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

Decision Regret in Patients with Appendiceal Cancer Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

BACKGROUND

Decision regret is an emerging patient reported outcome. The aim of this study was to assess the incidence of regret in patients with appendiceal cancer (AC) who underwent cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC).

PATIENTS AND METHODS

An anonymous survey was distributed to patients through the Appendix Cancer and Pseudomyxoma Peritonei (ACPMP) Research Foundation. The Decision Regret Scale (DRS) was employed, with DRS > 25 signifying regret. Patient demographics, tumor characteristics, postoperative outcomes, symptoms (FACT-C), and PROMIS-29 quality of life (QoL) scores were compared between patients who regretted or did not regret (NO-REG) the procedure.

RESULTS

A total of 122 patients were analyzed. The vast majority had no regret about undergoing CRS-HIPEC (85.2%); 18 patients expressed regret (14.8%). Patients with higher regret had: income ≤ $74,062 (72.2% vs 44.2% NO-REG; p = 0.028), major complications within 30 days of surgery (55.6% vs 15.4% NO-REG; p < 0.001), > 30 days hospital stay (38.9% vs 4.8% NO-REG; p < 0.001), a new ostomy (27.8% vs 7.7% NO-REG; p = 0.03), >1 CRS-HIPEC procedure (56.3% vs 12.6% NO-REG; p < 0.001). Patients with worse FACT-C scores had more regret (p < 0.001). PROMIS-29 QOL scores were universally worse in patients with regret. Multivariable analysis demonstrated > 30 days in the hospital, new ostomy and worse gastrointestinal symptom scores were significantly associated with regret.

CONCLUSIONS

The majority of patients with AC undergoing CRS-HIPEC do not regret undergoing the procedure. Lower income, postoperative complications, an ostomy, undergoing > 1 procedure, and with worse long-term gastrointestinal symptoms were associated with increased regret. Targeted perioperative psychological support and symptom management may assist to ameliorate regret.

Relationship between Cancer and Intention to Leave Work among Older Workers: A Cross-Sectional Internet-Based Study

Background and Objectives: Limited research has focused on the relationship between cancer, job loss, and factors associated with job loss among older workers. Therefore, in this study, we aimed to examine the relationship between cancer and intention to leave and between physical-health-related issues, mental-health-related issues, and cancer-related symptoms and intention to leave among older workers with cancer. Materials and Methods: This cross-sectional internet-based study included 4498 workers aged 60-75 years. Intention to leave was assessed based on whether individuals considered quitting their current jobs in the near future. Results: A multivariate logistic regression analysis showed a significant association between cancer and intention to leave (adjusted odds ratio [aOR]: 1.42, 95% confidence interval [CI]: 1.01-2.00, p = 0.045). In addition, physical-health-related issues (aOR: 2.33, 95% CI: 1.10-4.92, p = 0.026) and mental-health-related issues (aOR: 4.44, 95% CI: 1.80-10.98, p = 0.001) were significantly associated with the intention to leave. Conclusions: Healthcare providers and employers must address the physical- and mental-health-related issues facing older workers with cancer to help them secure their employment.

Financial Distress in Testicular Cancer Survivors and Its Impact on Cancer Survivors' Quality of Life in the German Healthcare System

INTRODUCTION

Testicular cancer accounts for the largest proportion of solid tumors in young adult men. With an average age of onset under 40 years and a relative 5-year survival of 97%, it is one of the prognostically favorable tumors. Little is known about the relationship between the financial burden and physical and emotional health of testicular cancer survivors. We examined the association between financial problems caused by cancer and the self-reported quality of life in a cohort-based sample of testicular cancer patients.

METHODS

A cross-sectional analysis of testicular cancer patients (n = 87, average age 39 years) was performed. Self-reported data were collected on demographics, income, wealth, cost-coping strategies, out-of-pocket costs, supportive medication compliance, quality of life, and perceived social isolation. A multivariable regression model was used to examine the relationship between the degree to which cancer caused financial burdens and the patients' reported quality of life.

RESULTS

The survey showed that, in addition to illness-related additional expenses, a disease-related loss of income can lead to severe financial disadvantages and impair quality of life. The study data show that concerns about the economic situation can increase the burden on patients which already results from cancer diagnosis and therapy. In this patient cohort, 32% reported financial stress.

CONCLUSION

Financial distress affects testicular cancer survivors in unique ways. To provide support, health professionals should consider survivors' developmental life stage to understand their financial stress, and ultimately, to improve quality of life.

Experienced financial toxicity among long-term cancer survivors: results from a national cross-sectional survey

PURPOSE

Financial toxicity, the subjective distress caused by objective financial burden, significantly impacts cancer survivors. Yet, enduring effects on survivors remain unclear. Therefore, we investigated the experienced objective financial burden and subjective financial distress in long-term cancer survivors.

METHODS

A cross-sectional nationwide online survey of adult cancer survivors ≥ 5y after diagnosis were analyzed. Objective financial burden was measured via extra expenses and income loss, while subjective financial distress covered psychological well-being, coping and support-seeking behavior, and financial concerns. Groups were compared (i.e., having cancer vs. former patients) by t-tests and chi-squared tests. Financial toxicity was visualized with Sankey plots and sunburst diagrams.

RESULTS

4,675 respondents completed the survey, of whom 2,391 (51%) were ≥ 5y after their cancer diagnosis. Among them, 75% experienced income loss and/or extra expenses after diagnosis. One-third of the previously employed respondents relied on work disability benefits. Further, 'being unable to make ends meet' increased from 2% before diagnosis to 13% ≥ 5y after diagnosis (p < .001). Additionally, 58% reported negative psychological impacts of financial toxicity, and 47% worried about their financial future.

CONCLUSIONS

Cancer survivors often face income loss and additional expenses, leading to ongoing financial difficulties that affect their psychological well-being. Despite this significant impact, there is a lack of guidance and support to help them manage these financial challenges. These findings highlight the need for healthcare professionals to recognize and address the financial challenges.

IMPLICATIONS FOR CANCER SURVIVORS

This study underscores the widespread financial challenges cancer survivors encounter, emphasizing the need for ongoing financial support and comprehensive assessments of their physical and psychological well-being.

Screening for Financial Toxicity Among Patients With Cancer: A Systematic Review

OBJECTIVE

Despite the pervasiveness and adverse impacts of financial toxicity (FT) in cancer care, there are no definitive measures for FT screening that have been widely integrated into clinical practice. The aim of this review is to evaluate current methods of assessing FT among patients with cancer and confirm factors associated with higher risk of FT.

METHODS

A systematic review was performed according to PRISMA guidelines. We included peer-reviewed studies that cross-sectionally, longitudinally, or prospectively measured the self-reported financial impact of patients undergoing cancer care in the United States.

RESULTS

Out of 1,085 identified studies, 51 met final inclusion criteria. Outcomes evaluated included FT measures or tools, time and setting of screening, FT prevalence, and sociodemographic or clinical patient-level associated factors. Our findings demonstrate that there is wide variability in FT screening practices including in the timing (diagnosis versus treatment versus survivorship), setting (clinic-based, online, telephone or mail), tools used (21 unique tools, 7 previously validated), and interpretations of screening results (varying FT score cutoffs defining high versus low FT). Younger age, lower income, lower education, non-White race, employment status change, advanced cancer stage, and systemic or radiation therapy were among factors associated with worse FT across the studies.

DISCUSSION

FT screening remains heterogenous within the United States. With the ever-escalating cost of cancer care, and the strong association between FT and poor patient outcomes, universal and routine FT screening is imperative in cancer care. Further research and multifaceted interventions identifying best practices for FT screening are needed.

Earnings and work loss after colon and rectal cancer: a Swedish nationwide matched cohort study

Background

Colorectal cancer is common and prognosis is improving. The conditions of survivors of treatment, including financial consequences, are thus important. The aim of this study was to quantify loss of earnings and work loss in working-age patients with colon and rectal cancer relative to matched comparators.

Methods

The study utilised data from the CRCBaSe database that is generated from the nationwide Swedish ColoRectal Cancer Register and includes data from several Swedish nationwide registers. The study period was 1995-2020 for rectal cancer patients and 2007-2020 for colon cancer patients. A retrospective population-based nationwide cohort study on earnings, disposable income, and work loss, in survivors of stage I-III colorectal cancer treatment was undertaken. Median regression was used to analyse earnings and disposable income, and logistic regression to analyse the probability of work loss.

Findings

A cohort of 8863 colorectal cancer survivors diagnosed before 2017 and 52,514 comparators matched on birth year, legal sex, and county of residence, was analysed. There was a clear reduction in earnings between the calendar year prior to and the calendar year after diagnosis, from € 31,319 to € 23,924 for colon cancer patients and from € 32,636 to € 22,647 for rectal cancer patients, and earnings never fully recovered during the 5-year follow-up. Disposable income was practically unaltered. The probability of work loss increased in the calendar year of diagnosis, from 29.8% to 25.3% the previous year to 83.3% and 84.4% for colon and rectal cancer patients respectively, and never fully recovered. The probability of work loss was similar between colon and rectal cancer survivors, but was higher among patients with rectal cancer who had received neoadjuvant therapy.

Interpretation

This study shows that despite an extensive welfare system providing maintained disposable income, there is a financial burden in the form of increased risk of work loss and a reduction in earnings among survivors of colorectal cancer.

Funding

The study was supported by the Swedish Cancer Society, the Swedish Cancer and Allergy Foundation, and the Stockholm Cancer Society, and supported by grants provided by the Regional Agreement on Medical Training and Clinical Research (ALF) between the Stockholm County Council and Karolinska Institutet.

Influence of age on financial toxicity in cancer patients

Objective

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

Methods

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

Results

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

Conclusions

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

Changes in income and employment after diagnosis among patients with multiple myeloma in The Netherlands

OBJECTIVE

Due to new treatment options, survival rates in multiple myeloma (MM) are improving. Consequently, maintaining work and income is becoming more important for patients and society. Therefore, we aimed to explore the change in income and employment in patients with MM.

METHODS

Data from the Netherlands Cancer Registry of MM patients diagnosed between 2012 and 2017 were merged with socioeconomic data from Statistics Netherlands. Descriptive statistics were used to analyse total income, income from employment, and accumulated income before and after diagnosis.

RESULTS

Income from employment decreased by 45% in MM patients, between 1 year before and 4 years after diagnosis Four years after diagnosis, 35% of the patients were still employed, with an accumulated 5-year productivity loss of €121 million. Higher income loss from employment and job loss was observed in female patients, patients with more extensive disease, or those not treated with autologous stem cell transplant.

CONCLUSION

Loss of (income from) employment among patients with MM was high, causing financial burden on the patient and society. With improving survival in MM, more research and awareness are needed to better assess the importance of income and work for MM patients and society.

Identifying the factors affecting financial toxicity status in patients with middle and advanced colorectal cancer: a cross-sectional study

Background

Colorectal cancer (CRC) ranks as the second most prevalent type of cancer in China. The financial implications of treatment are a significant factor to be taken into account for patients diagnosed with middle and advanced stages of colorectal cancer (III-IV CRC). The research aims to explore current financial toxicity (FT) conditions and analyze factors that may influence it in patients with middle and advanced CRC.

Method

This is a cross-sectional survey. The participants of the study were individuals diagnosed with middle and advanced colorectal cancer who were admitted to the hospital between January and June 2023. The cross-sectional survey utilized a variety of instruments, including a general information questionnaire, a cancer patient report outcome economic toxicity scale, a medical coping style questionnaire, an Anderson symptom assessment scale, a disease shame scale, and a social support scale. Multiple linear regression analysis was employed to examine the factors influencing FT.

Result

A cohort of 264 patients diagnosed with stage III-IV CRC were included in the study. The majority of patients with intermediate and advanced CRC (87.1%, n = 230) reported experiencing substantial financial strain. Multivariate analysis revealed that factors influencing FT included low family monthly income, out-of-pocket expenses, unemployment, undergoing surgical treatment, the level of stigma, and the severity of symptoms (P < 0.001).

Conclusion

Patients with stage III-IV cancer (CRC) demonstrate increased levels of financial toxicity (FT), a common occurrence in individuals with moderate to severe CRC. In patients with stage III-IV CRC, the presence of FT is correlated with various factors including family monthly income, medical payment methods, work status, surgical treatment, stigma levels, and symptom severity. These characteristics may serve as influencing factors for subsequent treatment decisions.

The Impact of Racial Disparities and the Social Determinants of Health on Esophageal and Gastric Cancer Outcomes

Reducing long-standing inequities in gastric and esophageal cancers is a priority of patients, providers, and policy makers. Many social determinants of health influence risk factors for disease development, incidence, treatment, and outcomes of gastric and esophageal cancers.

Financial Toxicity in Cancer Supportive Care: An International Survey

PURPOSE

The study aims to explore unmet social needs and sources of financial toxicities in patients as noted by health care professionals and researchers in cancer supportive care, shedding light on potential health disparities.

METHODS

In this cross-sectional survey, we anonymously surveyed active members of the Multinational Association of Supportive Care in Cancer (MASCC). The survey, structured in three sections, included questions regarding the routine assessment of social needs during patient consultations, sociodemographic aspects, factors influencing financial toxicity (FT), perceived support for managing FT, and available/desirable resources.

RESULTS

A total of 218 MASCC members were included, predominantly from high-income countries (HIC, 73.4%), with many age 41-60 years (56.5%) and female (56.9%). Drug/treatment cost and insurance coverage were the main sources for FT among the HIC, whereas participants from low-middle-income countries (LMIC) considered transportation cost, loss of employment because of cancer diagnosis, and unavailability of return-to-work services as the top three sources of FT. Respondents from LMIC (adjusted odds ratio [aOR], 3.01 [95% CI, 1.15 to 7.93]) and physicians (aOR, 2.67 [95% CI, 1.15 to 6.21]) were more likely to routinely assess financial coverages. Socioeconomic status was consistently ranked as one of the top three sources of financial toxicities by participants from LMIC (34%), HIC excluding the United States (38%), those who do not self-identify as racial/ethnic minority (36%), and physicians (40%).

CONCLUSION

This global survey of health care professionals and researchers in HIC and LMIC revealed varying approaches to assessing financial coverage and social needs. Socioeconomic status emerged as a consistent concern across countries, affecting financial toxicities. The study highlights the need for tailored approaches and improved resource visibility while emphasizing clinicians' pivotal role in addressing financial aspects of cancer care.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

IMPLICATIONS FOR CANCER SURVIVORS

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

Financial toxicity and its risk factors among patients with cancer in China: A nationwide multisite study

Objective

We assessed financial toxicity (FT) among Chinese patients with cancer and investigated associated risk factors guided by a multilevel conceptual framework.

Methods

Applying multistage stratified sampling, we selected six tertiary and six secondary hospitals across three economically diverse provinces in China. From February to October 2022, 1208 patients with cancer participated. FT was measured using the COmprehensive Score for financial Toxicity (COST), with 28 potential risk factors identified at multilevel. Multiple regression analysis was used for risk factor identification.

Results

FT prevalence was 82.6% (95% confidence interval [CI]: 80.5%, 84.8%), with high FT (COST score ≤ 18.5) observed in 40.9% of participants (95% CI: 38.1%, 43.7%). Significant risk factors included younger age at cancer diagnosis, unmarried status, low annual household income, negative impact of cancer on participants' or family caregiver's work, advanced cancer stage, longer hospital stay for cancer treatment or treatment-related side effects, high perceived stress, poor emotional/informational support, lack of social medical insurance or having urban and rural resident basic medical insurance, lack of commercial medical insurance, tertiary hospital treatment, and inadequate cost discussions with healthcare providers (all P < 0.05).

Conclusions

Cancer-related FT is prevalent in China, contributing to disparities in cancer care access and health-related outcomes. The risk factors associated with cancer-related FT encompasses multilevel, including patient/family, provider/practice, and payer/policy levels. There is an urgent need for collective efforts by patients, healthcare providers, policymakers, and insurers to safeguard the financial security and well-being of individuals affected by cancer, promoting health equities in the realm of cancer care.

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

BACKGROUND

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

METHODS

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

RESULTS AND DISCUSSION

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

Impact of Lung Cancer on Health-Related Quality of Life, Financial Toxicity, and Household Economics in Patients From the Public and the Private Healthcare Sector in Argentina

OBJECTIVES

Non-small cell lung cancer (NSCLC) is Argentina's first cause of cancer death. Most patients have an advanced stage at diagnosis, with poor expected survival. This study aimed to characterize the health-related quality of life (HRQOL) and economic impact of patients treated in the private healthcare sector and compare it with that of the public sector.

METHODS

We undertook an observational cross-sectional study that extended a previous study to a referral private center in Argentina. Outcomes included the EuroQol EQ-5D-3L (to assess HRQOL), Comprehensive Score for Financial Toxicity (financial toxicity instrument), Work Productivity and Activity Impairment - General Health (to assess productivity loss), and out-of-pocket expenses in adults diagnosed of NSCLC.

RESULTS

We included 30 consecutive patients from a private healthcare center (July 2021 to March 2022), totaling 131 patients (n = 101 from previous public study). The whole sample had low quality of life and relevant economic impact. Patients in the private healthcare sector showed lower disease severity and higher educational level and household income. In addition, private healthcare system patients showed higher utility (0.77 vs 0.73; P < .05) and lower impairment of daily activities (41% vs 59%; P = .01). Private health system patients also showed lower financial toxicity as measured by the Comprehensive Score for Financial Toxicity score (23.9 vs 20.14; P < .05) but showed no differences when financial toxicity was assessed as a dichotomic variable.

CONCLUSIONS

Although patients with NSCLC treated in a private healthcare center in Argentina showed a relevant HRQOL and economic impact, this impact was smaller than the one observed in publicly funded hospitals.

Association of food insecurity with overall and disease-specific mortality among cancer survivors in the US

PURPOSE

To investigate the association of food insecurity with overall and disease-specific mortality among US cancer survivors.

METHODS

Data from the National Health and Nutrition Examination Survey (NHANES 1999-2018) were used to examine the impact of food insecurity on mortality risks among cancer survivors in the US. Study participants aged ≥ 20 years who had a history of cancer and completed the Adult Food Security Survey Module were included. Mortality data [all-cause, cancer, and cardiovascular (CVD) specific] through December 31, 2019 were obtained through linkage to the National Death Index. Using multivariable Cox proportional hazard regression, hazard ratios of mortality based on food security status were estimated.

RESULTS

Among 5032 cancer survivors (mean age 62.5 years; 58.0% women; 86.2% non-Hispanic White), 596 (8.8%) reported food insecurity. Overall, 1913 deaths occurred (609 cancer deaths and 420 CVD deaths) during the median follow-up of 6.8 years. After adjusting for age, food insecurity was associated with a higher risk of overall (HR = 1.93; 95% CI = 1.56-2.39), CVD-specific (HR = 1.95; 95% CI = 1.24-3.05), and cancer-specific (HR = 1.70; 95% CI = 1.20-2.42) mortality (P < 0.001). However, after adjusting for socioeconomic characteristics and health-related factors (physical activity, diet quality measured by healthy eating index), the association between food insecurity and overall mortality was no longer statistically significant.

CONCLUSIONS

Food insecurity was associated with a greater risk of overall mortality among cancer survivors. Further studies are needed to confirm these findings and evaluate whether the observed association represents a causal phenomenon and, if so, whether the effect is modifiable with food assistance programs.

Employment status in cancer patients the first five years after diagnosis-a register-based study

PURPOSE

Work is important for identity formation, social status, and economic independency. Although some evidence within the field of work and cancer survivorship exists, no study has so far investigated employment status across all cancer diagnoses. Thus, the aim of the present study was to investigate the impact of all cancer diagnoses on employment status.

METHODS

Danish cancer patients aged 20-60 years, diagnosed between 2000 and 2015, were identified through Danish registers and matched 1:5 with cancer-free controls. Logistic and linear regression was performed separately in 11 cancer types to assess and compare work status and work participation between cancer patients and cancer-free controls one, three, and five years after diagnosis.

RESULTS

A total of 111,770 cancer patients and 507,003 cancer-free controls were included. All cancer types had lower chances of working one year after diagnosis (ORs between 0.05 and 0.76), with lung, colorectal, upper gastrointestinal, and blood cancer patients having the lowest chances. After three years, 10 of 11 cancer types had lower chances (ORs between 0.39 and 0.84). After five years, there were minimal differences between cancer patients and controls among most cancer types (ORs between 0.75 and 1.36).

CONCLUSION

Most cancer patients had lower chances of working compared with the general population until five years after diagnosis. However, patients with certain cancer types experienced lower chances of working all years, despite improvement over time.

IMPLICATIONS FOR CANCER SURVIVORS

The knowledge will help increase awareness on challenges regarding work-life after cancer. Furthermore, the distinguishing between diagnoses can inform to more targeted vocational rehabilitation.

The socioeconomic impact of cancer on patients and their relatives: Organisation of European Cancer Institutes task force consensus recommendations on conceptual framework, taxonomy, and research directions

Loss of income and out-of-pocket expenditures are important causes of financial hardship in many patients with cancer, even in high-income countries. The far-reaching consequences extend beyond the patients themselves to their relatives, including caregivers and dependents. European research to date has been limited and is hampered by the absence of a coherent theoretical framework and by heterogeneous methods and terminology. To address these shortages, a task force initiated by the Organisation of European Cancer Institutes (OECI) produced 25 recommendations, including a comprehensive definition of socioeconomic impact from the perspective of patients and their relatives, a conceptual framework, and a consistent taxonomy linked to the framework. The OECI task force consensus statement highlights directions for future research with a view towards policy relevance. Beyond descriptive studies into the dimension of the problem, individual severity and predictors of vulnerability should be explored. It is anticipated that the consensus recommendations will facilitate and enhance future research efforts into the socioeconomic impact of cancer and cancer care, providing a crucial reference point for the development and validation of patient-reported outcome instruments aimed at measuring its broader effects.

High Financial Hardship among Patients with Advanced Ovarian Cancer

Ovarian cancer is considered the most fatal and costly gynecologic cancer. Although personalized therapies have improved ovarian cancer prognosis, they have resulted in increased financial toxicity concerns among this population. This study evaluated financial toxicity in patients with advanced ovarian cancer. Using secondary data from a study of barriers to palliative care, financial toxicity (FT) was measured through the Comprehensive Score for Financial Toxicity scale. Univariate and bivariate analyses were used to assess the relationship between selected demographic (i.e., age, race, ethnicity, education, place of birth, insurance type, yearly household income, employment status) and treatment-specific variables (i.e., years since diagnosis, surgery, chemotherapy, radiation, hormonal and targeted therapy) with clinically relevant financial toxicity. Characteristics were compared using Fisher's exact or chi squared tests. A total of 38 participants with advanced ovarian cancer were included in this study; 24% (n = 9) reported clinically significant FT. Income (p = .001), place of birth (p = .048) and employment status (p = .001) were related to FT. Study findings highlight that advanced ovarian cancer patients experience high FT, particularly those with low income, who are not able to work and were born outside the US. Further research using larger datasets and more representative samples is needed to inform intervention development and implementation.

Employment-related Education and Support for Cancer Survivors: a Content Analysis of Employment Resources Offered on National Cancer Institute-Designated Cancer Center Websites

High rates of employment changes and associated concerns among cancer survivors following diagnosis and treatment suggest a need to examine what employment-related educational resources and support are currently being offered to cancer survivors and what gaps exist in those resources. In 2023, we conducted a content analysis of employment resources described on the websites of the NCI-Designated Cancer Centers that provide clinical care (N = 64) through a systematic review procedure using predetermined search terms and a standardized process to examine the availability and accessibility of such resources. Descriptive analyses were conducted to characterize the employment resources identified. In total, 175 employment resources were identified across 49 cancer center websites; 102 (58%) provided patient-facing education/information, 58 (33%) offered a consultation, 14 (8%) offered support groups/classes, and 1 (1%) was classified as "Other." Most (76%) resources were provided internally by the cancer center, and often, more than one discipline was involved, most commonly social work and medicine. These findings are encouraging as they suggest that most (77%) NCI-Designated Cancer Centers recognize employment support as a component of survivorship care. The multidisciplinary nature of the resources identified is supported by moderate evidence that multidisciplinary interventions appear to have the greatest potential to foster a return to work for cancer survivors and align with suggestions made by recent expert groups and guidelines regarding employment support for cancer survivors. Ongoing work is needed to assess the utilization, impact, and equity of available employment resources to optimize work outcomes among cancer survivors.

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.

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.

Much work to do about measuring work

Work ability is a critical economic and well-being indicator in cancer care. Yet, work ability is understudied in clinical trials and observational research and is often undocumented in medical records. Despite agreement on the importance of work from well-being, health insurance, and financial perspectives, standardized approaches for collecting, measuring, and analyzing work outcomes are lacking in the health-care setting. The necessary components for closing the gap in patient and caregiver employment research in health-care settings involve a common set of measures, including those that replace or translate generic measures of mental and physical functioning into work outcomes in observational and clinical trial research, standardized approaches to data collection and documentation, and the use of longitudinal data to understand the consequences of reduced work ability over time. We present a conceptual framework for the inclusion of work ability in outcomes research. We cover constructs for employment and work ability measurement that can be adopted in research, recorded as patient-level data, and used to guide treatment decisions. The inclusion of return to work and hours worked, productivity, and ability to perform in a similar job can support conversations that guide treatment decisions and minimize economic consequences. Our hope is that by considering impact on work ability, improved treatments will be developed, health inequities reduced, and resources directed toward aiding patients and their caregivers in balancing work and health demands.

Online description of services provided in adult survivorship programs across U.S. accredited cancer centers

PURPOSE

The American College of Surgeons Standard 4.8 requires an institution to implement a survivorship program to become a Commission on Cancer (CoC)-accredited cancer center. The online information offered by these cancer centers can help educate patients and their caregivers about available services. We assessed the content of survivorship program websites of CoC-accredited cancer centers in the United States.

METHODS

Of the 1245 CoC-accredited centers for adults, we sampled 325 institutions (26%) based proportionately on the 2019 new cancer cases by state. Website pages of the institutions' survivorship programs were assessed for information and services offered using the COC Standard 4.8. We included programs for adult survivors of adult- and childhood-onset cancers.

RESULTS

54.5% of the cancer centers did not have a survivorship program website. Of the 189 included programs, most were aimed at adult survivors in general, rather than those with specific cancer types. On average, five essential CoC-recommended services were described, most commonly nutrition, care plans, and psychology services. The least mentioned services were genetic counseling, fertility, and smoking cessation. Most programs described services offered to patients who had completed treatment, while 7.4% of described services for those with metastatic disease.

CONCLUSION

More than half of CoC-accredited programs did have information about cancer survivorship programs on their websites and when included, had variable and limited description of services.

IMPLICATIONS FOR CANCER SURVIVORS

Our study provides an overview of online cancer survivorship services and offers a methodology that may be used by cancer centers to review, expand, and improve the information described on their websites.

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

Background

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

Methods

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

Results

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

Conclusion

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

Effects of a Phone-Based Support Program for Women With Breast Cancer Undergoing Chemotherapy: A Pilot Study

Introduction

The increasing number of women with breast cancer undergoing chemotherapy may result in long-lasting, adverse physical side effects and reduced quality of life.

Objective

This study aimed to develop and assess the feasibility and preliminary effects of the Phone-Based Support Program for women with breast cancer undergoing chemotherapy. The primary outcome was self-care self-efficacy; secondary outcomes were symptom distress and quality of life.

Methods

This pilot study was conducted at a tertiary hospital in Jiangsu province, China, from February to March 2023. The Phone-Based Support Program was delivered to 20 participants through the smartphone application WeChat, consisting of learning, discussion, ask-the-expert, and personal stories components. Outcome measures were assessed at three time points: preintervention, postintervention, and follow-up.

Results

The Phone-Based Support Program was feasible and could improve self-care self-efficacy, decrease symptom distress, and promote quality of life. The program was well-accepted, and participants engaged actively in the online discussion and sought expert advice.

Conclusions

The Phone-Based Support Program showed feasibility and effectiveness in improving self-care self-efficacy, reducing symptom distress, and enhancing quality of life.

Cost in the United States of FDA-approved small molecule protein kinase inhibitors used in the treatment of neoplastic and non-neoplastic diseases

Because genetic alterations including mutations, overexpression, translocations, and dysregulation of protein kinases are involved in the pathogenesis of many illnesses, this enzyme family is the target of many drug discovery programs worldwide. The FDA has approved 80 small molecule protein kinase inhibitors with 77 drugs orally bioavailable. The data indicate that 69 of these medicinals are approved for the management of neoplasms including solid tumors such as breast and lung cancer as well as non-solid tumors such as leukemia. Moreover, the remaining 11 drugs target non-neoplastic diseases including psoriasis, rheumatoid arthritis, and ulcerative colitis. The cost of drugs was obtained from www.pharmacychecker.com using the FDA label to determine the dosage and number of tablets required per day. This methodology excludes any private or governmental insurance coverage, which would cover the entire cost or more likely a fraction of the stated price. The average monthly cost for the treatment of neoplastic diseases was $17,900 with a price of $44,000 for futibatinib (used to treat cholangiocarcinomas with FGFR2 fusions) and minimum of $5100 for binimetinib (melanoma). The average monthly cost for the treatment of non-neoplastic diseases was $6800 with a maximum of $17,000 for belumosudil (graft vs. host disease) and a minimum of $200 for netarsudil eye drops (glaucoma). There is a negative correlation of the cost of the drugs and the incidence of the targeted disease. Many of these agents are or were designated as orphan drugs meaning that there are fewer than 200,000 potential patients in the United States.

Financial Toxicity Experiences of Patients With Cancer in Indonesia: An Interpretive Phenomenological Analysis

OBJECTIVES

Financial toxicity (FT) is an important adverse effect of cancer. Recent systematic reviews have shown that FT may lead to treatment nonadherence and impaired health-related quality of life, both of which may adversely influence the survival rates of patients. However, less is known about how patients endure FT, particularly in low- and middle-income countries. The purpose of this study was to explore how patients with cancer experience and cope with FT in Indonesia.

METHODS

Semistructured in-depth interviews were conducted to explore the experiences of Indonesian patients with cancer. Qualitative data were analyzed using interpretive phenomenological analysis approach. We purposefully recruited 8 patients undergoing active treatment (aged 27-69 years) who had been diagnosed of cancer over 5 years before and possessed health insurance at the time of diagnosis.

RESULTS

We identified 2 main themes: (1) the experienced financial burden, with subthemes underinsurance, out-of-pocket nonhealthcare cancer-related costs, and negative income effect from employment disruption, and (2) the financial coping strategies, with subthemes reallocating household budget, seeking family support, rationalizing treatment decisions, and topping up insurance for family members.

CONCLUSIONS

This is the first interpretive phenomenological study on FT in the literature and the first qualitative FT study in Indonesia. Our findings provide insight into the occurrence of FT and coping strategies used by Indonesian patients with cancer. The subjective experiences of patients may be considered to further improve oncology care, support the need for measurement of FT, and provide mitigation programs for patients.

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

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

Multiple myeloma in people of working age in Czechia, Germany, and Poland: findings from a qualitative interview study

PURPOSE

The study sought to understand the experiences of working age adults with myeloma and their partner/family members, living in Czechia, Germany, and Poland.

METHODS

Qualitative interviews were conducted with 36 working age adults living with myeloma, and three family members. Data were collected from May to October 2022. Thematic analysis was applied to the data.

RESULTS

Healthcare and state support within each country are described. The degree of work engagement was informed by patients' symptom burden, treatment needs, state financial aid, and family/financial obligations. Many did not conceptualise their status as involving 'return to work' as they had continued to be engaged with their jobs throughout. For some, remote working enabled them to manage treatments/side-effects and their job, while avoiding infection. In some cases, patients did not tell their employer or colleagues about their illness, for fear of discrimination.

CONCLUSION

While experiences varied between countries, common across accounts was a struggle to balance ongoing treatments with employment, at a time when participants were expected to finance their own households and maintain their income and roles. Implications for Cancer Survivors To improve quality of life, clinical discussions around treatment decision-making should take into account patients' attitudes/approach to work, type of work engaged in, and other activities considered important to them. European Union and national cancer plans should set out optimum standards for employers, to ensure an equitable benchmark for how employees are supported. Such approaches would improve legal protections and better enforcement of employer policies to accommodate patients' limitations in the workplace.

Return to work after cancer-the impact of working conditions: A Norwegian Register-based Study

PURPOSE

The purpose of this study is to compare a cohort of cancer survivors with a cohort of cancer-free employees (1) with respect to employment prospects over a 15-year period and (2) with respect to the differential impact of working conditions on employment over this time period.

METHODS

The cancer cohort is retrieved from the Cancer Registry of Norway, while data on the non-cancer cohort are retrieved from register data managed by Statistics Norway. Job exposure matrices were used to remedy the lack of working-conditions information in the register data. We use nearest-neighbor matching to match the non-cancer cohort (the control group) to the cancer-survivor cohort (the treatment group). Cox regression analysis was applied to examine the relationships between working conditions, employment, and cancer. The results are reported separately for mechanical-job exposures and psychosocial exposures, as well as by gender.

RESULTS

Cancer survivors are more likely to experience reduced employment as compared to individuals without a history of cancer. Male cancer survivors in physically demanding occupations have an increased risk of reduced employment after being diagnosed with cancer. This does not apply to female cancer survivors. Regarding the impact of psychosocial exposures on employment, we find no differences over time between cancer survivors and the non-cancer population.

CONCLUSIONS

Male cancer survivors in physically demanding occupations have an increased risk of reduced employment after being diagnosed with cancer, whereas this is not the case for female cancer survivors. Psychosocial exposures do not impact the relative risk of reduced employment over time.

IMPLICATIONS FOR CANCER SURVIVORS

We suggest that return to work after cancer should be considered a process rather than only the re-entry step of resuming work. Thus, it is important to provide long-term support for cancer survivors. We recommend providing more attention to working conditions, particularly in occupations that involve a high level of mechanical-job exposures.

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.

Symptom Clusters in Survivorship and Their Impact on Ability to Work among Cancer Survivors

BACKGROUND

Cancer survivors often experience a range of symptoms after treatment which can impact their quality of life. Symptoms may cluster or co-occur. We aimed to investigate how symptoms and symptom clusters impact the ability to work among cancer survivors.

METHODS

We used symptom severity data and ability to work data routinely collected from cancer survivors attending a survivorship clinic after primary treatment with curative intent. We defined symptom clusters using single linkage and a threshold on the rescaled distances of <10. We then conducted a logistic regression to examine how symptoms and symptom clusters were related to the ability to work.

RESULTS

We analysed data from 561 cancer survivors, mean age 58 years and 1.5 years post diagnosis, with mixed diagnoses including breast (40.5%), colorectal (32.3%), and haematological cancers (15.3%). Limitations to work ability were reported by 34.9% of participants. Survivors experiencing pain, emotional, and cognitive symptom clusters were 14-17% more likely to report limitations in their ability to work. Older survivors and those with a higher stage disease were more likely to report limitations in their ability to work.

CONCLUSION

A better understanding and management of symptom severity and symptom clusters may help the sizable proportion of cancer survivors experiencing symptoms to participate in work after treatment.

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

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

Work-related experiences of prostate cancer survivors in Australia: a qualitative study

BACKGROUND

Prostate cancer (PCa) is the most diagnosed cancer in Australian men, and the number of survivors is growing with advances in diagnosis and treatment. Work participation following PCa diagnosis and treatment becomes a significant aspect of quality of life and survivorship. Using a qualitative phenomenological approach, we explored the work-related experiences of PCa survivors in Australia.

METHODS

Semi-structured telephone interviews were conducted with 16 men (6 salaried employees, 10 self-employed; 8 diagnosed ≥ 5 years) purposively sampled from a community setting. Interviews were inductively analysed.

RESULTS

Five main themes emerged: motivations to work; treatment decisions and work; the effects of PCa and its treatment on ability to participate in work; being an employee versus being self-employed; and personal agency. PCa and its treatment side-effects were detrimental to men's work capacity and ability, and could persist over an extended period. Most men expressed a strong desire to retain work or return to work. Discussions with healthcare professionals about work-related consequences were largely missing when treatment decisions were made. Self-employed men faced greater challenges than their salaried counterparts due to high financial burden and limited social and business support. Family, workplace and wider community support, and self-care, enhanced men's work participation experiences.

CONCLUSIONS

PCa and its treatment substantially and persistently impacted men's working lives, and their experiences were diverse and multifaceted. Self-employed and long-term PCa survivors face greater challenges and are at high risk of poor work outcomes. A systematic approach and involvement of stakeholders at all levels is required to support ongoing work participation.

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.

Impact of functional disability on health-care use and medical costs among cancer survivors

BACKGROUND

Cancer survivors with a disability are among the most vulnerable in health status and financial hardship, but no prior research has systematically examined how disability modifies health-care use and costs. This study examined the association between functional disability among cancer survivors and their health-care utilization and medical costs.

METHODS

We generated nationally representative estimates using the 2015-2019 Medical Expenditure Panel Survey. Outcomes included use of 6 service types (inpatient, outpatient, office-based physician, office-based nonphysician, emergency department, and prescription) and medical costs of aggregate services and by each of 6 service types. The primary independent variable was a categorical variable for the total number of functional disabilities. We employed multivariable generalized linear models and 2-part models, adjusting for sociodemographics and health conditions and accounting for survey design.

RESULTS

Among cancer survivors (n = 9359; weighted n = 21 046 285), 38.8% reported at least 1 disability. Compared with individuals without a disability, cancer survivors with 4 or more disabilities experienced longer hospital stays (adjusted average marginal effect = 1.14 days, 95% confidence interval [CI] = 0.55 to 1.73), more visits to an office-based physician (average marginal effect = 1.43 visits, 95% CI = 0.51 to 2.35), and a greater number of prescriptions (average marginal effect = 12.1 prescriptions, 95% CI = 9.27 to 15.0). Their total (average marginal effect = $9537, 95% CI = $5713 to $13 361) and out-of-pocket (average marginal effect = $639, 95% CI = $79 to $1199) medical costs for aggregate services were statistically significantly higher. By type, disability in independent living was most strongly associated with greater costs for aggregate services.

CONCLUSIONS

Cancer survivors with a disability experienced greater health-care use and higher costs. Cancer survivorship planning for health care and financial stability should consider the patients' disability profile.

Exploring the Use of a Digital Platform for Cancer Patients to Report Their Demographics, Disease and Therapy Characteristics, Age, and Educational Disparities: An Early-Stage Feasibility Study

INTRODUCTION

The increasing burden of cancer, the development of novel therapies, and the COVID-19 pandemic have made cancer care more complex. Digital innovation was then pushed toward developing platforms to facilitate access to cancer care. Age, education, and other disparities were, however, shown to limit the use of the digital health innovation. The aim of this early-stage feasibility study was to assess whether Greek cancer patients would register at CureCancer and self-report their demographics, disease and therapy characteristics, and socioeconomic issues. The study was organized by the Hellenic Society of Medical Oncology.

METHODS

Patients from nine cancer centers were invited to register on the CureCancer platform and complete an anonymous questionnaire on demographics, disease and therapy characteristics, and socioeconomic issues. Patients were also encouraged to upload, in a secure area for them, their medical files and share them with their physicians. They were then asked to comment on their experience of registration and how easy it was to upload their medical files.

RESULTS

Of the 159 patients enrolled, 144 (90.56%) registered, and 114 of those (79.16%) completed the questionnaire, suggesting that the study is feasible. Users' median age was 54.5 years, and 86.8% of them were university and high school graduates. Most patients (79.8%) reported their specific type of cancer diagnosis, and all reported their therapy characteristics. Breast and lung cancers were the most common. A total of 87 patients (76.3%) reported being on active cancer therapy, 46 (40.4%) had metastatic disease, and 51 (44.7%) received supportive care medications. Eighty-one (71.05%) patients received prior cancer therapies, and twenty-seven recalled prior supportive care medications. All patients reported visiting non-oncology Health Care Professionals during the study. Nineteen of 72 (26.39%) patients who worked prior to cancer diagnosis changed work status; 49 (42.98) patients had children under 24 years; and 16 (14%) patients lived alone. Nine (7.9%) patients were members of patient associations. Registration was "much/very much" easy for 98 (86.0%) patients, while 67 (58.8%) had difficulties uploading their files. Patients commented on the well-organized data access, improved communication, feeling safe, medication adherence, interventions from a distance, and saving time and money. Over 80% of patients "preferred the digital way".

DISCUSSION

A total of 114 patients succeeded in registering on the digital platform and reporting their demographics, disease and therapy characteristics, and socioeconomic issues. Age and educational disparities were disclosed and highlighted the need for educational programs to help older people and people of lower education use digital innovation. Health care policy measures would support patients' financial burden associated with work changes, living alone, and children under 24 years old at school or college. Policy actions would motivate patients to increase their participation in patient associations. According to the evidence DEFINED framework, the number of patients, and the focus on enrollment, engagement, and user experience, the study fulfills actionability level criterion 1.

Medical Financial Hardship and Food Security among Cancer Survivors in the United States

BACKGROUND

Some cancer survivors experience medical financial hardship, which may reduce their food security. The purpose of this study was to explore whether medical financial hardship is related to food security among cancer survivors.

METHODS

The study was based on cross-sectional data from the 2020 National Health Interview Survey. We used ordinal logistic regression to examine the relationship between material, psychological, and behavioral medical financial hardships and household food security (i.e., high, marginal, low, or very low) among individuals ages ≥18 years who reported a cancer diagnosis from a health professional (N = 4,130).

RESULTS

The majority of the sample reported high household food security (88.5%), with 4.8% reporting marginal, 3.6% reporting low, and 3.1% reporting very low household food security. In the adjusted model, the odds of being in a lower food security category were higher for cancer survivors who had problems paying or were unable to pay their medical bills compared with those who did not [OR, 1.73; 95% confidence interval (CI), 1.06-2.82, P = 0.027], who were very worried about paying their medical bills compared with those who were not at all worried (OR, 2.88; 95% CI, 1.64-5.07; P < 0.001), and who delayed medical care due to cost compared with those who did not (OR, 2.56; 95% CI, 1.29-5.09; P = 0.007).

CONCLUSIONS

Food insecurity is rare among cancer survivors. However, medical financial hardship is associated with an increased risk of lower household food security among cancer survivors.

IMPACT

A minority of cancer survivors experience medical financial hardship and food insecurity; social needs screenings should be conducted.

Trends in National Pharmaceutical Expenditure in Korea during 2011 - 2020

BACKGROUND

This study aimed to identify the trends in pharmaceutical expenditure (PE), share of PE in health expenditure (HE), and trends in expenditure by pharmacological groups (ATC level 1 classification) in Korea for a 10-year period (2011 - 2020) and compare the data with those of other Organisation for Economic Co-operation and Development (OECD) countries. Using the findings, we determined the current status of pharmaceutical expenditure (PE) management in Korea and derived the implications for establishing future macroscopic policies on PE.

MATERIALS AND METHODS

We analyzed the OECD Health Statistics and the Korean national health insurance claims database from January 2011 through December 2020. The outcome measures were HE, PE, and pharmaceutical sales data for ATC level 1 medicines from OECD Health Statistics data during 2011 - 2020. As OECD collects limited ATC level 1 data, we used the HIRA health insurance claims data for PEs of ATC level-1 classification, including D, L, P, and S.

RESULTS

PE in Korea increased by 38.5% from 19.9 billion USD in 2011 to 27.6 billion USD in 2020, whereas the share of PE in HE decreased by 6.3%p from 26.4% in 2011 to 20.1% in 2020. In 2020, Korea ranked third in PE per capita (760.9 USD PPP) and had the highest share of PE (20.1%) among the 19 OECD countries studied. By ATC level 1 class, the highest PE was A (alimentary tract and metabolism) at 4.3 billion USD, and L (antineoplastic and immunomodulating agents) had the highest increase at 13.4%; in contrast, J (anti-infectives for systemic use) had the lowest increase in annual average PE at -0.2% in 2020 relative to 2011. Among the 17 OECD countries, Korea had the highest and the third-highest expenditures for ATC codes A and J, respectively.

CONCLUSION

PE in Korea has continued to increase between 2011 and 2020, indicating the need for macroscopic management of PE. Our results on PE by ATC code may help health authorities in establishing future policies on PE.

The role of financial security in loneliness or sadness among Medicare-enrolled cancer survivors during the COVID-19 pandemic

INTRODUCTION

This study aims to estimate the relative decreased rate of financial security and increased rate of loneliness or sadness during the COVID-19 pandemic and investigate the association between financial security and loneliness or sadness among Medicare beneficiaries with a cancer history.

MATERIAL AND METHODS

We examined population-based, cross-sectional data from the Medicare Current Beneficiary Survey COVID-19 Winter 2021 survey. The study cohort included 1,632 Medicare beneficiaries (aged ≥65 years) with self-reported cancer history. The outcome was feelings of loneliness or sadness, and the independent variable was financial security during the 2020-2021 winter surge of COVID-19. We conducted weighted descriptive statistics, a cross-tabulation analysis, and multivariable logistic regression analyses.

RESULTS

Overall, 18.8% of cancer survivors reported increased feelings of loneliness or sadness and 11.2% reported decreased financial security during the 2020-2021 winter surge of COVID-19. Cancer survivors who reported decreased financial security had 93% higher odds of increased feelings of loneliness or sadness compared to those who reported feeling more or about the same financial security (Adjusted odds ratio [AOR] = 1.93; 95% Confidence Interval [CI] 1.25-3.01; p <0.004).

DISCUSSION

Decreased financial security and increased feelings of loneliness or sadness were prevalent among cancer survivors. Additional screenings and interventions beyond what are currently available are needed to ease the socioeconomic vulnerabilities experienced by cancer survivors.

The Dynamics of Financial Toxicity in Multiple Myeloma

INTRODUCTION/BACKGROUND

People with multiple myeloma are at risk for financial toxicity due to the high cost of treatment and prolonged treatment duration. However, little data exist regarding financial toxicity among people with myeloma.

PATIENTS AND METHODS

In this study, a cohort of 135 patients were recruited from an ongoing observational trial to complete the Comprehensive Score for financial Toxicity (COST). Participants were sent follow-up surveys at 3, 6, and 12 months.

RESULTS

The median age was 68 years; the majority were non-Hispanic whites (88%), male (63%), held a college degree (61%), and had left the workforce (70%). The median time from myeloma diagnosis was 28 months. The median COST score was 27; 48% of participants had a score below 27 and considered to have financial toxicity. The only characteristic associated with financial toxicity was a college degree. After controlling for other covariates, those with a college education were 69% less likely to have financial toxicity. Of the 108 participants who completed a follow-up survey, 34% reported changes in their financial toxicity status at a subsequent time point. Transitioning from not having financial toxicity to having financial toxicity was more common than the reverse.

CONCLUSION

Because financial toxicity is a dynamic process, which patients are experiencing it at any given time is difficult to predict. Focusing the research agenda on improved detection and intervention may be warranted.

Cancer survivorship experiences in Utah: an evaluation assessing indicators of survivors' quality of life, health behaviors, and access to health services

PURPOSE

The 2016-2020 Utah Comprehensive Cancer Prevention and Control Plan prioritized strategies to address cancer survivorship experiences. In this paper we present estimates for nine indicators evaluating these priorities, trends over time, and assess disparities in survivorship experiences across demographic subgroups.

METHODS

We surveyed a representative sample of Utah cancer survivors diagnosed between 2012 and 2019 with any reportable cancer diagnosis. We calculated weighted percentages and 95% confidence intervals (CI) for each indicator. We assessed change over time using a test for trend across survey years in a logistic regression model and used Rao-Scott F-adjusted chi-square tests to test the association between demographic characteristics and each survivorship indicator.

RESULTS

Most of the 1,793 respondents (93.5%) reported their pain was under control, 85.7% rated their overall health as good, very good, or excellent, but 46.5% experienced physical, mental, or emotional limitations. Only 1.7% of survivors aged 75 or older were current smokers, compared to 5.8% of 65-74-year-olds and 7.9% of survivors aged 55-74 (p < 0.006). No regular physical activity was reported by 20.6% and varied by survivor age and education level. The proportion who received a survivorship care plan increased from 34.6% in 2018 to 43.0% in 2021 (p = 0.025). However, survivors under age 55 were significantly less likely to receive a care plan than older survivors.

CONCLUSION

This representative survey of cancer survivors fills a gap in understanding of the cancer survivorship experience in Utah. Results can be used to evaluate and plan additional interventions to improve survivorship quality of life.

Financial toxicity among adolescent and young adult cancer survivors: A systematic review of educational attainment, employment, and income

PURPOSE

To identify, evaluate and summarize the evidence on educational attainment, employment status and income of AYAs surviving cancer.

METHODS

A search of six databases for articles published between 01/01/2010 and 03/31/2022 was performed. Articles with an AYA survivorship population, quantitative design and a cancer-free comparator group were included. Data extraction was conducted, and quality appraisal was completed using ROBINS-I. Results were summarized using a narrative synthesis.

RESULTS

A total of 2801 articles were identified, of which 12 were included. Among the limited evidence, educational attainment did not differ from cancer-free peers. Survivors were more likely to be unemployed, have lower incomes and require social security for income supplementation. Evidence suggested that females, diagnosis of brain cancer and the presence of late-effects were among the risk factors for severe outcomes.

CONCLUSIONS

Limited socioeconomic evidence exists for AYAs surviving cancer. Long-lasting financial toxicities occur and highlights a need for further investigation.

Financial toxicity: A practical review for gynecologic oncology teams to understand and address patient-level financial burdens

Financial toxicity describes the adverse impact patients experience from the monetary and time costs of cancer care. The financial burden patients experience comes from substantially increased out-of-pocket spending that often occurs concurrent with reduced income due to sick leave from work. Financial toxicity is common affecting approximately half of patients with a gynecological cancer depending on the validated instrument used for measurement. Financial toxicity is experienced by patients in three domains: economic hardship affecting patients' material conditions (i.e., medical debt), psychological response (i.e., distress), and health-related coping behaviors that patients adopt (i.e., foregoing care due to costs). Higher financial toxicity among cancer patients has been associated with decreased quality of life, impaired adherence to recommended care, and worse overall survival. In this review, we describe the current literature on financial toxicity, including how it can be assessed with validated tools, the downstream impact on patients, risk factors, and employment concerns of survivors. Whenever possible, we highlight data from research featuring patients with gynecologic cancer specifically. We also review studies with interventions aimed to mitigate financial toxicity and offer the reader real world examples of interventions currently being used. Lastly, we provide an overview of health policy developments relevant to financial toxicity and advocate for innovation in the development and implementation of strategies to decrease the financial toxicity patients experience following a diagnosis of gynecologic cancer.

Short-term effect of colorectal cancer on income: analysis of an Italian cohort

INTRODUCTION

The ability to return to work after a cancer diagnosis is a key aspect of cancer survivorship and quality of life. Studies have reported a significant risk of income loss for cancer survivors; however, there is limited evidence of the Italian context.

METHODS

The Work Histories Italian Panel (WHIP)-Salute database was used to select a cohort of incident cases of colorectal cancer (CRC) among workers in the private sector, based on hospital discharges. A propensity score matching was used to find a balanced control group for several confounders. Ordinary least square and logistic regressions were used to estimate the effect of a CRC diagnosis on annual income and the probability of switching from a full-time contract to a part-time one considering 3 years after the diagnosis.

RESULTS

Overall, we identified 925 CRC incident cases from 2006 until 2012. Our results confirm a statistically significant reduction in survivors' income compared with controls. This reduction was greater in the first year and then tend to decrease, with an average income loss over 3 years of about €12 000. Stratified analyses by sex and position confirmed the overall trend while indicating a strong effect modification. Regarding the switching from full-time to part-time employment, the results were never significant.

CONCLUSION

Income loss does not seem to be related to an increase in part-time contracts, but rather to survivors' reduced work capacity following the invasive treatments. Further research is needed to investigate the complex dynamics behind this association.

Breast cancer treatment planning using a novel spherical fuzzy CRITIC-REGIME

Breast cancer is the leading cause of cancer-related deaths, and choosing a suitable treatment plan for this disease has proved difficult for oncologists owing to the variety of criteria and alternatives that must be considered during the decision-making process. Since prospective treatment options influence patients’ health-related quality of life in a variety of ways, a methodology that can completely and objectively evaluate alternative treatments has become an essential issue. This paper proposes a novel multi-criteria decision-making (MCDM) methodology by integrating the CRiteria Importance Through Intercriteria Correlation (CRITIC) and the REGIME techniques and handles the problem of breast cancer treatment selection problem. CRITIC enables the determination of objective criterion weights based on the decision matrix, while REGIME ranks the options without the need for lengthy computations or normalization procedures. The suggested methodology is demonstrated in a spherical fuzzy atmosphere, which allows decision experts to independently express their degrees of membership, non-membership, and hesitancy in a broad three-dimensional spherical space. In the numerical example provided, three oncologists evaluate four breast cancer treatment alternatives, namely, surgery, radiotherapy, chemotherapy, and hormone therapy, with respect to five criteria, which are disease or tumor type, stage of disease, patient type, side effects, and financial status of the patient. The tumor type is determined to be the most important assessment criterion, and surgery is selected as the best course of action. The stability and validity of the proposed methodology are verified through sensitivity and comparative studies. The discussions, limitations, and future research avenues are also given within the study.

Associations of financial toxicity with symptoms and unplanned healthcare utilization among cancer patients taking oral chemotherapy at home: a prospective observational study

BACKGROUND

Cancer patients with financial toxicity experience psychological distress and often miss medical appointments and quit treatments early, which could be a barrier to the effective management of oral chemotherapy drugs at home. This study explores whether financial toxicity predicts symptoms and unplanned healthcare utilization among cancer patients taking oral chemotherapy at home, which will contribute to the safe management of oral chemotherapy.

METHODS

Data in this study was from a prospective observational study, which was conducted between October 2018 and December 2019. 151 patients completed the Comprehensive Score for Financial Toxicity at discharge and completed the MD Anderson Symptom Inventory and unplanned healthcare utilization questionnaires after finishing one cycle of oral chemotherapy at home. Regression analyses were conducted to explore the associations of financial toxicity with symptoms and unplanned healthcare utilization.

RESULTS

Among 151participants, 88.08% reported severe or moderate financial toxicity, 43.05% reported symptom interference, and 31.79% reported unplanned healthcare utilization while taking oral chemotherapy at home. Patients between the age of 45-60y (p = 0.042) have higher financial toxicity, while those living in urban areas (p = 0.016) have lower financial toxicity. Patients with worse financial toxicity suffered increased symptoms of fatigue, emotional distress, disturbed sleep, and lack of appetite. Consequently, their mood and personal relation with other significant suffered. However, no statistical differences in unplanned healthcare utilization were found among patients with different levels of financial toxicity.

CONCLUSION

Middle-aged adults and those living in suburban or rural areas experienced worse financial toxicity than other groups. Patients with worse financial toxicity experienced more severe psychological symptoms (e.g., fatigue, distress, disturbed sleep, and lack of appetite) and affective interference (e.g., mood and relations with others). Identifying at-risk patients is necessary to offer tailored support for psychological symptom management.

Financial toxicity of patients with lung cancer in China: Results from a National Survey Study

OBJECTIVE

To develop a comprehensive understanding of financial toxicity (FT) among patients with lung cancer in China and the major factors affecting FT.

METHODS

Drawing from a national cross-sectional survey, which used the validated comprehensive score for financial toxicity (COST) questionnaire, we estimated the prevalence and degree of FT. Patient coping actions were investigated. Pearson's chi tests and multinomial logistic regression were used to evaluate the predictors of FT in patients with lung cancer.

RESULTS

The median score of FT was 20 (scored on a range of 0-44, with lower scores indicating more severe toxicity). Altogether, 77% of the sample patients had FT (COST <26), 54.5% had mild FT (COST 14-25), and 22.5% had moderate and severe FT (COST 0-13). Living in the less-developed western region of China, being male, having a lower educational level, lower annual family income, and advanced stage or worse self-reported health status were significantly related to higher FT than their counterparts (p < 0.05). Patients with higher FT tended to have a lower level of medical compliance, a higher risk of incurring debts, and reduced living expenditures relative to those with lower FT.

CONCLUSION

Despite China's remarkable progress in the past two decades with regard to Universal Healthcare Coverage, FT still presents a serious challenge for patients with lung cancer. Keen attention must be paid to reducing the disproportionate high financial risks of patients with low socioeconomic status.

Comprehensive Score for Financial Toxicity and Health-Related Quality of Life in Patients With Cancer and Survivors: A Systematic Review and Meta-Analysis

OBJECTIVES

Financial toxicity is recognized as an important adverse effect of cancer treatment that may decrease patients' health-related quality of life (HRQOL). We aim to perform a systematic review and meta-analysis on studies investigating the association of HRQOL and financial toxicity measured with the Comprehensive Score for Financial Toxicity in patients with cancer and survivors.

METHODS

A systematic literature search was completed in PubMed, Web of Science, Cumulative Index to Nursing and Allied Health Literature, and PsycInfo (last update April 2022). Methodological quality of included studies was assessed using the Appraisal Tool for Cross-Sectional Studies and the Critical Appraisal Skills Program Cohort Study Checklist. Where possible, study outcomes were pooled by random-effects meta-analysis.

RESULTS

Thirty-one studies were included with a combined sample of 13 481 patients and survivors with more than 25 cancer types from 9 countries. Nineteen different validated HRQOL instruments were used in these studies, with the Functional Assessment of Cancer Therapy - General (n = 9), the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (n = 5), and EQ-5D (n = 5) being the most common. All but one included studies reported that higher financial toxicity was significantly associated with worse HRQOL. Ten HRQOL domains were correlated with financial toxicity, including physical health (r = 0.34-0.66), social health (r = 0.16-0.55), mental health (r = 0.21-0.54), and daily functioning (r = 0.23-0.52). The meta-analysis indicated a moderate correlation between financial toxicity and overall HRQOL as measured by the Functional Assessment of Cancer Therapy instruments (r = 0.49, 95% confidence interval 0.44-0.54).

CONCLUSIONS

This is the first systematic review and meta-analysis to summarize the literature on the association of financial toxicity and HRQOL in patients with cancer and survivors. Our findings substantiate financial toxicity as a relevant outcome of cancer care that is associated with a decline of HRQOL.