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

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.

Financial Distress in Genitourinary Cancer: Insights From CDC National Health Interview Survey

PURPOSE

This study leverages CDC National Health Interview Survey data to examine Financial Distress (FD) among genitourinary (GU) cancer survivors, specifically prostate cancer (PC), kidney cancer (KC), and bladder cancer (BC). It investigates the economic impacts faced by these patients, especially in relation to disparities in insurance coverage and its effects on material, psychological, and behavioral aspects of FD.

METHODS

We retrospectively analyzed responses from GU cancer survivors, stratifying by cancer status and age (18-64 years, ≥65 years). Medical financial hardship was divided into three domains: material, psychological, and behavioral. Associations between cancer history, hardship, and clinical factors were assessed using generalized ordinal logistic regressions.

RESULTS

Significant health care access disparities were found, particularly for mental health services, with 25% of younger BC survivors and 4.7% of younger KC survivors reporting affordability issues, in contrast to 2.7% of noncancer individuals. Dental care was also problematic, with higher avoidance rates among younger BC (27%) and KC (15%) survivors compared with the general population. Surprisingly, noncancer individuals reported more difficulty in affording prescriptions than BC survivors across both age groups. PC survivors, however, showed lower FD across all domains versus noncancer controls, indicating fewer concerns about medical bills and a lesser tendency to forgo care.

CONCLUSION

The study underscores significant gaps in the financial support system for GU cancer survivors, with urgent needs in mental and dental health care access. Policy interventions, including comprehensive insurance reforms, are imperative to alleviate the financial burdens on these individuals.

Beyond Medical Bills: High Prevalence of Financial Toxicity and Diverse Management Strategies Among Vietnamese Patients With Cancer

OBJECTIVES

This study was conducted to measure financial toxicity (FT) among patients with cancer in Vietnam using the COmprehensive Score for financial Toxicity (COST) and to describe the cost management strategies employed by these patients.

METHODS

This comprehensive cross-sectional study enrolled 634 patients from 2 specialized oncology hospitals in Vietnam. Using COST cut-off scores, FT was classified as none/mild (≥26), moderate (14-25), or severe (≤13). Cost management strategies, or coping mechanisms, were classified into 4 groups: lifestyle changes, financial resource strategies, treatment modifications, and support seeking.

RESULTS

The prevalence of FT was 91.8%, with 51.7% of participants demonstrating severe and 40.1% exhibiting moderate FT. Severe FT was significantly associated with female, low education level, unstable employment, low household economic status, and advanced cancer stage. The most common coping strategies were as follows: among lifestyle changes, reducing spending on basic items and leisure activities (78.7%) and cutting back on essential household expenses (66.4%); among financial resource strategies, borrowing money from relatives or friends (49.1%) and withdrawing funds from retirement or savings accounts (34.1%); within treatment modifications, switching treatment facilities or doctors due to cost concerns (9.3%); and within support seeking, obtaining help from welfare or community organizations (18.8%). All strategies were significantly more likely to be used by patients with severe FT.

CONCLUSIONS

FT was highly prevalent among patients with cancer. Most patients relied on lifestyle adjustments and coping strategies, underscoring the need for improved financial support systems to alleviate the economic burden associated with cancer care.

Financial Toxicity Among Patients With Metastatic Prostate Cancer: A Mixed Methods Approach to Identify Effective Interventions

INTRODUCTION

Financial toxicity associated with treatments for metastatic prostate cancer remains poorly defined. We sought to understand aspects of financial toxicity not captured in a commonly employed financial toxicity questionnaire and identify potential interventions to help alleviate financial toxicity through a convergent mixed methods approach.

METHODS

Patients seen at our institution's advanced prostate cancer clinic were approached for completion of the Comprehensive Score for Financial Toxicity (COST-FACIT) questionnaire (quantitative analysis). A maximal variation purposive sample was chosen to participate in focus group discussions (qualitative analysis). Conventional content analysis was performed using an inductive approach. COST-FACIT scores were compared between patients experiencing high and low financial toxicity using Wilcoxon rank sum test.

RESULTS

Three themes were identified through qualitative analysis: (1) workload, (2) coping strategies, and (3) communication. We found alignment with the existing theory of financial capacity across our findings. Two unique aspects of financial toxicity emerged that were not assessed quantitatively and deemed to be significant. Specifically, cost transparency (including health care teams knowledgeable about and willing to discuss costs) and inclusion of informal caregivers in financial toxicity screening and decision-making may guide future interventions aimed at limiting financial toxicity in this population.

CONCLUSIONS

Prolonged treatment courses involving multiple lines of treatment with varying costs result in distinct financial toxicity components for patients with metastatic prostate cancer that are not assessed with COST-FACIT. Improving cost transparency, health care team knowledge and engagement, and providing resources to support informal caregivers may have a significant impact on the financial toxicity experienced by these patients.

Cancer diagnosis and treatment in working-age adults: Implications for employment, health insurance coverage, and financial hardship in the United States

The rising costs of cancer care and subsequent medical financial hardship for cancer survivors and families are well documented in the United States. Less attention has been paid to employment disruptions and loss of household income after a cancer diagnosis and during treatment, potentially resulting in lasting financial hardship, particularly for working-age adults not yet age-eligible for Medicare coverage and their families. In this article, the authors use a composite patient case to illustrate the adverse consequences of cancer diagnosis and treatment for employment, health insurance coverage, household income, and other aspects of financial hardship. They summarize existing research and provide nationally representative estimates of multiple aspects of financial hardship and health insurance coverage, benefit design, and employee benefits, such as paid sick leave, among working-age adults with a history of cancer and compare them with estimates among working-age adults without a history of cancer from the most recently available years of the National Health Interview Survey (2019-2021). Then, the authors identify opportunities for addressing employment and health insurance coverage challenges at multiple levels, including federal, state, and local policies; employers; cancer care delivery organizations; and nonprofit organizations. These efforts, when informed by research to identify best practices, can potentially help mitigate the financial hardship associated with cancer.

Evaluation of Financial Interventions in Breast Cancer Care Worldwide: A Systematic Review

Background

Out-of-pocket costs are burdensome for breast cancer patients. Cost-reducing interventions, though implemented, have unclear comparative efficacy. This study aimed to critically evaluate characteristics of successful versus unsuccessful interventions designed to decrease out-of-pocket costs for breast cancer patients.

Methods

A systematic review was conducted in accordance with the PRISMA checklist. Embase, PubMed, Global Index Medicus, and Global Health were queried from inception to February 2021. Articles describing a financial intervention targeting costs for breast cancer screening, diagnosis, or treatment and addressing clinical or patient-level financial outcomes were included. Methodological quality was evaluated using the QualSyst tool. Interventions were organized in accordance with timing of implementation, with narrative description of intervention type, success, and outcomes.

Results

Of the 11,086 articles retrieved, 21 were included in this review. Of these, 14 consisted of interventions during screening, and seven during diagnosis or treatment. Free/subsidized screening mammography was the most common screening intervention; 91% of these programs documented successful outcomes. Patient navigation and gift voucher programs demonstrated mixed success. The most successful intervention implemented during diagnosis/treatment was reducing medication costs. Low-cost programs and direct patient financial assistance were also successful. Limitations included lack of standardization in outcome metrics across studies.

Conclusions

Financial interventions reducing prices through free screening mammography and decreasing medication costs were most successful. Less successful interventions were not contextually tailored, including gift card incentivization and low-cost treatment modalities. These findings can facilitate implementation of broader, more generalizable programs to reduce costs and improve outcomes during evaluation and management of breast cancer.

Medical financial hardship between young adult cancer survivors and matched individuals without cancer in the United States

BACKGROUND

Young adult cancer survivors face medical financial hardships that may lead to delaying or forgoing medical care. This study describes the medical financial difficulties young adult cancer survivors in the United States experience in the post-Patient Protection and Affordable Care Act period.

METHOD

We identified 1009 cancer survivors aged 18 to 39 years from the National Health Interview Survey (2015-2022) and matched 963 (95%) cancer survivors to 2733 control individuals using nearest-neighbor matching. We used conditional logistic regression to examine the association between cancer history and medical financial hardship and to assess whether this association varied by age, sex, race and ethnicity, and region of residence.

RESULTS

Compared with those who did not have a history of cancer, young adult cancer survivors were more likely to report material financial hardship (22.8% vs 15.2%; odds ratio = 1.65, 95% confidence interval = 1.50 to 1.81) and behavior-related financial hardship (34.3% vs 24.4%; odds ratio = 1.62, 95% confidence interval = 1.49 to 1.76) but not psychological financial hardship (52.6% vs 50.9%; odds ratio = 1.07, 95% confidence interval = 0.99 to 1.16). Young adult cancer survivors who were Hispanic or lived in the Midwest and South were more likely to report psychological financial hardship than their counterparts.

CONCLUSIONS

We found that young adult cancer survivors were more likely to experience material and behavior-related financial hardship than young adults without a history of cancer. We also identified specific subgroups of young adult cancer survivors that may benefit from targeted policies and interventions to alleviate medical financial hardship.

Relationship between nurses' perceptions and financial toxicity management in the public health insurance system

Aims: To describe nursing practices for financial toxicity management based on nurses' perceptions. Materials & methods: A survey was conducted with 615 oncology nurses in Japan, focusing on nurses' perspectives on the importance of financial toxicity, nursing practices to manage financial toxicity and factors inhibiting its management. Results: A total of 521 participated, of whom 266 respondents (51.1%) considered nurses' role important, and they engaged in a significantly higher proportion of nursing practices. Participants with greater perceptions of their role included certified or specialized nurses and nurses responsible for outpatient care. Conclusion: Interventions leveraging the expertise of certified or specialized nurses and nurses involved in outpatient care could help to spread proactive nurse practices addressing financial toxicity.

The cost burden of metastatic prostate cancer in the US populations covered by employer-sponsored health insurance

BACKGROUND

Recent advancements in the clinical management of metastatic prostate cancer include several costly therapies and diagnostic tests. The objective of this study was to provide updated information on the cost to payers attributable to metastatic prostate cancer among men aged 18 to 64 years with employer-sponsored health plans and men aged 18 years or older covered by employer-sponsored Medicare supplement insurance.

METHODS

By using Merative MarketScan commercial and Medicare supplemental data for 2009-2019, the authors calculated differences in spending between men with metastatic prostate cancer and their matched, prostate cancer-free controls, adjusting for age, enrollment length, comorbidities, and inflation to 2019 US dollars.

RESULTS

The authors compared 9011 patients who had metastatic prostate cancer and were covered by commercial insurance plans with a group of 44,934 matched controls and also compared 17,899 patients who had metastatic prostate cancer and were covered by employer-sponsored Medicare supplement plans with a group of 87,884 matched controls. The mean age of patients with metastatic prostate cancer was 58.5 years in the commercial samples and 77.8 years in the Medicare supplement samples. Annual spending attributable to metastatic prostate cancer was $55,949 per person-year (95% confidence interval [CI], $54,074-$57,825 per person-year) in the commercial population and $43,682 per person-year (95% CI, $42,022-$45,342 per person-year) in the population covered by Medicare supplement plans, both in 2019 US dollars.

CONCLUSIONS

The cost burden attributable to metastatic prostate cancer exceeds $55,000 per person-year among men with employer-sponsored health insurance and $43,000 among those covered by employer-sponsored Medicare supplement plans. These estimates can improve the precision of value assessments of clinical and policy approaches to the prevention, screening, and treatment of prostate cancer in the United States.

Association of Employment Disruptions and Financial Hardship Among Individuals Diagnosed with Cancer in the United States: Findings from a Nationally Representative Study

Financial hardship (FH), defined as adverse patient effects due to cancer costs, is experienced by approximately half of individuals diagnosed with cancer. Many individuals diagnosed with cancer also experience disruptions with their employment. This study examines associations of employment disruptions and FH among a nationally representative sample of individuals diagnosed with cancer in the United States. We utilized 2016/2017 Medical Expenditure Panel Survey Experiences with Cancer data from individuals who worked for pay following cancer diagnosis. Employment disruption included taking extended paid time off work; switching to part-time/less demanding jobs; and/or retiring early due to cancer diagnosis/treatment. FH domains included: material (e.g., borrowing money/financial sacrifices); psychologic (e.g., worrying about medical bills/income); and behavioral (delaying/forgoing healthcare services because of cost). Multivariable logistic regression analyses determined associations of employment disruption and FH. Among 732 individuals with a cancer history, 47.4% experienced employment disruptions; 55.9% experienced any FH. Any FH was significantly more common among individuals with versus without employment disruptions across multiple measures and domains (68.7% vs. 44.5%; P value of difference <0.0001). Individuals with employment disruptions were more likely to have any FH [OR, 2.38; 95% confidence interval (CI), 1.62-3.52] and more FHs (OR, 2.76; 95% CI, 1.96-3.89]. This study highlights that employment disruptions are common and significantly associated with multiple domains of FH among individuals with a cancer history. Employer workplace accommodation, physician discussions regarding potential impacts of cancer care on employment, and other policies to minimize employment disruptions among individuals diagnosed with cancer may reduce FH in this vulnerable population.

Significance

Individuals diagnosed with cancer may have employment disruptions; they may also develop FHs. People with cancer who have employment changes are more likely to also have FHs. Physicians and employers can help individuals with cancer through advancing planning, workplace assistance, and improved medical leave and insurance policies.

Healthcare affordability and effects on mortality among adults with liver disease from 2004 to 2018 in the United States

BACKGROUND & AIMS

Liver disease is associated with substantial morbidity and mortality, likely incurring financial distress (i.e. healthcare affordability and accessibility issues), although long-term national-level data are limited.

METHODS

Using the National Health Interview Survey from 2004 to 2018, we categorised adults based on report of liver disease and other chronic conditions linked to mortality data from the National Death Index. We estimated age-adjusted proportions of adults reporting healthcare affordability and accessibility issues. Multivariable logistic regression and Cox regression were used to assess the association of liver disease with financial distress and financial distress with all-cause mortality, respectively.

RESULTS

Among adults with liver disease (n = 19,407) vs. those without liver disease (n = 996,352), those with cancer history (n = 37,225), those with emphysema (n = 7,937), and those with coronary artery disease (n = 21,510), the age-adjusted proportion reporting healthcare affordability issues for medical services was 29.9% (95% CI 29.7-30.1%) vs. 18.1% (95% CI 18.0-18.3%), 26.5% (95% CI 26.3-26.7%), 42.2% (95% CI 42.1-42.4%), and 31.6% (31.5-31.8%), respectively, and for medications: 15.5% (95% CI 15.4-15.6%) vs. 8.2% (95% CI 8.1-8.3%), 14.8% (95% CI 14.7-14.9%), 26.1% (95% CI 26.0-26.2%), and 20.6% (95% CI 20.5-20.7%), respectively. In multivariable analysis, liver disease (vs. without liver disease, vs. cancer history, vs. emphysema, and vs. coronary artery disease) was associated with inability to afford medical services (adjusted odds ratio [aOR] 1.84, 95% CI 1.77-1.92; aOR 1.32, 95% CI 1.25-1.40; aOR 0.91, 95% CI 0.84-0.98; and aOR 1.11, 95% CI 1.04-1.19, respectively) and medications (aOR 1.92, 95% CI 1.82-2.03; aOR 1.24, 95% CI 1.14-1.33; aOR 0.81, 95% CI 0.74-0.90; and aOR 0.94, 95% CI 0.86-1.02, respectively), delays in medical care (aOR 1.77, 95% CI 1.69-1.87; aOR 1.14, 95% CI 1.06-1.22; aOR 0.88, 95% CI 0.79-0.97; and aOR 1.05, 95% CI 0.97-1.14, respectively), and not receiving the needed medical care (aOR 1.86, 95% CI 1.76-1.96; aOR 1.16, 95% CI 1.07-1.26; aOR 0.89, 95% CI 0.80-0.99; aOR 1.06, 95% CI 0.96-1.16, respectively). In multivariable analysis, among adults with liver disease, financial distress (vs. without financial distress) was associated with increased all-cause mortality (aHR 1.24, 95% CI 1.01-1.53).

CONCLUSIONS

Adults with liver disease face greater financial distress than adults without liver disease and adults with cancer history. Financial distress is associated with increased risk of all-cause mortality among adults with liver disease. Interventions to improve healthcare affordability should be prioritised in this population.

IMPACT AND IMPLICATIONS

Adults with liver disease use many medical services, but long-term national studies regarding the financial repercussions and the effects on mortality for such patients are lacking. This study shows that adults with liver disease are more likely to face issues affording medical services and prescription medication, experience delays in medical care, and needing but not obtaining medical care owing to cost, compared with adults without liver disease, adults with cancer history, are equally likely as adults with coronary artery disease, and less likely than adults with emphysema-patients with liver disease who face these issues are at increased risk of death. This study provides the impetus for medical providers and policymakers to prioritise interventions to improve healthcare affordability for adults with liver disease.

Pilot study of a Spanish language measure of financial toxicity in underserved Hispanic cancer patients with low English proficiency

Background

Financial toxicity (FT) reflects multi-dimensional personal economic hardships borne by cancer patients. It is unknown whether measures of FT-to date derived largely from English-speakers-adequately capture economic experiences and financial hardships of medically underserved low English proficiency US Hispanic cancer patients. We piloted a Spanish language FT instrument in this population.

Methods

We piloted a Spanish version of the Economic Strain and Resilience in Cancer (ENRICh) FT measure using qualitative cognitive interviews and surveys in un-/under-insured or medically underserved, low English proficiency, Spanish-speaking Hispanics (UN-Spanish, n = 23) receiving ambulatory oncology care at a public healthcare safety net hospital in the Houston metropolitan area. Exploratory analyses compared ENRICh FT scores amongst the UN-Spanish group to: (1) un-/under-insured English-speaking Hispanics (UN-English, n = 23) from the same public facility and (2) insured English-speaking Hispanics (INS-English, n = 31) from an academic comprehensive cancer center. Multivariable logistic models compared the outcome of severe FT (score > 6).

Results

UN-Spanish Hispanic participants reported high acceptability of the instrument (only 0% responded that the instrument was "very difficult to answer" and 4% that it was "very difficult to understand the questions"; 8% responded that it was "very difficult to remember resources used" and 8% that it was "very difficult to remember the burdens experienced"; and 4% responded that it was "very uncomfortable to respond"). Internal consistency of the FT measure was high (Cronbach's α = 0.906). In qualitative responses, UN-Spanish Hispanics frequently identified a total lack of credit, savings, or income and food insecurity as aspects contributing to FT. UN-Spanish and UN-English Hispanic patients were younger, had lower education and income, resided in socioeconomically deprived neighborhoods and had more advanced cancer vs. INS-English Hispanics. There was a higher likelihood of severe FT in UN-Spanish (OR = 2.73, 95% CI 0.77-9.70; p = 0.12) and UN-English (OR = 4.13, 95% CI 1.13-15.12; p = 0.03) vs. INS-English Hispanics. A higher likelihood of severely depleted FT coping resources occurred in UN-Spanish (OR = 4.00, 95% CI 1.07-14.92; p = 0.04) and UN-English (OR = 5.73, 95% CI 1.49-22.1; p = 0.01) vs. INS-English. The likelihood of FT did not differ between UN-Spanish and UN-English in both models (p = 0.59 and p = 0.62 respectively).

Conclusion

In medically underserved, uninsured Hispanic patients with cancer, comprehensive Spanish-language FT assessment in low English proficiency participants was feasible, acceptable, and internally consistent. Future studies employing tailored FT assessment and intervention should encompass the key privations and hardships in this population.

Career disruption and limitation of financial earnings due to cancer

PURPOSE

This study investigated how cancer diagnosis and treatment lead to career disruption and, consequently, loss of income and depletion of savings.

DESIGN

This study followed a qualitative descriptive design that allowed us to understand the characteristics and trends of the participants.

METHOD

Patients recruited (n = 20) for this study were part of the University of Kansas Cancer Center patient advocacy research group (Patient and Investigator Voices Organizing Together). The inclusion criteria were that participants must be cancer survivors or co-survivors, be aged 18 years or older, be either employed or a student at the time of cancer diagnosis, have completed their cancer treatment, and be in remission. The responses were transcribed and coded inductively to identify themes. A thematic network was constructed based on those themes, allowing us to explore and describe the intricacies of the various themes and their impacts.

RESULTS

Most patients had to quit their jobs or take extended absences from work to handle treatment challenges. Patients employed by the same employer for longer durations had the most flexibility to balance their time between cancer treatment and work. Essential, actionable items suggested by the cancer survivors included disseminating information about coping with financial burdens and ensuring that a nurse and financial navigator were assigned to every cancer patient.

CONCLUSIONS

Career disruption is common among cancer patients, and the financial burden due to their career trajectory is irreparable. The financial burden is more prominent in younger cancer patients and creates a cascading effect that financially affects close family members.

Financial toxicity in patients with leukemia undergoing hematopoietic stem cell transplantation: A systematic review

Financial toxicity (FT) is a term used to describe the objective financial burden of cancer care including the associated coping behaviors used by patients and their caregivers. FT has been shown to result in both direct financial burdens and in clinically relevant outcomes, such as non-adherence with care, diminished quality of life, and even decreased overall survival. Much of the data has been described in solid tumors, with limited investigations in the malignant hematology population. Patients with hematologic malignancies undergoing hematopoietic stem cell transplantation (HSCT) face a unique financial burden driven by lengthy hospitalizations and acute and chronic morbidity that have downstream implications on their income and costs. In this review, we discuss the prevalence of FT in patients with leukemia who are eligible for HSCT. We review the impact of FT on financial and clinical outcomes and the role of various interventions that have been studied within this population.

Financial toxicity assessment and associated factors analysis of patients with cancer in China

PURPOSE

Cancer-related expenditures present a lasting economic burden on patients and their families and may exert long-term adverse effects on the patients' life and quality of life. In this study, the comprehensive score for financial toxicity (COST) was used to investigate the financial toxicity (FT) levels and related risk factors in Chinese patients with cancer.

METHODS

Quantitative data were collected through a questionnaire covering three aspects: sociodemographic information, economic and behavioral cost-coping strategies, and the COST scale. Univariate and multivariate analyses were performed to identify factors associated with FT.

RESULTS

According to 594 completed questionnaires, the COST score ranged 0-41, with a median of 18 (mean±SD, 17.98±7.978). Over 80% of patients with cancer reported at least moderate FT (COST score <26). A multivariate model showed that urban residents, coverage by other health insurance policies, and higher household income and consumption expenditures were significantly associated with higher COST scores, indicative of lower FT. The middle-aged (45-59 years old), higher out-of-pocket (OOP) medication expenditures and hospitalizations, borrowed money, and forgone treatment were all significantly associated with lower COST scores, indicating higher FT.

CONCLUSION

Severe FT was associated with sociodemographic factors among Chinese patients with cancer, family financial factors, and economic and behavioral cost-coping strategies. Government should identify and manage the patients with high-risk characteristics of FT and work out better health policies for them.

Perceived Appropriateness of Assessing for Health-related Socioeconomic Risks Among Adult Patients with Cancer

Cancer treatment can trigger or exacerbate health-related socioeconomic risks (HRSR; food/housing insecurity, transportation/utilities difficulties, and interpersonal violence). The American Cancer Society and National Cancer Institute recommend HRSR screening and referral, but little research has examined the perceptions of patients with cancer on the appropriateness of HRSR screening in healthcare settings. We examined whether HRSR status, desire for assistance with HRSRs, and sociodemographic and health care-related factors were associated with perceived appropriateness of HRSR screening in health care settings and comfort with HRSR documentation in electronic health records (EHR). A convenience sample of adult patients with cancer at two outpatient clinics completed self-administered surveys. We used χ 2 and Fisher exact tests to test for significant associations. The sample included 154 patients (72% female, 90% ages 45 years or older). Thirty-six percent reported ≥1 HRSRs and 27% desired assistance with HRSRs. Overall, 80% thought it was appropriate to assess for HRSRs in health care settings. The distributions of HRSR status and sociodemographic characteristics were similar among people who perceived screening to be appropriate and those who did not. Participants who perceived screening as appropriate were three times as likely to report prior experience with HRSR screening (31% vs. 10%, P = 0.01). Moreover, 60% felt comfortable having HRSRs documented in the EHR. Comfort with EHR documentation of HRSRs was significantly higher among patients desiring assistance with HRSRs (78%) compared with those who did not (53%, P < 0.01). While initiatives for HRSR screening are likely to be seen by patients with cancer as appropriate, concerns may remain over electronic documentation of HRSRs.

Significance

National organizations recommend addressing HRSRs such as food/housing insecurity, transportation/utilities difficulties, and interpersonal violence among patients with cancer. In our study, most patients with cancer perceived screening for HRSRs in clinical settings as appropriate. Meanwhile, concerns may remain over the documentation of HRSRs in EHRs.

Impact of facilitating continued accessibility to cancer care during COVID-19 lockdown on perceived wellbeing of cancer patients at a rural cancer center in Rwanda

During the COVID-19 pandemic in Rwanda, Partners In Health Inshuti Mu Buzima collaborated with the Butaro Cancer Center of Excellence (BCCOE) to mitigate disruptions to cancer care by providing patients with free transportation to treatment sites and medication delivery at patients' local health facilities. We assessed the relationship between facilitated access to care and self-reported wellbeing outcomes. This cross-sectional telephone survey included cancer patients enrolled at BCCOE in March 2020. We used linear regression to compare six dimensions of quality of life (EORTC QLQ-C30), depression (PHQ-9), anxiety (GAD-7), and financial toxicity (COST) among patients who did and did not receive facilitated access to care. We also assessed access to cancer care and whether patient wellbeing and its association with facilitated access to care differed by socioeconomic status. Of 214 respondents, 34.6% received facilitated access to care. Facilitated patients were more likely to have breast cancer and be on chemotherapy. Facilitation was significantly associated with more frequent in-person clinical encounters, improved perceived quality of cancer care, and reduced transportation-related barriers. Facilitated patients had significantly better global health status (β = 9.14, 95% CI: 2.3, 16.0, p <0.01) and less financial toxicity (β = 2.62, 95% CI: 0.2,5.0, p = 0.03). However, over half of patients reported missing or delaying appointment. Patient wellbeing was low overall and differed by patient socioeconomic status, with poor patients consistently showing worse outcomes. Socioeconomic status did not modify the association between facilitated access to care and wellbeing indicators. Further, facilitation did not lead to equitable wellbeing outcomes between richer and poorer patients. Facilitated access to care during COVID-19 pandemic was associated with some improvements in access to cancer care and patient wellbeing. However, cancer patients still experienced substantial disruptions to care and reported low overall levels of wellbeing, with socioeconomic disparities persisting despite facilitated access to care. Implementing more robust, equity-minded facilitation and better patient outreach programs during health emergencies may promote better care and strengthen patient care overall and effect better patients' outcomes.

Medicare Part D Coverage Restrictions and Patient Cost-Sharing for Opioids Commonly Used for Cancer Pain, 2015-2021

PURPOSE

Nation-wide rapid declines in prescription opioid dispensing gave rise to concerns regarding restricted access to effective pain management for patients with cancer-related pain. One important mechanism for such restrictions could be through more restrictive insurance coverage for opioids. This study aims to assess recent changes in Medicare Part D formulary designs for opioids commonly used for cancer-related pain.

METHODS

We used data from the 2015-2021 Medicare Prescription Drug Plan (PDP) Formulary Files to assess formulary changes for six opioid-dose combinations commonly used for cancer-related pain. We estimated % of PDPs adopting prior authorization, quantity limits (and limits adopted), and a higher cost-sharing tier for each opioid-dose combination. We further estimated median and mean out-of-pocket (OOP) costs across all PDPs for a 30-day supply of the drug. Trends in proportions were tested using the Cochrane-Armitage test; trends in continuous measures were tested using the Jonckheere-Terpstra test.

RESULTS

Proportion of PDPs adopting prior authorization increased from close to 0% to about 50% for two long-acting opioids (P < .001). Distribution of quantity limits across PDPs shifted over time to being more restrictive for all opioids considered (P < .001). For four of the six opioids, the proportion of PDPs adopting tier 3 or above increased from below or about 50% to well over 70% (P < .001). For the same four opioids, median OOP costs doubled to quadrupled (P < .001).

CONCLUSION

Medicare PDP coverage has become increasingly restrictive for opioids commonly used for cancer-related pain, with multifold increases in patient OOP costs over the past 7 years. These changes pose concerns for patients with cancer needing opioid therapies for pain control and call for strategies to effectively exempt cancer-related pain from insurance and pharmacy rules intended to apply to opioids for noncancer chronic pain.

Underutilization of Guideline-Recommended Mismatch Repair/Microsatellite Instability Biomarker Testing in Advanced Colorectal Cancer

BACKGROUND

In 2017, DNA mismatch repair/microsatellite instability (MMR/MSI) testing was nationally recommended for advanced colorectal cancers based on favorable immune checkpoint inhibitor responses among patients with MMR-deficient/MSI-high tumors.

METHODS

Patients ages ≥20-years-old presenting with stage IV colorectal adenocarcinoma from 2010 to 2017 were identified from the National Cancer Database. 2017 was the latest year with available testing utilization data. Patient, tumor, socioeconomic, and care setting characteristics were evaluated for association with upfront MMR/MSI testing in 2017 using multivariable logistic regression and average adjusted predicted probabilities (%AAP).

RESULTS

Among 72,830 stage IV colorectal cancers, upfront MMR/MSI testing levels increased from 16.4% in 2010 to 56.4% in 2017. For patients diagnosed in 2017 (i.e., following national recommendations, n = 10,022), testing levels were lower for older patients (Padj &lt; 0.001), and were independent of patients' race/ethnicity and insurance status. Patients from the poorest quartile of households received less testing [49.6%AAP, 99.9% confidence interval (CI) 45.5-53.7] than patients from the 3rd (56.9%AAP, 99.9% CI, 53.3-60.6; Padj &lt; 0.001) or 4th quartiles (57.6%AAP, 99.9% CI, 54.3-60.9; Padj &lt; 0.001). Although testing levels improved most at community programs, they remained lower in 2017 (46.6%AAP, 99.9% CI, 41.0-52.1) compared with academic/NCI-designated comprehensive cancer centers (62.8%AAP, 99.9% CI, 59.7-65.8; Padj &lt; 0.001).

CONCLUSIONS

Upfront MMR/MSI testing utilization for patients with advanced colorectal cancer has increased but there is still substantial need for optimization. Testing utilization disproportionately lagged for patients who were older, from the poorest quartile of households, or managed at community cancer programs.

IMPACT

Our findings indicate opportunities for improving rates of MMR/MSI testing and reporting, possibly through incorporation into quality control and accreditation metrics.

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.

Financial toxicity and its impact on health outcomes and caregiver burden among adult cancer survivors in the USA

Aim: To examine the association between cancer-related financial toxicity on cancer survivors' physical and mental health outcomes and caregiver burden. Materials & methods: 2016-2017 Medical Expenditure Panel Survey data were used to identify adult cancer survivors with cancer-related financial toxicity. Multivariable regression analyses were employed to examine the association between cancer-related financial toxicity and cancer survivors' self-reported physical and mental health outcomes and caregiver burden. Results: A total of 53.7% of adult cancer survivors reported experiencing financial toxicity. Those who experienced financial toxicity reported 14% greater pain, and poorer physical and mental health outcomes as compared to those who did not experience financial toxicity, ranging from 38% greater odds for activity limitations to 427% greater odds for mental task limitation. Moreover, cancer survivors with financial toxicity reported 206% greater odds for caregiver burden. Conclusions: Intervention programs for reducing financial toxicity among adult cancer survivors and their caregivers should be developed.

Nonelderly Adult Cancer Survivors in High Deductible Health Plan: Healthcare Expenditure, Utilization and Access

Background: To compare healthcare expenditure, utilization and access between nonelderly adult cancer survivors enrolled in a high deductible health plan with a health savings account ("HDHP+HSA"), HDHP without HSA ("HDHP alone") and low deductible health plan ("LDHP"). Methods: 1735 cancer survivors, aged 18-64 years, with continuous private coverage identified from the 2012-2017 Medical Expenditure Panel Survey: HDHP alone (n = 353), HDHP+HSA (n = 242) and LDHP (n = 1140). Healthcare expenditures, utilization and inability/delay obtaining medical care were analyzed using generalized linear regressions with inverse propensity score weighting and doubly robust estimation. Results: HDHP alone group (23,255 USD) had significantly higher total healthcare expenditure compared to HDHP+HSA (15,580 USD, p = 0.012) and LDHP (16,261 USD, p = 0.016). HDHP alone (6089 USD; p = 0.002) and HDHP+HSA (5743 USD; p = 0.012) groups had significantly higher out-of-pocket (OOP) expenditure compared to LDHP (4853 USD). HDHP alone (17,128 USD, p = 0.010) and LDHP (12,645 USD, p = 0.045) had significantly higher private insurer payments compared to HDHP+HSA (9216 USD). No differences were found in utilization or inability/delay obtaining medical care across groups. Conclusions: Non-elderly adult cancer survivors with continuous coverage and comparable sociodemographic characteristics enrolled in HDHP with HSA displayed the lowest healthcare costs compared to HDHP without HSA and LDHP. HDHP+HSA had a significantly higher OOP expenditure than LDHP. No significant differences were observed in utilization or access among groups.

Financial toxicity, mental health, and gynecologic cancer treatment: The effect of the COVID-19 pandemic among low-income women in New York City

BACKGROUND

New York City (NYC) emerged as an epicenter of the COVID-19 pandemic, and marginalized populations were affected at disproportionate rates. The authors sought to determine the impact of COVID-19 on cancer treatment, anxiety, and financial distress among low-income patients with gynecologic cancer during the peak of the NYC pandemic.

METHODS

Medicaid-insured women who were receiving gynecologic oncology care at 2 affiliated centers were contacted by telephone interviews between March 15 and April 15, 2020. Demographics and clinical characteristics were obtained through self-report and retrospective chart review. Financial toxicity, anxiety, and cancer worry were assessed using modified, validated surveys.

RESULTS

In total, 100 patients completed the telephone interview. The median age was 60 years (range, 19-86 years), and 71% had an annual income <$40,000. A change in employment status and early stage cancer (stage I and II) were associated with an increase in financial distress (P < .001 and P = .008, respectively). Early stage cancer and telehealth participation were significantly associated with increased worry about future finances (P = .017 and P = .04, respectively). Lower annual income (<$40,000) was associated with increased cancer worry and anxiety compared with higher annual income (>$40,000; P = .036 and P = .017, respectively). When controlling for telehealth participation, income, primary language, and residence in a high COVID-19 prevalence area, a delay in medical care resulted in a 4-fold increased rate of anxiety (P = .023, 95% CI, 1.278-14.50). Race was not significantly associated with increased financial distress, cancer worry, or anxiety.

CONCLUSIONS

Low socioeconomic status was the most common risk factor for increased financial distress, cancer worry, and anxiety. Interventions aimed at improving access to timely oncology care should be implemented during this ongoing pandemic.

Affordable Care Act and Cancer Survivors' Financial Barriers to Care: Analysis of the National Health Interview Survey, 2009-2018

PURPOSE

Since Affordable Care Act (ACA) implementation in 2014, studies have demonstrated gains in insurance coverage for cancer survivors < 65 years. We assessed the impact of ACA implementation on financial barriers to care by stratifying survivors at age 65 years, when individuals typically become Medicare-eligible.

METHODS

We used data from respondents with cancer in the 2009-2018 National Health Interview Survey. We identified 21,954 respondents representing approximately 7.4 million survivors, who were then age-stratified at age 65 years. Survey responses regarding financial barriers to medical care and medications were analyzed, and age-stratified multivariable logistic regression modeling was performed, which evaluated the impact of ACA implementation on these measures, adjusted for demographic and socioeconomic variables.

RESULTS

After multivariable logistic regression, ACA implementation was associated with higher adjusted odds of Medicaid insurance (odds ratio [95% CI] 2.02 [1.72 to 2.36]; P < .0001) and lower adjusted odds of no insurance (0.57 [0.48 to 0.68]; P < .0001). Regarding financial barriers, ACA implementation was associated with lower adjusted odds of inability to afford medications (0.68 [0.59 to 0.79]; P < .0001), inability to afford dental care (0.83 [0.73 to 0.94]; P = .004), and delaying care (0.78 [0.69 to 0.89]; P = .002) in the 18-64 years group. Similarly, ACA implementation was associated with lower adjusted odds of secondary outcomes such as delaying refills, skipping doses, and anxiety over medical bills. Similar associations were not seen in the > 65 years group.

CONCLUSION

Survivor-reported measures of financial barriers in cancer survivors age 18-64 years significantly improved following ACA implementation. Similar changes were not seen in the Medicare-eligible cohort, likely because of high Medicare enrollment and few uninsured.

Relationship Between Financial Toxicity and Surgical Treatment for Early-Stage Breast Cancer: A Propensity Score-Matched Comparison of Breast-Conserving Therapy and Mastectomy

BACKGROUND

Financial toxicity (FT) can lead to decreased quality of life and poor treatment outcomes. However, there is limited published data on the extent to which the various surgical treatment approaches for early-stage breast cancer are determinants for FT.

STUDY DESIGN

We performed a single-institution cross-sectional survey of adult female patients with stage 0 to II breast cancer undergoing unilateral breast-conserving therapy or unilateral mastectomy. FT was measured using the Comprehensive Score for Financial Toxicity (COST) survey. Propensity matching was performed to optimize comparability of study groups. A multivariate regression model was used to identify factors associated with worsening FT as a robustness check. Our secondary end point was prevalence of coping strategies associated with cost of cancer care.

RESULTS

Among 294 patients who met inclusion criteria, 203 underwent breast-conserving therapy and 91 received mastectomy. We generated 72 total matched pairs and noted no differences in demographic and socioeconomic characteristics. Of these, 55 pairs had complete COST information, which was comparable on adjusted analysis (26.6 vs 24.7; p = 0.481). High annual income (β = 4.83; p < 0.001) and supplemental insurance (β = 5.37; p < 0.001) were significantly associated with higher COST scores, while change in employment status (β = -4.81; p < 0.001) correlated significantly with lower COST scores. No significant differences were observed in coping strategies.

CONCLUSIONS

Choice of BCT or mastectomy was not associated with a differential risk for FT in early-stage cancer. Decisions on ablative approach should be made based on patient preferences and disease-specific criteria. Transparent counseling on FT for high-risk populations promotes patient-centricity.

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.

Burden of Treatment among Elderly Patients with Cancer: A Scoping Review

Background: The objective of this scoping review is to understand how treatment burden is experienced in elderly patients with cancer and what the most prevalent dimensions of treatment burden are among this population. According to one conceptual model, there are six dimensions of treatment burden, including financial, medication, administrative, time/travel, lifestyle, and healthcare. Methods: A scoping review methodology framework was used to collected data from EMBASE CINAHL (Cumulative Index to Nursing and Allied Health Literature), Medline/PubMed, Scopus, Web of Science, Embase, and Cochrane from 2000 to March 2020. Studies which focused on treatment burden among elderly patients with cancer (+65 years) were selected. Data were extracted using a standardized proforma. Results: The results identified 3319 total papers. Of these, 24 met the inclusion criteria and were included in the scoping review. A significant proportion of these studies was conducted in the United States (n = 10) using self-reported, cross-sectional data. Financial burden was the most prevalent dimension of treatment burden, with 11 studies focusing on the direct and indirect costs associated with cancer treatment. Other but less obvious aspects of treatment burden elderly patients experienced included the length of time taken to access and administer treatment and medication-related burdens. Conclusions: Emerging findings suggest that the financial aspects of cancer treatment are a significant burden for most elderly cancer patients. Personalized healthcare interventions targeting ways to reduce and screen for treatment burden, particularly those related to cost, are urgently needed.

Residential mobility among adult cancer survivors in the United States

BACKGROUND

While residential mobility affects people's health, the dynamic of neighborhood tenure and its associated factors among cancer patients and survivors have not been studied in detail. This cross-sectional study aimed to identify sociodemographic factors associated with neighborhood tenure and relocation after the first cancer diagnosis among U.S. adult cancer survivors and patients.

METHODS

Based on a nationally representative sample of non-institutionalized civilian adults (≥18 years, n = 185,637) from the 2013-2018 National Health Interview Survey, we compared neighborhood tenure between adults with and without a history of cancer, and identified factors associated with their neighborhood tenure and relocation after the first cancer diagnosis, using propensity score matching, and logistic regression models with survey design incorporated.

RESULTS

Among adults with cancer (9.0%), 39.6% had a neighborhood tenure ≤10 years (vs. 61.2% among those without cancer), and 25.6% (equivalent to 5.4 million) relocated after their first cancer diagnosis. The odds of having shorter neighborhood tenure was higher among the cancer group in the propensity-matched samples (odds ratio = 1.05; 95% CI: 1.05-1.06; n = 17,259). Among cancer survivors, the odds of neighborhood relocation were negatively associated with increasing age, perceived neighborhood social cohesion, having high school level education, and being married; while positively associated with having family income below the poverty threshold, being uninsured, and living in non-Northeast regions.

CONCLUSIONS

High residential mobility was found among a sizable proportion of adults with a history of cancer, and was associated with multiple socioeconomic factors. Incorporating and addressing modifiable risk factors associated with residential mobility among cancer patients and survivors may offer new intervention opportunities to improve cancer care delivery and reduce cancer disparities.

Health Insurance Coverage Disruptions and Access to Care and Affordability among Cancer Survivors in the United States

BACKGROUND

Lack of health insurance is associated with having problems with access to high-quality care. We estimated prevalence and evaluated associations of insurance coverage disruptions and access to health care and affordability among cancer survivors in the United States.

METHODS

Adult cancer survivors ages 18 to 64 years with current private or public health insurance were identified from the 2011 to 2018 National Health Interview Survey (n = 7,186). Health insurance coverage disruption was measured as self-reports of any time in the prior year without coverage. Outcomes included preventive services use, problems with care affordability, and cost-related medication nonadherence in the prior year. We used separate multivariable logistic models to evaluate associations between coverage disruptions and study outcomes by current insurance coverage.

RESULTS

Among currently insured survivors, 3.7% [95% confidence interval (95% CI), 3.0%-4.4%] with private, and 7.8% (95% CI, 6.5%-9.4%) with public insurance reported coverage disruptions in 2011 to 2018. We estimated that approximately 260,000 survivors ages 18 to 64 years had coverage disruptions in 2018. Among privately and publicly insured survivors, those with coverage disruptions were less likely to report all preventive services use (16.9% vs. 36.2%; 14.6% vs. 25.3%, respectively) and more likely to report any problems with care affordability (55.0% vs. 17.7%; 71.1% vs. 38.4%, respectively) and any cost-related medication nonadherence (39.4% vs. 10.1%; 36.5% vs. 16.3%, respectively) compared with those continuously insured (all P < 0.05).

CONCLUSIONS

Coverage disruptions in the prior year were associated with problems with health care access and affordability among currently insured survivors.

IMPACT

Reducing coverage disruptions may help improve access and affordability for survivors.

Prospective Survey of Financial Toxicity Measured by the Comprehensive Score for Financial Toxicity in Japanese Patients With Cancer

PURPOSE

We previously reported on the pilot study assessing the feasibility of using the Japanese translation of the Comprehensive Score for Financial Toxicity (COST) tool to measure financial toxicity (FT) among Japanese patients with cancer. In this study, we report the results of the prospective survey assessing FT in Japanese patients with cancer using the same tool.

PATIENTS AND METHODS

Eligible patients were receiving chemotherapy for a solid tumor for at least 2 months. In addition to the COST survey, socioeconomic characteristics were collected by using a questionnaire and medical records.

RESULTS

Of the 191 patients approached, 156 (82%) responded to the questionnaire. Primary tumor sites were colorectal (n = 77; 49%), gastric (n = 39; 25%), esophageal (n = 16; 10%), thyroid (n = 9; 6%), head and neck (n = 4; 3%), and other (n = 11; 7%). Median COST score was 21 (range, 0 to 41; mean ± standard deviation, 12.1 ± 8.45), with lower COST scores indicating more severe FT. On multivariable analyses using linear regression, older age (β, 0.15 per year; 95% CI, 0.02 to 0.28; P = .02) and higher household savings (β, 8.24 per ¥15 million; 95% CI, 4.06 to 12.42; P < .001) were positively associated with COST score; nonregular employment (β, -5.37; 95% CI, -10.16 to -0.57; P = .03), retirement because of cancer (β, -5.42; 95% CI, -8.62 to -1.37; P = .009), and use of strategies to cope with the cost of cancer care (β, -5.09; 95% CI, -7.87 to -2.30; P < .001) were negatively associated with COST score.

CONCLUSION

Using the Japanese version of the COST tool, we identified various factors associated with FT in Japanese patients with cancer. These findings will have important implications for cancer policy planning in Japan.

The Changing Health Insurance Coverage Landscape in the United States

Changes in the health insurance coverage landscape in the United States during the past decade have important implications for receipt and affordability of cancer care. In this paper, we summarize evidence for the association between health insurance coverage and cancer prevention and treatment. We then discuss ongoing changes in health care coverage, including implementation of provisions of the Affordable Care Act, increasing prevalence of high-deductible health insurance plans, and factors that affect health care delivery, with a focus on vertical integration of hospitals and providers. We summarize the evidence for the effects of the changes in health coverage on care and discuss areas for future research with the goal of informing efforts to improve cancer care delivery and outcomes in the United States.

Adherence to Multiple Treatment Recommendations in Adolescents and Young Adults with Cancer: A Mixed Methods, Multi-Informant Investigation

Purpose: This mixed methods study sought to assess adolescent and young adult (AYA) adherence to three cancer treatment recommendations (medications, diet, physical activity), and determine the individual, family, and health system factors associated with suboptimal adherence. Methods: In Stage 1, 72 AYA-caregiver dyads completed a validated adherence interview and surveys about individual and family functioning. Matched providers (n = 34 who reported on 61 AYAs) completed global adherence ratings through survey. In Stage 2, a subset (n = 31) completed qualitative interviews. Results: Medication adherence was higher (M = 94.8%) than diet (M = 73.9%) and physical activity (M = 55.4%), although ≥50% demonstrated "Imperfect Adherence" for each subtask. Univariately, AYAs who missed a medication had more depressive symptoms, worse health-related quality of life (HRQOL), and more medication barriers; their families had more financial stress, worse family functioning, and lower self-efficacy. The odds of adhering to medications were lower with worse HRQOL (odds ratio [OR] = 1.08; 95% confidence interval [CI], 1.02-1.15) and family functioning (OR = 0.18; 95% CI, 0.04-0.91). The odds of adhering to physical activity and diet were lower with worse family functioning (OR = 0.09; 95% CI, 0.01-0.91) and more barriers (OR = 0.24, CI: 0.10-0.61), respectively. Qualitative themes further supported multilevel influences on AYA adherence. Conclusions: Adherence challenges were identified across medications, diet, and physical activity. Multilevel contextual factors were associated with suboptimal adherence, including poorer HRQOL and family functioning. Findings support the need to improve clinical adherence assessment and develop contextually tailored interventions.

Financial Toxicity and Cancer Therapy: A Primer for Radiation Oncologists

The diagnosis and treatment of cancer places patients at risk for serious financial consequences, which are detrimental to overall health and well-being. The concept of financial toxicity (FT) describes monetary and health implications related to the financial burden of receiving care. To investigate this important area, the authors first explore aspects of the modern American health care insurance system that relate to cancer care. Then they summarize relevant literature across multiple domains of FT that include monetary, functional, and patient-reported measures. The authors conclude by making simple recommendations to begin addressing FT in clinical practice.

High-Deductible Health Plans and Cancer Survivorship: What Is the Association With Access to Care and Hospital Emergency Department Use?

PURPOSE:

To examine the associations among high-deductible health plan (HDHP) enrollment, cancer survivorship, and access to care and utilization.

MATERIALS AND METHODS:

The 2010 to 2017 National Health Interview Survey was used to identify privately insured adults ages 18 to 64 years (cancer survivors, n = 4,321; individuals without a cancer history, n = 95,316). We used multivariable logistic regressions to evaluate the associations among HDHP/health savings account (HSA) status, delayed/forgone care for financial reasons, and hospital emergency department (ED) visits among cancer survivors compared with individuals without a cancer history.

RESULTS:

Among cancer survivors, HDHPs with or without HSA (8.9% and 13.9%, respectively; both P < .05) were associated with more delayed/forgone care compared with low-deductible health plans (LDHPs) (7.9%). HSA enrollment was associated with less delayed/forgone care among HDHP cancer survivors ( P < .05). ED visits were similar by insurance type. Among individuals without a cancer history, HDHP with or without HSA (9.5% and 10.8%, respectively; both P < .05) were both associated with more delayed/forgone care compared with LDHPs (5.9%). HSA enrollment also was associated with less delayed/forgone care among HDHP enrollees without a cancer history. A small difference in ED visits was observed between HDHPs without HSA (15.3%) and LDHPs (14.1%; P < .05) or HDHPs with HSA (13.4%; P < .05) among individuals without a cancer history.

CONCLUSION:

HDHP enrollment and HSA status affect access to care and hospital ED visits similarly by cancer history. HDHP enrollment may serve as a barrier to access to care among cancer survivors, although HSA enrollment coupled with an HDHP may mitigate the impact on access. HDHPs and HSA status were not associated with ED visits among cancer survivors. Improvement to care coordination efforts may be needed to reduce ED visits among privately insured cancer survivors.

Mediation analyses of socioeconomic factors determining racial differences in the treatment of diffuse large B-cell lymphoma in a cohort of older adults

Despite near universal health coverage under Medicare, racial disparities persist in the treatment of diffuse large B-cell lymphoma (DLBCL) among older patients in the United States. Studies evaluating DLBCL outcomes often treat socioeconomic status (SES) measures as confounders, potentially introducing biases when SES factors are mediators of disparities in cancer treatment.To examine differences in DLBCL treatment, we performed causal mediation analyses of SES measures, including: metropolitan statistical area (MSA) of residence; census-tract poverty level; and private Medicare supplementation using the Surveillance, Epidemiology and End Results-Medicare linked database between 2001 and 2011. In this retrospective cohort study of DLBCL patients ages 66+ years, we conducted a series of multivariable logistic regression analyses estimating odds ratios (OR) and 95% confidence intervals (CI) relating chemo- and/or immuno-therapy treatment and each SES measure, comparing non-Hispanic (NH)-black, Hispanic/Latino, and Asian/Pacific Islander (API) to NH-white patients.Compared to NH-white patients, racial/ethnic minority patients had lower odds of receiving chemo- and/or immuno-therapy treatment (NH-black: OR 0.84, 95% CI 0.65, 1.08; API: OR 0.80, 95% CI 0.64, 1.01; Hispanic/Latino: OR 0.78, 95% CI 0.64, 0.96) and higher odds of lacking private Medicare supplementation and residence within an urban MSA and poor census tracts. Adjustment for SES measures as confounders nullified observed racial differences. In causal mediation analyses, between 31% and 38% of race/ethnicity differences were mediated by having private Medicare supplementation.Providing equitable access to Medicare supplementation may reduce disparities in receipt of chemo- and/or immuno-therapy treatment in older DLBCL patients.

Patterns in Health Care Access and Affordability Among Cancer Survivors During Implementation of the Affordable Care Act

Importance

Cancer survivors face ongoing health issues and need access to affordable health care, yet studies examining health care access and affordability in this population are lacking.

Objectives

To evaluate health care access and affordability in a national sample of cancer survivors compared with adults without cancer and to evaluate temporal trends during implementation of the Affordable Care Act.

Design, Setting, and Participants

We used data from the National Health Interview Survey from 2010 through 2016 to conduct a population-based study of 30 364 participants aged 18 years or older. We grouped participants as cancer survivors (n = 15 182) and those with no reported history of cancer, whom we refer to as control respondents (n = 15 182), matched on age. We excluded individuals reporting a cancer diagnosis prior to age 18 years and those with nonmelanoma skin cancers.

Main Outcomes and Measures

We compared issues with health care access (eg, delayed or forgone care) and affordability (eg, unable to afford medications or health care services) between cancer survivors and control respondents. We also explored trends over time in the proportion of cancer survivors reporting these difficulties.

Results

Of the 30 364 participants, 18 356 (57.4%) were women. The mean (SD) age was 63.5 (23.5) years. Cancer survivors were more likely to be insured (14 412 [94.8%] vs 13 978 [92.2%], P < .001) and to have government-sponsored insurance (7266 [44.3%] vs 6513 [38.8%], P < .001) compared with control respondents. In multivariable models, cancer survivors were more likely than control respondents to report delayed care (odds ratio [OR], 1.38; 95% CI, 1.16-1.63), forgone medical care (OR, 1.76; 95% CI, 1.45-2.12), and/or inability to afford medications (OR, 1.77; 95% CI, 1.46-2.14) and health care services (OR, 1.46; 95% CI, 1.27-1.68) (P < .001 for all). From 2010 to 2016, the proportion of survivors reporting delayed medical care decreased each year (B = 0.47; P = .047), and the proportion of those needing and not getting medical care also decreased each year (B = 0.35; P = .04). In addition, the proportion of cancer survivors who reported being unable to afford prescription medication decreased each year (B=0.66; P = .004) and the proportion of those unable to afford at least 1 of 6 services decreased each year (B = 0.51; P = .01).

Conclusions and Relevance

Despite higher rates of insurance coverage, cancer survivors reported greater difficulties accessing and affording health care compared with adults without cancer. Importantly, the proportion of survivors reporting these issues continued a downward trend throughout our observation period in the years following the implementation of the Affordable Care Act. Our findings suggest incremental improvement in health care access and affordability after recent health care reform and provide an important benchmark as additional changes are likely to occur in the coming years.

Evaluation of a Novel Financial Navigator Pilot to Address Patient Concerns about Medical Care Costs

CONTEXT

Interventions are required that address patients' medically related financial needs.

OBJECTIVE

To evaluate a Financial Navigator pilot addressing patients' concerns/needs regarding medical care costs in an integrated health care system.

METHODS

Adults (aged ≥ 18 years) enrolled at Kaiser Permanente Northwest, who had a concern/need about medical care costs and received care in 1 of 3 clinical departments at the intervention or comparison clinic were recruited between August 1, 2016, and October 31, 2016. Baseline and 30-day follow-up participant surveys were administered to assess medical and nonmedical socioeconomic needs, satisfaction with medical care, and satisfaction with assistance with cost concerns. Physicians at both clinics were invited to complete a survey on medical care costs. We assessed participant characteristics and survey responses using descriptive statistics and 30-day change in satisfaction measures using multivariable linear regression models.

RESULTS

Eighty-five intervention and 51 comparison participants completed the baseline survey. At baseline, intervention participants reported transportation (52.9%), housing (38.2%), and social isolation (32.4%) needs; comparison participants identified employment (33.3%), food (33.3%), and housing (33.3%) needs. Intervention participants reported higher satisfaction with care (p = 0.01) and higher satisfaction with cost concerns assistance (p = 0.01) vs comparison participants at 30-day follow-up, controlling for baseline responses. Although most physicians (80%) reported discussing medical care costs with their patients, only 18% reported knowing about their patients' financial well-being.

CONCLUSION

We demonstrated the promise of a novel Financial Navigator pilot intervention to address medical care cost concerns and needs, and underscored the prevalence of nonmedical social needs in an economically vulnerable population.

Personalizing Value in Cancer Care: The Case for Incorporating Patient Preferences Into Routine Clinical Decision Making

Despite growing research demonstrating the potential for shared decision making (SDM) to improve health outcomes, patient preferences—including financial trade-offs—are still not routinely incorporated into health care decision making. As the US health care delivery system transitions to rewarding value-based care, the question of “value to whom?” assumes greater importance. To achieve the goals of value-based care, the patient voice must be incorporated into clinical decision making by embedding SDM as a routine part of clinical practice. Identified as a priority by the Centers for Medicare & Medicaid Services (CMS), SDM-related measures and initiatives have already been integrated into CMS’ Center for Medicare and Medicaid Innovation (Innovation Center) demonstration projects (eg, the Oncology Care Model and Transforming Clinical Practice Initiative) and value-based payment programs (eg, the Merit-based Incentive Payment System, Medicare Shared Savings Program) to incentivize more proactive SDM engagement between patients and their providers. Furthermore, CMS has also integrated formal shared decision-making encounters into coverage and reimbursement policies (eg, for implantable cardioverter defibrillators), demonstrating a growing interest in SDM and its potential for eliciting and promoting the integration of patient preferences into the clinical decision-making process. In addition to increasing policy efforts to promote SDM, we need more research investments aimed at understanding how to optimize the science and practice of meaningful SDM. The current landscape and proposed road map for next steps in research, outlined in this review article, will help ensure the transition of pilots and research projects regarding the implementation of SDM into sustainable solutions.

Cancer History, Health Insurance Coverage, and Cost-Related Medication Nonadherence and Medication Cost-Coping Strategies in the United States

OBJECTIVES

To evaluate the relationship between cancer history and cost-related medication nonadherence (CRN) as well as cost-coping strategies, by health insurance coverage.

METHODS

We used the 2013 to 2016 National Health Interview Survey to identify adults aged 18 to 64 years with (n = 3599) and without (n = 56 909) a cancer history. Cost-related changes in medication use included (1) CRN, measured as skipping, taking less, or delaying medication because of cost, and (2) cost-coping strategies, measured as requesting lower cost medication or using alternative therapies to save money. Separate multivariable logistic regressions were used to calculate the adjusted odds ratios (AORs) of CRN and cost-coping strategies associated with cancer history, stratified by insurance.

RESULTS

Cancer survivors were more likely than adults without a cancer history to report CRN (AOR 1.26; 95% confidence interval [CI] 1.10-1.43) and cost-coping strategies (AOR 1.10; 95% CI 0.99-1.19). Among the privately insured, the difference in CRN by cancer history was the greatest among those enrolled in high-deductible health plans (HDHPs) without health savings accounts (HSAs) (AOR 1.78; 95% CI 1.30-2.44). Among adults with HDHP and HSA, cancer survivors were less likely to report cost-coping strategies (AOR 0.62; 95% CI 0.42-0.90). Regardless of cancer history, CRN and cost-coping strategies were the highest for those uninsured, enrolled in HDHP without HSA, and without prescription drug coverage under their health plan (all P<.001).

CONCLUSIONS

Cancer survivors are prone to CRN and more likely to use cost-coping strategies. Expanding options for health insurance coverage, use of HSAs for those with HDHP, and enhanced prescription drug coverage may effectively address CRN.

Economic Burden Associated with Cancer Caregiving

OBJECTIVE

The societal value of unpaid caregiving is estimated to exceed $470 billion annually. In spite of the high value care they provide, caregivers experience significant financial burden. This paper examines the sources and impact of financial burden on cancer caregivers.

DATA SOURCES

Survey of the published peer-reviewed literature complemented by Web-based sources.

CONCLUSION

Caregivers for cancer patients may experience financial burden disproportionately relative to other caregivers because of the intensity of care they provide and the cost and complexity of cancer treatment. Financial burden stems from employment loss and cost of care and can continue long after the death of the patient. Few federal policy protections are available for caregivers.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses can play an important role in recognizing the needs of caregivers and act as navigators to connect caregivers to available resources.

Drug Recovery and Copay Assistance Program in a Community Cancer Center: Charity and Challenges

PURPOSE

The cost of cancer care is escalating dramatically, in part because of the rising expense of systemic cancer therapy. This creates financial dilemmas for patients and insurers and potential economic disruption for institutions attempting to provide cancer care to the underserved. Our institution initiated a drug recovery and copay assistance program (DRCAP) to mitigate the impact of the rising cost of parenteral medications.

METHODS

We performed a 3-year review of our strategies to mitigate financial burden of parenteral therapeutics and supportive care medicines. Financial metrics were established and analyzed before and after implementing DRCAP. Medication encounters and associated costs were stratified by adolescents and young adults (15 to 39 years of age), and adults 40 years of age and older and were annualized from 2016 to 2018.

RESULTS

The DRCAP resulted in a total of nearly $3.5 million worth of drugs replaced or copay assistance yearly in 2017 and 2018. This accounted for approximately 10% of our pharmacy budget for parenteral medications in each of these years. The vast majority was received in the form of drug replacement. The DRCAP resulted in assistance to 173 and 256 patients in 2017 and 2018, respectively.

CONCLUSION

A DRCAP increased availability of otherwise unaffordable parenteral oncolytics and resulted in cost savings for our institution. Adolescents and young adults were disproportionately represented because of inadequate or no insurance. Despite the salutary benefits, such programs likely inflate the overall cost of cancer care. Cancer care providers participating in a DRCAP will remain in this conundrum until market forces can affect the cost of oncology therapeutics.

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.

Race, financial hardship, and limiting care due to cost in a diverse cohort of cancer survivors

PURPOSE

Estimate prevalence of types of cancer-related financial hardship by race and test whether they are associated with limiting care due to cost.

METHODS

We used data from 994 participants (411 white, 583 African American) in a hospital-based cohort study of survivors diagnosed with breast, colorectal, lung, or prostate cancer since January 1, 2013. Financial hardship included decreased income, borrowing money, cancer-related debt, and accessing assets to pay for cancer care. Limiting care included skipping doses of prescribed medication, refusing treatment, or not seeing a doctor when needed due to cost. Logistic regression models controlled for sociodemographic factors.

RESULTS

More African American than white survivors reported financial hardship (50.3% vs. 41.0%, p = 0.005) and limiting care (20.0% vs. 14.2%, p = 0.019). More white than African American survivors reported utilizing assets (9.3% vs. 4.8%, p = 0.006), while more African American survivors reported cancer-related debt (30.5% vs. 18.5%, p < 0.001). Survivors who experienced financial hardship were 4.4 (95% CI: 2.9, 6.6) times as likely to limit care as those who did not. Borrowing money, cancer-related debt, and decreased income were each independently associated with limiting care, while accessing assets was not.

CONCLUSIONS

The prevalence of some forms of financial hardship differed by race, and these were differentially associated with limiting care due to cost.

IMPLICATIONS FOR CANCER SURVIVORS

The ability to use assets to pay for cancer care may protect survivors from limiting care due to cost. This has differential impacts on white and African American survivors.

Minimizing the burden of cancer in the United States: Goals for a high-performing health care system

Between 1991 and 2015, the cancer mortality rate declined dramatically in the United States, reflecting improvements in cancer prevention, screening, treatment, and survivorship care. However, cancer outcomes in the United States vary substantially between populations defined by race/ethnicity, socioeconomic status, health insurance coverage, and geographic area of residence. Many potentially preventable cancer deaths occur in individuals who did not receive effective cancer prevention, screening, treatment, or survivorship care. At the same time, cancer care spending is large and growing, straining national, state, health insurance plans, and family budgets. Indeed, one of the most pressing issues in American medicine is how to ensure that all populations, in every community, derive the benefit from scientific research that has already been completed. Addressing these questions from the perspective of health care delivery is necessary to accelerate the decline in cancer mortality that began in the early 1990s. This article, part of the Cancer Control Blueprint series, describes challenges with the provision of care across the cancer control continuum in the United States. It also identifies goals for a high-performing health system that could reduce disparities and the burden of cancer by promoting the adoption of healthy lifestyles; access to a regular source of primary care; timely access to evidence-based care; patient-centeredness, including effective patient-provider communication; enhanced coordination and communication between providers, including primary care and specialty care providers; and affordability for patients, payers, and society.

Cost-related Nonadherence to Medication Treatment Plans: Native Hawaiian and Pacific Islander National Health Interview Survey, 2014

BACKGROUND

Adherence to medication treatment plans is important for chronic disease (CD) management. Cost-related nonadherence (CRN) puts patients at risk for complications. Native Hawaiians and Pacific Islanders (NHPI) suffer from high rates of CD and socioeconomic disparities that could increase CRN behaviors.

OBJECTIVE

Examine factors related to CRN to medication treatment plans within an understudied population.

RESEARCH DESIGN

Using 2014 NHPI-National Health Interview Survey data, we examined CRN among a nationally representative sample of NHPI adults. Bonferroni-adjusted Wald test and multivariable logistic regression were performed to examine associations among financial burden-related factors, CD status, and CRN.

RESULTS

Across CD status, NHPI engaged in CRN behaviors had, on an average, increased levels of perceived financial stress, financial insecurity with health care, and food insecurity compared with adults in the total NHPI population. Regression analysis indicated perceived financial stress [adjusted odds ratio (AOR)=1.16; 95% confidence intervals (CI), 1.10-1.22], financial insecurity with health care (AOR=1.96; 95% CI, 1.32-2.90), and food insecurity (AOR=1.30; 95% CI, 1.06-1.61) all increase the odds of CRN among those with CD. We also found significant associations between perceived financial stress (AOR=1.15; 95% CI, 1.09-1.20), financial insecurity with health care (AOR=1.59; 95% CI, 1.19-2.12), and food insecurity (AOR=1.31; 95% CI, 1.04-1.65) and request for lower cost medication.

CONCLUSIONS

This study demonstrated health-related and non-health-related financial burdens can influence CRN behaviors. It is important for health care providers to collect and use data about the social determinants of health to better inform their conversations about medication adherence and prevent CRN.

Communicating the Financial Burden of Treatment With Patients

In recent years, high health care costs and the financial burden of cancer care have received increased attention. In response to the financial burden of cancer care, patients may jeopardize their health outcomes by not properly adhering to prescribed therapies or even forgoing and delaying care in an effort to defray costs. In addition, the financial burden experienced by patients with cancer may negatively impact clinical outcomes, such as quality of life, physical and psychological symptoms, and potentially, even survival. Notably, in the current era of targeted treatment and immunotherapies for patients with cancer, the rising costs of cancer continue to remain at the forefront of patient concerns. Therefore, a critical need exists to determine how best to assist patients with the cost burden of cancer diagnosis and treatment.