Death or Debt? National Estimates of Financial Toxicity in Persons with Newly-Diagnosed Cancer

Mortgage Borrowing and Chronic Disease Outcomes in Older Age: Evidence From Biomarker Data in the Health and Retirement Study

OBJECTIVES

The medical diagnosis of a disease is common in older age and can carry significant financial costs. For many older adults, equity in a home is their primary component of wealth; however, housing wealth is illiquid. We analyze the relationship between the liquidation of housing wealth through mortgage borrowing on older homeowners' ability to successfully control a disease.

METHODS

We use data on homeowners aged 65 and older from the 1998-2016 waves of the Health and Retirement Study (N = 3,457). We use biomarkers and physical health indicators to measure disease control following a medical diagnosis of diabetes, heart condition, high blood pressure, lung disease, or cancer. Random effects linear probability and instrumental variable regressions estimate the associations of housing wealth, new mortgage borrowing, and disease control.

RESULTS

Descriptively, 28% of older homeowners who borrow against home equity are not controlled on their disease, compared to 33% of non-borrowers. Panel data instrumental variable regressions show that each $10,000 borrowed from home equity after diagnosis is associated with a 17-percentage-point reduction in the probability of the disease not being controlled.

DISCUSSION

Many older adults are not able or willing to liquidate housing wealth, and the ability to borrow also depends on changes in home values. Thus, housing wealth is not a uniform social determinant of health but is shaped by older adults' participation in financial markets.

Prevalence of and Factors Associated with Financial Toxicity After Pancreatectomy and Gastrectomy

BACKGROUND

Financial toxicity (FT) refers to the adverse impact of cancer treatment costs on patients' experiences, potentially leading to poor adherence to treatment and outcomes. However, the prevalence of FT among patients undergoing major upper gastrointestinal cancer operations, as well as factors associated with FT, remain unclear.

METHODS

We conducted a cross-sectional study by sending the Comprehensive Score for financial Toxicity (COST) survey and Surgery-Q (a survey specifically developed for this study) to patients who underwent gastrectomy or pancreatectomy for malignant disease at our institution in 2019-2021.

RESULTS

We sent the surveys to 627 patients and received responses from 101 (16%) patients. The FT prevalence (COST score <26) was 48 (48%). Patients likely to experience FT were younger than 50 years of age, of non-White race, earned an annual income <$75,000, and had credit scores <740 (all p < 0.05). Additionally, longer hospital stay (p = 0.041), extended time off work for surgery (p = 0.011), and extended time off work for caregivers (p = 0.005) were associated with FT. Procedure type was not associated with FT; however, patients who underwent minimally invasive surgery (MIS) had a lower FT probability (p = 0.042). In a multivariable analysis, age <50 years (p = 0.031) and credit score <740 (p < 0.001) were associated with high FT risk, while MIS was associated with low FT risk (p = 0.024).

CONCLUSIONS

Patients with upper gastrointestinal cancer have a major risk of FT. In addition to predicting the FT risk before surgery, facilitating quicker functional recovery with the appropriate use of MIS is considered important to reducing the FT risk.

Financial burden among metastatic breast cancer patients: a qualitative inquiry of costs, financial assistance, health insurance, and financial coping behaviors

PURPOSE

Metastatic breast cancer (MBC) patients often face substantial financial burden due to prolonged and expensive therapy. However, in-depth experiences of financial burden among MBC patients are not well understood.

METHODS

Qualitative interviews were conducted to describe the experiences of financial burden for MBC patients, focusing on the drivers of financial burden, their experience using their health insurance, accessing financial assistance, and any resulting cost-coping behaviors. Interviews were transcribed and qualitatively analyzed using a descriptive phenomenological approach to thematic analysis.

RESULTS

A total of n = 11 MBC patients or caregiver representatives participated in the study. MBC patients were on average 50.2 years of age (range: 28-65) and 72.7% non-Hispanic White. MBC patients were diagnosed as metastatic an average of 3.1 years (range: 1-9) before participating in the study. Qualitative analysis resulted in four themes including (1) causes of financial burden, (2) financial assistance mechanisms, (3) health insurance and financial burden, and (4) cost-coping behaviors. Both medical and non-medical costs drove financial burden among participants. All participants reported challenges navigating their health insurance and applying for financial assistance. Regardless of gaining access to assistance, financial burden persisted for nearly all patients and resulted in cost-coping behaviors.

CONCLUSION

Our findings suggest that current systems for health insurance and financial assistance are complex and difficult to meet patient needs. Even when MBC patients accessed assistance, excess financial burden persisted necessitating use of financial coping-behaviors such as altering medication use, maintaining employment, and taking on debt.

Patient and Family Financial Burden in Cancer: A Focus on Differences across Four Provinces, and Reduced Spending Including Decisions to Forego Care in Canada

GOAL

This study aimed to examine provincial differences in patient spending for cancer care and reductions in household spending including decisions to forego care in Canada.

METHODS

Nine-hundred and one patients with cancer, from twenty cancer centers across Canada, completed a self-administered questionnaire (P-SAFE version 7.2.4) (344 breast, 183 colorectal, 158 lung, and 216 prostate) measuring direct and indirect costs and spending changes.

RESULTS

Provincial variations showed a high mean out-of-pocket cost (OOPC) of CAD 938 (Alberta) and a low of CAD 280 (Manitoba). Differences were influenced by age and income. Income loss was highest for Alberta (CAD 2399) and lowest for Manitoba (CAD 1126). Travel costs were highest for Alberta (CAD 294) and lowest for British Columbia (CAD 67). Parking costs were highest for Ontario (CAD 103) and lowest for Manitoba (CAD 53). A total of 41% of patients reported reducing spending, but this increased to 52% for families earning

CONCLUSIONS

Levels of financial burden for patients with cancer in Canada vary provincially, including for OOPC, travel and parking costs, and lost income. Decisions to forego cancer care are highest in relation to vitamins/supplements, CAM, and drugs. Provincial differences suggest that regional health policies and demographics may impact patients' overall financial burden.

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Key Words

• cancer
• financial burden
• financial toxicity
• foregone care
• out-of-pocket costs
• regional differences
• self-administered questionnaire

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MESH Headings

• Humans
• Neoplasms/economics
• Neoplasms/therapy
• Male
• Female
• Cost of Illness
• Middle Aged
• Aged
• Health Expenditures/statistics & numerical data
• Canada
• Surveys and Questionnaires
• Adult
• Manitoba

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Affiliation(s)

Christopher J. Longo DeGroote School of Business—Health Policy & Management, McMaster University, Hamilton, ON L8S 4L8, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5S 1A1, Canada;
Tuhin Maity DeGroote School of Business—Health Policy & Management, McMaster University, Hamilton, ON L8S 4L8, Canada;
Margaret I. Fitch Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON M5S 1A1, Canada;
Jesse T. Young Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5S 1A1, Canada; Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, ON M5T 1R8, Canada Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, VIC 3052, Australia Centre for Adolescent Health, Murdoch Children’s Research Institute, Parkville, VIC 3052, Australia School of Population and Global Health, The University of Western Australia, Crawley, WA 6009, Australia Curtin School of Population Health, Curtin University, Bentley, WA 6102, Australia

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The Affordable Care Act and income-based disparities in health care coverage and spending among nonelderly adults with cancer

The Patient Protection and Affordable Care Act (ACA) significantly reduced uninsured individuals and improved financial protection; however, escalating costs of cancer treatment has led to substantial out-of-pocket expenses, causing severe financial and mental health distress for individuals with cancer. Mixed evidence on the ACA's ongoing impact highlights the necessity of assessing health-spending changes across income groups for informed policy interventions. In our nationally representative survey evaluating the early- and long-term effects of the ACA on nonelderly adult patients with cancer, we categorized individuals-based income subgroups defined by the ACA for eligibility. We found that ACA implementation increased insurance coverage, which was particularly evident after 2 years of implementation. Early post-ACA (within two years of implementation), there were declines in out-of-pocket spending for the lowest and low-income groups by 26.52% and 38.31%, respectively, persisting long-term only for the lowest-income group. High-income groups experienced continuously increased out-of-pocket and premium spending by 25.39% and 34.28%, respectively, with a notable 122% increase in the risk of high-burden spending. This study provides robust evidence of income-based disparities in financial burden for cancer care, emphasizing the need for health care policies promoting equitable care and addressing spending disparities across income brackets.

Logistic burdens of cancer care: A qualitative study

Cancer treatment often creates logistic conflicts with everyday life priorities; however, these challenges and how they are subjectively experienced have been largely unaddressed in cancer care. Our goal was to describe time and logistic requirements of cancer care and whether and how they interfered with daily life and well-being. We conducted interviews with 20 adults receiving cancer-directed treatment at a single academic cancer center. We focused on participants' perception of the time, effort, and energy-intensiveness of cancer care activities, organization of care requirements, and preferences in how to manage the logistic burdens of their cancer care. Participant interview transcripts were analyzed using an inductive thematic analysis approach. Burdens related to travel, appointment schedules, healthcare system navigation, and consequences for relationships had roots both at the system-level (e.g. labs that were chronically delayed, protocol-centered rather than patient-centered bureaucratic requirements) and in individual circumstances (e.g. greater stressors among those working and/or have young children versus those who are retired) that determined subjective burdensomeness, which was highest among patients who experienced multiple sources of burdens simultaneously. Our study illustrates how objective burdens of cancer care translate into subjective burden depending on patient circumstances, emphasizing that to study burdens of care, an exclusive focus on objective measures does not capture the complexity of these issues. The complex interplay between healthcare system factors and individual circumstances points to clinical opportunities, for example helping patients to find ways to meet work and childcare requirements while receiving care.

Systemic Therapy for Advanced Hepatocellular Carcinoma: ASCO Guideline Update

PURPOSE

To update an evidence-based guideline to assist in clinical decision-making for patients with advanced hepatocellular carcinoma (HCC).

METHODS

ASCO convened an Expert Panel to update the 2020 guideline on systemic therapy for HCC. The panel updated the systematic review to include randomized controlled trials (RCTs) published through October 2023 and updated recommendations.

RESULTS

Ten new RCTs met the inclusion criteria and were added to the evidence base.

RECOMMENDATIONS

Atezolizumab + bevacizumab (atezo + bev) or durvalumab + tremelimumab (durva + treme) may be offered first-line for patients with advanced HCC, Child-Pugh class A liver disease, and Eastern Cooperative Oncology Group performance status 0-1. Where there are contraindications to these therapies, sorafenib, lenvatinib, or durvalumab may be offered first-line. Following first-line treatment with atezo + bev, second-line therapy with a tyrosine kinase inhibitor (TKI), ramucirumab (for patients with alpha-fetoprotein [AFP] ≥400 ng/mL), durva + treme, or nivolumab + ipilimumab (nivo + ipi) may be recommended for appropriate candidates. Following first-line therapy with durva + treme, second-line therapy with a TKI is recommended. Following first-line treatment with sorafenib or lenvatinib, second-line therapy options include cabozantinib, regorafenib for patients who previously tolerated sorafenib, ramucirumab (AFP ≥400 ng/mL), nivo + ipi, or durvalumab; atezo + bev or durva + treme may be considered for patients who did not have access to these therapies in the first-line setting, and do not have contraindications. Pembrolizumab or nivolumab are also options for appropriate patients following sorafenib or lenvatinib. Third-line therapy may be considered in Child-Pugh class A patients with good PS, using one of the agents listed previously that has a nonidentical mechanism of action with previously received therapy. A cautious approach to systemic therapy is recommended for patients with Child-Pugh class B advanced HCC. Further guidance on choosing between options is included within the guideline.Additional information is available at www.asco.org/gastrointestinal-cancer-guidelines.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Post-surgery financial toxicity and its influencing factors in colorectal cancer care: A cross-sectional study

PURPOSE

This study aimed to investigate the influence factors of financial toxicity experienced by colorectal cancer patients after surgery. The results will provide deep insights for developing effective intervention strategies to address this common issue of colorectal cancer care.

METHODS

In this cross-sectional study, we recruited 213 postoperative patients with colorectal cancer from February 2023 to July 2023 in two major public hospitals. Patients completed the General Information Questionnaire, Comprehensive Scores for Financial Toxicity (COST), Self-perceived Burden Scale (SPBS), Family Resilience Questionnaire (FaREQ), and Social Support Rating Scale (SSRS). A multiple linear regression model was used to investigate the influence factors of financial toxicity.

RESULTS

The mean score of financial toxicity was medium (18.91 ± 7.90) in this study. Financial toxicity score was negatively correlated with self-perceived burden (r = -0.333, P < 0.01) and positively associated with family resilience (r = 0.365, P < 0.01) and social support (r = 0.388, P < 0.01). Via multiple linear regression analysis, we identified seven significant factors associated with financial toxicity, including family income [(95 %CI: 1.075-3.123); P = 0.000], self-perceived burden [(95 %CI: 0.300∼-0.038); P = 0.012], stoma [(95 %CI: 5.309∼-1.682); P = 0.000], social support [(95 %CI:0.058-0.407); P = 0.009], cancer stage [(95 %CI: 2.178∼-0.170); P = 0.022], postoperative duration [(95 %CI: 1.900∼-0.332); P = 0.005], and family resilience [(95 %CI: 0.028-0.203); P = 0.010].

CONCLUSIONS

Financial toxicity was prevalent among postoperative colorectal cancer patients. Additional support and early interventions should be given to high-risk patients, including those with stomas, advanced disease stages, or experiencing longer postoperative duration. Apart from demographic factors, we identified that self-perceived burden, family resilience, and social support were also associated with financial toxicity, providing a new perspective for developing effective strategies against financial toxicity.

Can a Low-Phosphate Diet for Chronic Kidney Disease Treat Cancer? An Interdisciplinary Literature Review

Background: Cancer therapeutics have a low success rate in clinical trials. An interdisciplinary approach is needed to translate basic, clinical, and remote fields of research knowledge into novel cancer treatments. Recent research has identified high dietary phosphate intake as a risk factor associated with cancer incidence. A model of tumor dynamics predicted that reducing phosphate levels sequestered in the tumor microenvironment could substantially reduce tumor size. Coincidently, a low-phosphate diet is already in use to help patients with chronic kidney disease manage high serum phosphate levels. Methods: A grounded-theory literature-review method was used to synthesize interdisciplinary findings from the basic and clinical sciences, including oncology, nephrology, nutritional epidemiology, and dietetic research on cancer. Results: Findings of tumor remission associated with fasting and a ketogenic diet, which lower intake of dietary phosphate, support the hypothesis that a low-phosphate diet will reduce levels of phosphate sequestered in the tumor microenvironment and reduce tumor size. Additionally, long-term effects of a low-phosphate diet may reverse dysregulated phosphate metabolism associated with tumorigenesis and prevent cancer recurrence. Conclusions: Evidence in this article provides the rationale to test a low-phosphate diet as a dietary intervention to reduce tumor size and lower risk of cancer recurrence.

Cancer-Related Financial Hardship Screening as Part of Practice Transformation

BACKGROUND

Data on financial hardship, an "adverse event" in individuals with cancer, are needed to inform policy and supportive care interventions and reduce adverse economic outcomes.

METHODS

Lay navigator-led financial hardship screening was piloted among University of Alabama at Birmingham oncology patients initiating treatment in October 2020. Financial hardship screening, including reported financial distress and difficulty, was added to a standard-of-care treatment planning survey. Screening feasibility and completion and proportions of reported financial distress and difficulty were calculated overall and by patient race and rurality. The risk of financial distress by patient sociodemographics was estimated.

RESULTS

Patients who completed a treatment planning survey (N=2741) were 18% Black, Indigenous, or persons of color (BIPOC) and 16% rural dwelling. The majority of patients completed financial hardship screening (90%), surpassing the target feasibility completion rate of 75%. The screening revealed 34% of patients were experiencing financial distress, including 49% of BIPOC and 30% of White patients. Adjusted models revealed BIPOC patients had a 48% higher risk of financial distress compared with those who were White (risk ratio 1.48, 95% CI, 1.31-1.66). Large differences in reported financial difficulties were seen comparing patients who were BIPOC and White (utilities: 33% vs. 10%, upfront medical payments: 44% vs. 23%, transportation: 28% vs. 12%, respectively).

CONCLUSIONS

The collection of patient-reported financial hardship data via routine clinical care was feasible and identified racial inequities at treatment initiation. Efforts to collect patient economic data should support the design, implementation, and evaluation of patient-centered interventions to improve equity and reduce the impact of financial hardship.

The Risk of Catastrophic Healthcare Expenditures Among Prostate and Bladder Cancer Survivors in the United States

INTRODUCTION

Little is known about the rates of catastrophic health care expenditures among survivors of prostate and bladder cancer or the factors that place patients at highest risk for undue cost.

MATERIALS AND METHODS

The Medical Expenditure Panel Survey was utilized to identify prostate and bladder cancer survivors from 2011 to 2019. Rates of catastrophic health care expenditures (out-of-pocket health care spending >10% household income) were compared between cancer survivors and adults without cancer. A multivariable regression model was used to identify risk factors for catastrophic expenditures.

RESULTS

Among 2620 urologic cancer survivors, representative of 3,251,500 (95% CI 3,062,305-3,449,547) patients annually after application of survey weights, there were no significant differences in catastrophic expenditures among respondents with prostate cancer compared to adults without cancer. Respondents with bladder cancer had significantly greater rates of catastrophic expenditures (12.75%, 95% CI 9.36%-17.14% vs. 8.33%, 95% CI 7.66%-9.05%, P = .027). Significant predictors of catastrophic expenditures in bladder cancer survivors included older age, comorbidities, lower income, retirement, poor health status, and private insurance. Though White respondents with bladder cancer had no significantly increased risk of catastrophic expenditures, among Black respondents the risk of catastrophic expenditures increased from 5.14% (95% CI 3.95-6.33) without bladder cancer to 19.49% (95% CI 0.84-38.14) with bladder cancer (OR 6.41, 95% CI 1.28-32.01, P = .024).

CONCLUSIONS

Though limited by small sample size, these data suggest that bladder cancer survivorship is associated with catastrophic health care expenditures, particularly among Black cancer survivors. These findings should be taken as hypothesis-generating and warrant further investigation with larger sample sizes and, ideally, prospective investigation.

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.

Younger Patients with Colon Cancer are More Likely to Experience Financial Toxicity Than Older Patients

BACKGROUND

The incidence of young-onset colon cancer is increasing. This study investigated the extent to which financial hardships associated with colon cancer care are associated with patient age.

METHODS

A consecutive sample of patients with non-metastatic colon cancer who underwent resection at a comprehensive cancer center between 2017 and 2019 were retrospectively enrolled from a clinical database. Patients with one or more of the following events associated with their colon cancer care were categorized as having experienced financial toxicity: two or more bills sent to collections, application for a payment plan, settlement, bankruptcy, or enrollment in a financial assistance program.

RESULTS

Of 764 patients identified, 157 (21 %) experienced financial toxicity. In a univariable analysis, financial toxicity was significantly associated with younger age, female sex, nonpartnered marital status, and median income by ZIP code area (p < 0.05). A multivariable analysis showed that with each 10-year decrease in patient age, the odds of financial toxicity increased by 30 % (odds ratio [OR], 1.30; 95 % confidence interval [CI], 1.14-1.48). With each $50,000 decrease in median income by ZIP code area, the odds of financial toxicity increased by 35 % (OR, 1.35; 95 % CI, 1.05-1.74).

CONCLUSIONS

Younger patients with colon cancer are at greater risk for financial toxicity than older patients. As this population continues to grow, so will the need for timely and effective financial support mechanisms.

Relationships Among Health Insurance Literacy, Financial Toxicity, and Sociodemographic Factors in Patients With Cancer

PURPOSE

The objective of the study was to describe the prevalence of health insurance literacy (HIL) and investigate how patient-reported outcome measures assessing HIL are related to financial toxicity in patients with cancer.

METHODS

We assessed HIL and financial toxicity in 404 patients enrolled between December 2019 and January 2021 at two medical centers in the United States. We conducted exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) to explore and test the relationships among the factors and items. We fit structural equation models (SEMs) to find the relationships among the factors and sociodemographic/clinical characteristics.

RESULTS

The EFA revealed items loaded on four factors: knowledge about health insurance, confidence related to HIL (HIL confidence), information-seeking behavior related to health insurance, and financial toxicity. The four-factor CFA model had good fit statistics (comparative fit index, 0.960; Tucker-Lewis index, 0.958; root mean square error of approximation, 0.046; and standardized root mean square residual, 0.086). In SEM, income, education level, and race positively predicted knowledge about health insurance. Knowledge about health insurance and number of total lines of cancer treatment was positively associated with HIL confidence. Higher income, older age, and HIL confidence were associated with less financial toxicity. Higher levels of financial toxicity, HIL confidence, and knowledge were associated with greater information-seeking behavior.

CONCLUSION

Our findings showed how different aspects of HIL are related to financial toxicity even after adjustment for sociodemographic and clinical characteristics. Future studies should investigate the longitudinal relationships among these factors to help develop interventions to mitigate financial toxicity.

Financial toxicity in thyroid cancer survivors

PURPOSE OF REVIEW

Financial burden and distress are high in patients with thyroid cancer. However, little has been done to evaluate potential interventions to mitigate financial toxicity in survivors. This review will cover current data on the impact of financial toxicity on quality of life and clinical outcomes in patients with thyroid cancer and highlight areas for future study.

RECENT FINDINGS

Thyroid cancer incidence has nearly tripled in the past decades, and cost of treatment is predicted to rise more than other cancers over the next decade. With mean age of diagnosis at 51 years, most patients begin treatment while still working, do not qualify for Medicare or Social Security, and are susceptible to higher financial burden. Though thyroid cancer has high survival rates, some studies suggest patients have worse quality of life and higher financial burden than more morbid cancers.

SUMMARY

Thyroid cancer survivors have high rates of financial toxicity, and there remains need for longitudinal studies to evaluate how financial burden may change during the treatment process while also assessing potential tools to mitigate this burden.

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

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

New technology in prostate cancer and financial toxicity

The management of prostate cancer has significantly evolved over the last few decades with the emergence of new diagnostic and treatment technologies, which are typically more expensive than the previous alternatives. However, decision-making regarding which diagnostics and treatment to pursue is often influenced by perceived benefits, adverse effects, and physician recommendations, without considering the financial liability borne by patients. New technologies may exacerbate financial toxicity by replacing less costly alternatives, promoting unrealistic expectations, and expanding treatment to those who would have previously gone untreated. More judicious use of technologies with an understanding of the contexts in which they are most beneficial may help prevent avoidable financial toxicity to patients.

Suicide after a Diagnosis of Cancer: Follow-Up of 1.4 Million Individuals, 2009-2019

Background: The study explores whether Polish cancer patients face elevated suicide risk, emphasizing the vital need to comprehend and mitigate their unique mental health struggles. Methods: We conducted a cohort study based on Polish National Cancer Registry data (diagnosis in 2009-2019). Age-, sex-, and year-standardized mortality ratios (SMR) are presented with 95% confidence intervals (CIs) overall and by sex. Results: The study included 1.43 million individuals diagnosed with cancer. There were 830 suicide cases in this group. The overall SMR for suicide was 1.34 (95% CI 1.25-1.43). The highest risk of suicide death was observed in the first six months after diagnosis (SMR = 1.94, 1.69-2.21): cancers of the heart and pleura (19.15, 2.32-69.18), an unspecified site (3.99, 1.09-10.22), and the esophagus (3.34, 1.08-7.79). The highest overall risk of suicide after cancer diagnosis was observed in esophageal (2.94, 1.47-5.26), gastric (2.70, 2.00-3.57), cervical (2.20, 1.06-4.05), and head and neck cancers (2.06, 1.52-2.72). Conclusions: Patients with cancer face significantly higher suicide risk, peaking within six months post-diagnosis. Urgent integration of suicide risk screening and prevention into cancer care is crucial, supporting mental well-being and guiding proactive healthcare strategies.

Mitigating long-term and delayed adverse events associated with cancer treatment: implications for survivorship

Despite the importance of chemotherapy-associated adverse events in oncology practice and the broad range of interventions available to mitigate them, limited systematic efforts have been made to identify, critically appraise and summarize the totality of evidence on the effectiveness of these interventions. Herein, we review the most common long-term (continued beyond treatment) and late or delayed (following treatment) adverse events associated with chemotherapy and other anticancer treatments that pose major threats in terms of survival, quality of life and continuation of optimal therapy. These adverse effects often emerge during and continue beyond the course of therapy or arise among survivors in the months and years following treatment. For each of these adverse effects, we discuss and critically evaluate their underlying biological mechanisms, the most commonly used pharmacological and non-pharmacological treatment strategies, and evidence-based clinical practice guidelines for their appropriate management. Furthermore, we discuss risk factors and validated risk-assessment tools for identifying patients most likely to be harmed by chemotherapy and potentially benefit from effective interventions. Finally, we highlight promising emerging supportive-care opportunities for the ever-increasing number of cancer survivors at continuing risk of adverse treatment effects.

The challenges of managing patients with cancer in the workplace: Needs, opportunities and perspectives of occupational physicians

Cancer is a global major public health problem since it is a leading cause of death, accounting for nearly 10 million deaths in 2020 worldwide and the most recent epidemiological data suggested that its global impact is growing significantly. In this context, cancer survivors have to live for a long time often in a condition of disability due to the long-term consequences, both physical and psychological. These difficulties can seriously impair their working ability, limiting the employability. In this context, the occupational physician plays a key role in the implementation and enforcement of measures to support the workers affected by cancer, to address issues such as the information on health promotion, the analysis of work capacity and the management of disability at work and also promoting a timely and effective return to work and preserving their employability. Therefore, the aim of this study was to gather useful information to support the occupational physicians in the management of workers affected by cancer, through a survey on 157 Italian occupational physicians. Based on the interviewees' opinions, the most useful occupational safety and health professionals in terms of job retention and preservation of workers affected by cancer are the employers and the occupational physicians themselves, whose role is crucial in identifying and applying the most effective reasonable accommodations that should be provided to the workers affected by cancer. The provision of these accommodations take place on the occasion of mandatory health surveillance medical examination to which the worker affected by cancer is subjected when he returns to work. Results on training and information needs showed that the management of the workers affected by cancer is essentially centered on an appropriate fitness for work judgment and on the correct performance of health surveillance. However, an effective and successful management model should be based on a multidisciplinary and integrated approach that, from the earliest stages of the disease, involves the occupational physicians and employers.

Food Insecurity, Healthcare Utilization, and Healthcare Expenditures: A Longitudinal Cohort Study

Objective: This study examines the longitudinal association between household food insecurity and healthcare utilization and expenditure. Methods: A multi-wave longitudinal cohort study was conducted using the 2008-2019 and 2021 waves of the Korean Welfare Panel Study. The baseline data included participants aged ≥19 years with valid responses to the food insecurity and healthcare questionnaires in the 2008 wave (n = 12,166). Healthcare outcomes encompassed outpatient visits, inpatient admissions, days hospitalized, and personal healthcare expenditure. Random effects Poisson and linear regressions were estimated. Results: Severe food insecurity was associated with a higher incidence rate of outpatient visits (IRR, 1.14; 95% CI, 1.12-1.17), days of hospitalization (IRR, 1.18; 95% CI, 1.13-1.22), and inpatient admissions (IRR, 1.40; 95% CI, 1.18-1.65). Moderate food insecurity was associated with 10.4% (β = -0.11; 95% CI, -0.14 to -0.07) or 238,276 KRW reductions in personal healthcare expenditures in the subsequent year. Conclusion: Household food insecurity was linked to increased healthcare utilization and reduced personal healthcare expenditure among Korean adults. Our findings present opportunities to identify target populations for healthcare policies and interventions.

Financial well-being as a mediator of the relationship between multimorbidity and health-related quality of life in people with cancer

BACKGROUND

It is unknown whether financial well-being mediates the impact of multimorbidity on the health-related quality of life (HRQoL) of cancer patients.

METHODS

Participants were recruited from three outpatient oncology clinics of Hong Kong public hospitals. Multimorbidity was assessed using the Charlson Comorbidity Index. Financial well-being, the mediator of the association between multimorbidity and HRQoL outcomes, was assessed using the Comprehensive Score for Financial Toxicity Functional Assessment of Chronic Illness Therapy. The HRQoL outcomes were assessed using the Functional Assessment of Cancer Therapy - General (FACT-G) and its four sub-dimensions. Mediation analyses were conducted using SPSS PROCESS v4.1.

RESULTS

Six-hundred and forty cancer patients participated in the study. Multimorbidity had a direct effect on FACT-G scores independent of financial well-being (β for path c' = -0.752, p < 0.001). In addition, multimorbidity had an indirect effect on FACT-G scores through its effect on financial well-being (β for path a = -0.517, p < 0.05; β for path b = 0.785, p < 0.001). Even after adjustments were made for the covariates, the indirect effect of multimorbidity on FACT-G via financial well-being remained significant, accounting for 38.0% of the overall effect, indicating partial mediation. Although there were no statistically significant associations between multimorbidity, social well-being, and emotional well-being, the indirect effects of multimorbidity on physical and functional well-being through financial well-being remained significant.

CONCLUSIONS

Poor financial well-being attributable to multimorbidity partially mediates the direct impact of chronic conditions on HRQoL in Chinese cancer patients, particularly their physical and functional well-being.

Evaluating Work Impairment as a Source of Financial Toxicity in Cancer Healthcare and Negative Impacts on Health Status

How the socioeconomic factors intersect for a particular patient can determine their susceptibility to financial toxicity, what costs they will encounter during treatment, the type and quality of their care, and the potential work impairments they face. The primary goal of this study was to evaluate financial factors leading to worsening health outcomes by the cancer subtype. A logistic model predicting worsening health outcomes while assessing the most influential economic factors was constructed by the University of Michigan Health and Retirement Study. A forward stepwise regression procedure was implemented to identify the social risk factors that impact health status. Stepwise regression was done on data subsets based on the cancer types of lung, breast, prostate, and colon cancer to determine whether significant predictors of worsening health status were different or the same across cancer types. Independent covariate analysis was also conducted to cross-validate our model. On the basis of the model fit statistics, the two-factor model has the best fit, that is, the lowest AIC among potential models of 3270.56, percent concordance of 64.7, and a C-statistics of 0.65. The two-factor model used work impairment and out-of-pocket costs, significantly contributing to worsening health outcomes. Covariate analysis demonstrated that younger patients with cancer experienced more financial burdens leading to worsening health outcomes than elderly patients aged 65 years and above. Work impairment and high out-of-pocket costs were significantly associated with worsening health outcomes among cancer patients. Matching the participants who need the most financial help with appropriate resources is essential to mitigate the financial burden.

Significance

Among patients with cancer, work impairment and out-of-pocket are the two primary factors contributing to adverse health outcomes. Women, African American or other races, the Hispanic population, and younger individuals have encountered higher work impairment and out-of-pocket costs due to cancer than their counterparts.

A systematic review on the cost-effectiveness assessment of tisagenlecleucel for refractory or relapsing B-cell acute lymphoblastic leukemia (R/R B-ALL) treatment in children and young adults

BACKGROUND AIMS

The advanced therapy product tisagenlecleucel is a CD19-directed genetically modified autologous T-cell immunotherapy that has brought hope for children and young adults with relapsed/refractory (R/R) B-cell acute lymphoblastic leukemia (B-ALL). We sought to evaluate the cost-effectiveness of tisagenlecleucel compared with conventional salvage therapies in pediatric and young adult patients with R/R B-ALL.

METHODS

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses parameters as registered in International Prospective Register of Systematic Reviews (CRD42021266998). Literature was searched using the MEDLINE databases via PubMed, EMBASE, Lilacs, the Cochrane Central Register of Controlled Trials and Web of Science in January 2022. Titles were screened independently by two reviewers. Articles deemed to meet the inclusion criteria were screened independently on abstract, and full texts were reviewed.

RESULTS

In total, 5627 publications were identified, from which six eligible studies were selected. The conventional therapies identified were blinatumomab (Blina), clofarabine monotherapy (Clo-M), clofarabine combined with cyclophosphamide and etoposide (Clo-C) and the combination of fludarabine, cytarabine and idarubicin (FLA-IDA). The discounted incremental cost-effectiveness ratio (ICER) per quality-adjusted life year (QALY) gained for tisagenlecleucel compared with Clo-C and Blina averages was $38 837 and $25 569, respectively. In relation to the cost of the drug, the average of tisagenlecleucel was approximately 4.3 times, 10.8 times or 4.7 times greater than the Clo-M, Clo-C and Blina, respectively.

CONCLUSIONS

This systematic review highlighted that tisagenlecleucel is a much more expensive therapy than conventional alternatives. However, tisagenlecleucel performed well on the ICER, not exceeding $100 000/QALY. It was also found that the advanced therapy product was more effective than the conventional small molecule and biological drugs, in terms of life years and QALY gained.

Guaranteed Income and Financial Treatment Trial (GIFT Trial or GIFTT): a 12-month, randomized controlled trial to compare the effectiveness of monthly unconditional cash transfers to treatment as usual in reducing financial toxicity in people with cancer who have low incomes

Cancer-related financial hardship (i.e., financial toxicity) has been associated with anxiety and depression, greater pain and symptom burden, treatment nonadherence, and mortality. Out-of-pocket healthcare costs and lost income are primary drivers of financial toxicity, however, income loss is a pronounced risk factor for cancer patients with low incomes. There has been little progress in developing an income intervention to alleviate financial toxicity cancer patients with low incomes. Unconditional cash transfers (UCT), or guaranteed income, have produced positive health effects in experiments with general low-income populations, but have not yet been evaluated in people with cancer. The Guaranteed Income and Financial Treatment (GIFT) Trial will use a two-arm randomized controlled trial to compare the efficacy of a 12-month UCT intervention providing $1000/month to treatment as usual on financial toxicity, health-related quality of life and treatment adherence in people with cancer who have low-incomes. The study will recruit 250 Medicaid beneficiaries with advanced cancer from two comprehensive cancer centers in Philadelphia, obtain informed consent, and randomize patients to one of two conditions: (1) $1,000/month UCT or (2) treatment as usual. Both arms will receive information on financial toxicity and the contact information for their hospital social worker or financial advocate upon enrollment. Participants will complete online surveys at baseline, 3, 6, 9, and 12 months from enrollment to collect patient-reported data on primary (i.e., financial toxicity, health-related quality of life, and treatment adherence) and secondary outcomes (i.e., anxiety, depression, food insecurity, housing stability). Social security records will be used to explore the effect on mortality at 2, 3, and 5 years post-enrollment. Linear mixed-models will be used to analyze all primary and secondary continuous outcomes over time and general estimating equations with a logit link and binary distribution for all binary outcomes over time. Differences between treatment and control groups and treatment effects will be determined using models that control for age, gender, race, baseline food security, baseline housing stability, and baseline ECOG. Findings from this study will have significant implications for the development and implementation of programs and policies that address the financial burden of cancer and other serious illnesses.

Financial stress among skin cancer patients: a cross-sectional review of the 2013-2018 National Health Interview Survey

Financial stress among skin cancer patients may limit treatment efficacy by forcing the postponement of care or decreasing adherence to dermatologist recommendations. Limited information is available quantifying the anxiety experienced by skin cancer patients from both healthcare and non-healthcare factors. Therefore, the present study sought to perform a retrospective cross-sectional review of the 2013-2018 cycles of the National Health Interview Survey (NHIS) to determine the prevalence, at-risk groups, and predictive factors of skin cancer patient financial stress. Survey responses estimated that 11.45% (95% Cl 10.02-12.88%) of skin cancer patients experience problems paying medical bills, 20.34% (95% Cl 18.97-21.71%) of patients worry about the medical costs, 13.73% (95% Cl 12.55-14.91%) of patients worry about housing costs, and 37.48% (95% Cl 35.83-39.14%) of patients worry about money for retirement. Focusing on at-risk groups, black patients, uninsured patients, and patients with low incomes (< 200% poverty level) consistently experienced high rates of financial stress for each of the four measures. Multivariable logistic regression revealed low education, lack of insurance, and low income to be predictive of financial stress. These findings suggest that a considerable proportion of skin cancer patients experience financial stress related to both healthcare and non-healthcare factors. Where possible, the additional intricacy of treating patients at risk of high financial stress may be considered to optimize patient experience and outcomes.

Are credit scores and financial well-being associated with physical health?

Consumer credit score has been used as an indicator of financial strain that could potentially impact health. Subjective financial well-being, or one's feelings about one's expectations, preferences, and satisfaction with their financial situation, is related to financial strain. This study examined whether subjective financial well-being mediates the association between credit score and self-reported physical health in a national representative sample. Using structural equation modeling (SEM), we test whether a mediating association exists between self-rated credit score and self-rated physical health. Results suggest that, after controlling for sociodemographic variables, those who reported higher credit scores have better health (β = 0.175, p < .001) and higher financial well-being (β = 0.469, p < .001), and those who reported higher financial well-being have better health (β = 0.265, p < .001). The mediation effect of financial well-being on the association between credit and physical health is also positive and statistically significant (β = 0.299, p < .001). Thus, subjective feelings about one's financial situation would enhance the observed positive association between credit and health. Practice and policy implications are included.

Medication Payments by Insurers and Patients for the Treatment of Metastatic Castrate-Resistant Prostate Cancer

PURPOSE

The implications of high prices for cancer drugs on health care costs and patients' financial burdens are a growing concern. Patients with metastatic castrate-resistant prostate cancer (mCRPC) are often candidates for multiple first-line systemic therapies with similar impacts on life expectancy. However, little is known about the gross and out-of-pocket (OOP) payments associated with each of these drugs for patients with employer-sponsored health insurance. We therefore aimed to determine the gross and OOP payments of first-line drugs for mCRPC and how the payments vary across drugs.

METHODS

This retrospective cohort study included 4,298 patients with prostate cancer who initiated therapy with one of six drugs approved for first-line treatment of mCRPC between July 1, 2013, and June 30, 2019. We compared gross and OOP payments during the 6 months after initiation of treatment for mCRPC using private payer claims data across patients using different first-line drugs.

RESULTS

Gross payments varied across drugs. Over the 6 months after the index prescription, mean unadjusted gross drug payments were highest for patients receiving sipuleucel-T ($115,525 USD) and lowest for patients using docetaxel ($12,804 USD). OOP payments were lower than gross drug payments; mean 6-month OOP payments were highest for cabazitaxel ($1,044 USD) and lowest for docetaxel ($296 USD). There was a wide distribution of OOP payments within drug types.

CONCLUSION

Drugs for mCRPC are expensive with large differences in payments by drug type. OOP payments among patients with employer-sponsored health insurance are much lower than gross drug payments, and they vary both across and within first-line drug types, with some patients making very high OOP payments. Although lowering drug prices would reduce pharmaceutical spending for patients with mCRPC, decreasing patient financial burden requires understanding an individual patient's benefit design.

Factors Associated with the Decision to Decline Chemotherapy in Metastatic Non-Small Cell Lung Cancer

(1) Background: Disparities in cancer treatment and outcomes have long been well-documented in the medical literature. With the eruption of advances in new treatment modalities, the long-existing disparities are now being further uncovered and brought to the attention of the medical community. While social health determinants have previously been linked to treatment disparities in lung cancer, we analyzed data from the National Cancer Database to explore sociodemographic and geographic factors related to accepting or declining physician-recommended chemotherapy. Patients diagnosed with metastatic lung cancer between 2004 and 2016 who declined chemotherapy recommended by their physicians were included in this study. Multivariate logistic regression analysis was performed. Cox Regression and Kaplan-Meier analyses were performed to look for survival characteristics. (2) Results: 316,826 patients with Stage IV lung cancer were identified. Factors related to a higher rate of refusal by patients included older age > 70, female sex, low income, lack of insurance coverage, residency in the New England region, and higher comorbidity. Patients living in areas with lower education were less likely to decline chemotherapy. (3) Conclusion: Further understanding of the factors impacting treatment decisions would be essential to improve the efficacy of care delivery in patients with cancer and reduce reversible causes of disparity.

The Success of Cancer Crowdfunding Campaigns: Project and Text Analysis

BACKGROUND

Recent studies have analyzed the factors that contribute to variations in the success of crowdfunding campaigns for a specific cancer type; however, little is known about the influential factors among crowdfunding campaigns for multiple cancers.

OBJECTIVE

The purpose of this study was to examine the relationship between project features and the success of cancer crowdfunding campaigns and to determine whether text features affect campaign success for various cancers.

METHODS

Using cancer-related crowdfunding projects on the GoFundMe website, we transformed textual descriptions from the campaigns into structured data using natural language processing techniques. Next, we used penalized logistic regression and correlation analyses to examine the influence of project and text features on fundraising project outcomes. Finally, we examined the influence of campaign description sentiment on crowdfunding success using Linguistic Inquiry and Word Count software.

RESULTS

Campaigns were significantly more likely to be successful if they featured a lower target amount (Goal amount, β=-1.949, z score=-82.767, P<.001) for fundraising, a higher number of previous donations, agency (vs individual) organizers, project pages containing updates, and project pages containing comments from readers. The results revealed an inverted U-shaped relationship between the length of the text and the amount of funds raised. In addition, more spelling mistakes negatively affected the funds raised (Number of spelling errors, β=-1.068, z score=-38.79, P<.001).

CONCLUSIONS

Difficult-to-treat cancers and high-mortality cancers tend to trigger empathy from potential donors, which increases the funds raised. Gender differences were observed in the effects of emotional words in the text on the amount of funds raised. For cancers that typically occur in women, links between emotional words used and the amount of funds raised were weaker than for cancers typically occurring among men.

Significance of music therapy in treating depression and anxiety disorders among people with cancer

Globally, cancer cases and mortality have recently escalated and have attracted global concern. The clinical diagnosis and manifestation of cancer can result in significant mental health issues like depression and anxiety disorders. The tendency of people with cancer to suffer from psychological disorders such as anxiety and depression is usually high. A significant number of deaths related to cancer may likely not be from the killer disease but from psychological disorders associated with the illness. The utilization of music as a remedial approach to healing mental disorders cannot be overstated. Thus, identifying the impacts of music therapy in dealing with depression and anxiety disorders among people with cancer is relevant, as the majority of methods used in treating cancer have some side effects which may trigger psychological disorders in cancer patients. Ultimately, this study explored the significance of music therapy in treating depression and anxiety disorders among people with cancer. To achieve the aim of this study, the authors employed a narrative literature review to investigate the significance of music therapy in addressing depression and anxiety disorders among people with cancer. The type of literature review employed in this study is to provide an understanding of the selected research papers. The review found that music therapy significantly reduces depression and anxiety disorders among breast cancer, lung cancer, prostate cancer, and colorectal cancer patients. It is needful for healthcare providers to incorporate music therapy interventions while treating people with cancer. This will help reduce cancer deaths resulting from psychological disorders rather than the killer disease, cancer. However, the standardized procedures and evaluation criteria for applying music-based intervention strategies in oncology medicine still need to be further established and improved.

The Role of Cryoablation in Breast Cancer Beyond the Oncologic Control: COST and Breast-Q Patient-Reported Outcomes

BACKGROUND

Cryoablation has been established as a minimally invasive alternative to resection of early-stage breast cancer; however, there are no data on the cost and impact on patients' financial, psychosocial, sexual, physical, and cosmetic outcomes utilizing this approach. This study compares cost-effectiveness and patient-reported quality-of-life factors in cryoablation versus resection.

METHODS

Women with early-stage, low-risk infiltrating ductal carcinomas ≤ 1.5 cm underwent cryoablation or resection. Adjuvant therapy was provided according to tumor board recommendations. Direct and indirect costs were tracked for both groups. Financial toxicity and well-being outcome were measured by administering the Comprehensive Score of Financial Toxicity (COST) and BREAST-Q surveys, respectively, at 6-month follow-up.

RESULTS

Of the 34 eligible patients, 14 (41.1%) consented for cryoablation and 20 (58.8%) underwent resection. The median (centile) (range) follow-up was 35.0 (21.3) (15-50) months for cryoablation vs. 25 (20.8) (17-50) months for resection [p = 0.6479]. Mean (standard deviation) cost of care for cryoablation versus resection was $2221.70 (615.70) versus $16,896.50 (1332.40) [p < 0.0001], and median financial well-being scores for the cryoablation versus resection groups were 38.0 (34.5, 40.0) versus 10 (5.3, 14.0) [p < 0.0001]. Poor financial well-being was directly correlated with the cost of care [p < 0.0001]. Median psychosocial well-being scores were similar across both groups, however the cryoablation group had higher scores for physical [100 (100, 100) vs. 89 (79, 100); p = 0.0141], sexual [100 (91, 100) vs. 91 (87.5, 91); p = 0.0079], and cosmetic [100 (100, 100) vs. 88 (88, 100); p = 0.0171] outcomes.

CONCLUSION

Cryoablation offers a cost-effective and quality-of-life advantage compared with resection for early-stage, low-risk breast cancer.

Financial burden among cancer patients: A national-level perspective

BACKGROUND

This research study aimed to evaluate the financial burden among older cancer patients and its corresponding risk factors. Factors such as increasing treatment costs and work limitations often lead cancer patients to bankruptcy and poor quality of life. These consequences, in turn, can cause higher mortality rates among these patients.

METHODS

This retrospective cohort study utilized data from the Health Retirement Study (HRS), conducted by the University of Michigan (N = 18,109). Eligible participants had responses captured from years 2002 to 2016. Participants were classified according to any self-reported cancer diagnosis (yes or no) and were compared on the basis of financial, work, and health-related outcomes. Propensity score (PS) matching was applied to reduce the effects of potential confounding factors. Also only, individuals with an age ≥50 and ≤85 during Wave 6 were retained.

RESULTS

Multivariate analysis with random effects revealed several indicators of financial burden when comparing participants with a cancer diagnosis to those with no history of cancer. Mean out-of-pocket costs associated with a cancer diagnosis were $1058 higher when compared to participants with no history of cancer, suggesting that even cancer patients with insurance coverage faced out-of-pocket costs. Respondents with cancer patients had higher odds of encountering financial hardship if they are facing Work Limitations (OR = 2.714), Regular use of Medications (OR = 2.518), Hospital Stays (OR = 2.858), Declining Health (OR = 2.349), or were being covered under government health insurance (OR = 5.803) than respondents who did not have cancer, or suffered from mental health issues such as Depression (OR = 0.901).

CONCLUSION

Cancer patients contend with increasing financial costs during their treatment. However, most newly diagnosed patients are not aware of these costs and are given few resources to handle them.

Is 3D-printed prosthesis stable and economic enough for anterior spinal column reconstruction after spinal tumor resection? A retrospective comparative study between 3D-printed off-the-shelf prosthesis and titanium mesh cage

OBJECT

To investigate the stability and cost-effectiveness of the three-dimensional-printed (3DP) off-the-shelf (OTS) prosthesis in the reconstruction of the anterior column of the thoracic/lumbar spine after tumor resection.

METHODS

Thirty-five patients (26 with primary malignant tumors and nine with metastatic malignant tumors) who underwent tumor resection and anterior column reconstruction between January 2014 and January 2019 were included in a single institute. Patients were divided into the 3DP OTS prosthesis (3DP) group (n = 14) and the titanium mesh cage (TMC) group (n = 21) by the type of implant. The operation time, intraoperative blood loss, hospital stay, history of radiotherapy, surgical level and total cost were collected and compared between the two groups. Mechanical complications and radiological parameters including mean vertebral height, subsidence, fixation failure(nonunion, migration, screw loosening, rod breakage) rate were recorded at preoperation, 1 week, 3 months, 6 months, 12 months after surgery then at 1 year interval or stop until the end of survival. The follow-up patients were also sent with short form-36 to assess their health-related quality of life (HRQoL) and questions about the current condition of their disease.

RESULTS

The mean overall follow-up was 24.6 months. Of the 35 patients involved, six patients died and six were lost to follow-up. The differences between the two groups in operative time, intraoperative blood loss, and hospital stay were not statistically significant (p > 0.05). The differences in fixation failure and the subsidence rate between the two groups were not statistical significant (p > 0.05). The difference of subsidence rate between the cases with and without osteoporosis, cases with and without radiotherapy was statistically significant within each group (p < 0.05). However, the difference of subsidence rate between the surgical level above or below T10 was not statistically significant (p > 0.05). The response rate of the questionnaire among the survived patients was 100% (23/23 patients). The results of the Short Form- (SF-)36 between the two groups were similar (p > 0.05). The total cost was higher in the 3DP group (p < 0.05) with its higher graft cost (p < 0.05), but the differences in internal fixation cost and other cost were not statistically significant between groups (p > 0.05).

CONCLUSION

Compared to TMC, the 3DP OTS prosthesis achieved similar clinical and radiological results in spinal anterior spinal column reconstruction of thoracic/lumbar spinal tumor resection. However, the 3DP OTS prosthesis was more expansive than TMC.

Financial Toxicity in the Post-Health Reform Era

The Patient Protection and Affordable Care Act (ACA), enacted in March 2010, was comprehensive health care reform legislation aimed to improve health care access and quality of care and curb health care-related costs. This review focuses on key provisions of the ACA and their impact on financial toxicity. We will focus our review on cancer care, because this is the most commonly studied disease process in respect to financial toxicity. Patients with cancer face rising expenditures and financial burden, which in turn impact quality of life, compliance to treatment, and survival outcomes. Health insurance expansion include dependent-coverage expansion, Medicaid expansion, and establishment of the Marketplace. Coverage reform focused on reducing financial barriers by limiting cost sharing. Payment reforms included new innovative payment and delivery systems to focus on improving outcomes and reducing costs. Challenges remain as efforts to reduce costs have led to the expansion of insurance plans, such as high-deductible health plans, that may ultimately worsen financial toxicity in cancer and high out-of-pocket costs for further diagnostic testing and procedures. Further research is necessary to evaluate the long-term impacts of the ACA provisions-and threats to the ACA-on outcomes and the costs accrued by patients.

Do different shocks in health matter for wealth?

We study the effect of hospital admissions for specific conditions on wealth for the Dutch population aged 70-79. We consider 14 disease groups that affect mortality and disability to different extents. We apply a "difference-in-timing" design comparing individuals admitted in one year to similar individuals admitted later. Because the protection against income risks and medical spending is high, we can identify changes in saving behaviors driven by preferences for consumption, saving, and bequests, rather than by changes in budget constraints. Although the health shocks differ in mortality and disability, we find hardly any impact on wealth across conditions.

Out-of-pocket cost by cancer stage at diagnosis in commercially insured patients in the United States

AIMS

Out-of-pocket (OOP) costs may constitute a substantial financial burden to patients diagnosed with cancer. Earlier stage diagnosis and treatment of cancers may promote decreased morbidity and mortality, subsequently also lowering costs. To better understand costs experienced by patients with cancer, OOP costs by stage post-diagnosis were estimated.

MATERIALS AND METHODS

A retrospective analysis was conducted using Optum's de-identified Integrated Claims-Clinical dataset with Enriched Oncology, which includes data from commercially insured members (June 1, 2015-July 31, 2020). Mean annual and cumulative OOP costs (co-pay + co-insurance + deductible) (2020 USD) were reported through a 3-year period post-cancer diagnosis among adult commercially insured members (not including Medicare Advantage members) diagnosed with staged breast, cervical, colorectal, lung, ovarian, or prostate cancer between January 1, 2016 and June 30, 2020 with continuous enrollment for ≥1-month post-diagnosis.

RESULTS

A total of 7,494 eligible members were identified who were diagnosed with breast, cervical, colorectal, lung, ovarian, or prostate cancer. A greater proportion of OOP costs were incurred in year 1 post-diagnosis but remained relatively high through year 3 post-diagnosis. Cumulative mean OOP costs were as high as $35,243 (lung stage IV) per commercially insured patient by year 3 post-diagnosis and were generally higher among those diagnosed at later stages (III/IV) than those diagnosed at earlier stages (I/II) across all cancers.

LIMITATIONS

Generalizability of these results is limited to those with commercial health insurance coverage. Additionally, cancer staging was dependent on accuracy of staging as recorded in the electronic medical record and as determined by Optum's proprietary algorithm using natural language processing.

CONCLUSION

Cumulative mean OOP costs among commercially insured patients during the 3-year period post-cancer diagnosis were substantial and generally higher among those with later stage cancer diagnoses. Diagnosis of cancer at earlier stages may allow for more timely treatment and lessen patient OOP costs.

Barriers and facilitators to early-stage lung cancer care in the USA: a qualitative study

PURPOSE

Improved outcomes in lung cancer treatment are seen in high-volume academic centers, making it important to understand barriers to accessing care at such institutions. Few qualitative studies examine the barriers and facilitators to early-stage lung cancer care at US academic institutions.

METHODS

Adult patients with suspected or diagnosed early-stage non-small cell lung cancer presenting to a multidisciplinary lung cancer clinic at a US academic institution over a 6-month period beginning in 2019 were purposively sampled for semi-structured interviews. Semi-structured interviews were conducted and a qualitative content analysis was performed using the framework method. Themes relating to barriers and facilitators to lung cancer care were identified through iterative team-based coding.

RESULTS

The 26 participants had a mean age of 62 years (SD: 8.4 years) and were majority female (62%), white (77%), and urban (85%). We identified 6 major themes: trust with providers and health systems are valued by patients; financial toxicity negatively influenced the diagnostic and treatment experience; social constraints magnified other barriers; patient self-advocacy as a facilitator of care access; provider advocacy could overcome other barriers; care coordination and good communication were important to patients.

CONCLUSIONS

We have identified several barriers and facilitators to lung cancer care at an academic center in the US. These factors need to be addressed to improve quality of care among lung cancer patients. Further work will examine our findings in a community setting to understand if our findings are generalizable to patients who do not access a tertiary cancer care center.

Expert Insights on Current Treatments for Hepatocellular Carcinoma: Clinical and Molecular Approaches and Bottlenecks to Progress

Hepatocellular carcinoma (HCC) is a primary liver tumor that typically occurs in the setting of chronic liver disease/cirrhosis. Treatment modalities for HCC have evolved and given the variety of treatment options, a multi-disciplinary approach requiring input from surgical, medical, and radiation oncology, hepatology, and interventional radiology is necessary. Multiple advances have been made over the last decade regarding treatment of HCC, especially advanced disease. Resection and transplantation remain as cornerstone curative-intent treatment options. For patients who are not candidates for curative-intent therapy, exciting progress has been made in molecular and cellular approaches to systemic therapy for HCC including immunotherapies and tyrosine kinase inhibitors. Although the prognosis for advanced HCC remains poor, the armamentarium of therapies has increased, and valuable years of life can be gained with these therapies. While the main therapeutic modality for early-stage disease remains resection, multimodal immunotherapy has emerged as first-line treatment for advanced disease. We herein review different clinical and molecular treatment modalities related to the treatment of HCC, as well as provide insights into future directions for HCC treatment. We highlight how research and progress are needed to move into a new era of molecular and cellular treatments.

Managing the onset of a new disease in older age: Housing wealth, mortgage borrowing, and medication adherence

The relationship between wealth and health is an important yet complex topic for health research. While prior studies document the importance of wealth for healthy aging, the understanding of the mechanisms through which wealth supports health consumption is limited. We investigate the wealth-to-health link by explicitly modeling the effect of liquidating home equity through borrowing on health expenditures, measured here as cost-related non-adherence to prescription medications (CRN), following the onset of one of six costly diseases on or after age 65. Using individual-level data from the 2002-2018 waves of the U.S. Health and Retirement Study (3,772 respondents; 13,708 observations), we exploit exogenous spatial and intertemporal variation in ZIP-code level house values to instrument for borrowing. Results indicate each additional $10,000 in new mortgage borrowing is associated with a 1.6 percentage point reduction in CRN. In subsample regressions, this relationship is strongest for older adults for whom home equity is their largest source of wealth. In a falsification test, we find no relationship between house value changes and CRN for older renters, and no effect of mortgage borrowing on prescription drug non-adherence for health or memory reasons. Our results contribute to the literature by documenting how housing wealth can be tapped by older adults through borrowing to smooth health-related consumption following disease diagnosis. However, not all older homeowners are willing or able to borrow from home equity. Our findings suggest that it is not simply the stock of housing wealth that leads to better health outcomes, but instead the liquidation of housing wealth. Housing wealth is thus not a uniform social determinate of health for older homeowners as it is moderated by the ability to borrow.

Association of Chronic Disease With Patient Financial Outcomes Among Commercially Insured Adults

Importance

The bidirectional association between health and financial stability is increasingly recognized.

Objective

To describe the association between chronic disease burden and patients' adverse financial outcomes.

Design, Setting, and Participants

This cross-sectional study analyzed insurance claims data from January 2019 to January 2021 linked to commercial credit data in January 2021 for adults 21 years and older enrolled in a commercial preferred provider organization in Michigan.

Exposures

Thirteen common chronic conditions (cancer, congestive heart failure, chronic kidney disease, dementia, depression and anxiety, diabetes, hypertension, ischemic heart disease, liver disease, chronic obstructive pulmonary disease and asthma, serious mental illness, stroke, and substance use disorders).

Main Outcomes and Measures

Adjusted probability of having medical debt in collections, nonmedical debt in collections, any delinquent debt, a low credit score, or recent bankruptcy, adjusted for age group and sex. Secondary outcomes included the amount of medical, nonmedical, and total debt among individuals with nonzero debt.

Results

The study population included 2 854 481 adults (38.4% male, 43.3% female, 12.9% unknown sex, and 5.4% missing sex), 61.4% with no chronic conditions, 17.7% with 1 chronic condition, 14.8% with 2 to 3 chronic conditions, 5.4% with 4 to 6 chronic conditions, and 0.7% with 7 to 13 chronic conditions. Among the cohort, 9.6% had medical debt in collections, 8.3% had nonmedical debt in collections, 16.3% had delinquent debt, 19.3% had a low credit score, and 0.6% had recent bankruptcy. Among individuals with 0 vs 7 to 13 chronic conditions, the predicted probabilities of having any medical debt in collections (7.6% vs 32%), any nonmedical debt in collections (7.2% vs 24%), any delinquent debt (14% vs 43%), a low credit score (17% vs 47%) or recent bankruptcy (0.4% vs 1.7%) were all considerably higher for individuals with more chronic conditions and increased with each added chronic condition. Among individuals with medical debt in collections, the estimated amount increased with the number of chronic conditions ($784 for individuals with 0 conditions vs $1252 for individuals with 7-13 conditions) (all P < .001). In secondary analyses, results showed significant variation in the likelihood and amount of medical debt in collections across specific chronic conditions.

Conclusions and Relevance

This cross-sectional study of commercially insured adults linked to patient credit report outcomes shows an association between increasing burden of chronic disease and adverse financial outcomes.

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.

Financial toxicity in female patients with breast cancer: a national cross-sectional study in China

PURPOSE

To quantify financial toxicity of female patients with breast cancer in China and investigate its factors and patients' coping strategies.

METHODS

The Comprehensive Score for Financial Toxicity (COST) is defined by using a structured questionnaire containing 12 items measuring perceived affordability of healthcare services, with the range of scoring of which being from 0 to 44 (higher score indicates lower financial toxicity). From January to March 2021, a total of 664 female patients diagnosed with stage 0-IV breast cancer were recruited from 33 public tertiary cancer hospitals located in 31 provinces of China. Multivariate linear regression models were used.

RESULTS

The median age of patients was 48 years (range: 26-84 years), and 62.04% lived in urban areas. The median COST score was 21.00 (interquartile range: 15-26). Older age, higher household income, and better self-reported health status were associated with lower financial toxicity, while a bigger household size, being retired or unemployed, stage IV cancer, and a history of targeted therapy were associated with higher financial toxicity (all P < 0.05). Nearly half of the patients reported using at least one coping strategy, including considering quitting treatment, delaying treatment, and failing to take medicine or attend medical visits as instructed. The people with increased financial toxicity seem to adopt more coping strategies.

CONCLUSIONS

Financial toxicity and coping strategies are common among Chinese women with breast cancer. An understanding of the factors regarding financial toxicity may help oncologists and policy-makers identify at-risk patients and develop targeted interventions.

Industry Relationships With Medical Oncologists: Who Are the High-Payment Physicians?

PURPOSE:

Many oncologists have relationships with industry. Previous work has shown that these payments are usually modest; however, there exist a subset of medical oncologists who receive more than $100,000 US dollars (USD) annually. Here, we describe the characteristics of these physicians.

METHODS:

This retrospective cohort study used the Open Payments data set to identify all US-based medical oncologists/hematologists who received $100,000+ USD in general payments linked to cancer medications in 2018. Open Payments and a web-based search were used to identify physician characteristics, demographics, research profile, and leadership positions.

RESULTS:

One hundred thirty-nine medical oncologists received > $100,000 USD in general payments. The median payment was $154,613 USD, and the total payment was $24.2 million USD. These high-payment physicians represent 1% of all US medical oncologists (N = 10,620) yet account for 37% of all industry payments in 2018. Sixty percent (84 of 139) and 21% (29 of 139) of these high-payment physicians hold hospital and specialty association leadership roles, respectively. One quarter (24%, 33 of 139) serve on journal editorial boards, and 10% (14 of 139) have authored clinical practice guidelines; 72% (100 of 139) hold faculty appointments.

CONCLUSION:

A small number of medical oncologists receive very high payments from the pharmaceutical industry. These physicians hold major leadership roles within oncology. Further work is needed to understand the extent to which these conflicts of interest may shape clinical practice and policy.

Chemotherapy and Related Female Sexual Dysfunction: A Review of Literature

Context: Cancer is a detrimental illness that affects patients’ quality of life and other aspects of a healthy life. Chemotherapy has been shown to have a direct and indirect effect on the sex organs of women. Evidence Acquisition: We searched in databases including PubMed, Scopus, and Google scholar. The keywords for our search were as follows: “Chemotherapy” OR “Cancer treatment” AND “Sexual dysfunction “OR “Sexuality” OR "libido” OR "dyspareunia" OR "orgasmic disorder" OR "sexual disorder". We evaluated the articles based on their abstract and 92 studies were selected and used in the present study. Results: Chemotherapeutic agents damage ovaries and could cause premature ovarian failure. Furthermore, chemotherapy disturbs the femininity aspects of patients and reduces their libido. In this review article, we aimed at a better understanding the effect of chemotherapy on the sexual function of female cancer survivals. Conclusions: In conclusion, chemotherapy is one of the most common cancer treatments affecting sexual health aspects, such as decreased libido, arousal and orgasm, dyspareunia, dysfunction of the sexual response cycle before puberty, and vulvovaginal atrophy. However, many patients are reluctant to discuss their sexual problems.

Geographical Disparities and Factors Associated With the Decision to Decline Chemotherapy in Breast Cancer

PURPOSE

Social determinants of health have been linked to treatment-related disparities in breast cancer. We analyzed data from a large national registry to explore factors related to accepting or declining recommended chemotherapy and whether patients' decisions vary geographically across the United States.

METHODS

We used the National Cancer Database to study treatment decision making in patients with advanced breast cancer (American Joint Committee on Cancer clinical stage III-IV) between 2004 and 2017. We focused the analysis on patients who were recommended chemotherapy by their physicians but who declined this treatment. Multivariate logistic regression analysis was performed.

RESULTS

A total of N = 215,284 patients with stage III and IV breast cancers were included. Patients in the New England region were more likely to refuse chemotherapy compared with the rest, with patients in the East South Central regions (AL, KY, MS, and TN) and West South Central (AR, LA, OK, and TX) noted to be least likely to refuse chemotherapy. Factors related to a higher rate of refusal by patients included older age > 70 years; hormone receptor-positive tumors; and having higher comorbidity. Patients identified as Hispanic, those who are privately insured, and patients at academic institutions were less likely to decline chemotherapy.

CONCLUSION

This analysis identified a significant difference in rates of refusal of recommended chemotherapy by geographical location, insurance status, and treatment facility after adjusting for known social determinants of health. Further understanding of the factors affecting treatment decisions would be important to improve the efficacy of care delivery in patients with cancer and reduce reversible causes of disparity.

Risk factors for financial toxicity in patients with gynecologic cancer

BACKGROUND

The cost of cancer care is high and rising. Evidence of increased patient cost burden is prevalent in the medical literature and has been defined as "financial toxicity," the financial hardship and financial concerns experienced by patients because of a disease and its related treatments. With targeted therapies and growing out-of-pocket costs, patient financial toxicity is a growing concern among patients with gynecologic cancer.

OBJECTIVE

This study aimed to determine the prevalence of financial toxicity and identify its risk factors in patients with gynecologic cancer treated at a large cancer center using objective data.

STUDY DESIGN

Using institutional databases, we identified patients with gynecologic cancer treated from January 2016 to December 2018. Patients with a preinvasive disease were excluded. Financial toxicity was defined according to institutionally derived metrics as the presence of ≥1 of the following: ≥2 bills sent to collections, application or granting of a payment plan, settlement, bankruptcy, financial assistance program enrollment, or a finance-related social work visit. Clinical characteristics were gathered using a 2-year look-back from the time of the first financial toxicity event or a randomly selected treatment date for those not experiencing toxicity. Risk factors were assessed using chi-squared tests. All significant variables on univariate analysis were included in the logistic regression model.

RESULTS

Of the 4655 patients included in the analysis, 1155 (25%) experienced financial toxicity. In the univariate analysis, cervical cancer (35%), stage 3 or 4 disease (24% and 30%, respectively), younger age (35% for age <30 years), nonpartnered marital status (31%), Black (45%) or Hispanic (37%) race and ethnicity, self-pay (48%) or commercial insurance (30%), clinical trial participation (31%), more imaging studies (39% for ≥9), ≥1 emergency department visit (36%), longer inpatient stays (36% for ≥20 days), and more outpatient clinician visits (41% for ≥20 visits) were significantly associated with financial toxicity (P<.01). In multivariate analysis, younger age, nonpartnered marital status, Black and Hispanic race and ethnicity, commercial insurance, more imaging studies, and more outpatient physician visits were significantly associated with financial toxicity.

CONCLUSION

Financial toxicity is an increasing problem for patients with gynecologic cancer. Our analysis, using objective measures of financial toxicity, has suggested that demographic factors and healthcare utilization metrics may be used to proactively identify at-risk patients for financial toxicity.