strategies they used to manage financial toxicity.

CONCLUSIONS

Financial toxicity related to cancer treatment is experienced differently by rural women cancer survivors depending on financial and job security and insurance type. Financial assistance and navigation programs should be tailored to support rural patients experiencing different forms of financial toxicity.

IMPLICATIONS FOR CANCER SURVIVORS

Rural cancer survivors with financial security and private insurance may benefit from policies aimed at limiting patient cost-sharing and financial navigation to help patients understand and maximize their insurance benefits. Rural cancer survivors who are financially and/or job insecure and have public insurance may benefit from financial navigation services tailored to rural patients that can assist with living expenses and social needs.

ESMO expert consensus statements on the screening and management of financial toxicity in patients with cancer

BACKGROUND

Financial toxicity, defined as both the objective financial burden and subjective financial distress from a cancer diagnosis and its treatment, is a topic of interest in the assessment of the quality of life of patients with cancer and their families. Current evidence implicates financial toxicity in psychosocial, economic and other harms, leading to suboptimal cancer outcomes along the entire trajectory of diagnosis, treatment, supportive care, survivorship and palliation. This paper presents the results of a virtual consensus, based on the evidence base to date, on the screening and management of financial toxicity in patients with and beyond cancer organized by the European Society for Medical Oncology (ESMO) in 2022.

METHODS

A Delphi panel of 19 experts from 11 countries was convened taking into account multidisciplinarity, diversity in health system contexts and research relevance. The international panel of experts was divided into four working groups (WGs) to address questions relating to distinct thematic areas: patients with cancer at risk of financial toxicity; management of financial toxicity during the initial phase of treatment at the hospital/ambulatory settings; financial toxicity during the continuing phase and at end of life; and financial risk protection for survivors of cancer, and in cancer recurrence. After comprehensively reviewing the literature, statements were developed by the WGs and then presented to the entire panel for further discussion and amendment, and voting.

RESULTS AND DISCUSSION

A total of 25 evidence-informed consensus statements were developed, which answer 13 questions on financial toxicity. They cover evidence summaries, practice recommendations/guiding statements and policy recommendations relevant across health systems. These consensus statements aim to provide a more comprehensive understanding of financial toxicity and guide clinicians globally in mitigating its impact, emphasizing the importance of further research, best practices and guidelines.

The interplay of financial toxicity, health care team communication, and psychosocial well-being among rural cancer patients and survivors

BACKGROUND

Financial toxicity contributes to psychosocial distress among cancer patients and survivors. Yet, contextual factors unique to rural settings affect patient experiences, and a deeper understanding is needed of the interplay between financial toxicity and health care team communication and its association with psychosocial well-being among rural oncology patients.

PURPOSE

We examined associations between financial toxicity and psychosocial well-being among rural cancer patients, exploring variability in these linkages by health care team communication.

METHODS

Using data from 273 rural cancer patients who participated in Cancer Support Community's Cancer Experience Registry, we estimated multivariable regression models predicting depression, anxiety, and social function by financial toxicity, health care team communication, and the interplay between them.

RESULTS

We demonstrate robust associations between financial toxicity and psychosocial outcomes among our sample of rural cancer patients and survivors. As financial toxicity increased, symptoms of depression and anxiety increased. Further, financial toxicity was linked with decreasing social function. Having health care team conversations about treatment costs and distress-related care reduced the negative impact of financial toxicity on depressive symptoms and social function, respectively, in rural cancer patients at greatest risk for financial burden.

CONCLUSIONS

Financial toxicity and psychosocial well-being are strongly linked, and these associations were confirmed in a rural sample. A theorized buffer to the detrimental impacts of financial toxicity-health care team communication-played a role in moderating these associations. Our findings suggest that health care providers in rural oncology settings may benefit from tools and resources to bolster communication with patients about costs, financial distress, and coordination of care.

Out-of-pocket payments and loss of income among long-term breast cancer survivors in Germany: a multi-regional population-based study

PURPOSE

This study aims to examine the magnitude of out of pocket (OOP) payments and income loss, as well as to identify socioeconomic and clinical factors among long-term breast cancer (BC) survivors in Germany.

METHODS

We examine data from 2654 long-term BC survivors in Germany that participated in the "CAncEr Survivorship - A multi-Regional population-based study" (CAESAR) and who were at least 5 years post diagnosis. BC-related OOP payments and income loss both within the 12 months prior to the survey were analyzed. Two-part regression models were performed to identify socioeconomic and clinical factors.

RESULTS

OOP payments were incurred by 51.9% of survivors with a total mean spending of 566 euros. Income loss was present among 9.6% of survivors and averaged 5463 euros among those reporting such. Socioeconomic and clinical factors associated with higher OOP payments (p ≤ 0.05) included age at time of diagnosis (65-79 years), education (10-11 years), (early) retirement, stage of diagnosis (stage III), time from diagnosis (more than 10 years), comorbidities (at least 1), and the use of rehabilitation services. Regarding income loss, age at time of diagnosis (50-59 years), (early) retirement, stage of diagnosis (stage II), time from diagnosis (5-7 years), comorbidities (at least 1), and receiving chemotherapy treatment were associated with higher losses.

CONCLUSIONS

For some survivors in Germany, financial burden can be considerably high despite comprehensive healthcare and support from social security.

IMPLICATIONS FOR CANCER SURVIVORS

OOP payments related to domestic help and nursing staff as well as to outpatient care are most frequent.

Factors affecting the economic burden of breast cancer in southern Iran

BACKGROUND

Breast cancer (BC) is the most common cancer in the world, and is associated with significant economic costs for patients and communities. Therefore, the information on the costs of the disease and the identification of its underlying factors will provide insights into designing effective interventions and reducing the costs. Thus, the present study aimed to identify the factors affecting the economic burden of breast cancer from all medical centers providing diagnostic and treatment services in southern Iran.

METHODS

A list of factors affecting the economic burden of breast cancer was obtained based on the effective factors searched in the databases, including PubMed, ProQuest, Scopus, ISI Web of Science, SID, and Magiran, and the opinions of BC cancer specialists. Then, the data on 460 breast cancer patients was collected from March 2020 to March 2022. The relationship between the factors affecting Breast Cancer costs was analyzed using SPSS 13.0 software by the use of multiple regression analysis.

RESULTS

The results of the multiple regression analysis showed that stages (P-value < 0.001), being an extreme user (p = 0.025), type of treatment center (P-value < 0.001), income (P-value < 0.001), chemotherapy side effects (P-value < 0.001), and distance to the nearest health center (P-value < 0.001) were important factors affecting the costs of breast cancer patients.

CONCLUSIONS

According to the results, encouraging people to undergo annual screenings, increasing insurance coverage, assuring the patients about the desirability and adequacy of the provided medical services, deploying specialists in chemotherapy centers (especially nutritionists) to recommend special diets, and establishing cancer diagnostic and treatment centers in high-population cities could help reduce the costs of breast cancer patients.

Understanding advanced practice registered nurse perspectives on providing care to people with a history of breast cancer

BACKGROUND

People with a history of breast cancer (PHBC) face a lifelong risk of treatment-related sequelae affecting their quality of life. Stakeholders advocate for improving breast cancer survivorship outcomes by increasing clinicians' knowledge of cancer survivorship issues. In Missouri, advanced practice registered nurses (APRNs) in nononcology settings provide routine survivorship care to PHBC; however, little is known about how they approach survivorship care planning for PHBC.

PURPOSE

Examine perspectives of Missouri APRNs practicing in nononcology settings about providing survivorship care to PHBC.

METHODS

A combination of grounded theory and thematic analysis techniques was used for focus groups and semistructured interviews. The interviews were audio-recorded, transcribed, and analyzed using grounded theory coding methods.

RESULTS

Nineteen nononcology Missouri-based APRNs (18 NPs, 1 CNS/DNP) shared their perspectives about managing care for PHBC. We identified four major themes. Our participants (1) attuned their baseline assessment techniques to a history of breast cancer; (2) were prepared to order additional evaluations; (3) were willing to proactively figure out next best steps for PHBC beyond theneed for breast cancer recurrence surveillance; and (4) suggest that streamlining cancer survivorship care resources would benefit both clinicians and PHBC.

CONCLUSIONS

Our findings shed light on how APRNs approach care planning for PHBC and the needs of nononcology APRNs for managing PHBC.

IMPLICATIONS FOR PRACTICE

Advanced practice registered nurses are well-positioned to improve cancer survivorship care. Increasing knowledge of cancer survivorship care guidelines could improve long-term health outcomes of PHBC. Access to cancer survivorship resources or experts via telehealth/technology for both APRNs and patients could improve survivorship care and overall health of PHBC.

Timing of autologous fat grafting in implant-based breast reconstruction: Best practices based on systematic review and meta-analysis

BACKGROUND

Fat grafting is commonly undertaken as a third-stage procedure in patients with staged implant-based breast reconstruction (IBR). However, fat grafting performed during second-stage expander/implant exchange provides faster results without an additional procedure and associated risks (Patel et al., 2020). We previously demonstrated that fat grafting during second-stage expander/implant exchange did not increase clinical complications (Patel et al., 2020). As a corollary, this study investigates patients' satisfaction with second- versus third-stage fat grafting to help establish a set of best practices for the timing of fat grafting in such patients.

METHODS

A review of PubMed/MEDLINE databases (2010-2022) was performed to identify articles investigating the quality of life in patients undergoing second- or third-stage fat grafting after IBR. BREAST-Q scores were pooled using random-effects modeling and the DerSimonian-Laird method. Post-hoc sensitivity analyses were completed using the Hartung-Knapp-Sidik-Jonkman method. The Haldane-Anscombe correction was used for outcomes with low counts. All study analyses adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

Six studies (216 patients) were included. Pooled random-effects modeling demonstrated no significant changes in BREAST-Q satisfaction with outcome scores when comparing patients who received second- versus third-stage fat grafting (p = 0.178) with results robust to sensitivity analyses. In addition, pooled analyses of the available data demonstrated that second-stage fat grafting did not increase downstream revision surgery needs compared to third-stage fat grafting.

CONCLUSIONS

In combination with our prior work, this meta-analysis suggests that second-stage fat grafting provides not only equivalent but improved clinical and quality of life outcomes with fewer procedures in patients undergoing expander/IBR.

Cancer Survivors Living in Rural Settings: A Qualitative Exploration of Concerns, Positive Experiences and Suggestions for Improvements in Survivorship Care

In Canada, the number of cancer survivors continues to increase. It is important to understand what continues to present difficulties after the completion of treatment from their perspectives. Various factors may present barriers to accessing help for the challenges they experience following treatment. Living rurally may be one such factor. This study was undertaken to explore the major challenges, positive experiences and suggestions for improvement in survivorship care from rural-dwelling Canadian cancer survivors one to three years following treatment. A qualitative descriptive analysis was conducted on written responses to open-ended questions from a national cross-sectional survey. A total of 4646 individuals living in rural areas responded to the survey. Fifty percent (2327) were male, and 2296 (49.4%) were female; 69 respondents were 18 to 29 years (1.5%); 1638 (35.3%) were 30 to 64 years; and 2926 (63.0%) were 65 years or older. The most frequently identified major challenges (n = 5448) were reduced physical capacity and the effects of treatment. Positive experiences included family and friend support and positive self-care practices. The suggestions for improvements focused on the need for better communication and information about self-care, side effect management, and programs and services, with more programs available locally for practical and emotional support.

The Impact of Travel Distance and Income on Breast Reconstruction after Mastectomy in a Rural Population

Factors that influence breast reconstruction after mastectomy have been previously examined in national databases. The purpose of this study was to determine the impact of patient travel distance and income on breast reconstruction after mastectomy in a rural population.

Methods

Retrospective review of mastectomy patients from 2017 to 2021 was performed from our prospectively enrolled tumor registry. Analysis included frequencies and percentages, descriptive statistics, χ ² analysis, independent sample t tests, and multivariable analysis.

Results

In total, 462 patients were included. Median BMI was 27.6 kg/m², 96.1% of patients were White, and median age at diagnosis was 60.0 years. Reconstruction rate was 52.6%, and median length of follow-up was 24.6 months. No significant difference was found in the distance traveled by patients who underwent reconstruction (16.6 versus 16.7 miles; P = 0.94). Rates of reconstruction in patients who traveled 0-10 miles, 11-30 miles, and over 30 miles did not differ significantly (P = 0.16). Median household income was significantly different in reconstructed and nonreconstructed patients ($55,316.00 versus $51,629.00; P = 0.047). Rates of reconstruction were significantly higher in patients with median household income greater than $65,000 (P = 0.024). This difference was not significant on multivariable analysis.

Conclusions

Travel distance did not significantly impact reconstruction rates after mastectomy, while household income did on univariable analysis. Studies at an institutional or regional level remain valuable, especially in populations that may not be accurately represented in larger database studies. Our findings highlight the importance of patient education, resource allocation, and multidisciplinary approach to breast cancer care, especially in the rural setting.

The economic cost of cancer treatment in Iran

BACKGROUND

With more than 12 million new cases of cancers and nearly 7.6 million deaths worldwide in 2020, cancer is currently the third leading cause of mortality in the world. The costs spent on treating patients with cancer account for a significant amount of healthcare costs. Healthcare expenditures for cancer treatment have also increased significantly and are projected to skyrocket further over the next decade. This study was conducted to determine medical and non-medical direct costs for the prevention of cancer in patients hospitalized in 10 selected educational hospitals in Iran.

MATERIALS AND METHODS

The study employed a cross-sectional design and was conducted in 10 selected educational hospitals in Tabriz, Tehran, Isfahan, Mashhad, and Shiraz in 2020. Using a researcher-made questionnaire, we assessed direct medical costs and direct non-medical costs of cancer in patients over 20 years old with kinds of breast, prostate, leukemia, lymphatic, stomach, liver, lung, bladder, uterine, and intestine cancers who undertook oncology treatments (n = 2410). Data were analyzed using descriptive statistics including mean and standard deviation and analytic statistics such as Kolmogorov-Smirnov, analysis of variance, and t-test, using SPSS 18 and P ≤0.05.

RESULT

The mean direct non-medical cost paid out of pocket per month was $99.6 ± $10.81 USD, and the mean direct medical cost per month was $1029.4 ± $68.5 USD. The total cost paid by the patients was $889.4 ± 69.81 USD per month.

CONCLUSION

Given the increasing number of patients with cancer, it is necessary to increase the number of special centers for the prevention and treatment of cancers. Dissemination of information about the costs of illnesses and their complications enables decision-makers to make a proper comparison between different uses of resources. Moreover, to support the patients, the health system must implement plans to decrease out-of-pocket payments by patients.

The role of physical arm function and demographic disparities in breast cancer survivors’ ability to return to work

Purpose

Ability to return to work (RTW) is an important aspect of breast cancer that is limited for many survivors. With 90% survivorship in the USA, it is imperative that focus shifts toward the improvement of physical arm function to improve survivors’ ability to RTW. This narrative review discusses the role of physical arm function and demographic disparities in breast cancer survivor RTW.

Methods

Literature on physical function, arm function, and demographic disparities following breast cancer treatment and their implications for RTW is discussed.

Results

The ability to RTW is a key component of recovery for breast cancer survivors, but challenges and inequalities persist. Treatment effects can induce and prolong functional disability, affecting survivors’ ability to RTW. These effects may be compounded for survivors whose occupation requires physical arm function. The RTW landscape, including the occupations survivors have, the physical function required for job tasks, and availability of workplace accommodations, is also unclear. Additional demographic disparities (e.g., income, live in rural area) exist, but the extent to which these factors influence RTW is not well understood. More work is needed to understand the compounded impact of treatment effects, demographic disparities, and occupational factors on RTW. Multidisciplinary rehabilitation that includes occupational counseling and exercise is a promising approach, but widespread adoption in the US healthcare model presents an ongoing challenge. Areas for further research are highlighted.

Conclusion

There is an incomplete understanding of the effects of treatment on physical arm function and the role of demographic disparities on breast cancer survivor RTW.

Supportive care needs and psychosocial outcomes of rural versus urban women with breast cancer

OBJECTIVE

To identify whether supportive care needs vary according to remoteness and area-level socio-economic status (SES) and to identify the combinations of socio-demographic, area-level and health factors that are associated with poorer quality of life, psychological distress and severity of unmet supportive care needs METHODS: Cross sectional data was collected from women with a breast cancer diagnosis (n=2,635) in Queensland, Australia, through a telephone survey including socio-demographic, health, psychosocial and supportive care needs measures. Hierarchical regression and cluster analyses were applied to assess the predictors of unmet need and psychosocial outcomes and to identify socio-demographic and health status profiles of women, comparing their level of unmet needs and psychosocial outcomes.

RESULTS

Women living in outer regional areas reported the highest severity of unmet need in the patient care domain. Greater unmet need for health systems and information and patient care was also evident for those in moderately and most disadvantaged areas. Three clusters were identified reflecting (1) older women with poorer health and lower education (19%); (2) younger educated women with better health and private insurance (61%); and (3) physically active women with localised cancer who had completed treatment (20%). Poorer outcomes were evident in the first two of these clusters.

CONCLUSIONS

This better understanding of the combinations of characteristics associated with poorer psychosocial outcomes and higher unmet need can be used to identify women with higher supportive care needs early and to target interventions. This article is protected by copyright. All rights reserved.

The Cancer Financial Experience (CAFÉ) study: randomized controlled trial of a financial navigation intervention to address cancer-related financial hardship

BACKGROUND

There is an urgent need for evidence on how interventions can prevent or mitigate cancer-related financial hardship. Our objectives are to compare self-reported financial hardship, quality of life, and health services use between patients receiving a financial navigation intervention versus a comparison group at 12 months follow-up, and to assess patient-level factors associated with dose received of a financial navigation intervention.

METHODS

The Cancer Financial Experience (CAFÉ) study is a multi-site randomized controlled trial (RCT) with individual-level randomization. Participants will be offered either brief (one financial navigation cycle, Arm 2) or extended (three financial navigation cycles, Arm 3) financial navigation. The intervention period for both Arms 2 and 3 is 6 months. The comparison group (Arm 1) will receive enhanced usual care. The setting for the CAFÉ study is the medical oncology and radiation oncology clinics at two integrated health systems in the Pacific Northwest. Inclusion criteria includes age 18 or older with a recent cancer diagnosis and visit to a study clinic as identified through administrative data. Outcomes will be assessed at 12-month follow-up. Primary outcomes are self-reported financial distress and health-related quality of life. Secondary outcomes are delayed or foregone care; receipt of medical financial assistance; and account delinquency. A mixed methods exploratory analysis will investigate factors associated with total intervention dose received.

DISCUSSION

The CAFÉ study will provide much-needed early trial evidence on the impact of financial navigation in reducing cancer-related financial hardship. It is theory-informed, clinic-based, aligned with patient preferences, and has been developed following preliminary qualitative studies and stakeholder input. By design, it will provide prospective evidence on the potential benefits of financial navigation on patient-relevant cancer outcomes. The CAFÉ trial's strengths include its broad inclusion criteria, its equity-focused sampling plan, its novel intervention developed in partnership with clinical and operations stakeholders, and mixed methods secondary analyses related to intervention dose offered and dose received. The resulting analytic dataset will allow for rich mixed methods analysis and provide critical information related to implementation of the intervention should it prove effective.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05018000 . August 23, 2021.

Development, Therapeutic Evaluation and Theranostic Applications of Cubosomes on Cancers: An Updated Review

Cancer is a group of disorders characterized by aberrant gene function and alterations in gene expression patterns. In 2020, it was anticipated that 19 million new cancer cases would be diagnosed globally, with around 10 million cancer deaths. Late diagnosis and interventions are the leading causes of cancer-related mortality. In addition, the absence of comprehensive cancer therapy adds to the burden. Many lyotropic non-lamellar liquid-crystalline-nanoparticle-mediated formulations have been developed in the last few decades, with promising results in drug delivery, therapeutics, and diagnostics. Cubosomes are nano-structured liquid-crystalline particles made of specific amphiphilic lipids in particular proportions. Their ability to encapsulate lipophilic, hydrophilic, and amphiphilic molecules within their structure makes them one of a kind. They are biocompatible, versatile drug carriers that can deliver medications through various routes of administration. Many preclinical studies on the use of cubosomes in cancer treatment and theranostic applications have been conducted. However, before cubosomes may be employed in clinical practice, significant technical advances must be accomplished. This review summarizes the development of cubosomes and their multifunctional role in cancer treatment based on the most recent reports.

Living in Rural Areas and Receiving Cancer Treatment Away From Home: A Qualitative Study Foregrounding Temporality

We used explorative interviews to gauge (inter)personal, physiological, and emotional challenges of seven rural cancer patients who traveled long distances to cancer treatment centers. After a thematic analysis, we foregrounded experiences of temporality by using a phenomenologically inspired approach. The analysis resulted in three themes: (a) An epiphany of “what really matters in life”—time gains new meaning, (b) Feeling out of sync with others and own body—striving for coherence and simultaneity, and (c) Being torn between benefits of home and treatments site—time and distance as a tangible aspect of traveling and being away. Under these themes, 13 meaning units were generated, which reflected changes in temporality. During treatment, life primarily revolved around repeating circles of travel arrangements, staying on top of treatment schedule, and synchronizing a home life with a life away from home. Nurses should provide comprehensive care to enhance stability in cancer patients’ temporal experiences.

Identifying missing links in the conceptualization of financial toxicity: a qualitative study

Purpose

Financial toxicity can have a major impact on the quality of life of cancer survivors but lacks conceptual clarity and understanding of the interrelationships of the various aspects that constitute financial toxicity. This study aims to extract major drivers and mediators along the pathway from cancer-related costs to subjective financial distress from the patients’ experiences to establish a better understanding of financial toxicity as a patient-reported outcome.

Methods

Qualitative semistructured interviews with 39 cancer patients were conducted in Germany and addressed patient experiences with cancer-related financial burden and distress in a country with a statutory health care system. Transcripts were analyzed using content analysis.

Results

Several aspects of financial burden need to be considered to understand financial toxicity. The assessment of the ability to make ends meet now or in the future and the subjective evaluation of financial adjustments—namely, the burden of applied financial adjustments and the availability of financial adjustment options—mediate the connection between higher costs and subjective financial distress. Moreover, bureaucracy can influence financial distress through a feeling of helplessness during interactions with authorities because of high effort, non-traceable decisions, or one’s own lack of knowledge.

Conclusion

We identified four factors that mediate the impact of higher costs on financial distress that should be addressed in further studies and targeted by changes in policies and support measures. Financial toxicity is more complex than previously thought and should be conceptualized and understood more comprehensively in measurements, including the subjective assessment of available adjustment options and perceived burden of financial adjustments.

Out-of-pocket costs in gastrointestinal cancer patients: Lack of a perfectly framed problem contributing to financial toxicity

Fighting cancer is an economically expensive challenge for both health care payers, and the patients and their families and the median costs for cancer care are rapidly increasing in the last decade. Although both direct and indirect costs of medical assistance have been a frequent source of distress and contention, however analysis of the non-medical expenses incurred directly by cancer patients has not received adequate attention. Developing a deeper understanding of so-called "out-of-pocket" costs may be necessary. Out-of-pocket costs for medical care range from 7 % to 11 % of medical costs for all payers. However, the range of out-of-pocket costs shows considerable variability in different studies. In this review, we reviewed available data concerning direct and indirect medical costs, including psychosocial ones.

DISCO App: study protocol for a randomized controlled trial to test the effectiveness of a patient intervention to reduce the financial burden of cancer in a diverse patient population

Background

Financial toxicity, the material and psychological burden of the cost of treatment, affects 30–50% of people with cancer, even those with health insurance. The burden of treatment cost can affect treatment adherence and, ultimately, mortality. Financial toxicity is a health equity issue, disproportionately affecting patients who are racial/ethnic minorities, have lower incomes, and are < 65 years old. Patient education about treatment cost and patient-oncologist cost discussions are recommended as ways to address financial toxicity; however, research shows cost discussions occur infrequently (Altice et al. J Natl Cancer Inst 109:djw205, 2017; Schnipper et al. J Clin Oncol 34:2925-34, 2016; Zafar et al. Oncologist 18:381-90, 2013; American Cancer Society Cancer Action Network 2010). Our overall goal is to address the burden of financial toxicity and work toward health equity through a tailorable education and communication intervention, the DISCO App. The aim of this longitudinal randomized controlled trial is to test the effectiveness of the DISCO App on the outcomes in a population of economically and racially/ethnically diverse cancer patients from all age groups.

Methods

Patients diagnosed with breast, lung, colorectal, or prostate cancer at a NCI-designated comprehensive cancer center in Detroit, MI, will be randomized to one of three study arms: one usual care arm (arm 1) and two intervention arms (arms 2 and 3). All intervention patients (arms 2 and 3) will receive the DISCO App before the second interaction with their oncologist, and patients in arm 3 will receive an intervention booster. The DISCO App, presented on an iPad, includes an educational video about treatment costs, ways to manage them, and the importance of discussing them with oncologists. Patients enter socio-demographic information (e.g., employment, insurance status) and indicate their financial concerns. They then receive a tailored list of questions to consider asking their oncologist. All patients will have up to two interactions with their oncologist video recorded and complete measures at baseline, after the recorded interactions and at 1, 3, 6, and 12 months after the second interaction. Outcome measures will assess discussions of cost, communication quality, knowledge of treatment costs, self-efficacy for treatment cost management, referrals for support, short- and longer-term financial toxicity, and treatment adherence.

Discussion

If effective, this intervention will improve awareness of and discussions of treatment cost and alleviate the burden of financial toxicity. It may be especially helpful to groups disproportionately affected by financial toxicity, helping to achieve health equity.

Trial registration

ClinicalTrials.gov NCT04766190. Registered on February 23, 2021

Out-of-pocket costs associated with head and neck cancer treatment

Background

Out‐of‐pocket costs (OOPC) associated with treatment have significant implications on quality of life and survival in cancer patients. Head and neck cancer patients face unique treatment‐related challenges, but to date OOPC have been understudied in this population.

Aims

This study aims to identify and measure OOPC for patients with head and neck cancer (HNC) in Ontario.

Methods

HNC patients between 2015 and 2018 at Princess Margaret Cancer Centre in Toronto were recruited. Participants completed OOPC questionnaires and lost income questions during radiation, post‐surgery, and 3, 6, 12, and 24 months after completion of treatment. Associations between OOPC and treatment modality and disease site were tested with multivariable hurdle regression.

Results

A total of 1545 questionnaires were completed by 657 patients. Median estimated OOPC for the total duration of treatment for participants undergoing chemoradiation was $1452 [$0–14 616], for surgery with adjuvant radiation or chemoradiation (C/RT) was $1626, for radiation therapy alone was $635, and for surgery alone was $360. The major expenses for participants at the mid‐treatment time‐point was travel (mean $424, standard error of the mean [SEM] $34) and meals, parking, and accommodations (mean $617, SEM $67). In multivariable analysis, chemoradiation, surgery with C/RT, and radiation were associated with significantly higher OOPC than surgery alone during treatment (791% higher, p < .001; 539% higher, p < .001; 370% higher, p < .001 respectively) among patients with non‐zero OOPC. Participants with non‐zero OOPC in the laryngeal cancer group paid 49% lower OOPC than those with oropharyngeal cancers in adjusted analysis (p = .025).

Conclusions

Patients undergoing treatment for HNC pay significant OOPC. These costs are highest during treatment and gradually decrease over time. OOPC vary by patient demographics, clinical factors, and, in particular, treatment modality.

Psychosocial well-being and supportive care needs of cancer patients and survivors living in rural or regional areas: a systematic review from 2010 to 2021

Purpose

To summarise what is currently known about the psychosocial morbidity, experiences, and needs of people with cancer and their informal caregivers, who live in rural or regional areas of developed countries.

Methods

Eligible studies dating from August 2010 until May 2021 were identified through several online databases, including MEDLINE, EMBASE, PsychINFO, and RURAL (Rural and Remote Health Database). Results were reported according to the PRISMA guidelines and the protocol was registered on PROSPERO (CRD42020171764).

Results

Sixty-five studies were included in this review, including 20 qualitative studies, 41 quantitative studies, and 4 mixed methods studies. Qualitative research demonstrated that many unique psychosocial needs of rural people remain unmet, particularly relating to finances, travel, and accessing care. However, most (9/19) quantitative studies that compared rural and urban groups reported no significant differences in psychosocial needs, morbidity, or quality of life (QOL). Five quantitative studies reported poorer psychosocial outcomes (social and emotional functioning) in urban cancer survivors, while three highlighted poorer outcomes (physical functioning, role functioning, and self-reported mental health outcomes) in the rural group.

Conclusion

Recent research shows that rural people affected by cancer have unique unmet psychosocial needs relating to rurality. However, there was little evidence that rural cancer survivors report greater unmet needs than their urban counterparts. This contrasts to the findings from a 2011 systematic review that found rural survivors consistently reported worse psychosocial outcomes. More population-based research is needed to establish whether uniquely rural unmet needs are due to general or cancer-specific factors.

Physical, emotional, and practical concerns, help-seeking and unmet needs of rural and urban dwelling adult cancer survivors

PURPOSE

This study explores the influence of residency location on the experiences of cancer survivors. The influence of where individuals live during cancer screening, diagnosis, and treatment has been described in various countries. However, understanding the context of residency on experiences during survivorship has received less attention.

METHODS

A survey was designed to assess experiences of cancer survivors transitioning to follow-up care. Descriptive statistics were used to contrast physical, emotional, and practical concerns, help-seeking, and unmet needs of rural and urban dwelling respondents. Difference in proportions of greater than 5% were considered clinically meaningful.

RESULTS

In total, 13,319 respondents completed the survey of which 4646 met the criteria for rural dwelling (e.g., living in villages or towns with 10,000 or less residents or on an acreage, ranch, or farm). Proportions of respondents in rural and urban groups were similar in terms of level of concerns. Differences were observed for help seeking regarding return to work and for difficulty in obtaining help regarding taking care of children and other family members, changes in relationships with family, friends and co-workers, and getting to and from appointments. Unmet needs existed across all domains and were similar in both groups. A larger proportion of rural dwelling respondents experienced unmet needs regarding return to work.

CONCLUSIONS

[implications]: High proportions of cancer survivors experienced concerns following cancer treatment. However, rural dwelling survivors were more challenged in obtaining help for selected concerns. Implications exist for development of community-based support services in rural settings.

Preferences of quality delivery of palliative care among cancer patients in low- and middle-income countries: A review

BACKGROUND

All forms of cancer pose a tremendous and increasing problem globally. The prevalence of cancer across the globe is anticipated to double over the next two decades. About 50% of most cancer cases are expected to occur in low- and middle-income countries (LMICs), where there is a greater disproportionate level in mortality. Access to effective and timely care for cancer patients remains a challenge, especially in LMICs due to late disease diagnosis and detection, coupled with the limited availability of appropriate therapeutic options and delay in proper interventions.

METHODOLOGY

This study explored several mixed-method researches and randomized trials that addressed the preferences of quality delivery of palliative care among cancer patients in LMICs. A designated set of keywords such as Palliative Care; Preferences; Cancer patients; Psycho-social Support; End-of-life Care; Low and Middle-Income Countries were inserted on electronic databases to retrieve articles. The databases include PubMed, Scinapse, Medline, The Google Scholar, Academic search premier, SAGE, and EBSCO host.

RESULTS

Findings from this review discussed the socioeconomic and behavioral factors, which address the quality delivery of palliative care among cancer patients. These factors if measured with acceptance level in cancer patients could help to address areas that need improvement from the stage of disease diagnosis to the end-of-life.

SIGNIFICANCE OF THE RESULTS

Valuable collaborations among international and local health institutions are needed to build and implement a systematic framework for palliative care in LMICs. Policies and programs that are country and culturally specific, encompassing both theoretical and practical models of care in the milieu of existing quandaries should be developed.

Associations of Household Income with Health-Related Quality of Life Following a Colorectal Cancer Diagnosis Varies With Neighborhood Socioeconomic Status

BACKGROUND

Existing evidence indicates household income as a predictor of health-related quality of life (HRQoL) following a colorectal cancer diagnosis. This association likely varies with neighborhood socioeconomic status (nSES), but evidence is limited.

METHODS

We included data from 1,355 colorectal cancer survivors participating in the population-based Puget Sound Colorectal Cancer Cohort (PSCCC). Survivors reported current annual household income; we measured HRQoL via the Functional Assessment of Cancer Therapy - Colorectal (FACT-C) tool. Using neighborhood data summarized within a 1-km radial buffer of Census block group centroids, we constructed a multidimensional nSES index measure. We employed survivors' geocoded residential addresses to append nSES score for Census block group of residence. With linear generalized estimating equations clustered on survivor location, we evaluated associations of household income with differences in FACT-C mean score, overall and stratified by nSES. We used separate models to explore relationships for wellbeing subscales.

RESULTS

We found lower household income to be associated with clinically meaningful differences in overall FACT-C scores [<$30K: -13.6; 95% confidence interval (CI): -16.8 to -10.4] and subscale wellbeing after a recent colorectal cancer diagnosis. Relationships were slightly greater in magnitude for survivors living in lower SES neighborhoods.

CONCLUSIONS

Our findings suggest that recently diagnosed lower income colorectal cancer survivors are likely to report lower HRQoL, and modestly more so in lower SES neighborhoods.

IMPACT

The findings from this work will aid future investigators' ability to further consider the contexts in which the income of survivors can be leveraged as a means of improving HRQoL.

Incidence of household catastrophic and impoverishing health expenditures among patients with Breast Cancer in Iran

Background

Breast cancer disease is the most common cancer among Iranian women and imposing a significant financial burden on the households. This study calculated out-of-pocket (OOP), catastrophic health expenditure (CHE), and impoverishing health spending attributed to breast cancer in Iran.

Methods

In this cross-sectional household study, clinical and financial information on breast cancer and also household information (expenditures and income) were obtained through face-to-face interviews and completing a questionnaire by 138 women with this disease in 2019. We applied three non-food expenditure thresholds of 40, 20, and 10% to defining the CHE. Disease costs included periodical visits, diagnostic services, hospitalization care, treatment and rehabilitation services, home, and informal care. Households were disaggregated into socioeconomic status quintiles based on their Adult Equivalent values standardized monthly consumption expenditures. To identify the factors affecting these indicators, we performed the two different multivariate logistic regression models.

Results

This study finds that each patient had a monthly average OOP payment of $US 97.87 for the requested services, leading to impoverished of 5.07% and exposed 13.77% of their households to CHE. These indicators have been mainly concentrated among the poor, as they have spent a large part of their meager income on buying the needed services, and for this purpose, most of them forced to sell their assets, borrow, or take a bank loan.

Conclusions

The patients in lower SES quintiles can be protected from impoverishing and catastrophic health spending by expanding insurance coverage, providing financial risk protection programs, and increasing access to quality and effective public sector services. Alongside, expanding inpatient coverage and adding drug benefits for the poor can significantly decrease their OOP payments.

The Financial Burden of Cancer on Families in the United States

This study examined the relationship between a diagnosis of cancer and the likelihood of having any out-of-pocket costs (OOPC) and medical debt, and the amounts of OOPC and medical debt, at the household level. We used the 2013 Panel Study of Income Dynamics, a continuous, representative panel survey that collects demographic, economic, and social data in the United States. The analytic sample included head of households and their spouse (if married), 18–64 years old. Two-part models were used. The first part consisted of logistic regression models and the second part consisted of generalized linear models with logarithmic link and a gamma distribution. Logistic regression results showed odds of 2.13 (CI: 1.27, 3.57, p < 0.01) for any OOPC and odds of 1.55 (CI: 0.93, 2.58, p < 0.1) for any medical debt for households in which either the head or spouse (if married) reported a diagnosis of cancer compared to those that did not report a diagnosis of cancer. Likewise, results from the second part of the model for households with a positive amount of OOPC showed an exponentiated coefficient of 1.73 (CI: 1.33, 2.25, p < 0.01) for households in which either the head or spouse (if married) reported a diagnosis of cancer compared to households without a diagnosis of cancer. This study shows that a diagnosis of cancer places a financial burden on families, particularly with all types of debt, in the United States even after controlling for differences between households with a diagnosis of cancer and those without a diagnosis of cancer.

The Out-of-Pocket Cost Burden of Cancer Care-A Systematic Literature Review

BACKGROUND

Out-of-pocket costs pose a substantial economic burden to cancer patients and their families. The purpose of this study was to evaluate the literature on out-of-pocket costs of cancer care.

METHODS

A systematic literature review was conducted to identify studies that estimated the out-of-pocket cost burden faced by cancer patients and their caregivers. The average monthly out-of-pocket costs per patient were reported/estimated and converted to 2018 USD. Costs were reported as medical and non-medical costs and were reported across countries or country income levels by cancer site, where possible, and category. The out-of-pocket burden was estimated as the average proportion of income spent as non-reimbursable costs.

RESULTS

Among all cancers, adult patients and caregivers in the U.S. spent between USD 180 and USD 2600 per month, compared to USD 15-400 in Canada, USD 4-609 in Western Europe, and USD 58-438 in Australia. Patients with breast or colorectal cancer spent around USD 200 per month, while pediatric cancer patients spent USD 800. Patients spent USD 288 per month on cancer medications in the U.S. and USD 40 in other high-income countries (HICs). The average costs for medical consultations and in-hospital care were estimated between USD 40-71 in HICs. Cancer patients and caregivers spent 42% and 16% of their annual income on out-of-pocket expenses in low- and middle-income countries and HICs, respectively.

CONCLUSIONS

We found evidence that cancer is associated with high out-of-pocket costs. Healthcare systems have an opportunity to improve the coverage of medical and non-medical costs for cancer patients to help alleviate this burden and ensure equitable access to care.

Socioeconomic impact of breast cancer on young women in Ghana: A qualitative study

Aim

This study was undertaken to discover the socioeconomic impact of breast cancer on young women in Ghana.

Methods

A qualitative exploratory and descriptive design was used to recruit 12 young women from the University of Ghana hospital, 37 Military hospital and Ridge hospital. Individual interviews were conducted face to face and data transcribed verbatim and analysed using content analysis.

Results

Three themes emerged: perceptions and beliefs; economic concerns; and secrecy. Participants perceived that breast cancer was a test of faith, a spiritual disease that is contagious and disgraceful. Mostly, participants stopped work to cater for themselves, and as a result, they encountered financial challenges. Their challenges were compounded with conscious efforts to keep diagnosis secret to avoid being stigmatized.

Conclusion

Young women living with breast cancer need support physically, economically and socially from healthcare providers, their families and the society at large.

The psychosocial cost burden of cancer: A systematic literature review

Background and Objective

Psychosocial costs, or quality of life costs, account for psychological distress, pain, suffering and other negative experiences associated with cancer. They contribute to the overall economic burden of cancer that patients experience. But this category of costs remains poorly understood. This hinders opportunities to make the best cancer control policy decisions. This study explored the psychosocial cost burden associated with cancer, how studies measure psychosocial costs and the impact of this burden.

Methods

A systematic literature review of academic and grey literature published from 2008 to 2018 was conducted by searching electronic databases, guided by the Institute of Medicine’s conceptualization of psychosocial burden. Results were analyzed using a narrative synthesis and a weighted proportion of populations affected was calculated. Study quality was assessed using the Ottawa‐Newcastle instrument.

Results

A total of 25 studies were included. There was variation in how psychosocial costs were conceptualized and an inconsistent approach to measurement. Most studies measured social dimensions and focused on the financial consequences of paying for care. Fewer studies assessed costs associated with the other domains of this burden, including psychological, physical, and spiritual dimensions. Fourty‐four percent of cancer populations studied were impacted by psychosocial costs and this varied by disease site (38%‐71%). Two studies monetized the psychosocial cost burden, estimating a lifetime cost per case ranging from CAD$427753 to CAD$528769. Studies were of varying quality; 60% of cross‐sectional studies had a high risk of bias.

Conclusions

Consistency in approach to measurement would help to elevate this issue for researchers and decision makers. At two‐thirds of the total economic burden of cancer, economic evaluations should account for psychosocial costs to better inform decision‐making. More support is needed to address the psychosocial cost burden faced by patients and their families.

'It was a big monetary cut'-A qualitative study on financial toxicity analysing patients' experiences with cancer costs in Germany

Receiving information about expected costs promptly after a cancer diagnosis through psycho-oncology care or social counselling is crucial for patients to be prepared for the financial impact. Nevertheless, less is known about financial impacts for cancer patients in countries with statutory health insurance. This study aims to explore the full scope of costs that constitute the financial impact of a cancer diagnosis in Germany and to identify the reasons for high financial decline. Semistructured interviews with 39 cancer patients were conducted between May 2017 and April 2018. Narratives were analysed via qualitative content analysis. Several factors influenced cancer patients' indirect costs and direct medical and non-medical costs. For many patients, these changes resulted in higher indirect costs caused by income losses, especially when surcharges for shift work, travel expenses or company benefits ceased and were not reimbursed. Higher direct medical costs were caused by co-payments and additional non-refundable costs. Non-medical costs were reported to increase for some patients and to decrease for others, as for example, leisure activity costs either increasing because of pampering oneself to cope with the diagnosis and undergoing therapy or decreasing because of not being able to participate in leisure activities during therapy. When analysing the financial impacts of individuals' total costs, we found that some patients experienced no financial decline or an overall financial increase. Most patients experienced overall higher costs, and income loss was the main driver of a high financial decline. Nevertheless, decreased non-medical costs due to lower work-related and leisure activity costs could compensate for these higher costs. Cancer patients are confronted with a variety of changes in their financial situations, even in countries with statutory health insurance. Screening for cancer patients with a high risk of financial decline should consider any effects on indirect costs and direct medical and nonmedical costs.

Cancer-Related Debt and Mental-Health-Related Quality of Life among Rural Cancer Survivors: Do Family/Friend Informal Caregiver Networks Moderate the Relationship?

Social connectedness generally buffers the effects of stressors on quality of life. Is this the case for cancer-related debt among rural cancer survivors? Drawing on a sample of 135 rural cancer survivors, we leverage family/friend informal caregiver network data to determine if informal cancer caregivers buffer or exacerbate the effect of cancer-related debt on mental-health-related quality of life (MHQOL). Using data from the Illinois Rural Cancer Assessment, a survey of cancer survivors in rural Illinois, we estimate the association between cancer-related debt and MHQOL and whether informal caregiver network size and characteristics moderate this association. Over a quarter of survivors (27%) reported cancer-related debt, and those who did reported worse MHQOL. However, this association only held for survivors who had an informal caregiver network. These findings supplement what is already known about the role of social connectedness in cancer survivors' health outcomes. We offer possible explanations for these findings.

Financial distress among cancer survivors in Appalachian Kentucky

BACKGROUND

Rural residence may exacerbate cancer-related financial distress. Limited research has focused on Appalachian cancer survivors' experience with financial distress.

AIMS

The primary aim of this study was to estimate the prevalence of financial distress among cancer survivors residing in Appalachian Kentucky with a specific focus on the impact of rurality and to elucidate the risk factors impacting financial distress among this population.

METHODS AND RESULTS

Appalachian Kentucky residents were sampled for receipt of a health survey based on county-level rurality. Analyses describe the prevalence and predictors of financial distress among cancer survivors. Subsequent analyses were conducted with Health Information National Trends Survey (HINTS) data to compare local versus national estimates of financial distress. Almost two-thirds of Appalachian survivors reported financial distress compared to one-third of the HINTS sample. Appalachian survivors residing in the most rural counties reported higher distress; this finding was not supported in the national sample. In multivariable analyses, gender, current age, and household income were associated with financial distress among Appalachians; only income was significant among the national sample.

CONCLUSION

Appalachian cancer survivors have higher than national estimates of financial distress; rurality and socioeconomics are drivers of this disparity.

Disparities in Postmastectomy Breast Reconstruction: A Systematic Review of the Literature and Modified Framework for Advancing Research Toward Intervention

BACKGROUND

As the United States' population diversifies, eliminating disparities in health and healthcare has become increasingly important across all disciplines of medicine, including plastic and reconstructive surgery. This is evidenced by the growing body of literature in recent years focusing on disparities in postmastectomy breast reconstruction. No study to date has evaluated whether this research is progressing appropriately to promote tangible evidence-based interventions to reduce these disparities.

METHODS

A systematic literature review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines was performed to identify studies focusing on disparities in postmastectomy breast reconstruction. A previously established public health framework for advancing health disparities research was used to inform analysis of the quality and progression of the included studies. This triphasic framework categorizes disparities research as follows: detecting (identifies and measures disparities in vulnerable populations), understanding (establishes determinants of disparities), or reducing (proposes and evaluates interventions for eliminating disparities).

RESULTS

Ninety-five studies were identified between 1979 and 2016, with 61 (64.2%) published after 2010. The majority of studies (51.6%) were retrospective cohort or case-control studies (American Society of Plastic Surgery level III evidence). Fifty-eight (63.7%), 31 (34.1%), and 2 (2.2%) studies provided detecting-, understanding- and reducing-phase disparities research, respectively. Non-plastic and reconstructive surgery journals accounted for 70.5% of all articles and for most higher phase research articles, publishing 83.9% and 100% of second and third phase studies, respectively. Disparity categories investigated included race/ethnicity, age, income, insurance status/type, geography, and education level, with race/ethnicity being the most common (73.7%). The most commonly measured outcome was percent of subpopulation receiving reconstruction (63, 66.3%), followed by reconstruction type (14, 16.7%). Patient-, provider-, system-, and research-level factors were all identified as potential targets for interventions to reduce disparities.

CONCLUSIONS

Despite a recent increase in literature focusing on postmastectomy breast reconstruction disparities, the majority focuses on identifying vulnerable populations with inadequate progression to second (understanding) and third (reducing) phases. Increasing research funding, availability of language-concordant and culturally concordant educational materials, and advocacy and sociopolitical awareness within the plastic surgery community is necessary to advance research on postmastectomy breast reconstruction and, ultimately, eliminate it.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Drivers of cost differences between US breast cancer survivors with or without lymphedema

PURPOSE

Breast cancer-related lymphedema is an adverse effect of breast cancer surgery affecting nearly 30% of US breast cancer survivors (BCS). Our previous analysis showed that, even 12 years after cancer treatment, out-of-pocket healthcare costs for BCS with lymphedema remained higher than for BCS without lymphedema; however, only half of the cost difference was lymphedema-related. This follow-up analysis examines what, above and beyond lymphedema, contributes to cost differences.

METHODS

This mixed methods study included 129 BCS who completed 12 monthly cost diaries in 2015. Using Cohen's d and multivariable analysis, we compared self-reported costs across 13 cost categories by lymphedema status. We elicited quotes about specific cost categories from in-person interviews with 40 survey participants.

RESULTS

Compared with BCS without lymphedema, BCS with lymphedema faced 122% higher mean overall monthly direct costs ($355 vs $160); had significantly higher co-pay, medication, and other out-of-pocket costs, lower lotion costs; and reported inadequate insurance coverage and higher costs that persisted over time. Lotion and medication expenditure differences were driven by BCS' socioeconomic differences in ability to pay.

CONCLUSIONS

Elevated patient costs for BCS with lymphedema are for more than lymphedema itself, suggesting that financial coverage for lymphedema treatment alone may not eliminate cost disparities.

IMPLICATIONS FOR CANCER SURVIVORS

The economic challenges examined in this paper have long been a concern of BCS and advocates, with only recent attention by policy makers, researchers, and providers. BCS identified potential policy and programmatic solutions, including expanding insurance coverage and financial assistance for BCS across socioeconomic levels.

Standardized activities for lay patient navigators in breast cancer care: Recommendations from a citywide implementation study

BACKGROUND

There is a need for guidelines on patient navigation activities to promote both the quality of patient navigation and the standards of reimbursement for these services because a lack of reimbursement is a major barrier to the implementation, maintenance, and sustainability of these programs.

METHODS

A broad community-based participatory research process was used to identify the needs of patients for navigation. A panel of stakeholders of clinical providers was convened to identify specific activities for navigators to address the needs of patients and providers with the explicit goal of reducing delays in the initiation of cancer treatment and improving adherence to the care plan.

RESULTS

Specific activities were identified that could be generalized to all patient navigation programs for care during active cancer management to address the needs of vulnerable communities.

CONCLUSIONS

Oncology programs that seek to implement lay patient navigation may benefit from the adoption of these activities for quality monitoring. Such activities are necessary as we consider reimbursement strategies for navigators without clinical training or licensure.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Financial Hardship and the Economic Effect of Childhood Cancer Survivorship

In addition to the long-term physical and psychological sequelae of cancer therapy, adult survivors of childhood cancer are at an elevated risk for financial hardship. Financial hardship can have material, psychological, and behavioral effects, including high out-of-pocket medical costs, asset depletion and debt, limitations in or inability to work, job lock, elevated stress and worry, and a delaying or forgoing of medical care because of cost. Most financial hardship research has been conducted in survivors of adult cancers. The few studies focused on childhood cancer survivors have shown that these individuals are at elevated risk for having difficulties with affording needed health care and report high out-of-pocket medical expenses, difficulty with paying medical bills, or consideration of filing for bankruptcy. Childhood cancer survivors are more likely to be unable to work or to have missed work because of poor health. They are more likely to report difficulties with obtaining insurance coverage and rely more frequently on government-sponsored insurance. Globally, countries able to provide curative cancer therapies have witnessed a growing population of survivors, which places a burden on their health care systems because survivors are more likely to require hospitalization and experience a higher burden of chronic illness than the general population. Guidelines for surveillance for late effects are intended to reduce the burden of morbidity, but research is needed to determine whether such surveillance is cost effective. Of note, risk-based survivor care should include routine surveillance for financial hardship. Improved measures of financial hardship, enhanced data infrastructure, and research studies to identify survivors and families most vulnerable to financial hardship and adverse health outcomes will inform the development of targeted programs to serve as a safety net for those at greatest risk.

Rural Disparities in Treatment-Related Financial Hardship and Adherence to Surveillance Colonoscopy in Diverse Colorectal Cancer Survivors

Background: Cancer survivors increasingly report financial hardship as a consequence of the high cost of cancer care, yet the financial experience of rural cancer survivors remains largely unstudied. The purpose of this study was to investigate potential rural disparities in the likelihood of financial hardship and nonadherence to surveillance colonoscopy.Methods: Individuals diagnosed with localized or regional colorectal cancer between 2004 and 2012 were ascertained by the population-based New Mexico Tumor Registry. Participants completed a mailed questionnaire or telephone survey about their colorectal cancer survivorship experience, including treatment-related financial hardship and receipt of surveillance colonoscopy. Multivariable logistic regression was used to estimate adjusted odds ratios (ORs) and 95% confidence intervals (CIs).Results: Compared with urban colorectal cancer survivors (n = 168), rural colorectal cancer survivors (n = 109) were slightly older; more likely to be married (65% vs. 59%) and have an annual income <$30,000 (37% vs. 27%); and less likely to be employed (35% vs. 41%), have a college degree (28% vs. 38%), or a high level of health literacy (39% vs. 51%). Rural survivors were twice as likely as urban survivors to report treatment-related financial hardship (OR, 1.86; 95% CI, 1.06-3.28) and nonadherence to surveillance colonoscopy guidelines (OR, 2.28; 95% CI, 1.07-4.85). In addition, financial hardship was independently associated with nonadherence to surveillance colonoscopy (OR, 2.17; 95% CI, 1.01-4.85).Conclusions: Substantial rural disparities in the likelihood of financial hardship and nonadherence to surveillance colonoscopy exist.Impact: Treatment-related financial hardship among rural colorectal cancer survivors may negatively affect adherence to guideline-recommended follow-up care. Cancer Epidemiol Biomarkers Prev; 27(11); 1275-82. ©2018 AACR.

Most impactful factors on the health-related quality of life of a geriatric population with cancer

BACKGROUND

As the population of older adults with cancer continues to grow, the most important factors contributing to their health-related quality of life (HRQOL) remain unclear.

METHODS

A total of 1457 older adults (aged ≥65 years) with cancer participated in a telephone survey. Outcomes were measured using the Physical Component Summary (PCS) and Mental Component Summary (MCS) scores of the 12-Item Short Form Survey (SF-12) from the Medical Outcomes Study (version 2). Statistical techniques used to identify factors in 4 domains (physical, psychological, social, and spiritual) most strongly associated with HRQOL included linear models, recursive partitioning, and random forests. Models were developed in a training data set (920 respondents) and performance was assessed in a validation data set (537 respondents).

RESULTS

Respondents were a median of 19 months from diagnosis, and 28.1% were receiving active treatment. The most relevant factors found to be associated with PCS were symptom severity, comorbidity scores, leisure-time physical activity, and having physical support needs. The most relevant factors for MCS were having emotional support needs, symptom severity score, and the number of financial hardship events. Results were consistent across modeling techniques. Symptoms found to be strongly associated with PCS included fatigue (adjusted proportion of summary score's variance [R² ] = 0.34), pain (adjusted R² = 0.32), disturbed sleep (adjusted R² = 0.16), and drowsiness (adjusted R² = 0.16). Symptoms found to be strongly associated with MCS included fatigue (adjusted R² = 0.23), problems remembering things (adjusted R² = 0.17), disturbed sleep (adjusted R² = 0.16), and lack of appetite (adjusted R² = 0.16).

CONCLUSIONS

The findings of the current study support the importance of addressing persistent symptoms, managing comorbidities, promoting leisure-time physical activity, and addressing financial challenges. A long-term comprehensive approach is needed to ensure the well-being of older adults with cancer. Cancer 2018;124:596-605. © 2017 American Cancer Society.

Consumer credit as a novel marker for economic burden and health after cancer in a diverse population of breast cancer survivors in the USA

BACKGROUND

Consumer credit may reflect financial hardship that patients face due to cancer treatment, which in turn may impact ability to manage health after cancer; however, credit's relationship to economic burden and health after cancer has not been evaluated.

METHODS

From May to September 2015, 123 women with a history of breast cancer residing in Pennsylvania or New Jersey completed a cross-sectional survey of demographics, socioeconomic position, comorbidities, SF-12 self-rated health, economic burden since cancer diagnosis, psychosocial stress, and self-reported (poor to excellent) credit quality. Ordinal logistic regression evaluated credit's contribution to economic burden and self-rated health.

RESULTS

Mean respondent age was 64 years. Mean year from diagnosis was 11.5. Forty percent of respondents were Black or Other and 60% were White. Twenty-four percent self-reported poor credit, and 76% reported good to excellent credit quality. In adjusted models, changing income, using savings, borrowing money, and being unable to purchase a health need since cancer were associated with poorer credit. Better credit was associated with 7.72 ([1.22, 14.20], p = 0.02) higher physical health t-score, and a - 2.00 ([- 3.92, - 0.09], p = 0.04) point change in psychosocial stress.

CONCLUSIONS

This exploratory analysis establishes the premise for consumer credit as a marker of economic burden and health for breast cancer survivors. Future work should validate these findings in larger samples and for other health conditions.

IMPLICATIONS FOR CANCER SURVIVORS

Stabilizing and monitoring consumer credit may be a potential intervention point for mitigating economic burden after breast cancer.

Out-of-pocket costs and burden among rural breast cancer survivors

Little is known about out‐of‐pocket (OOP) costs incurred for medical and health needs by rural breast cancer survivors and what factors may be associated with higher OOP costs and the associated economic burden. Data were examined for 432 survivors participating in the Rural Breast Cancer Survivor Intervention trial. OOP costs were collected using the Work and Finances Inventory survey at baseline and four assessments every 3 months. Mean and median OOP costs and burden (percent of monthly income spent on OOP costs) were reported and factors associated with OOP costs and burden identified with generalized linear models fitted with over‐dispersed gamma distributions and logarithmic links (OOP costs) and with beta distributions with logit link (OOP burden). OOP costs per month since the end of treatment were on average $232.7 (median $95.6), declined at the next assessment point to $186.5 (median $89.1), and thereafter remained at that level. Mean OOP burden was 9% at baseline and between 7% and 8% at the next assessments. Factors suggestive of contributing to higher OOP costs and OOP burden were the following: younger age, lower income, time in survivorship from diagnosis, and use of supportive services. OOP costs burden rural breast cancer survivors, particularly those who are younger and low income. Research should investigate the impact of OOP costs and interventions to reduce economic burden.