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

Unmet financial needs among patients crowdfunding to support gynecologic cancer care

BACKGROUND

Patients may use crowdfunding to solicit donations, typically from multiple small donors using internet-based means, to offset the financial toxicity of cancer care.

OBJECTIVE

To describe crowdfunding campaigns by gynecologic cancer patients and to compare campaign characteristics and needs expressed between patients with cervical, uterine, and ovarian cancer.

STUDY DESIGN

We queried the public crowdfunding forum GoFundMe.com for "cervical cancer," "uterine cancer," and "ovarian cancer." The first 200 consecutive posts for each cancer type fundraising within the United States were analyzed. Data on campaign goals and needs expressed were manually extracted. Descriptive statistics and bivariate analyses were performed.

RESULTS

Among the 600 fundraising pages, the median campaign goal was $10,000 [IQR $5000-$23,000]. Campaigns raised a median of 28.6% of their goal with only 8.7% of campaigns reaching their goal after a median of 54 days online. On average, ovarian cancer campaigns had higher monetary goals, more donors, and larger donation amounts than cervical cancer campaigns and raised more money than both cervical and uterine cancer campaigns. Campaigns were fundraising to support medical costs (80-85%) followed by lost wages (36-56%) or living expenses (27-41%). Cervical cancer campaigns reported need for non-medical costs more frequently than uterine or ovarian cancer campaigns. States without Medicaid expansions (31% of the national population) were over-represented among cervical cancer and uterine cancer, but not ovarian cancer campaigns.

CONCLUSIONS

Crowdfunding pages reveal patients fundraising for out-of-pocket costs in the thousands of dollars and a wide range of unmet financial needs based on cancer type.

Multidimensional Model of Energy in Patients With Cancer

OBJECTIVES

Evidence suggests that energy is a distinct symptom from fatigue in patients with cancer. The purpose of this paper is to present the Multidimensional Model of Energy in Patients with Cancer (MMEPC) that is based on emerging evidence and to make recommendations for clinical practice and future research.

METHODS

The literature was reviewed to determine various factors associated with variations in energy in patients with cancer. In addition, some of the emerging evidence in the model is supported by studies of energy in the general population and in patients with other chronic conditions.

RESULTS

Based on a review of the literature, specific concepts in the MMEPC include: person factors, clinical factors, cancer-related factors, biological factors, factors associated with energy balance, and co-occurring symptoms. The evidence to support the association between each of these factors and variations in energy levels in patients with cancer is described and synthesized.

CONCLUSION

This article provides emerging evidence on factors that influence variations in energy levels in patients with cancer. While the fundamental biobehavioral and biologic mechanisms that underlie variations in energy levels are not well understood, the model can be used to design pre-clinical and clinical studies of energy in patients with cancer. In addition, while emerging evidence supports the hypothesis that fatigue and energy are distinct symptoms, additional research on common and distinct risk factors and underlying mechanisms is warranted to be able to develop and test precision interventions for one or both symptoms.

IMPLICATIONS FOR NURSING PRACTICE

The risk factors (eg, being female, sleep quality) associated with variations in energy levels in patients with cancer identified in this paper have important clinical implications. Clinicians can use the identified risk factors to guide their assessments; identify high-risk patients with decrements in energy decrement; and develop targeted energy conservation interventions for the patients.

Financial Toxicity in Renal Patients (FINTORE) Study: A Cross-Sectional Italian Study on Financial Burden in Kidney Disease-A Project Protocol

Financial toxicity (FT) refers to the negative impact of health-care costs on clinical conditions. In general, social determinants of health, especially poverty, socioenvironmental stressors, and psychological factors, are increasingly recognized as important determinants of non-communicable diseases, such as chronic kidney disease (CKD), and their consequences. We aim to investigate the prevalence of FT in patients at different stages of CKD treated in our universal health-care system and from pediatric nephrology, hemodialysis, peritoneal dialysis and renal transplantation clinics. FT will be assessed with the Patient-Reported Outcome for Fighting Financial Toxicity (PROFFIT) score, which was first developed by Italian oncologists. Our local ethics committee has approved the study. Our population sample will answer the sixteen questions of the PROFFIT questionnaire, seven of which are related to the outcome and nine the determinants of FT. Data will be analyzed in the pediatric and adult populations and by group stratification. We are confident that this study will raise awareness among health-care professionals of the high risk of adverse health outcomes in patients who have both kidney disease and high levels of FT. Strategies to reduce FT should be implemented to improve the standard of care for people with kidney disease and lead to truly patient-centered care.

The interplay of financial toxicity, health care team communication, and psychosocial well-being among rural cancer patients and survivors

BACKGROUND

Financial toxicity contributes to psychosocial distress among cancer patients and survivors. Yet, contextual factors unique to rural settings affect patient experiences, and a deeper understanding is needed of the interplay between financial toxicity and health care team communication and its association with psychosocial well-being among rural oncology patients.

PURPOSE

We examined associations between financial toxicity and psychosocial well-being among rural cancer patients, exploring variability in these linkages by health care team communication.

METHODS

Using data from 273 rural cancer patients who participated in Cancer Support Community's Cancer Experience Registry, we estimated multivariable regression models predicting depression, anxiety, and social function by financial toxicity, health care team communication, and the interplay between them.

RESULTS

We demonstrate robust associations between financial toxicity and psychosocial outcomes among our sample of rural cancer patients and survivors. As financial toxicity increased, symptoms of depression and anxiety increased. Further, financial toxicity was linked with decreasing social function. Having health care team conversations about treatment costs and distress-related care reduced the negative impact of financial toxicity on depressive symptoms and social function, respectively, in rural cancer patients at greatest risk for financial burden.

CONCLUSIONS

Financial toxicity and psychosocial well-being are strongly linked, and these associations were confirmed in a rural sample. A theorized buffer to the detrimental impacts of financial toxicity-health care team communication-played a role in moderating these associations. Our findings suggest that health care providers in rural oncology settings may benefit from tools and resources to bolster communication with patients about costs, financial distress, and coordination of care.

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

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

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.

An implementation science approach to the systematic study of access to gynecologic cancer care

INTRODUCTION

Barriers to access to cancer care are profoundly threatening to patients with gynecologic malignancies. Implementation science focuses on empirical investigation of factors influencing delivery of clinical best practices, as well as interventions designed to improve delivery of evidence-based care. We outline one prominent framework for conducting implementation research and discuss its application to improving access to gynecologic cancer care.

METHODS

Literature on the use of the Consolidated Framework for Implementation Research (CFIR) was reviewed. Delivery of cytoreductive surgery for advanced ovarian carcinoma was selected as an illustrative case of an evidence-based intervention (EBI) in gynecologic oncology. CFIR domains were applied to the context of cytoreductive surgical care, highlighting examples of empirically-assessable determinants of care delivery.

RESULTS

CFIR domains include Innovation, Inner Setting, Outer Setting, Individuals, and Implementation Process. "Innovation" relates to characteristics of the surgical intervention itself; "Inner Setting" relates to the environment in which surgery is delivered. "Outer Setting" refers to the broader care environment influencing the Inner Setting. "Individuals" highlights attributes of persons directly involved in care delivery, and "Implementation Process" focuses on integration of the Innovation within the Inner Setting.

CONCLUSIONS

Prioritization of implementation science methods in the study of access to gynecologic cancer care will help ensure that patients are able to utilize interventions with the greatest prospect of benefiting them.