Economic hardship of minority and non-minority cancer survivors 1 year after diagnosis: another long-term effect of cancer?

Financial hardship screening among Native American patients with cancer: a qualitative analysis

BACKGROUND

Cancer-related financial hardship is an increasingly recognized concern for patients, families, and caregivers. Many Native American (NA) patients are at increased risk for cancer-related financial hardship due to high prevalence of low income, medical comorbidity, and lack of private health insurance. However, financial hardship screening (FHS) implementation for NA patients with cancer has not been reported. The objective of this study is to explore facilitators and barriers to FHS implementation for NA patients.

METHODS

We conducted key informant interviews with NA patients with cancer and with clinical staff at an academic cancer center. Included patients had a confirmed diagnosis of cancer and were referred to the cancer center through the Indian Health Service, Tribal health program, or Urban Indian health program. Interviews included questions regarding current financial hardship, experiences in discussing financial hardship with the cancer care and primary care teams, and acceptability of completing a financial hardship screening tool at the cancer center. Clinical staff included physicians, advanced practice providers, and social workers. Interviews focused on confidence, comfort, and experience in discussing financial hardship with patients. Recorded interviews were transcribed and thematically analyzed using MAXQDA® software.

RESULTS

We interviewed seven patients and four clinical staff. Themes from the interviews included: 1) existing resources and support services; 2) challenges, gaps in services, and barriers to care; 3) nuances of NA cancer care; and 4) opportunities for improved care and resources. Patients identified financial challenges to receiving cancer care including transportation, lodging, food insecurity, and utility expenses. Patients were willing to complete a FHS tool, but indicated this tool should be short and not intrusive of the patient's financial information. Clinical staff described discomfort in discussing financial hardship with patients, primarily due to a lack of training and knowledge about resources to support patients. Having designated staff familiar with I/T/U systems was helpful, but perspectives differed regarding who should administer FHS.

CONCLUSIONS

We identified facilitators and barriers to implementing FHS for NA patients with cancer at both the patient and clinician levels. Findings suggest clear organizational structures and processes are needed for financial hardship to be addressed effectively.

A scoping review of racial, ethnic, socioeconomic, and geographic disparities in the outcomes of older adults with cancer

INTRODUCTION

Cancer health disparities are widespread. Nevertheless, the disparities in outcomes among diverse survivors of cancer ages 65 years and older ("older") have not been systematically evaluated.

METHODS

We conducted a scoping review of original research articles published between January 2016 and September 2023 and indexed in Medline (Ovid), Embase, Scopus, and CINAHL databases. We included studies evaluating racial, ethnic, socioeconomic disadvantaged, geographic, sexual and gender, and/or persons with disabilities disparities in treatment, survivorship, and mortality among older survivors of cancer. We excluded studies with no a priori aims related to a health disparity, review articles, conference proceedings, meeting abstracts, studies with unclear methodologies, and articles in which the disparity group was examined only as an analytic covariate. Two reviewers independently extracted data following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis reporting guidelines.

RESULTS

After searching and removing duplicates, 2573 unique citations remained and after screening 59 articles met the inclusion criteria. Many investigated more than one health disparity, and most focused on racial and ethnic (n = 44) or socioeconomic (n = 25) disparities; only 10 studies described geographic disparities, and none evaluated disparities in persons with disabilities or due to sexual and gender identity. Research investigating disparities in outcomes among diverse older survivors of cancer is increasing gradually-68% of eligible articles were published between 2020 and 2023. Most studies focused on the treatment phase of care (n = 28) and mortality (n = 26), with 16 examined disparities in survivorship, symptoms, or quality of life. Most research was descriptive and lacked analyses of potential underlying mechanisms contributing to the reported disparities.

CONCLUSION

Little research has evaluated the effect of strategies to reduce health disparities among older patients with cancer. This lack of evidence perpetuates cancer inequities and leaves the cancer care system ill equipped to address the unique needs of the rapidly growing and increasingly diverse older adult cancer population.

Forgoing physician visits due to cost: regional clustering among cancer survivors by age, sex, and race/ethnicity

BACKGROUND

Innovative treatments have improved cancer survival but also increased financial hardship for patients. While demographic factors associated with financial hardship among cancer survivors are known in the USA, the role of geography is less clear.

METHODS

We evaluated prevalence of forgoing care due to cost within 12 months by US Census region (Northeast, North Central/Midwest [NCMW], South, West) by demographic factors (age, sex, race/ethnicity) among 217,981 cancer survivors aged 18 to 82 years from the 2015-2019 Behavioral Risk Factor Surveillance System survey. We summarized region- and group-specific prevalence of forgoing physician visits due to cost and used multilevel logistic regression models to compare regions.

RESULTS

The prevalence of forgoing physician visits due to cost was highest in the South (aged < 65 years: 19-38%; aged ≥ 65: 4-21%; adjusted odds ratios [OR], NCMW versus South, OR: 0.63 [0.56-0.71]; Northeast versus South, OR: 0.63 [0.55-0.73]; West versus South, OR: 0.73 [0.64-0.84]). Across the USA, including regions with broad Medicaid expansion, younger, female, and persons of color most often reported cost-related forgoing physician visits.

CONCLUSION

Forgoing physician visits due to cost among cancer survivors is regionally clustered, raising concerns for concentrated poor long-term cancer outcomes. Underlying factors likely include variation in regional population compositions and contextual factors, such as Medicaid expansion and social policies. Disproportionate cost burden among survivors of color in all regions highlight systemic barriers, underscoring the need to improve access to the entire spectrum of care for cancer survivors, and especially for those most vulnerable.

Importance of Patient Health Insurance Coverage and Out-of-Pocket Costs for Genomic Testing in Oncologists' Treatment Decisions

PURPOSE

Use of genomic testing, especially multimarker panels, is increasing in the United States. Not all tests and related treatments are covered by health insurance, which can result in substantial patient out-of-pocket (OOP) costs. Little is known about oncologists' treatment decisions with respect to patient insurance coverage and OOP costs for genomic testing.

METHODS

We identified 1,049 oncologists who used multimarker tumor panels from the 2017 National Survey of Precision Medicine in Cancer Treatment. Separate multivariable ordinal logistic regressions examined associations of oncologist-, practice-, and area-level characteristics and oncologists' ratings of importance (very, somewhat, or a little/not important) of insurance coverage and OOP costs for genomic testing in treatment decisions, adjusting for oncologist years of experience, sex, race and ethnicity, specialty, use of next-generation sequencing (NGS) tests, region, tumor boards, patient insurance mix, and area-level socioeconomic characteristics.

RESULTS

Among oncologists, 47.3%, 32.7%, and 20.0% reported that patient insurance coverage for genomic testing was very, somewhat, or a little/not important, respectively, in treatment decisions. In addition, 56.9%, 28.0%, and 15.2% reported that OOP costs for testing were very, somewhat, or a little/not important, respectively. In adjusted analyses, oncologists who used NGS tests were more likely to report patient insurance and OOP costs as important (odds ratio [OR], 2.00 [95% CI, 1.16 to 3.45] and OR, 2.12 [95% CI, 1.22 to 3.68], respectively) in treatment decisions compared with oncologists who did not use these tests, as were oncologists who treated solid tumors, rather than only hematological cancers. More years of experience and higher percentages of Medicaid or self-paid/uninsured patients in the practice were associated with reporting insurance coverage (OR, 1.43 [95% CI, 1.09 to 1.89]) and OOP costs (OR, 1.51 [95% CI, 1.13 to 2.01]) as important. Oncologists in practices with molecular tumor boards for genomic tests were less likely to report coverage (OR, 0.63 [95% CI, 0.47 to 0.85]) and OOP costs (OR, 0.72 [95% CI, 0.53 to 0.97]) as important than their counterparts in practices without these tumor boards.

CONCLUSION

Most oncologists rate patient health insurance and OOP costs for genomic tests as important considerations in subsequent treatment recommendations. Modifiable factors associated with these ratings can inform interventions to support patient-physician decision making about care.

Comparisons of financial hardship in cancer care by family structure and among those with and without minor children using nationally representative data

INTRODUCTION

While demographic risk factors of cancer-related financial hardships have been studied, having minor children or being single have rarely been assessed in the context of healthcare-related financial hardships.

METHODS

Using data from the 2015 to 2018 National Health Interview Survey, we assessed financial hardship (material and psychological hardship; behavioral coping due to costs: delaying/foregoing care, reducing prescription costs, or skipping specialists or follow-up care) among adults aged 18-59 years with cancer (N = 2844) by minor child parenting status and family structure. In a secondary analysis, we compared this group with individuals without cancer. Using logistic regression models, we compared those with and without children aged <18 years, further distinguishing between those who were single versus one of two or more adults in the family.

RESULTS

Compared to individuals from families with two or more adults/without children, single adults with children more often reported cancer-related financial hardships, for example material hardship (45.9% vs. 38.8%), and reducing prescription costs, (50.7% vs. 34.4%, adjusted OR 1.57, 95% CI 1.07-2.28). Single adults without minor children and those from families with two or more adults/with minor children also reported greater financial hardships on some dimensions. Associations were similar among those without cancer, but the overall magnitude of financial hardships was lower compared to those with cancer.

CONCLUSIONS

Our findings suggest that having minor children, and being a single adult are risk factors for cancer-related financial hardship. Financial vulnerability associated with family structure should be taken into consideration in healthcare, and especially cancer care.

Job Loss and Well-Being Among Chinese American Breast Cancer Survivors: The Mediating Role of Income and Perceived Stress

BACKGROUND

A growing number of studies suggest that job loss has detrimental effects on cancer survivors. However, the underlying mechanisms are not well understood. Furthermore, minorities including Asian American cancer survivors remain understudied, yet they suffer from job loss more often. The present study examined the prevalence of job loss in Chinese American breast cancer survivors (CABCS) and investigated the relationship between job loss and well-being in this group and the underlying mechanisms.

METHOD

CABCS completed a questionnaire that included demographic, employment, and clinical information, as well as measures of psychosocial well-being. Descriptive analyses were conducted to gauge the prevalence of job loss, linear regressions were used to test associations between job loss and well-being, and path analyses were conducted to test mediations.

RESULTS

About 45.4% of survivors lost their job after being diagnosed with cancer, and only 35.2% of those who lost their job regained employment up to the assessment time. Job loss was associated with reduced income, which was associated with higher perceived stress, which, in turn, was associated with lower overall quality of life (QoL) and greater depressive symptoms.

CONCLUSIONS

Findings highlight the high prevalence of job loss and its negative effects on QoL and depression among CABCS. It is important for health care professionals to be sensitive to adverse financial events affecting minority BCS. In addition to offering BCS necessary practical assistance, psychosocial interventions focusing on reducing perceived stress associated with the cancer experience may be effective in mitigating some long-term consequences of job loss.

Impact of Income on Physical Concerns, Help Seeking, and Unmet Needs of Adult Cancer Survivors

Purpose

Cancer treatment can have consequences for individuals which may have profound impact on daily living. Accessing assistance can be problematic. This study explores associations between income and concerns, help-seeking, and unmet needs related to physical changes following cancer treatment.

Method

A national survey was conducted with cancer survivors about experiences with follow-up care one to three years after treatment. We report a trend analysis describing associations between income and cancer survivors' concerns, help-seeking, and unmet needs related to physical changes after treatment.

Results

In total 5,283 cancer survivors between 18 and 64 years responded, of which 4,264 (80.7%) indicated annual household income. The majority of respondents were survivors of breast (34.4%), colorectal (15.0%), and prostate (14.0%) cancers. Over 90% wrote about experiencing physical changes following cancer treatment. Survivors with low annual household incomes of less than $25,000 (CAN) reported the highest levels of concern about multiple physical changes and were more likely to seek help to address them.

Conclusions

Cancer survivors can experience various physical challenges and unmet needs following cancer treatment and difficulty obtaining relevant help across all income levels. Those with low income are more severely affected. Financial assessment and tailored follow-up are recommended.

Perspectives of Cancer Survivors with Low Income: A Content Analysis Exploring Concerns, Positive Experiences, and Suggestions for Improvement in Survivorship Care

The number of cancer survivors in Canada has reached 1.5 million and is expected to grow. It is important to understand cancer survivors' perspectives about the challenges they face after treatment is completed. Many factors create barriers to accessing assistance, and limited income may be a significant one. This study is a secondary analysis of data from a publicly available databank (Cancer Survivor Transitions Study) regarding the experiences of Canadian cancer survivors. The goal was to explore major challenges, positive experiences, and suggestions for improvement in survivorship care for low-income Canadian cancer survivors one to three years following treatment. A total of 1708 survey respondents indicated a low annual household income (<$25,000 CD). A content analysis was performed utilizing written comments to open-ended questions. The major challenges respondents described focused on physical capacity limits and treatment side effects; positive experiences emphasized support and attentive care; and suggestions for improvements highlighted the need for better support, information about self-care and side effect management, and timely follow-up care. The relationships between household income and the management of survivors' physical, emotional, and practical concerns require consideration. The design of follow-up care plans, programs, services, and financial assessments of patients may prepare survivors for predictable issues and costs in their transition to survivorship.

Delayed cancer diagnosis in the pregnant patient: navigating a complex medical and ethical dilemma

Prompt diagnosis of cancer in pregnancy is necessary to ensure timely management and improve outcomes. However, there are a several reasons why diagnosis may be delayed in pregnancy. Three major contributors to delayed diagnosis and treatment are patient delay, provider delay, and referral delay. This article aims to (1) increase physician awareness of this problem by providing a detailed review of the main culprits of delayed diagnosis and treatment of cancer in the pregnant patient, (2) discuss the complex ethical issues at hand in these cases, and (3) provide suggestions on how to better address such cases with the goal of improving patient outcomes.

Cardiovascular disease in adolescent and young adult cancer survivors: Impact of sociodemographic and modifiable risk factors

BACKGROUND

There is a growing population of adolescent and young adult (AYA) cancer survivors (ages 15-39 years), and they have an elevated risk of developing cardiovascular disease (CVD). Little is known about the contribution of sociodemographic and modifiable factors to the risk of CVD in AYA survivors and whether these factors differentially modulate their risk compared with that in the general population. The current study sought to fill these gaps.

METHODS

Self-reported data from the US National Health Interview Survey (2009-2018) were used to identify AYA cancer survivors (≥2 years postdiagnosis) and age-matched and sex-matched controls. The risk of CVD based on sociodemographic factors (sex, race/ethnicity, income, education) and modifiable risk factors (diabetes, body mass index, smoking, physical activity) was determined within and between survivors and controls using logistic regression models.

RESULTS

In total, 4766 AYA cancer survivors and 47,660 controls were included. The odds of CVD were significantly higher in survivors than in controls by sex, race/ethnicity, income, education, smoking status, and physical activity. An annual household income <$50,000 disproportionately increased the odds of CVD in survivors. One third of survivors reported no moderate-to-vigorous-intensity physical activity (MVPA). Performing any MVPA lowered the odds of CVD in survivors (odds ratio, 0.61; 95% CI, 0.450.81) and controls (odds ratio, 0.68; 95% CI, 0.61-0.77).

CONCLUSIONS

Sociodemographic and modifiable risk factors increased the odds of CVD in AYA survivors, in some cases disproportionately, compared with controls. Understanding health behavior trajectories among different sociodemographic populations is needed to identify opportunities to lower the risk of CVD. Performing any MVPA is particularly important for AYA survivors.

Implementation of an educational intervention to improve medical student cost awareness: a prospective cohort study

BACKGROUND

In the context of rising healthcare costs, formal education on treatment-related financial hardship is lacking in many medical schools, leaving future physicians undereducated and unprepared to engage in high-value care.

METHOD

We performed a prospective cohort study to characterize medical student knowledge regarding treatment-related financial hardship from 2019 to 2020 and 2020-2021, with the latter cohort receiving a targeted educational intervention to increase cost awareness. Using Kirkpatrick's four-level training evaluation model, survey data was analyzed to characterize the acceptability of the intervention and the impact of the intervention on student knowledge, attitudes, and self-reported preparedness to engage in cost-conscious care.

RESULTS

Overall, N = 142 medical students completed the study survey; 61 (47.3%) in the non-intervention arm and 81 (66.4%) in the intervention arm. Of the 81 who completed the baseline survey in the intervention arm, 65 (80.2%) completed the immediate post-intervention survey and 39 (48.1%) completed the two-month post-intervention survey. Following the educational intervention, students reported a significantly increased understanding of common financial terms, access to cost-related resources, and level of comfort and preparedness in engaging in discussions around cost compared to their pre-intervention responses. The majority of participants (97.4%) reported that they would recommend the intervention to future students. A greater proportion of financially stressed students reported considering patient costs when making treatment decisions compared to their non-financially stressed peers.

CONCLUSIONS

Targeted educational interventions to increase cost awareness have the potential to improve both medical student knowledge and preparedness to engage in cost-conscious care. Student financial stress may impact high-value care practices. Robust curricula on high-value care, including treatment-related financial hardship, should be formalized and universal within medical school training.

Exploring cancer care needs for Latinx adults: a qualitative evaluation

PURPOSE

Latinx adults with cancer, as compared with non-Latinx White adults, are diagnosed with more advanced stages and experience worse quality of life. Identifying barriers in cancer care among low-income Latinx adults is crucial to designing and implementing culturally appropriate interventions. The objective of this study was to explore the specific barriers encountered by Latinx adults after a cancer diagnosis and perspectives on the use of community health workers (CHWs) to address these barriers.

METHODS

We conducted semi-structured qualitative interviews with low-income Latinx adults with a past or current history of cancer and/or their caregivers in a community oncology clinic located in an agricultural community in California. Analysis was based in grounded theory and performed using the constant comparative method.

RESULTS

Sixteen interviews were conducted with patients alone (n = 11), a caregiver alone (n = 1), and patient-caregiver pairs (n = 4 patients; n = 4 caregivers). Four major themes emerged: (1) low cancer health literacy including cancer diagnosis and treatment, cancer fatalism, navigating next steps after diagnosis, advance directives, and precision medicine; (2) challenges in communicating and receiving supportive services due to language barriers; (3) stress and anxiety regarding financial hardships related to job loss, insurance barriers, and the COVID-19 pandemic; (4) the need for supportive, bilingual, and bicultural personnel to assist in overcoming these challenges.

CONCLUSIONS

Low-income Latinx adults with cancer and their caregivers experience health literacy, communication, and financial barriers that impede quality cancer care delivery. Embedding CHWs in the care team could be one way to address these barriers to culturally concordant, accessible care.

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.

Impact of Health Care-Associated Cost Concerns on Mammography Utilization: Cross-Sectional Survey Results From the National Health Interview Survey

PURPOSE

Health care-related cost concerns and financial toxicity are increasingly recognized barriers along the breast cancer care continuum. The purpose of this study was to evaluate the association between patient-reported cost concerns and screening mammography utilization.

METHODS

Survey participants aged 40 to 74 years from the 2018 National Health Interview Survey without personal history of breast cancer were included (response rate: 64%). Respondents were queried if they had experienced specific access-related health care barriers. Multiple variable logistic regression analyses were performed to evaluate the association between barriers to care and patient-reported screening mammography utilization.

RESULTS

Of survey respondents, 7,511 women were included. Of this group, 68.9% reported receiving a screening mammogram within the last 2 years and 52.2% reported receiving a screening mammogram within the last year. Of all survey respondents, 48.4% reported worry paying medical bills. Patients who reported worry about paying medical bills (odds ratio [OR] 0.86; 95% confidence interval [CI]: 0.76-0.97; P = .01), challenges affording dental care (OR 0.65; 95% CI: 0.54-0.77; P < .01), and challenges affording eyeglasses (OR 0.67; 95% CI: 0.54-0.84; P < .01) were less likely to report screening mammography use than their respective counterparts. Patients who skipped medication doses (OR 0.69; 95% CI: 0.52-0.91; P < .01), took less medication, (OR 0.63; 95% CI: 0.48-0.82; P < .01), and delayed filling prescriptions (OR 0.71; 95% CI: 0.56-0.90; P < .01) to save money were also less likely to report receiving mammography screening.

CONCLUSION

Patient-reported cost-related barriers are associated with decreased utilization of routine mammography.

Long-Term Outcomes among Adolescent and Young Adult Survivors of Acute Leukemia: A Surveillance, Epidemiology, and End Results Analysis

BACKGROUND

There is a growing population of adolescent and young adult (AYA, age 15-39 years) acute leukemia survivors in whom long-term mortality outcomes are largely unknown.

METHODS

The current study utilized the Surveillance, Epidemiology, and End Results (SEER) registry to assess long-term outcomes of AYA acute leukemia 5-year survivors. The impact of diagnosis age, sex, race/ethnicity, socioeconomic status, and decade of diagnosis on long-term survival were assessed utilizing an accelerated failure time model.

RESULTS

A total of 1,938 AYA acute lymphoblastic leukemia (ALL) and 2,350 AYA acute myeloid leukemia (AML) survivors diagnosed between 1980 and 2009 were included with a median follow-up of 12.3 and 12.7 years, respectively. Ten-year survival for ALL and AML survivors was 87% and 89%, respectively, and 99% for the general population. Survival for AYA leukemia survivors remained below that of the age-adjusted general population at up to 30 years of follow-up. Primary cancer mortality was the most common cause of death in early survivorship with noncancer causes of death becoming more prevalent in later decades of follow-up. Male AML survivors had significantly worse survival than females (survival time ratio: 0.61, 95% confidence interval: 0.45-0.82).

CONCLUSIONS

AYA leukemia survivors have higher mortality rates than the general population that persist for decades after diagnosis.

IMPACT

While there have been improvements in late mortality, long-term survival for AYA leukemia survivors remains below that of the general population. Studies investigating risk factors for mortality and disparities in late effects among long-term AYA leukemia survivors are needed.

State legislative trends related to biomarker testing

Comprehensive biomarker testing has become the standard of care for informing the choice of the most appropriate targeted therapy for many patients with advanced cancer. Despite evidence demonstrating the need for comprehensive biomarker testing to enable the selection of appropriate targeted therapies and immunotherapy, the incorporation of biomarker testing into clinical practice lags behind recommendations in National Comprehensive Cancer Network guidelines. Coverage policy differences across insurance health plans have limited the accessibility of comprehensive biomarker testing largely to patients whose insurance covers the recommended testing or those who can pay for the testing, and this has contributed to health disparities. Furthermore, even when insurance coverage exists for recommended biomarker testing, patients may incur burdensome out-of-pocket costs depending on their insurance plan benefits, which may also create barriers to testing. Prior authorization for biomarker testing for some patients can add an administrative burden and may delay testing and thus treatment if it is not done in a timely manner. Recently, three states (Illinois, Louisiana, and California) passed laws designed to improve access to biomarker testing at the state level. However, there is variability among these laws in terms of the population affected, the stage of cancer, and whether the coverage of testing is mandated, or the legislation addresses only prior authorization. Advocacy efforts by patient advocates, health care professionals, and professional societies are imperative at the state level to further improve coverage for and access to appropriate biomarker testing.

Association Between Household Income and Self-Perceived Health Status and Poor Mental and Physical Health Among Cancer Survivors

Background: Health-related quality of life (HRQoL) is multidimensional and is composed of, at a minimum, self-perceived health status, physical functioning, and psychological well-being. HRQoL measures reflect the extent of disability and dysfunction associated with a chronic disease such as cancer. The objective of this study is to examine factors associated with HRQoL among cancer survivors.

Methods: Data from the 2009 Behavioral Risk Factor Surveillance System survey was used to examine factors associated with HRQoL among participants who reported having ever been diagnosed with cancer. Four questions associated with HRQoL included self-perceived health status, number of bad physical health days, and number of bad mental health days per month. Least square regression and logistic regression models, adjusted for confounding variables, were used for an ordinal and dichotomous [5 (bad) vs. 1–4 (excellent, very good, good, fair)] scale of HRQoL, respectively.

Results: Fifty nine thousand one hundred seventy three participants reported having ever been diagnosed with cancer. Adjusted mean self-perceived health status (5-point scale) among survivors of thyroid, colon, lung, cervical, breast, prostate, and ovarian cancer was 3.83 (0.05), 4.02 (0.04), 4.36 (0.06), 3.77 (0.03), 3.88 (0.03), 3.78 (0.04), and 3.96 (0.05), respectively. After adjusting for confounders, a positive dose-response effect was observed between income range and all three HRQoL measures across all seven cancer sites. Income was consistently and inversely associated with a higher chance for reporting poorer HRQoL [OR: 0.64, 95% CI: 0.57–0.71], [OR: 0.63, 95% CI: 0.48–0.82], [OR: 0.67, 95% CI: 0.56–0.80], [OR: 0.69, 95% CI: 0.56–0.86], [OR: 0.55, 95% CI: 0.49–0.62], [OR:0.55, 95% CI: 0.44–0.69], [OR: 0.75, 95% CI: 0.62–0.91] among those with thyroid, colon, lung, cervical, breast, prostate, and ovarian cancer, respectively.

Discussion: This study found that income range was associated with HRQoL among cancer survivors. It is plausible that financial resources may lessen the overall burden of cancer survivors, which could improve health-related quality of life among cancer survivors.

Exploring the relationships between income and emotional/practical concerns and help-seeking by older adult cancer survivors: A secondary analysis

PURPOSE

The number of older cancer survivors is growing rapidly and expected to double through the next decade. Survivors can face challenges from treatment as well as other co-morbid conditions which may influence quality of living and generate distress. Understanding more about factors influencing whether older cancer survivors receive the help they desire is important for cancer program planning. The purpose of this analysis was to understand relationships between income and emotional/practical concerns, help-seeking experiences and unmet needs of adults 65+ years one to three years following cancer treatment.

MATERIALS AND METHODS

A survey was conducted with randomly selected Canadian cancer survivors about their survivorship care. Drawing from these publicly available data, this secondary analysis examines prevalence of concerns, help-seeking, receipt of help, reasons for not seeking help, responses to information questions, and overall unmet needs for trends across income groups.

RESULTS

7975 respondents 65+ years responded, of which the 5891 (73.9%) indicating annual household income were analyzed. Over 80% responded to questions regarding emotional/practical concerns following treatment with the largest proportions reporting emotional concerns for anxiety/fear of cancer returning (63%) and depression (49%), and practical concerns regarding transportation for appointments (33%) and paying healthcare bills (31%). Individuals with household incomes <$25,000 reported higher levels of concern than other income groups and higher proportions sought assistance for their concerns. Across income levels, 20% reported difficulty finding assistance to address their concerns.

DISCUSSION

Older cancer survivors across all income categories reported emotional/practical concerns, lack of information about these issues, and unmet needs regarding both emotional and practical concerns. Many encountered challenges obtaining help with those in lower income categories more severely affected despite Canada's universal health care system. Financial burden ought to be assessed with older survivors on an on-going basis to ensure relevant intervention.

Follow-up Interactive Long-Term Expert Ranking (FILTER): a crowdsourcing platform to adjudicate risk for survivorship care

Objectives

To develop an online crowdsourcing platform where oncologists and other survivorship experts can adjudicate risk for complications in follow-up.

Materials and Methods

This platform, called Follow-up Interactive Long-Term Expert Ranking (FILTER), prompts participants to adjudicate risk between each of a series of pairs of synthetic cases. The Elo ranking algorithm is used to assign relative risk to each synthetic case.

Results

The FILTER application is currently live and implemented as a web application deployed on the cloud.

Discussion

While guidelines for following cancer survivors exist, refinement of survivorship care based on risk for complications after active treatment could improve both allocation of resources and individual outcomes in long-term follow-up.

Conclusion

FILTER provides a means for a large number of experts to adjudicate risk for survivorship complications with a low barrier of entry.

Disparities in the long-term survival of adolescent and young adult diffuse large B cell lymphoma survivors

PURPOSE

The population of adolescent and young adult (AYA, ages 15-39 years) diffuse large B-cell lymphoma (DLBCL) survivors is growing, however long-term overall survival patterns and disparities are largely unknown.

METHODS

The current study utilized the Surveillance, Epidemiology, and End Results (SEER) registry to assess the impact of race/ethnicity, sex, socioeconomic status, and rurality on long-term survival in 5-year DLBCL survivors using an accelerated failure time model.

RESULTS

Included were 4767 5-year survivors of AYA DLBCL diagnosed between the years 1980 and 2009 with a median follow-up time of 13.4 years. Non-Hispanic Black survivors had significantly worse long-term survival than non-Hispanic White survivors (Survival Time Ratio (STR): 0.53, p < 0.0001). Male sex (STR: 0.57, p < 0.0001) and older age at diagnosis were also associated with reduced long-term survival. There was no evidence that survival disparities improved over time.

CONCLUSIONS

Racial disparities persist well into survivorship among AYA DLBCL survivors. Studies investigating specific factors associated with survival disparities are urgently needed to better address these disparities.

Communicating Critical Information to Cancer Survivors: an Assessment of Survivorship Care Plans in Use in Diverse Healthcare Settings

Survivorship care plans (SCPs) serve to communicate critical information needed for cancer survivors' long-term follow-up care. The extent to which SCPs are tailored to meet the specific needs of underserved patient populations is understudied. To fill this gap, this study aimed to assess the content and communication appropriateness of SCPs collected from diverse healthcare settings. We analyzed collected SCPs (n = 16) for concordance with Institute of Medicine (IOM) recommendations for SCP content and for communication appropriateness using the Suitability Assessment of Materials (SAM) instrument. All plans failed to incorporate all IOM criteria, with the majority of plans (n = 11) incorporating less than 60% of recommended content. The average reading grade level of all the plans was 14, and only one plan received a superior rating for cultural appropriateness. There is significant variation in the format and content of SCPs used in diverse hospital settings and most plans are not written at an appropriate reading grade level nor tailored for underserved and/or minority patient populations. Co-designing SCPs with diverse patient populations is crucial to ensure that these documents are meeting the needs and preferences of all cancer survivors.

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

Financial Hardship in Survivorship Care Delivery

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

Correlates of financial toxicity in adult cancer patients and their informal caregivers

BACKGROUND

Financial toxicity is commonly reported by cancer patients, but few studies have assessed caregiver perceptions. We aimed to validate the modified Comprehensive Score for Financial Toxicity (COST) in cancer caregivers, identify factors associated with financial toxicity in both patients and caregivers, and assess the association of caregiver financial toxicity with patient and caregiver outcomes.

METHODS

Using a convenience sampling method, 100 dyads of adult cancer patients and a primary caregiver visiting outpatient oncology clinics (Jan-Sep 2019) were recruited. We assessed the internal consistency and convergent and divergent validity of the modified COST. Multivariable analyses identified correlates of financial toxicity. Association of financial toxicity with care non-adherence, lifestyle-altering behaviors (e.g., home refinance/sale, retirement/saving account withdrawal), and quality of life (QOL) was investigated.

RESULTS

Recruited patient vs. caregiver characteristics were as follows: mean age: 60.6 vs. 56.5; 34% vs. 46.4% female; 79% vs. 81.4% white. The caregiver COST measure demonstrated high internal consistency (Cronbach α = 0.91). In patients, older age (B, 0.3 [95% CI, 0.1-0.4]) and higher annual household income (B, 14.3 [95% CI, 9.3-19.4]) correlated with lower financial toxicity (P < 0.05). In caregivers, lower patient financial toxicity (B, 0.4 [95% CI, 0.2-0.6]) and cancer stages 1-3 (compared to stage 4) (B, 4.6 [95% CI, 0.4-8.8]) correlated with lower financial toxicity (P < 0.05). Increased caregiver financial toxicity correlated with higher care non-adherence in patients, increased lifestyle-altering behaviors, and lower QOL in patients and caregivers (P < 0.05).

CONCLUSION

The COST measure can also be used to assess caregiver financial toxicity. Caregivers' financial toxicity was associated with negative outcomes for both dyad members.

Impact of Race, Ethnicity, and Socioeconomic Status over Time on the Long-term Survival of Adolescent and Young Adult Hodgkin Lymphoma Survivors

BACKGROUND

Although there are growing numbers of adolescent and young adult (AYA) Hodgkin lymphoma (HL) survivors, long-term overall survival (OS) patterns and disparities in this population are underreported. The aim of the current study was to assess the impact of race/ethnicity, socioeconomic status (SES), rurality, diagnosis age, sex, and HL stage over time on long-term survival in AYA HL survivors.

METHODS

The authors used the Surveillance, Epidemiology, and End Results (SEER) registry to identify survivors of HL diagnosed as AYAs (ages 15-39 years) between the years 1980 and 2009 and who were alive 5 years after diagnosis. An accelerated failure time model was used to estimate survival over time and compare survival between groups.

RESULTS

There were 15,899 5-year survivors of AYA HL identified, with a median follow-up of 14.4 years and range up to 33.9 years from diagnosis. Non-Hispanic black survivors had inferior survival compared with non-Hispanic white survivors [survival time ratio (STR): 0.71, P = 0.002]. Male survivors, older age at diagnosis, those diagnosed at higher stages, and those living in areas of higher SES deprivation had unfavorable long-term survival. There was no evidence of racial or sex-based survival disparities changing over time.

CONCLUSIONS

Racial, SES, and sex-based disparities persist well into survivorship among AYA HL survivors.

IMPACT

Disparities in long-term survival among AYA HL survivors show no evidence of improving over time. Studies investigating specific factors associated with survival disparities are needed to identify opportunities for intervention.

Clinical Implications of Nonbiological Factors With Colorectal Cancer Patients Younger Than 45 Years

Background

To evaluate the clinical implications of non-biological factors (NBFs) with colorectal cancer (CRC) patients younger than 45 years.

Methods

In the present study, we have conducted Cox proportional hazard regression analyses to evaluate the prognosis of different prognostic factors, the hazard ratios (HRs) were shown with 95% confidence intervals (CIs). Kaplan-Meier method was utilized to compare the prognostic value of different factors with the log-rank test. NBF score was established according to the result of multivariate Cox analyses.

Results

In total, 15129 patients before 45 years with known NBFs were identified from the SEER database. Only county-level median household income, marital status and insurance status were NBFs that significantly corelated with the cause specifical survival in CRC patients aged less than 45 years old (P < 0.05). Stage NBF 1 showed 50.5% increased risk of CRC-specific mortality (HR = 1.505, 95% CI = 1.411-1.606, P < 0.001). Stage NBF 0 patients were associated with significantly increased CRC-specific survival (CCSS) when compared with the stage NBF 1 patients in different AJCC TNM stages.

Conclusions

NBF stage (defined by county-level median household income, marital status and insurance status) was strongly related to the prognosis of CRC patients. NBFs should arouse enough attention of us in clinical practice of patients younger than 45 years.

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

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

Racial/ethnic differences in health-related quality of life among female breast cancer survivors: cross-sectional findings from the Medical Expenditure Panel Survey

OBJECTIVES

Breast cancer survivors have reported worse health-related quality of life (HRQoL) outcomes on some subscales when compared with members of the general population. However, the increased attention to breast cancer survivorship should have improved the HRQoL of these survivors. Our aim was to examine whether physical and mental component scores (PCS-12 and MCS-12) using the Short Form (SF-12) questionnaire were different for racial/ethnic minorities, specifically for Black and Hispanic women relative to White women. Furthermore, we stratified the data by age group to evaluate these racial/ethnic differences in HRQoL of breast cancer survivors.

STUDY DESIGN

Cross-sectional study.

METHODS

Pooled cross-sectional analyses using data from the Medical Expenditure Panel Survey between 2008 and 2016 were conducted. Pooled ordinary least squares (OLS) regression was used to examine the racial/ethnic differences in PCS-12 and MCS-12 scores of breast cancer survivors. Furthermore, stratified analyses by age group were conducted to evaluate racial/ethnic differences in HRQoL by the age of breast cancer survivors.

RESULTS

After adjusting for confounders, there was no association between race/ethnicity and PCS-12 scores. However, Hispanic breast cancer survivors had statistically significantly lower MCS-12 scores (by 1.9 points [95% confidence interval {CI}: -3.53 to -0.37]) when compared with White breast cancer survivors. For PCS-12, after stratifying by age, the adjusted analyses showed no significant differences in PCS-12 scores when White female breast cancer survivors were compared with the other racial/ethnic categories. On the other hand, Black female survivors aged <50 years had 4.3 points (95% CI: 0.46-8.13) higher MCS-12 scores when compared with their White counterparts, while Hispanic breast cancer survivors aged <50 years had 3.1 points (95% CI: -0.40-6.69) higher MCS-12 scores relative to White women. Furthermore, among female breast cancer survivors aged ≥50 years, Hispanic women had 3.2 points (95% CI: -4.98 to -1.40) lower MCS-12 scores than White women.

CONCLUSION

Our study generated findings showing the racial/ethnic differences in HRQoL of breast cancer survivors and presented results stratified by age group. These findings provide the much-needed rationale for targeted and racial/ethnic-specific HRQoL improvement strategies among breast cancer survivors.

Systematic review of financial burden assessment in cancer: Evaluation of measures and utility among adolescents and young adults and caregivers

The cost of cancer care is rising and represents a stressor that has significant and lasting effects on quality of life for many patients and caregivers. Adolescents and young adults (AYAs) with cancer are particularly vulnerable. Financial burden measures exist but have varying evidence for their validity and reliability. The goal of this systematic review is to summarize and evaluate measures of financial burden in cancer and describe their potential utility among AYAs and their caregivers. To this end, the authors searched PubMed, Embase, the Cochrane Library, CINAHL, and PsycINFO for concepts involving financial burden, cancer, and self-reported questionnaires and limited the results to the English language. They discarded meeting abstracts, editorials, letters, and case reports. The authors used standard screening and evaluation procedures for selecting and coding studies, including consensus-based standards for documenting measurement properties and study quality. In all, they screened 7250 abstracts and 720 full-text articles to identify relevant articles on financial burden. Eighty-six articles met the inclusion criteria. Data extraction revealed 64 unique measures for assessing financial burden across material, psychosocial, or behavioral domains. One measure was developed specifically for AYAs, and none were developed for their caregivers. The psychometric evidence and study qualities revealed mixed evidence of methodological rigor. In conclusion, several measures assess the financial burden of cancer. Measures were primarily designed and evaluated in adult patient populations with little focus on AYAs or caregivers despite their increased risk of financial burden. These findings highlight opportunities to adapt and test existing measures of financial burden for AYAs and their caregivers.

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.

The Occupational Participation of Latinx Cancer Survivors and Their Family Caregivers Living in Survivorship: A Qualitative Exploration Informed by Multiple Stakeholders

The purpose of this study was to examine the lived experiences of Latinx cancer survivors and their family caregivers during survivorship. Eighteen semi-structured interviews were conducted with a variety of stakeholders including Latinx cancer survivors (n = 8), their family caregivers (n = 5), and cancer care providers (n = 5). Data were analyzed thematically to describe occupational participation. Latinx families lived in political, economic, language, and social contexts that facilitated and hindered their well-being. Survivors simultaneously experienced occupational deprivation and posttraumatic growth. To promote occupational justice, occupational therapy practitioners and researchers are called to partner with Latinx survivors and their families to facilitate skills needed for everyday participation.

Racial Differences in the Influence of Health Care System Factors on Informal Support for Cancer Care Among Black and White Breast and Lung Cancer Survivors

This retrospective, secondary qualitative analysis investigates whether health system factors influence social support among Black and white breast and lung cancer survivors and racial differences in support. These data come from race- and cancer-stratified focus groups (n = 6) and interviews (n = 2) to inform a randomized controlled trial utilizing antiracism and community-based participatory research approaches. Findings indicate social support was helpful for overcoming treatment-related challenges, including symptom management and patient-provider communication; racial differences in support needs and provision were noted. Resources within individual support networks reflect broader sociostructural factors. Reliance on family/friends to fill gaps in cancer care may exacerbate racial disparities.

Financial toxicity and strain among men receiving prostate cancer care in an equal access healthcare system

Purpose

To examine financial toxicity and strain among men in an equal access healthcare system based on social determinants and clinical characteristics.

Methods

Observational study among men receiving prostate cancer care (n = 49) at a Veterans Health Administration (VHA) facility. Financial hardship included overall financial strain and financial toxicity due to healthcare costs. Financial strain was measured with one item asking how much money they have leftover at the end of the month. Financial toxicity was measured with the Comprehensive Score for Financial Toxicity (COST) scale.

Results

Comprehensive Score for Financial Toxicity scores among participants indicated moderate levels of financial toxicity (M = 24.4, SD = 9.9). For financial strain, 36% of participants reported that they did not have enough money left over at the end of the month. There were no racial or clinically related differences in financial toxicity, but race and income level had significant associations with financial strain.

Conclusion

Financial toxicity and strain should be measured among patients in an equal access healthcare system. Findings suggest that social determinants may be important to assess, to identify patients who may be most likely to experience financial hardship in the context of obtaining cancer care and implement efforts to mitigate the burden for those patients.

What Do Men with Metastatic Prostate Cancer Consider When Making Treatment Decisions? A Mixed-methods Study

OBJECTIVE

Metastatic prostate cancer (mPCa) patients often make complicated treatment decisions, yet decision aids to facilitate shared decision-making for mPCa are uncommon. To inform the development of patient-centered mPCa decision aids, we examined what mPCa survivors considered most important when making treatment decisions.

METHODS

Using an exploratory sequential approach, we conducted three focus groups with 14 advanced prostate cancer survivors (n=5, n=3, n=6 in each group) to identify considerations for making treatment decisions. Focus groups were audio-recorded and transcribed, and we identified qualitative themes. We then developed a quantitative survey to assess the importance of each theme and administered the survey to mPCa survivors (N=100). We used relative frequencies to determine the most strongly endorsed items and chi-squared and Fisher's exact tests to assess associations with participant characteristics.

RESULTS

Focus groups yielded 11 themes, and the resulting survey included 20 items. The most strongly endorsed mPCa treatment considerations were: relying on physician's treatment recommendations (79% strongly agree); wanting to feel well enough to spend quality time with loved ones (72% strongly agree); the importance of dying in a manner consistent with one's wishes (70% strongly agree); hoping to eliminate cancer completely (68% strongly agree); and optimizing treatment efficacy (65% strongly agree). Age, race, marital status, employment status, and self-reported health were related to how strongly men endorsed various considerations for mPCa treatment decision-making.

CONCLUSION

We identified multiple considerations that mPCa survivors appraised when making treatment decisions. These data may inform the development of patient-centered decision aids for mPCa.

Financial toxicity and employment status in cancer survivors. A systematic literature review

Background

Financial toxicity has traditionally been attributed to the rising costs of cancer care. As ability to work impacts one’s financial situation, limited employment and reduced income may also contribute to financial toxicity. We examined evidence of the association between financial toxicity and employment status in cancer survivors.

Methods

A systematic literature review was performed via PubMed, Web of Science, CINAHL, and PsycINFO with search terms including “Cancer,” “Financial toxicity,” and “Employment” on September 25, 2019.

Results

Thirty-one papers met eligibility criteria. Thirteen studies were rated as having high quality, 16 as adequate, and two as low. Being actively treated for cancer had serious negative consequences on employment and medical expenditures. Unemployment, changed or reduced employment, lost days at work, poor work ability, and changes to employment were associated with a higher risk of financial toxicity. Patients who were younger, non-white, unmarried, of low education, living with dependents, residing in non-metropolitan service areas, with lower income, and of low socioeconomic status were more at risk of financial toxicity. Other variables associated with financial toxicity included having a mortgage/personal loan, higher out of pocket costs and household bills, limited health insurance, more severely ill, on active treatment, and lower functioning or quality of life.

Conclusion

Cancer negatively affects employment, and these changes are significant contributors to financial toxicity. Researchers, healthcare professionals, and patients themselves should all cooperate to tackle these complex issues.

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

INTRODUCTION

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Patterns of racial/ethnic disparities in baseline health-related quality of life and relationship with overall survival in patients with colorectal cancer

PURPOSE

Racial disparities are evident in colorectal cancer (CRC) prognosis with black patients experiencing worse outcomes than Hispanics and whites, yet mediators of these disparities are not fully known. The aim of this study is to identify variables that contribute to racial/ethnic disparities in health-related quality of life (HR-QoL) and overall survival in CRC.

METHODS

Using SF-12 questionnaires, we assessed HR-QoL in 1132 CRC patients by calculating their physical (PCS) and mental composite summary (MCS) scores. Associations between poor PCS/MCS and sociodemographic factors were estimated and survival differences were identified by race/ethnicity.

RESULTS

Hispanic patients who never married were at greater risk of poor PCS (OR 2.69; 95% CI 1.11-6.49; P = 0.028) than were currently married patients. College education was associated with a decreased risk of poor PCS in Hispanic and white, but not black, patients. Gender was significantly associated with poor MCS among white patients only. CRC patients who reported a poor PCS or MCS had poor survival, with differences in median survival times (MSTs) by race. The effect of PCS was strongest in white CRC patients with a difference in overall MST of > 116 months between those with favorable versus poor physical HR-QoL. Black patients who reported poor Physical and Mental HR-QoL showed significant risk of a poor outcome.

CONCLUSION

These findings suggest that racial/ethnic disparities in CRC survival may be related to differences in HR-QoL. Identified mediators of HR-QoL could supplement current CRC management strategies to improve patients' survival.

Multilevel determinants of financial toxicity in breast cancer care: perspectives of healthcare professionals and Latina survivors

PURPOSE

Financial toxicity is a multidimensional side effect of cancer treatment. Yet, most relevant research has focused on individual-level determinants of financial toxicity and characterized only patient perspectives. This study examined the multilevel determinants of financial toxicity from the perspectives of Latina breast cancer survivors and healthcare professionals.

METHODS

We analyzed qualitative data from focus groups with 19 Latina breast cancer survivors and interviews with 10 healthcare professionals recruited through community partners and venues in Chicago.

RESULTS

At the individual-level, the lack of knowledge and prioritization regarding financial aspects of care (e.g., costs of treatment, insurance coverage) was identified as important determinants of financial toxicity. However, healthcare professionals emphasized the need for early financial planning, while survivors prioritized survival over financial concerns immediately after diagnosis. At the interpersonal-level, social networks were identified as important platforms for disseminating information on financial resources. At the community-level, community norms and dynamics were identified as important barriers to seeking financial assistance. Access to culturally astute community-based organizations was considered one potential solution to eliminate these barriers. At the organizational/healthcare policy-level, financial assistance programs' restrictive eligibility criteria, lack of coverage post-treatment, limited availability, and instability were identified as major determinants of financial toxicity.

CONCLUSION

Our findings suggest that multilevel interventions at the individual-, interpersonal-, community-, and organizational/healthcare policy-levels are needed to adequately address financial toxicity among Latina and other survivors from disadvantaged communities.

Calidad de Vida: a systematic review of quality of life in Latino cancer survivors in the USA

BACKGROUND

Cancer is the leading cause of death among Hispanics/Latinos. Thus, understanding health-related quality of life (HRQOL) needs among this diverse racial/ethnic group is critical. Using Ferrell's multidimensional framework for measuring QOL, we synthesized evidence on HRQOL needs among Hispanic/Latino cancer survivors.

METHODS

We searched MEDLINE/PubMed, EMBASE, CINAHL, and PsycINFO, for English language articles published between 1995 and January 2020, reporting HRQOL among Hispanic/Latino cancer survivors in the USA.

RESULTS

Of the 648 articles reviewed, 176 met inclusion criteria, with 100 of these studies focusing exclusively on breast cancer patients and no studies examining end-of-life HRQOL issues. Compared with other racial/ethnic groups, Hispanics/Latinos reported lower HRQOL and a higher symptom burden across multiple HRQOL domains. Over 80% of studies examining racial/ethnic differences in psychological well-being (n = 45) reported worse outcomes among Hispanics/Latinos compared with other racial/ethnic groups. Hispanic/Latino cancer survivors were also more likely to report suboptimal physical well-being in 60% of studies assessing racial/ethnic differences (n = 27), and Hispanics/Latinos also reported lower social well-being relative to non-Hispanics/Latinos in 78% of studies reporting these outcomes (n = 32). In contrast, reports of spiritual well-being and spirituality-based coping were higher among Hispanics/Latinos cancer survivors in 50% of studies examining racial/ethnic differences (n = 15).

DISCUSSION

Findings from this review point to the need for more systematic and tailored interventions to address HRQOL needs among this growing cancer survivor population. Future HRQOL research on Hispanics/Latinos should evaluate variations in HRQOL needs across cancer types and Hispanic/Latino subgroups and assess HRQOL needs during metastatic and end-of-life disease phases.

Building a Culturally Competent Workforce to Care for Diverse Older Adults: Scope of the Problem and Potential Solutions

The population of minority older adults is going to explode over the next four decades. Older adults from racial and ethnic minorities face persistent and pervasive health disparities. Health disparities exert a huge fiscal burden on the nation. The national financial cost of health disparities for the years 2002 to 2006 was an estimated 1.23 trillion dollars. As the aging population becomes more diverse, these disparity-related costs are expected to increase. Older adults from racial and ethnic minorities face multiple barriers to accessing health and support services that will help them to age and die in place in the community. Patient-related barriers include limited English proficiency, low health literacy, varying levels of acculturation, biases about Western healthcare and medications, mistrust of clinicians, inability to navigate the complex healthcare system, and cultural beliefs and taboos. Clinician-related barriers include ageism (ie, discrimination against older people due to negative and inaccurate stereotypes), conscious and unconscious bias, being deeply entrenched in the culture of biomedicine, and the lack of training in the principles and practice of providing culturally respectful care. Health system-related barriers include lack of culturally tailored services, including access to medical interpreters. We conclude by identifying three specific strategies to facilitate culturally humble and respectful care for diverse patients. J Am Geriatr Soc 67:S423-S432, 2019.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Financial hardship among rural cancer survivors: An analysis of the Medical Expenditure Panel Survey

Some cancer survivors report spending 20% of their annual income on medical care. Undue financial burden that patients face related to the cost of care is referred to as financial hardship, which may be more prevalent among rural cancer survivors. This study examined contrasts in financial hardship among 1419 rural and urban cancer survivors using the 2011 Medical Expenditure Panel Survey supplement - The Effects of Cancer and Its Treatment on Finances. We combined four questions, creating a measure of material financial hardship, and examined one question on financial worry. We conducted multivariable logistic regression analyses, which produced odds ratios (OR) for factors associated with financial hardship and worry, and then generated average adjusted predicted probabilities. We focused on rural and urban differences classified by metropolitan statistical area (MSA) designation, controlling for age, education, race, marital status, health insurance, family income, and time since last cancer treatment. More rural cancer survivors reported financial hardship than urban survivors (23.9% versus 17.1%). However, our adjusted models revealed no significant impact of survivors' MSA designation on financial hardship or worry. Average adjusted predicted probabilities of financial hardship were 18.6% for urban survivors (Confidence Interval [CI]: 11.9%-27.5%) and 24.2% for rural survivors (CI: 15.0%-36.2%). For financial worry, average adjusted predicted probabilities were 19.9% for urban survivors (CI: 12.0%-31.0%) and 18.8% for rural survivors (CI: 12.1%-28.0%). Improving patient-provider communication through decision aids and/or patient navigators may be helpful to reduce financial hardship and worry regardless of rural-urban status.

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.

Insurance Status is an Independent Predictor of Overall Survival in Patients With Stage III Non-small-cell Lung Cancer Treated With Curative Intent

INTRODUCTION

Population studies suggest an impact of insurance status on oncologic outcomes. We sought to explore this in a large single-institution cohort of patients with non-small-cell lung cancer (NSCLC).

MATERIALS AND METHODS

We retrospectively analyzed 342 consecutive patients (January 2000 to December 2013) curatively treated for stage III NSCLC. Patients were categorized by insurance status as uninsured (U), Medicare/Medicaid + Veterans Affairs (M/M + VA), or Private (P). The χ² test was utilized to compare categorical variables. The Kaplan-Meier approach and the Cox proportional hazard models were used to analyze overall survival (OS) and freedom from recurrence (FFR).

RESULTS

Compared with M/M + VA patients, P insurance patients were more likely to be younger (P < .001), married (P < .001), Caucasian (P = .001), reside in higher median income zip codes (P < .001), have higher performance status (P < .001), and undergo consolidation chemotherapy (P < .001) and trimodality therapy (P < .001). Diagnosis to treatment was delayed > 30 days in U (67.3%), M/M + VA (68.1%), and P (52.6%) patients (P = .017). Compared with the M/M + VA and U cohorts, P insurance patients had improved OS (median/5-year: 30.7 months/34.2%, 19 months/17%, and 16.9 months/3.8%; P < .001) and FFR (median/5-year: 18.4 months/27.3%, 15.2 months/23.2%, and 11.4 months/4.8%; P = .012), respectively. On multivariate analysis, insurance status was an independent predictor for OS (P = .017) but not FFR.

CONCLUSION

Compared with U or M/M + VA patients, P insurance patients with stage III NSCLC were more likely to be optimally diagnosed and treated, resulting in a doubling of median OS for P versus U patients. Improved access to affordable health insurance is critical to combat inequities in access to care and has potential for improvements in cancer outcomes.

Methods for measuring financial toxicity after cancer diagnosis and treatment: a systematic review and its implications

Patients experiencing financial distress as a side-effect of cancer are not only reported in the United States, but also in third-party payer healthcare systems in Europe. Since validated survey instruments are a prerequisite for robust and comparable results, we aimed to compile and classify available instruments to enable both a better understanding of the underlying construct of financial toxicity and to facilitate further studies that are adjustable to various healthcare systems. We did a systematic literature search on studies that provide data on perceived cancer-related financial distress experienced by adult patients using PubMed, CINAHL and Web of Science databases up to 2018. We analyzed all detected instruments, items domains and questions with regard to their wording, scales and the domains of financial distress covered. Among 3298 records screened, 41 publications based on 40 studies matched our inclusion criteria. Based on the analysis of 352 different questions we identified 6 relevant subdomains that represent perceptions of and reactions to experienced financial distress: (i) active financial spending, (ii) use of passive financial resources, (iii) psychosocial responses, (iv) support seeking, (v) coping with care or (vi) coping with ones' lifestyle. We found an inconsistent coverage and use of these domains that makes it difficult to compare and quantify the prevalence of financial distress. Moreover, some existing instruments do not reflect relevant domains for patients in third-party payer systems. There is neither a consistent understanding of the construct of financial burden nor do available instruments cover all relevant aspects of a patients' distress perception. We encourage using the identified six domains to further develop survey instruments and adjust them to different health systems.

The social and economic toll of cancer survivorship: a complex web of financial sacrifice

PURPOSE

To assess the financial outcomes and associated social and economic effects on cancer survivors and their families.

METHODS

We assessed the responses of 1656 cancer survivors to a survey with both closed- and open-ended questions about cancer-related financial sacrifices they and their family experienced and evaluated differences in financial sacrifice by reported levels of cancer-related debt.

RESULTS

The most commonly reported financial sacrifices included cutbacks on household budgets, challenges with health care insurance and costs, career/self-advancement constraints, reduction/depletion of assets, and inability to pay bills. Survivors who incurred $10,000 or more in debt were significantly more likely to report social and economic impacts, including housing concerns and strained relationships.

CONCLUSIONS

Our analysis demonstrates both the frequency with which cancer survivors and families must make financial sacrifices as a result of their cancer, and the variety of forms that this sacrifice can take, even for individuals who have health insurance. The many types of financial hardship create challenges that are unique to each survivor and family.

IMPLICATIONS FOR CANCER SURVIVORS

Interventions that allow for personalized assistance with the specific financial and social needs of cancer survivors and their families have the potential to address a critical aspect of the long-term wellbeing of this important population.