Crowdsourcing to measure financial toxicity in gynecologic oncology

Mirvetuximab soravtansine in platinum-resistant recurrent ovarian cancer with high folate receptor-alpha expression: a cost-effectiveness analysis

OBJECTIVE

Mirvetuximab soravtansine (MIRV), a new antibody-drug conjugate, versus the investigator's choice of chemotherapy (IC) was the first treatment to demonstrate benefits for progression-free and overall survival in platinum-resistant recurrent ovarian cancer (PROC) with high folate receptor-alpha (high-FRα) expression. Efficacy, safety, and economic effectiveness make MIRV the new standard of care for these patients.

METHODS

Based on patients and clinical parameters from MIRASOL (GOG 3045/ENGOT-ov55) phase III randomized controlled trials, the Markov model with a 20-year time horizon was established to evaluate the cost and efficacy of MIRV and IC for PROC with high-FRα expression, considering the bevacizumab-pretreated situation from the American healthcare system. Total cost, life-years (LYs), quality-adjusted life-years (QALYs), incremental cost-effectiveness ratio (ICER), and incremental net health benefits were the main outcome indicators and compared with willingness-to-pay threshold of $100,000/QALY. Sensitivity and scenario analyses were conducted.

RESULTS

Compared with the IC, MIRV was associated with incremental costs of $538,251, $575,674, and $188,248 with the corresponding QALYs (LYs) increased by 0.90 (1.55), 1.09 (1.88), and 0.53 (0.79), leading to ICERs of $596,189/QALY ($347,995/LY), $530,061/QALY ($306,894/LY), and $1,011,310/QALY ($680,025/LY) in the overall, bevacizumab-naïve, and bevacizumab-pretreated patients, respectively. When MIRV is reduced by more than 75%, it may be a cost-effective treatment.

CONCLUSION

At the current price, MIRV for PROC with high-FRα expression is not the cost-effective strategy in the US. However, its treatment has higher health benefits in bevacizumab-naïve patients, which is likely to be an alternative.

Immune checkpoint inhibitor combinations for patients with advanced endometrial cancer: a network meta-analysis and cost-utility analysis

BACKGROUND

Immune checkpoint inhibitor combinations show significant survival advantages compared with chemotherapy for patients with advanced endometrial cancer.

OBJECTIVE

To compare the efficacy, safety, and cost-effectiveness of different immunotherapy combinations for clinician and patient decision-making.

METHODS

The PubMed, Embase, Cochrane, and Web of Science Databases were reviewed from January 1, 2010 to October 30, 2023, for phase III randomized controlled trials of first-line immunotherapy combinations in patients with advanced endometrial cancer. Bayesian network meta-analysis was performed to obtain hazard ratios (HRs) of overall survival and progression-free survival, relative risks (RRs) of adverse events, and corresponding p value. The lifetime Markov model of cost-effectiveness analysis was developed to summarize the cost, life-years, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios at the US$150 000/QALY of willingness-to-pay of six first-line treatment strategies.

RESULTS

Four trials were identified, involving 2577 patients. Dostarlimab plus chemotherapy or durvalumab plus chemotherapy with olaparib was associated with more survival benefits than other immunotherapy regimens and chemotherapy in the mismatch repair-deficient microsatellite instability-high (dMMR/MSI-H) and mismatch repair-proficient microsatellite-stable (pMMR/MSS) population, respectively. Further, pembrolizumab plus chemotherapy versus chemotherapy increased efficacy (cost) by 3.76 QALYs and US$540 817, which yielded incremental cost-effectiveness ratios of US$143 894/QALY in the dMMR/MSI-H population.

CONCLUSION

First-line durvalumab plus chemotherapy with olaparib, and dostarlimab plus chemotherapy, were more beneficial for survival in the pMMR/MSS and dMMR/MSI-H populations, respectively. Only pembrolizumab plus chemotherapy versus chemotherapy was cost-effective for patients with dMMR/MSI-H endometrial cancer in the USA.

Implementation of a financial navigation program in gynecologic oncology

BACKGROUND

"Financial Toxicity" (FT) is the financial burden imposed on patients due to disease and its treatment. Approximately 50% of gynecologic oncology patients experience FT. This study describes the implementation and outcomes of a novel financial navigation program (FNP) in gynecologic oncology.

METHODS

Patients presenting for initial consultation with a gynecologic oncologist from July 2022 to September 2023 were included. A FNP was launched inclusive of hiring a financial navigator (FN) in July 2022, and implementing FT screening in October 2022. We prospectively captured patient referrals to the FN, collecting clinical, demographic, financial and social needs information, along with FN interventions and institutional support service referrals. Referrals to the FN and support services were quantified before and after screening implementation.

RESULTS

There were 1029 patients with 21.6% seen before and 78.4% after screening initiation. Median age was 58 (IQR 46-68). The majority were non-Hispanic white (60%) with private insurance (61%). A total of 10.5% patients were referred to the FN. Transportation (32%), financial assistance (20.5%) and emotional support (15.4%) were the most common needs identified. A higher proportion of patients referred to the FN identified as Black, had government-funded insurance or diagnoses of uterine or cervical cancers (p < 0.05). Post-screening referrals to FN increased (5% vs. 12.9%, p < 0.001), while referrals to other support services decreased (9.5% vs. 2.9%, p < 0.001).

CONCLUSIONS

Implementation of the FNP was feasible, though presence of both a FN and FT screening maximized its effectiveness. Further investigation is needed to understand screening barriers and evaluate longer-term impact.

Screening for Health-Related Social Needs and Financial Toxicity Among Patients With Cancer Treated With Radiation Therapy: Findings From a Quality Improvement Project

INTRODUCTION

Financial toxicity is common among patients with cancer, as are co-occurring health-related social risks (HRSRs). There is limited evidence to support best practices in screening for HRSRs and financial toxicity in the cancer context. This analysis sought to understand variations of identified needs based on treatment course using data from a large screening program.

METHODS

This 2022 to 2023 screening quality improvement program included four services (breast, gastrointestinal, gynecologic, thoracic) at an urban comprehensive cancer center. The Comprehensive Score for Financial Toxicity measured financial toxicity. Patients completed an HRSR checklist documenting food, housing, medication, or transportation insecurity and financial borrowing practices. Differences were evaluated by treatment course (radiation therapy [RT] versus other treatment and RT plus chemotherapy versus other treatment).

RESULTS

Screening surveys were sent to 70,983 unique patients; 38,249 completed a screening survey (54% response rate). Of responders, 4% (n = 1,686) underwent RT in the 120 days before their survey, and 3% (n = 1,033) received RT in combination with chemotherapy. Overall, patients receiving RT had lower unadjusted Comprehensive Score for Financial Toxicity scores, indicating worse financial toxicity. The proportion of patients receiving RT reporting unmet transportation (15% versus 12%, P < .001) and food (13% versus 11%, P = .02) needs was significantly higher than for patients not receiving RT. More patients receiving RT borrowed money than did patients not receiving RT (17% versus 15%, P = .02). In multivariable models, RT (alone or in combination) was associated with worse financial toxicity and transportation difficulties.

CONCLUSIONS

Screening for financial toxicity and HRSR is possible at a large cancer center. Patients receiving RT have higher transportation insecurity and worse financial toxicity compared with those receiving other treatments. Tailored intervention throughout the treatment trajectory is essential.

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.

#HashtagThis - Everything you need to know about launching your gynecologic oncology social media research career: A report from Gynecologic Oncology Reports and Society of Gynecologic Oncology Education Committee

On February 6th, 2024, Gynecologic Oncology Reports and the Society of Gynecologic Oncology Education Committee co-hosted a webinar about ways to use social media for career enhancement and for dissemination of research. During the discussion, we reviewed:i.how to identify one's goals, target audience, and select a social media platform.ii.how to navigate the negatives of social media.iii.how to develop one's online academic brand.iv.how to use social media for academic promotion and career advancement.v.how to use social media as a research tool.vi.how to use visual tools to bring attention to one's research.The objective of this report is to review the literature on social media in oncology and review the webinar presentation.

"Having cancer is very expensive": A qualitative study of patients with ovarian cancer and PARP inhibitor treatment

OBJECTIVE

To examine patient barriers and facilitators to PARP inhibitor (PARP-I) maintenance therapy in ovarian cancer. PARP-I improves survival in ovarian cancer, but these multi-year therapies cost around $100,000 annually and are under-prescribed.

METHODS

We recruited patients with ovarian cancer treated with PARP-I maintenance therapy at an academic health system for a semi-structured interview. Patient demographics, including genetics and PARP-I cost, were self-reported. We assessed patient experiences with barriers and facilitators of PARP-I usage. Two team members used a thematic approach to analyze and identify key themes.

RESULTS

In May 2022, we interviewed 10 patients (mean age = 65 years; 80% White; 60% with a germline genetic mutation). Patients paid on average $227.50 monthly for PARP-I, straining resources for some participants. While sampled patients were insured, all patients identified having no or inadequate insurance as a major barrier to PARP-I. At the same time, all participants prioritized clinical effectiveness over costs of care. Patients identified PARP-I delivery from specialty pharmacies, separate and different from other medications, as a potential barrier, but each had been able to navigate delivery. Patients expressed significant initial side effects of PARP-I as a potential barrier yet reported clinician communication and prompt dose reduction as facilitating continuation.

CONCLUSIONS

Patients identified cost, restrictive pharmacy benefits, and initial side effects as barriers to PARP-I usage. Having insurance and a supportive care team were identified as facilitators. Enhancing communication about PARP-I cost and side effects could improve patient experience and receipt of evidence-based maintenance therapy in ovarian cancer.

Assessment of the prevalence and related factors of financial toxicity in cancer patients based on the COST scale: A systematic review and meta-analysis

PURPOSE

The high cost of cancer treatment exposes patients to financial toxicity during treatment; however, no study has comprehensively analyzed the incidence of financial toxicity using a validated assessment tool. In this study, the objective was to ascertain the incidence of financial toxicity in cancer patients and the factors influencing it.

METHODS

Nine electronic databases were retrieved to collect cross-sectional studies reporting financial toxicity in cancer patients. A random effects meta-analysis was applied to yield the overall prevalence of financial toxicity. Subgroup analyses were conducted depending on the factors affecting financial toxicity.

RESULTS

In total, 30 studies met our inclusion criteria. The pooled prevalence of financial toxicity in cancer patients was 48% (95%CI:38%-58%, I2 = 99.4%, p < 0.001). In the subgroup analysis, a higher prevalence of financial toxicity in patients aged <67 years (47%, 95%CI: 28%-66%, I2 = 97.5%, p < 0.001), female (46%, 95%CI:39%-53%, I2 = 94.9%,p < 0.001), lung cancer(57%, 95%CI:38%-75%, I2 = 96.9%, p < 0.001), developing countries (64%, 95%CI:55%-72%, I2 = 98.1%, p < 0.001), time of investigation following COVID-19 (53%, 95%CI:37%-69%, I2 = 99.4%, p < 0.001).

CONCLUSION

Financial toxicity is prevalent in cancer patients and is increasingly evident after COVID-19. Furthermore, the odds of financial toxicity are higher in patients who are female, younger, whose cancer type is lung cancer, and from developing countries. These findings emphasize the significance of evaluating financial toxicity in cancer patients after COVID-19, especially in developing countries. This may play a pivotal role in helping patients cope with financial toxicity.

Financial toxicity among people with metastatic cancer: findings from the Cancer Experience Registry

PURPOSE

This study describes financial toxicity (FT) reported by people with metastatic cancer, characteristics associated with FT, and associations between FT and compensatory strategies to offset costs.

METHODS

Cancer Support Community's Cancer Experience Registry data was used to identify respondents with a solid tumor metastatic cancer who completed the Functional Assessment of Chronic Illness Therapy COmprehensive Score for Financial Toxicity (FACIT-COST) measure. Multivariable logistic regression analyses examined associations between respondent characteristics and FT, and FT and postponing medical visits, nonadherence to medications, and postponing supportive and/or psychosocial care.

RESULTS

484 individuals were included in the analysis; the most common cancers included metastatic breast (31%), lung (13%), gynecologic (10%), and colorectal (9%). Approximately half of participants (50.2%) reported some degree of FT. Those who were non-Hispanic White, Hispanic, or multiple races (compared to non-Hispanic Black), and who reported lower income, less education, and being less than one year since their cancer diagnosis had greater odds of reporting FT. Individuals with any level of FT were also more likely to report postponing medical visits (Adjusted Odds Ratio [OR] 2.58; 95% Confidence Interval [CI] 1.45-4.58), suboptimal medication adherence (Adjusted OR 5.05; 95% CI 2.77-9.20) and postponing supportive care and/or psychosocial support services (Adjusted OR 4.16; 95% CI 2.53-6.85) compared to those without FT.

CONCLUSIONS

With increases in the number of people living longer with metastatic cancer and the rising costs of therapy, there will continue to be a need to systematically screen and intervene to prevent and mitigate FT for these survivors.

A Financial Toxicity Screening and Care Coordination Quality Improvement Program in a Gynecology Oncology Urban Practice

Background

Educating a multidisciplinary team on financial toxicity (FT) risk, screening, and care coordination is an approach to addressing gaps in care among newly diagnosed patients with stage III or IV cancer.

Objective

The goal of this quality improvement project (QIP) was to supply an education program for the multidisciplinary team providing insights for the following objectives: (1) Increase the rate of FT screening where there was no baseline screening, (2) Increase referrals for resource care coordination among patients experiencing FT, and (3) Evaluate the relationship between FT and selected demographic identifiers during the 8-week project.

Methods

The Plan-Do-Study-Act (PDSA) model was adopted for learning and leading the change during the QIP, focusing on the COmprehensive Score for financial Toxicity (COST) and resource care coordination for newly diagnosed participants with stage III or IV gynecologic cancer.

Results

Of the 42 (80.75%) participants consenting to the QIP, 61.90% had COST scores below 23, with 100% (26) of the participants receiving referrals for resource care coordination. On average, 6.50 patients enter the practice for care, with 50% (3.25) reporting FT. At this rate, 162.50 patients were experiencing FT in a 50-week year and were not receiving resource care coordination. However, because some patients did not consent to the QIP, the average FT (Yes) count could potentially be between 199.50 to 225.00 patients in a 50-week year, leading to a potential 62.50 with FT (or 28% of 225.00) not receiving referrals. Age was the main driver for FT COST Score in this QIP. Many variables were unobserved in this QIP and could impact the FT COST Score. However, separate modeling reveals that age alone explains approximately 15% of FT COST scores' observed changes. Controlling for more variables may refine the model, but it seems unlikely by the data analysis that age would disappear as a driver of change in the FT COST score.

Conclusion

Developing a multidisciplinary education program focusing on a structured QIP-PDSA plan can be an example of standardizing an FT screening and care coordination program. The QIP team successfully incorporated a PDSA model roadmap screening program to identify the participants experiencing FT and promptly referred 100% for resource care coordination.

Financial toxicity in pregnancy and postpartum

INTRODUCTION

The financial burden of pregnancy in the United States can be high and is associated with worse mental health and birth outcomes. Research on the financial burden of health care, such as the development of the COmprehensive Score for Financial Toxicity (COST) tool, has been conducted primarily among patients with cancer. This study aimed to validate the COST tool and use it to measure financial toxicity and its impacts among obstetric patients.

METHODS

We used survey and medical record data from obstetric patients at a large medical center in the United States. We validated the COST tool using common factor analysis. We used linear regression to identify risk factors for financial toxicity and to investigate associations between financial toxicity and patient outcomes including satisfaction, access, mental health, and birth outcomes.

RESULTS

The COST tool measured two distinct constructs of financial toxicity in this sample: current financial toxicity and concern over future financial toxicity. Racial/ethnic category, insurance, neighborhood deprivation, caregiving, and employment were associated with current financial toxicity (P < 0.05 for all). Only racial/ethnic category and caregiving were associated with concern over future financial toxicity (P < 0.05 for all). Both current and future financial toxicity were associated with worse patient-provider communication, depressive symptoms, and stress (P < 0.05 for all). Financial toxicity was not associated with birth outcomes or keeping obstetric visits.

CONCLUSIONS

The COST tool captures two constructs among obstetric patients, current and future financial toxicity, both of which are associated with worse mental health and patient-provider communication.

Factors associated with increased financial toxicity after the completion of radiation treatment for gynecologic cancer

PURPOSE

We evaluated financial toxicity (FT) in patients with gynecologic cancer treated with radiation and assessed the impact of the COVID-19 pandemic on patients' financial wellbeing.

METHODS

Patients completed a survey 1 month after completing radiation from August 2019-March 2020 and November 2020-June 2021. The survey included the COmprehensive Score for Financial Toxicity (COST) tool, EQ-5D to measure quality of life (QOL) and pandemic-related questions for the second survey period. High FT was COST score ≤ 23.

RESULTS

Of 97 respondents (92% response rate), 49% completed the survey pre-pandemic and 51% after; the majority were white (76%) and had uterine cancer (64%). Sixty percent received external beam radiation with or without brachytherapy; 40% had only brachytherapy. High FT was associated with worse QOL (r = -0.37, P < 0.001), younger age and type of insurance (both p ≤ 0.03). Respondents with high FT were 6.0 (95% CI 1.0-35.9) times more likely to delay/avoid medical care, 13.6 (95% CI 2.9-64.3) times more likely to borrow money, and 6.9 (95% CI 1.7-27.2) times as likely to reduce spending on basic goods. The pandemic cohort had a smaller proportion of respondents with high FT than the pre-pandemic cohort (20% vs. 35%, p = 0.10) and a higher median COST score (32 (IQR 25-35) vs. 27 (IQR 19-34), p = 0.07).

CONCLUSION

Privately insured, younger respondents who received radiation for gynecologic cancer were at risk for FT. High FT was associated with worse QOL and economic cost-coping strategies. We observed less FT in the pandemic cohort, though not statistically different from the pre-pandemic cohort.

Association between financial toxicity and health-related quality of life of patients with gynecologic cancer

OBJECTIVES

Patients often struggle with their financial situation during cancer treatment due to treatment-related costs or loss of income. This resulting negative effect is called financial toxicity, which is a known as a side effect of cancer care. This study aimed to evaluate the association between financial toxicity and health-related quality of life among patients with gynecologic cancer using validated questionnaires.

METHODS

In this multicenter study, patients with gynecologic cancer receiving anti-cancer drug treatment for > 2 months were recruited. Patients answered the COmprehensive Score for Financial Toxicity (COST) tool, EORTC-QLQ-C30, disease-specific tools (EORTC-QLQ-OV28/CX24/EN24), and EQ-5D-5L. Spearman's rank correlation coefficient was used to determine associations.

RESULTS

Between April 2019 and July 2021, 109 cancer patients completed the COST questionnaire. The mean COST score was 19.82. Strong associations were observed between financial difficulty (r = - 0.616) in the EORTC-QLQ-C30 and body image (r = 0.738) in the EORTC-QLQ-CX24, while weak associations were noted between the global health status/quality of life (r = 0.207), EQ-5D-5L index score (r = 0.252), and several function and symptom scale scores with the COST score.

CONCLUSIONS

Greater financial toxicity was associated with worse health-related quality of life scores, such as financial difficulty in gynecologic cancer patients and body image in cervical cancer patients as strong associations, and weakly associated with general health-related quality of life scores and several function/symptom scales.

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.

Factor Analysis of Health Care Access With Ovarian Cancer Surgery and Gynecologic Oncologist Consultation

IMPORTANCE

Poor health care access (HCA) is associated with racial and ethnic disparities in ovarian cancer (OC) survival.

OBJECTIVE

To generate composite scores representing health care affordability, availability, and accessibility via factor analysis and to evaluate the association between each score and key indicators of guideline-adherent care.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used data from patients with OC diagnosed between 2008 and 2015 in the Surveillance, Epidemiology, and End Results (SEER) Medicare database. The SEER Medicare database uses cancer registry data and linked Medicare claims from 12 US states. Included patients were Hispanic, non-Hispanic Black, and non-Hispanic White individuals aged 65 years or older diagnosed from 2008 to 2015 with first or second primary OC of any histologic type (International Classification of Diseases for Oncology, 3rd Edition [ICD-O-3] code C569). Data were analyzed from June 2020 to June 2022.

EXPOSURES

The SEER-Medicare data set was linked with publicly available data sets to obtain 35 variables representing health care affordability, availability, and accessibility. A composite score was created for each dimension using confirmatory factor analysis followed by a promax (oblique) rotation on multiple component variables.

MAIN OUTCOMES AND MEASURES

The main outcomes were consultation with a gynecologic oncologist for OC and receipt of OC-related surgery in the 2 months prior to or 6 months after diagnosis.

RESULTS

The cohort included 8987 patients, with a mean (SD) age of 76.8 (7.3) years and 612 Black patients (6.8%), 553 Hispanic patients (6.2%), and 7822 White patients (87.0%). Black patients (adjusted odds ratio [aOR], 0.75; 95% CI, 0.62-0.91) and Hispanic patients (aOR, 0.81; 95% CI, 0.67-0.99) were less likely to consult a gynecologic oncologist compared with White patients, and Black patients were less likely to receive surgery after adjusting for demographic and clinical characteristics (aOR, 0.76; 95% CI, 0.62-0.94). HCA availability and affordability were each associated with gynecologic oncologist consultation (availability: aOR, 1.16; 95% CI, 1.09-1.24; affordability: aOR, 1.13; 95% CI, 1.07-1.20), while affordability was associated with receipt of OC surgery (aOR, 1.08; 95% CI, 1.01-1.15). In models mutually adjusted for availability, affordability, and accessibility, Black patients remained less likely to consult a gynecologic oncologist (aOR, 0.80; 95% CI, 0.66-0.97) and receive surgery (aOR, 0.80; 95% CI, 0.65-0.99).

CONCLUSIONS AND RELEVANCE

In this cohort study of Hispanic, non-Hispanic Black, and non-Hispanic White patients with OC, HCA affordability and availability were significantly associated with receiving surgery and consulting a gynecologic oncologist. However, these dimensions did not fully explain racial and ethnic disparities.

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.

Financial toxicity following surgical treatment for colorectal cancer: a cross-sectional study

PURPOSE

Financial toxicity has become a global public health issue. The purpose of the study is to investigate and analyze the influencing factors of financial toxicity in patients with non-metastatic colorectal cancer.

METHODS

A convenient sample of 250 patients with stage I-III colorectal cancer was investigated in the study. They completed a set of questionnaires, including the Comprehensive Score for Financial Toxicity questionnaire, the Perceived Social Support Scale, and the Hospital Anxiety and Depression Scale. Univariate and multivariate linear regression were performed to investigate the influencing factors of financial toxicity.

RESULTS

Over half (52.8%, n = 132) of the colorectal cancer survivors experienced financial toxicity. Multivariate regression analysis showed that the factors associated with financial toxicity were young age, unemployment, low annual household income, chemotherapy, and the lack of sufficient social support (p < 0.05).

CONCLUSIONS

Financial toxicity is common among non-metastatic colorectal cancer survivors. Young age, lower annual household income, unemployment, chemotherapy, and insufficient social support were associated with financial toxicity.

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.

The utility of physical examination in ovarian cancer recurrence detection: a retrospective analysis informing virtual surveillance care

OBJECTIVES

Given the recent rapid increase in telemedicine in the setting of the COVID-19 pandemic, we sought to investigate the utility of symptom review, CA125, and physical examination in the detection of ovarian cancer recurrence to determine the role of virtual surveillance care in the COVID-19 era.

METHODS

This retrospective cohort study included patients diagnosed with ovarian cancer between 2013 and 2020 who achieved remission after primary treatment and then had recurrence while in a routine surveillance program. Modalities that detected recurrence including symptoms, CA125, physical examination, or 'other,' which was denoted if imaging was obtained for reasons other than suspected recurrence and recurrence was incidentally identified, were recorded. Descriptive statistics were performed to summarize the cohort.

RESULTS

One hundred and nine patients met inclusion criteria. At time of recurrence, elevated CA125 was present in 97 (89.0%) patients, symptoms in 41 (37.6%), and abnormal physical exam findings in 27 (24.8%). Recurrence was incidentally found with imaging obtained for reasons other than suspicion of recurrence in six (5.5%) patients. Recurrence was suspected based on multiple modalities in 46 (42.2%) patients. Elevated CA125, symptoms, or both were present in 102 (93.6%) patients. Of patients with abnormal physical exam findings, 26 (96.3%) also had elevated CA125 or symptoms present. Recurrence was suspected based on physical exam findings alone in one (0.9%) patient.

CONCLUSIONS

Over 90% of ovarian cancer recurrences were detected by rising CA125, symptoms, or both. Only one patient had recurrence detected by physical examination alone. Given that review of symptoms and CA125 can be conducted virtually, virtual visits may offer a reasonable alternative to in-person visits for ovarian cancer surveillance for patients who have pre-treatment elevated CA125.

Validity of the COmprehensive Score for financial Toxicity (COST) in patients with gynecologic cancer

OBJECTIVE

Financial toxicity is a financial burden of cancer care itself, which leads to worse quality of life and higher mortality and is considered an adverse effect. The COmprehensive Score for financial Toxicity (COST) tool is a patient-reported outcome measurement used to evaluate financial toxicity. We aimed to validate the internal consistency and reproducibility of the COST tool in patients with gynecologic cancer.

METHODS

In this multicenter study covering the period April 2019 to July 2021, using the COST tool in Japan, patients diagnosed with ovarian, cervical, or endometrial cancer receiving systemic anti-cancer drug therapy for more than 2 months were eligible. Patients with no out-of-pocket costs for direct medical costs were excluded. The patients answered the initial test and a retest, which was completed from 2 to 14 days after the initial test. Internal consistency and reproducibility were assessed using Cronbach's alpha and intraclass correlation coefficient (ICC), respectively. Cronbach's alpha ≥0.8 indicates good internal consistency, and ICC ≥0.8 is highly reliable.

RESULTS

A total of 112 patients (ovarian: 50, cervical: 26, endometrial: 36) responded to the initial test, and 89 patients answered the retest from 2 to 14 days after the initial test. The median patient age was 58 (range, 28-78) years. The median COST score was 19. Cronbach's alpha showed good internal consistency at 0.83 (95% CI 0.78 to 0.87). The ICC at 0.850 (95% CI 0.777 to 0.900) showed high reliability.

CONCLUSIONS

The COST tool has good internal consistency and reliable reproducibility in patients with gynecologic cancer in Japan. The COST tool quantifies financial toxicity in the insurance system, where patients have limited out-of-pocket direct medical costs. The results support the use of the COST tool in patients with gynecologic cancer.

Patient-reported benefit from proposed interventions to reduce financial toxicity during cancer treatment

INTRODUCTION

Financial toxicity is common and pervasive among cancer patients. Research suggests that gynecologic cancer patients experiencing financial toxicity are at increased risk for engaging in harmful cost-coping strategies, including delaying/skipping treatment because of costs, or forsaking basic needs to pay medical bills. However, little is known about patients' preferences for interventions to address financial toxicity.

METHODS

Cross-sectional surveys to assess financial toxicity [Comprehensive Score for Financial Toxicity (COST)], cost-coping strategies, and preferences for intervention were conducted in a gynecologic cancer clinic waiting room. Associations with cost-coping were determined using multivariate modeling. Unadjusted odds ratios (ORs) explored associations between financial toxicity and intervention preferences.

RESULTS

Among 89 respondents, median COST score was 31.9 (IQR: 21-38); 35% (N = 30) scored < 26, indicating they were experiencing financial toxicity. Financial toxicity was significantly associated with cost-coping (adjusted OR = 3.32 95% CI: 1.08, 14.34). Intervention preferences included access to transportation vouchers (38%), understanding treatment costs up-front (35%), minimizing wait times (33%), access to free food at appointments (25%), and assistance with minimizing/eliminating insurance deductibles (23%). In unadjusted analyses, respondents experiencing financial toxicity were more likely to select transportation assistance (OR = 2.67, 95% CI: 1.04, 6.90), assistance with co-pays (OR = 9.17, 95% CI: 2.60, 32.26), and assistance with deductibles (OR = 12.20, 95% CI: 3.47, 43.48), than respondents not experiencing financial toxicity.

CONCLUSIONS

Our findings confirm the presence of financial toxicity in gynecologic cancer patients, describe how patients attempt to cope with financial hardship, and provide insight into patients' needs for targeted interventions to mitigate the harm of financial toxicity.

Greater financial toxicity relates to greater distress and worse quality of life among breast and gynecologic cancer survivors

BACKGROUND

Financial toxicity includes distress and burden from cancer-related costs. Women are more likely to experience worse cancer-related financial outcomes than men. This study evaluated breast and gynecologic cancer patients' subjective experiences of financial toxicity and associations with distress and quality of life (QOL).

METHODS

A cross-sectional survey study included measures of financial toxicity (Comprehensive Score for Financial Toxicity [COST] Version 2), distress (Patient Health Questionnaire), and QOL (Functional Assessment of Cancer Therapy). Chi-square, t-tests, and ANOVAs examined bivariate relationships. Two regression models tested associations between financial toxicity and distress and QOL, controlling for covariates. Financial toxicity subgroups were compared based on a validated grading system.

RESULTS

Participants (N = 273; 74% breast cancer) averaged 54.65 years (SD = 12.08), were 3.42 years (SD = 4.20) post-diagnosis, and 33% reported cancer-related change in employment status. Financial toxicity was "mild" overall (COST M = 26.11, SD = 11.14); 32% worried about cancer-related financial problems (quite a bit/very much; item-level analysis). Worse financial toxicity related to younger age (p < 0.001), identifying as a non-Asian minority (p = 0.03) or Hispanic (p = 0.01), being single (p < 0.001), lower education (p = 0.004), lower income (p < 0.001), late-stage disease (p = 0.001), recurrent disease (p = 0.004), and active treatment (p < 0.001). In separate multivariable models, greater financial toxicity related to greater distress (β = -0.45 p < 0.001) and worse QOL (β = 0.58, p < 0.001). Financial toxicity subgroups reported clinically significant differences in distress and QOL (p's < 0.05).

CONCLUSIONS

Cancer-related financial burden is associated with pervasive negative effects and may impact subgroups differently. Future research should explore financial experiences across subgroups, aiming to better identify those at risk and build targeted interventions.

Economic distress, financial toxicity, and medical cost-coping in young adult cancer survivors during the COVID-19 pandemic: Findings from an online sample

Background

Young adult (YA) cancer survivors are at risk for financial toxicity during and after cancer treatment. Financial toxicity has been associated with medical‐related cost‐coping behaviors such as skipping or delaying treatment. The coronavirus disease 2019 (COVID‐19) pandemic has resulted in dire economic consequences that may worsen financial hardship among young survivors.

Methods

This was a cross‐sectional survey; data collection occurred online. A convenience sample was recruited through YA cancer advocacy groups and social media. Negative economic events associated with the COVID‐19 pandemic (eg, income loss, increased debt, and decreased job security) and medical‐related cost‐coping were documented. A validated measure assessed cancer‐related financial toxicity.

Results

Participants (N = 212) had a mean age of 35.3 years at survey completion and a mean age of 27.4 years at diagnosis. Financial toxicity (mean, 14.0; SD, 9.33) was high. Two‐thirds of the sample experienced at least 1 negative economic event during COVID‐19, and 71% engaged in at least 1 medical cost‐coping behavior. Cost‐coping and pandemic‐related negative economic events were significantly correlated with cancer‐related financial toxicity. In multivariable analyses, pandemic‐related negative economic events and financial toxicity were associated with cost‐coping.

Conclusions

Acute negative economic events associated with the COVID‐19 pandemic may exacerbate cancer‐related financial toxicity and overall financial hardship among YAs and lead to cost‐coping behaviors that can compromise survivorship care and health outcomes. Multilevel, systematic interventions are needed to address the financial needs of YA survivors after the global pandemic.

This study illustrates how the acute negative economic events associated with the coronavirus disease 2019 pandemic may have exacerbated existing cancer‐related financial toxicity and general financial hardship among young adult cancer survivors. These negative economic events and financial toxicity are associated with cost‐coping behaviors that can compromise survivorship care and health outcomes.