Financial Hardships Experienced by Cancer Survivors: A Systematic Review

Financial burden following adult liver transplantation is common and associated with adverse recipient outcomes

The financial impact of liver transplantation has been underexplored. We aimed to identify associations between high financial burden (≥10% annual income spent on out-of-pocket medical costs) and work productivity, financial distress (coping behaviors in response to the financial burden), and financial toxicity (health-related quality of life, HRQOL) among adult recipients of liver transplant. Between June 2021 and May 2022, we surveyed 207 adult recipients of liver transplant across 5 US transplant centers. Financial burden and distress were measured by 25 items adapted from national surveys of cancer survivors. Participants also completed the Work Productivity and Activity Impairment and EQ-5D-5L HRQOL questionnaires. In total, 23% of recipients reported high financial burden which was significantly associated with higher daily activity impairment (32.9% vs. 23.3%, p =0.048). In adjusted analyses, the high financial burden was significantly and independently associated with delayed or foregone medical care (adjusted odds ratio, 3.95; 95% CI, 1.85-8.42) and being unable to afford basic necessities (adjusted odds ratio, 5.12; 95% CI: 1.61-16.37). Recipients experiencing high financial burden had significantly lower self-reported HRQOL as measured by the EQ-5D-5L compared to recipients with low financial burden (67.8 vs. 76.1, p =0.008) and an age-matched and sex-matched US general population (67.8 vs. 79.1, p <0.001). In this multicenter cohort study, nearly 1 in 4 adult recipients of liver transplant experienced a high financial burden, which was significantly associated with delayed or foregone medical care and lower self-reported HRQOL. These findings underscore the need to evaluate and address the financial burden in this population before and after transplantation.

Health-related social needs, medical financial hardship, and mortality risk among cancer survivors

BACKGROUND

Cancer survivors may face challenges affording food, housing, and other living necessities, which are known as health-related social needs (HRSNs). However, little is known about the associations of HRSNs and mortality risk among adult cancer survivors.

METHODS

Adult cancer survivors were identified from the 2013-2018 National Health Interview Survey (NHIS) and linked with the NHIS Mortality File with vital status through December 31, 2019. HRSNs, measured by food insecurity, and nonmedical financial worries (e.g., housing costs), was categorized as severe, moderate, and minor/none. Medical financial hardship, including material, psychological, and behavioral domains, was categorized as 2-3, 1, or 0 domains. Using age as the time scale, the associations of HRSNs and medical financial hardship and mortality risk were assessed with weighted adjusted Cox proportional hazards models.

RESULTS

Among cancer survivors 18-64 years old (n = 5855), 25.5% and 18.3% reported moderate and severe levels of HRSNs, respectively; among survivors 65-79 years old (n = 5918), 15.6% and 6.6% reported moderate and severe levels of HRSNs, respectively. Among cancer survivors 18-64 years old, severe HRSNs was associated with increased mortality risk (hazards ratio [HR], 2.00; 95% confidence interval [CI], 1.36-2.93, p < .001; reference = minor/none) in adjusted analyses. Among cancer survivors 65-79 years old, 2-3 domains of medical financial hardship was associated with increased mortality risk (HR, 1.58; 95% CI, 1.13-2.20, p = .007; reference = 0 domain).

CONCLUSIONS

HSRNs and financial hardship are associated with increased mortality risk among cancer survivors; comprehensive assessment of HRSN and financial hardship connecting patients with relevant services can inform efforts to mitigate adverse consequences of cancer.

Exploring the Relationship Among Financial Hardship, Anxiety, and Depression in Patients With Cancer: A Longitudinal Study

PURPOSE

Financial hardship (FH) is a complex issue in cancer care, affecting material conditions, well-being, and coping behaviors. This study aimed to longitudinally examine FH, anxiety, depressive symptoms, and their associations while incorporating social determinants of health and health care cost covariates in a sample of patients diagnosed with cancer.

METHODS

This prospective, longitudinal cohort study analyzed data from 2,305 participants from the Northwestern University Improving the Management of Symptoms during and following Cancer Treatment trial. Outcomes assessed at baseline and at 3, 6, 9, and 12 months postbaseline included depressive symptoms, anxiety, and FH. Analysis involved random intercept cross-lagged panel models to explore between- and within-person effects, incorporating factors such as age, sex, insurance status, neighborhood area deprivation, health care charges, out-of-pocket costs, and health literacy.

RESULTS

The cohort had a mean age of 60.7 (standard deviation [SD] = 12.7) years and was mostly female (64.9%) and White (86.2%). Correlations were found between FH and depressive symptoms (r = 0.310) and anxiety (r = 0.289). A predictive relationship was observed between FH and depressive symptoms, with baseline and 6-month depressive symptom levels predicting later FH (baseline β = .079, P = .070; 6-month β = .072, P = .081) and 9-month FH significantly predicting 12-month depressive symptoms (β = .083, P = .025), even after accounting for health care charges and out-of-pocket costs. Baseline and 9-month anxiety showed a predictive relationship with subsequent FH (baseline β = .097, P = .023; 9-month β = .071, P = .068).

CONCLUSION

FH emerged as a prominent issue, with nearly half of participants experiencing some level of FH. Depressive symptoms and anxiety were related to FH. These findings underscore the need for a comprehensive approach in cancer care that concurrently addresses anxiety, depressive symptoms, and FH, recognizing their interconnected impact.

Financial hardship screening among Native American patients with cancer: a qualitative analysis

BACKGROUND

Cancer-related financial hardship is an increasingly recognized concern for patients, families, and caregivers. Many Native American (NA) patients are at increased risk for cancer-related financial hardship due to high prevalence of low income, medical comorbidity, and lack of private health insurance. However, financial hardship screening (FHS) implementation for NA patients with cancer has not been reported. The objective of this study is to explore facilitators and barriers to FHS implementation for NA patients.

METHODS

We conducted key informant interviews with NA patients with cancer and with clinical staff at an academic cancer center. Included patients had a confirmed diagnosis of cancer and were referred to the cancer center through the Indian Health Service, Tribal health program, or Urban Indian health program. Interviews included questions regarding current financial hardship, experiences in discussing financial hardship with the cancer care and primary care teams, and acceptability of completing a financial hardship screening tool at the cancer center. Clinical staff included physicians, advanced practice providers, and social workers. Interviews focused on confidence, comfort, and experience in discussing financial hardship with patients. Recorded interviews were transcribed and thematically analyzed using MAXQDA® software.

RESULTS

We interviewed seven patients and four clinical staff. Themes from the interviews included: 1) existing resources and support services; 2) challenges, gaps in services, and barriers to care; 3) nuances of NA cancer care; and 4) opportunities for improved care and resources. Patients identified financial challenges to receiving cancer care including transportation, lodging, food insecurity, and utility expenses. Patients were willing to complete a FHS tool, but indicated this tool should be short and not intrusive of the patient's financial information. Clinical staff described discomfort in discussing financial hardship with patients, primarily due to a lack of training and knowledge about resources to support patients. Having designated staff familiar with I/T/U systems was helpful, but perspectives differed regarding who should administer FHS.

CONCLUSIONS

We identified facilitators and barriers to implementing FHS for NA patients with cancer at both the patient and clinician levels. Findings suggest clear organizational structures and processes are needed for financial hardship to be addressed effectively.

Neighborhood-level deprivation and survival in lung cancer

BACKGROUND

Despite recent advances in lung cancer therapeutics and improving overall survival, disparities persist among socially disadvantaged populations. This study aims to determine the effects of neighborhood deprivation indices (NDI) on lung cancer mortality. This is a multicenter retrospective cohort study assessing the relationship between NDI and overall survival adjusted for age, disease stage, and DNA methylation among biopsy-proven lung cancer patients. State-specific NDI for each year of sample collection were computed at the U.S. census tract level and dichotomized into low- and high-deprivation.

RESULTS

A total of 173 non small lung cancer patients were included, with n = 85 (49%) and n = 88 (51%) in the low and high-deprivation groups, respectively. NDI was significantly higher among Black patients when compared with White patients (p = 0.003). There was a significant correlation between DNA methylation and stage for HOXA7, SOX17, ZFP42, HOXA9, CDO1 and TAC1. Only HOXA7 DNA methylation was positively correlated with NDI. The high-deprivation group had a statistically significant shorter survival than the low-deprivation group (p = 0.02). After adjusting for age, race, stage, and DNA methylation status, belonging to the high-deprivation group was associated with higher mortality with a hazard ratio of 1.81 (95%CI: 1.03-3.19).

CONCLUSIONS

Increased neighborhood-level deprivation may be associated with liquid biopsy DNA methylation, shorter survival, and increased mortality. Changes in health care policies that consider neighborhood-level indices of socioeconomic deprivation may enable a more equitable increase in lung cancer survival.

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.

Financial strain, neighborhood cohesion, and health-related quality of life among rural and urban Spanish-speaking Latina breast cancer survivors

PURPOSE

Among Latina breast cancer survivors, explore associations between rural/urban residence and health-related quality of life (HRQL), and whether associations are moderated by financial strain and low neighborhood cohesion.

METHODS

We combined baseline data from two randomized controlled trials of a stress management intervention conducted among 151 urban and 153 rural dwelling Latinas with nonmetastatic breast cancer. Generalized linear models estimated associations between rural/urban status and HRQL (overall, emotional, social-family, physical, and functional well-being), and we examined moderation effects of financial strain and low neighborhood cohesion, controlling for age, marital status, and breast cancer characteristics.

RESULTS

Rural women reported better emotional (β = 1.85; 95% CI = 0.37, 3.33), functional (β = 2.23; 95% CI = 0.69, 3.77), and overall (β = 5.68; 95% CI = 1.12, 10.25) well-being than urban women, regardless of degree of financial strain or neighborhood cohesion; moderation effects were not statistically significant. Financial strain was inversely associated with emotional (β = -2.34; 95% CI = 3.63, -1.05), physical (β = -2.56; 95% CI = -4.12, -1.01), functional (β = -1.61; 95% CI = -2.96, -0.26), and overall (β = -6.67; 95% CI = -10.96, -2.98) well-being. Low neighborhood cohesion was inversely associated with emotional (β = -1.27; 95% CI = -2.50, -0.04), social-family (β = -1.72; 95% CI = -3.02, -0.42), functional (β = -1.63; 95% CI = -2.92, -0.34), and overall (β = -5.95; 95% CI = 9.76, -2.14) well-being.

CONCLUSIONS

Rural Latina breast cancer survivors reported better emotional, functional and overall well-being than their urban counterparts. Greater financial strain and less neighborhood cohesion were associated with worse HRQL on most domains regardless of rural/urban context.

IMPLICATIONS FOR CANCER SURVIVORS

Interventions that focus on increasing perceived neighborhood cohesion and reducing or better managing financial strain, could help improve Latina cancer survivors' well-being.

Development and validation of FinTox: A new screening tool to assess cancer-related financial toxicity

PURPOSE

This study aimed to develop and validate FinTox, a concise tool for screening and managing financial toxicity in oncology settings.

METHODS

Development involved qualitative interviews with healthcare providers and patients, and feedback from a 7-member expert panel resulting in a 5-item measure that evaluates financial strain, psychological responses, and care modifications. Psychometric evaluations examined factor structure, internal consistency, test-retest reliability, and concurrent and convergent validity. Associations between FinTox scores and sociodemographic/medical factors were also analyzed using univariate and multivariable regression models.

RESULTS

Twelve healthcare providers and 20 patients were interviewed, and 268 patients (69.8% female, 47.4% non-Hispanic White) completed surveys including FinTox, the Comprehensive Score for Financial Toxicity (COST), health-related quality of life (HRQOL) measures, and sociodemographic questions. FinTox demonstrated excellent internal consistency (Cronbach's alpha = 0.90) and test-retest reliability (ICC = 0.95). Significant correlations with the COST (r = -0.62, p < 0.001) and HRQOL measures corroborated content and convergent validity. Diagnostic accuracy was evidenced by a sensitivity of 72.3%, specificity of 85.2%, positive predictive value of 83.2%, and negative predictive value of 70.3%. Higher FinTox scores were also associated with receiving care at a safety-net hospital, Black race, household income <600% of the federal poverty level, and Stage 4 cancer.

CONCLUSION

FinTox's robust psychometric properties and diagnostic accuracy position it as a reliable tool for detecting financial toxicity. Future research should evaluate its responsiveness to changes over time and integration into clinical workflows.

Financial Toxicity Among Women with Breast Cancer Varies by Age and Race

INTRODUCTION

Financial toxicity negatively affects clinical outcomes in breast cancer. Underrepresented demographics may be at higher risk for financial toxicity. We characterized disparities on the basis of age and other factors.

PATIENTS AND METHODS

Surveys completed by women with stage 0-IV breast cancer treated at Memorial Sloan Kettering Cancer Center between 06/2022 and 05/2023 were analyzed. The comprehensive score for financial toxicity (COST) scale was used to assess financial toxicity. Descriptive statistics were calculated for differences in financial toxicity/related factors, and outcomes by age and race. Associations between variables of interest and COST scores were analyzed using linear regression.

RESULTS

Of 8512 respondents (75% white, 9.3% Asian, 8.4% Black), most (68%) had clinical stage 0/I disease. Stratified by age, young Black women had higher financial toxicity than young white or Asian women (p < 0.001). On multivariable analysis, women age < 45 years experienced higher financial toxicity than older women (coefficient - 2.0, 95% CI - 2.8 to - 1.1, p < 0.001). Compared with white women, financial toxicity was greater among Black (coefficient - 6.8, 95% CI - 7.8 to - 5.8) and Asian women (coefficient - 3.5, 95% CI - 4.4 to - 2.5). Cost-related medication non-adherence was more frequent among Black and Asian women (p < 0.001). Asian women more often paid for treatment with savings than white and Black women (p < 0.001). Young women reported using savings for treatment-related costs more than older (45% vs. 32%); p < 0.001).

CONCLUSIONS

Racial minorities and young patients are disproportionately affected by financial toxicity. Further studies are planned to determine how financial toxicity evolves over time and whether referral to financial services effectively reduces toxicity.

Assessing the Validity of the Centers for Medicare & Medicaid Services Measure in Identifying Potentially Preventable Emergency Department Visits by Patients With Cancer

PURPOSE

The Centers for Medicare & Medicaid Services (CMS) implemented chemotherapy measures (OP-35) to reduce potentially preventable emergency department visits (PPEDVs) and hospitalizations. This study evaluated the validity of the OP-35 measure in identifying PPEDVs among patients with cancer.

METHODS

This is a cross-sectional study, which used data from the 2012-2022 National Hospital Ambulatory Medical Care Survey. ED visits are assessed and compared on the basis of three measures: immediacy using Emergency Severity Index (ESI), disposition (discharge v hospitalization), and OP-35 criteria.

RESULTS

Between 2012 and 2022, a weighted sample of 46,723,524 ED visits were made by patients with cancer. Among reported ESI cases, 25.2% (8,346,443) was high urgency. In addition, 30.3% (14,135,496) of ED visits among patients with cancer led to hospitalizations. Using the OP-35 measure, it was found that 20.85% (9,743,977) was PPEDVs. A 21.9% (10,232,102) discrepancy between discharge diagnosis (CMS billing codes) and chief complaints was identified. Further analysis showed that 19.2% (1,872,556) of potentially preventable ED visits (CMS OP-35) were high urgency and 32.6% (3,181,280) resulted in hospitalization.

CONCLUSION

The CMS approach to identifying PPEDVs has limitations. First, it may overcount preventable visits by including high-urgency or hospitalization-requiring cases. Second, relying on final diagnoses for retrospective preventability judgment can be misleading as they may not reflect the initial reason for the visit. In addition, differentiating causes for ED visits in patients with cancer undergoing various treatments is challenging as the approach does not distinguish between chemotherapy-related complications and others. Identification inconsistencies arise because of varying coding practices and chosen preventable conditions, lacking consensus and alignment with specific hospital or patient needs. Finally, the model fails to consider crucial nonclinical factors like social support, economic barriers, and alternative care access, potentially unfairly penalizing hospitals serving underserved populations.

Association between financial hardship and psychological burden and the role of social and mental health support: An observational study

We aimed to assess the association between medical financial hardship and psychological burden and the moderating role of social and mental health support. 2021 United States National Health Interview Survey was used. Financial hardship was defined as having financial worry, material hardship, or cost-related care nonadherence. Psychological burden was measured using perceived general health status, satisfaction with life, and serious psychological distress (SPD). Of 29,370 included adults, 49% experienced financial hardship in the last 12 months. Financial hardship was associated with a higher psychological burden (odds ratio [OR], 3.58; 95% confidence interval [CI], 2.43-5.47 for SPD). Eleven percent received counseling/therapy from mental health professionals, and 90% had experienced frequent social support. Frequent social support was associated with lower financial hardship (OR, 0.71; 95% CI, 0.63-0.80) and psychological burden (OR, 0.28; 95% CI, 0.19-0.42 for SPD). Previous mental health support was associated with higher financial hardship (OR,1.40; 95% CI, 1.28-1.54) and psychological burden (OR, 9.75; 95% CI, 6.97-13.94 for SPD). Those experiencing financial hardship had lower odds of SPD if they received mental health support in the last 12 months (OR, 0.57; 95% CI, 0.39-0.85). Future interventions should also focus on improving social support and mental health for patients as a way of mitigating medical financial hardship.

Material, Psychological, and Behavioral Financial Hardship Among Lesbian, Gay, and Bisexual Cancer Survivors in the United States

PURPOSE

Driven by anti-LGBTQ+ stigma, emerging literature suggests that lesbian, gay, and bisexual (LGB) cancer survivors experience financial hardship (FH) more frequently than heterosexual survivors. However, few studies have used nationally representative samples to estimate this inequity.

METHODS

National Health Interview Survey data from 2019 to 2022 were pooled and weighted. Outcomes included material, psychological, and behavioral FH. The behavioral domain was further broken down into subdomains including medical care, prescription medications, and mental health care. Multivariable logit models controlling for a variety of factors were used to generate LGB and heterosexual predicted probabilities and differential effects for each FH outcome. Stratified estimates were generated by sex and age groups.

RESULTS

A total of N = 374 LGB and N = 12,757 heterosexual cancer survivors were included in this analysis. In adjusted analyses, LGB cancer survivors had significantly higher material (19%, 95% CI, 15 to 24 v 12%, 95% CI, 11 to 13; P = .004), psychological (44%, 95% CI, 38 to 51 v 37%, 95% CI, 36 to 38; P = .035), and behavioral (23%, 95% CI, 18 to 28 v 13%, 95% CI, 13 to 14; P < .0001) FH than heterosexual survivors. LGB cancer survivors also had higher medical behavioral (11%, 95% CI, 7 to 15 v 7%, 95% CI, 6 to 7; P = .030), prescription medication behavioral (14%, 95% CI, 10 to 19 v 10%, 95% CI, 9 to 10; P = .032), and mental health behavioral (9%, 95% CI, 6 to 13 v 3%, 95% CI, 3 to 4; P < .0001) FH than heterosexual survivors. Stratified estimates revealed young LGB cancer survivors had the highest probability of each outcome (material: 31%, 95% CI, 23 to 40; psychological: 58%, 95% CI, 50 to 66; behavioral: 45%, 95% CI, 36 to 53).

CONCLUSION

In this nationally representative analysis, LGB cancer survivors experience substantial inequities in all FH outcomes. It is crucial that future FH interventional work should prioritize populations at the highest risk of FH, such as LGB cancer survivors.

Predicting the Population Health Economic Impact of Current and New Cancer Treatments for Colorectal Cancer: A Data-Driven Whole Disease Simulation Model for Predicting the Number of Patients with Colorectal Cancer by Stage and Treatment Line in Australia

OBJECTIVES

Effective healthcare planning, resource allocation, and budgeting require accurate predictions of the number of patients needing treatment at specific cancer stages and treatment lines. The Predicting the Population Health Economic Impact of Current and New Cancer Treatments (PRIMCAT) for Colorectal Cancer (CRC) simulation model (PRIMCAT-CRC) was developed to meet this requirement for all CRC stages and relevant molecular profiles in Australia.

METHODS

Real-world data were used to estimate treatment utilization and time-to-event distributions. This populated a discrete-event simulation, projecting the number of patients receiving treatment across all disease stages and treatment lines for CRC and forecasting the number of patients likely to utilize future treatments. Illustrative analyses were undertaken, estimating treatments across disease stages and treatment lines over a 5-year period (2022-2026). We demonstrated the model's applicability through a case study introducing pembrolizumab as a first-line treatment for mismatch-repair-deficient stage IV.

RESULTS

Clinical registry data from 7163 patients informed the model. The model forecasts 15 738 incident and 2821 prevalent cases requiring treatment in 2022, rising to 15 921 and 2871, respectively, by 2026. Projections show that over 2022 to 2026, there will be a total of 116 752 treatments initiated, with 43% intended for stage IV disease. The introduction of pembrolizumab is projected for 706 patients annually, totaling 3530 individuals starting treatment with pembrolizumab over the forecasted period, without significantly altering downstream utilization of subsequent treatments.

CONCLUSIONS

PRIMCAT-CRC is a versatile tool that can be used to estimate the eligible patient populations for novel cancer therapies, thereby reducing uncertainty for policymakers in decisions to publicly reimburse new treatments.

Asking the "Right" Questions about Financial Hardship: Using Cognitive Interviews with Adolescents and Young Adults with Cancer and Their Caregivers to Inform Measure Development

Purpose: Financial hardship as a result of cancer treatment can have a significant and lasting negative impact on adolescents and young adults (AYAs) and their families. To address a lack of developmentally informed and psychometrically sound measures of financial hardship for AYAs and their caregivers, we used rigorous measurement development methods recommended by the National Institutes of Health's Patient-Reported Outcomes Measurement Information System® (PROMIS®) to determine comprehensibility and relevance of measure content. Methods: Our multi-step approach involved item identification, refinement, and generation; translatability and reading level review; and cognitive interviews. A purposive sample of 25 AYAs and 10 caregivers participated, ensuring representation across age, education, gender, race/ethnicity, and cancer type. Results: Fifty patient-reported and caregiver-reported items were developed across material, psychosocial, and behavioral subdomains of financial hardship. Translatability and reading level reviews resulted in 22 patient-reported and 25 caregiver-reported items being rewritten. Eighty-eight percent of patients and all caregivers described the items as easy to answer. Younger AYAs (15 to 25 years of age) were more likely to say the items were less relevant for them. Forty-six patient-reported and 48 caregiver-reported items were recommended for further testing. Conclusion: This study is the first to use in-depth qualitative methods to center AYA patient and caregiver experiences in the creation of new measures of financial hardship. Data support the comprehensibility and content validity of these preliminary item banks. Future large-scale, quantitative testing will lead to additional refinements and support the use of short forms and computer-adaptive testing for a diverse sample of AYAs and their caregivers.

Demographic and Clinical Factors Associated With Health-Related Quality-of-Life Profiles Among Prostate Cancer Survivors

PURPOSE

Our purpose was to describe the prevalence and predictors of symptom and function clusters related to physical, emotional, and social components of general health-related quality of life (HRQOL) in a population-based sample of prostate cancer (PCa) survivors.

METHODS

Participants (N = 1,162) completed a baseline survey at a median of 9 months after diagnosis to ascertain the co-occurrence of eight symptom and functional domains that are common across all cancers and not treatment-specific. We used latent profile analysis (LPA) to identify subgroup profiles of survivors with low, moderate, or high HRQOL levels. Multinomial logistic regression models were used to identify clinical and sociodemographic factors associated with survivors' membership in the low versus moderate or high HRQOL profile.

RESULTS

The LPA identified 16% of survivors who were categorized in the low HRQOL profile at baseline, indicative of the highest symptom burden and lowest functioning. Factors related to survivors' membership in the low versus higher HRQOL profile groups included less than age 65 years at diagnosis, identifying as non-Hispanic Black race, not working, being a former versus never smoker, systemic therapy, less companionship, more comorbidities, lower health care financial well-being, or less spirituality. Several factors remained associated with remaining in the low versus higher HRQOL profiles on the follow-up survey (n = 699), including younger age, Black race, comorbidity, and lower financial and spiritual well-being.

CONCLUSION

About one of six PCa survivors experienced elevated physical and psychosocial symptoms that were independent of local curative therapy, but with younger age, race, comorbidity, and lower financial and spiritual well-being as stable risk factors for poor HRQOL over time.

A systematic review on the impact of financial insecurity on the physical and psychological well-being for people living with terminal illness

BACKGROUND

People living with terminal illness are at higher risk of experiencing financial insecurity. The variance in definitions of financial insecurity, in addition to its impact on the well-being of this population has not yet been systematically analysed.

AIM

To understand the definition, prevalence and impact of financial insecurity on the physical and psychological well-being of people living with terminal illness.

DESIGN

A systematic review with a narrative synthesis (prospectively registered; CRD42023404516).

DATA SOURCES

Medline, Embase, CINAHL, AMED, PsycINFO, ProQuest Central and Cochrane Central Register of Controlled Trials, from inception to May 2023. Included studies had to measure or describe the impact of financial insecurity on an aspect of participants' physical or mental well-being. Study quality was assessed using the Hawker tool.

RESULTS

A total of 26 studies were included in the review. Financial insecurity was defined using many different definitions and terminology. Out of 4824 participants, 1126 (23%) reported experiencing high levels of financial insecurity. Nine studies reported 21 unique analyses across three domains of physical well-being. Out of those 21 analyses, 10 (48%) reported a negative result (an increase in financial insecurity was reported with a decrease in physical well-being). Twenty-one studies reported 51 unique analyses across nine domains of psychological well-being. Out of these analyses, 35 (69%) reported a negative result (an increase in financial insecurity was reported with a decrease in psychological well-being).

CONCLUSIONS

People living with terminal illness require support with their financial situation to ensure their well-being is not negatively impacted by financial insecurity.

Cancer Patients: Forgiveness, Discomfort Intolerance and Psychiatric Symptoms

Objectives: Cancer patients try to find answers in the light of their individual experiences and if they cannot adapt in line with the answers, various psychiatric symptoms may occur. There are studies supporting that "forgiveness" helps reduce the emotional burden of patients with cancer in their ability to discomfort intolerance of the disease, find meaning in the life. The aim of this study is to evaluate forgiveness, discomfort intolerance, and psychiatric symptoms in cancer patients. Methods: The data of this study, which was conducted with 208 cancer patients receiving outpatient chemotherapy treatment, Personal Information Form was collected with Heartland Forgiveness Scale, Brief Symptom Inventory, and Discomfort Intolerance Scale. Result: It has been determined that cancer patients have a high level of forgiveness, a moderate tolerance to tolerate discomfort, and enable low level of occurrence of psychiatric symptoms. As the level of self-forgiveness and forgiveness of patients increases, the incidence of psychiatric symptoms decreases. Conclusion: In line with the findings, it can be thought that the high level of forgiveness of cancer patients towards their illness allows them to experience less psychiatric symptoms and increase their tolerance to the disorder. Awareness of both patients and healthcare personnel can be increased by preparing training programs that address forgiveness in individuals diagnosed with cancer in healthcare institutions.

Hypofractionated Radiation Therapy: A Cross-sectional Survey Study of US Radiation Oncologists

OBJECTIVES

For many malignancies, hypofractionated radiotherapy (HFRT) is an accepted standard associated with decreased treatment time and costs. United States provider beliefs regarding HFRT likely impact its adoption but are poorly studied. We surveyed US-based radiation oncologists (ROs) to gauge HFRT utilization rates for prostate (PC), breast (BC), and rectal cancer (RC) and to characterize the beliefs governing these decisions.

METHODS

From July to October 2021, an anonymized, online survey was electronically distributed to ROs actively practicing in the United States. Demographic and practice characteristic information was collected. Questions assessing rates of offering HFRT for PC, BC, and RC and perceived limitations towards using HFRT were administered.

RESULTS

A total of 203 eligible respondents (72% male, 72% White, 53% nonacademic practice, 69% with 11+ years in practice) were identified. Approximately 50% offered stereotactic body radiation therapy (SBRT) for early/favorable intermediate risk PC. Although >90% of ROs offered whole-breast HFRT for early-stage BC, only 33% offered accelerated partial-breast irradiation (APBI). Overall, 41% of ROs offered short-course neoadjuvant RT for RC. The primary reported barriers to HFRT utilization were lack of data, inexperience, and referring provider concerns.

CONCLUSIONS

HFRT is safe, effective, and beneficial, yet underutilized-particularly prostate SBRT, APBI, and short-course RT for RC. Skills retraining and education of ROs and referring providers may increase utilization rates.

Understanding racial differences in financial hardship among older adults surviving cancer

BACKGROUND

Despite Medicare coverage, financial hardship is a prevalent issue among those diagnosed with cancer at age 65 years and older, particularly among those belonging to a racial or ethnic minority group. Sociodemographic, clinical, and area-level factors may mediate this relationship; however, no studies have assessed the extent to which these factors contribute to the racial/ethnic disparities in financial hardship.

METHODS

Surveys assessing financial hardship were completed by 721 White (84%) or Black (16%) patients (aged 65 years and older) who were diagnosed with breast (34%), prostate (27%), lung (17%), or colorectal (14%) cancer or lymphoma (9%) at the University of Alabama at Birmingham between 2000 and 2019. Financial hardship included material, psychological, and behavioral domains. Nonlinear Blinder-Oaxaca effect decomposition methods were used to evaluate the extent to which individual and area-level factors contribute to racial disparities in financial hardship.

RESULTS

Black patients reported lower income (65% vs. 34% earning <$50,000) and greater scores on the Area Deprivation Index (median, 93.0 vs. 55.0). Black patients reported significantly higher rates of overall (39% vs. 18%), material (29% vs. 11%), and psychological (27% vs. 11%) hardship compared with White patients. Overall, the observed characteristics explained 51% of racial differences in financial hardship among cancer survivors, primarily because of differences in income (23%) and area deprivation (11%).

CONCLUSIONS

The current results identify primary contributors to racial disparities in financial hardship among older cancer survivors, which can be used to develop targeted interventions and allocate resources to those at greatest risk for financial hardship.

Cost-of-care discussions for individuals with advanced non-small cell lung cancer and melanoma: Findings from a large, population-based pilot study

BACKGROUND

Costs of cancer care can result in patient financial hardship; many professional organizations recommend provider discussions about treatment costs as part of high-quality care. In this pilot study, the authors examined patient-provider cost discussions documented in the medical records of individuals who were diagnosed with advanced non-small cell lung cancer (NSCLC) and melanoma-cancers with recently approved, high-cost treatment options.

METHODS

Individuals who were newly diagnosed in 2017-2018 with stage III/IV NSCLC (n = 1767) and in 2018 with stage III/IV melanoma (n = 689) from 12 Surveillance, Epidemiology, and End Results regions were randomly selected for the National Cancer Institute Patterns of Care Study. Documentation of cost discussions was abstracted from the medical record. The authors examined patient, treatment, and hospital factors associated with cost discussions in multivariable logistic regression analyses.

RESULTS

Cost discussions were documented in the medical records of 20.3% of patients with NSCLC and in 24.0% of those with melanoma. In adjusted analyses, privately insured (vs. publicly insured) patients were less likely to have documented cost discussions (odds ratio [OR], 0.54; 95% confidence interval [CI], 0.37-0.80). Patients who did not receive systemic therapy or did not receive any cancer-directed treatment were less likely to have documented cost discussions than those who did receive systemic therapy (OR, 0.39 [95% CI, 0.19-0.81] and 0.46 [95% CI, 0.30-0.70], respectively), as were patients who were treated at hospitals without residency programs (OR, 0.64; 95% CI, 0.42-0.98).

CONCLUSIONS

Cost discussions were infrequently documented in the medical records of patients who were diagnosed with advanced NSCLC and melanoma, which may hinder identifying patient needs and tracking outcomes of associated referrals. Efforts to increase cost-of-care discussions and relevant referrals, as well as their documentation, are warranted.

Measures of financial toxicity in cancer survivors: a systematic review

PURPOSE

Comprehensive cancer-related financial toxicity (FT) measures as a multidimensional construct are lacking. The aims of this systematic review were to (1) identify full measures designed explicitly for assessing FT and evaluate their psychometric properties (content validity, structural validity, reliability, and other measurement properties) using Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN), and (2) provide an analysis of the domains of FT covered in these measures.

METHODS

MEDLINE, CINAHL, Web of Science, and Cochrane CENTRAL were searched for quantitative studies published from January 2000 to July 2023 that reported psychometric properties of FT measures in cancer survivors. The psychometric properties of FT measures and study risk of bias were analysed using COSMIN. Each FT measure was compared against the six domains of FT recommended by Witte and colleagues. Results were synthesized narratively. The detailed search strategies are available in Table S1.

RESULTS

Six FT tools including the COST-FACIT, PROFFIT, FIT, SFDQ, HARDS, and ENRICh-Spanish were identified. The COST-FACIT measure had good measurement properties. No measure reached an excellent level for overall quality but was mostly rated as sufficient. The SFDQ, HARDS, and ENRICh-Spanish were the most comprehensive in the inclusion of the six domains of FT.

CONCLUSION

This review emphasizes the need for validated multidimensional FT measures that can be applied across various cancer types, healthcare settings, and cultural backgrounds. Furthermore, a need to develop practical screening tools with high predictive ability for FT is highly important, considering the significant consequences of FT. Addressing these gaps in future research will further enhance the understanding of FT.

Mixed-Methods Study on the Responsiveness of the Comprehensive Score for Financial Toxicity Among People With Multiple Myeloma

PURPOSE

Financial toxicity is a contributor to the psychosocial burden of cancer care. There is no consensus measure of financial toxicity; however, recent studies have adopted the Comprehensive Score for Financial Toxicity (COST). Despite its growing popularity, data on the responsiveness to change of the COST instrument are lacking. To address this gap in the literature, we performed a sequential mixed-methods study of people with multiple myeloma.

MATERIALS AND METHODS

In the quantitative phase of the study, we collected COST scores at two time points approximately 8 weeks apart from 72 patients. In the qualitative phase, we conducted semistructured interviews with a subset of 12 patients who reported the largest changes in scores. The qualitative data were analyzed using a deductive coding scheme developed using the Framework Method in the context of a commonly cited conceptual model of financial toxicity.

RESULTS

The median absolute change in COST scores was four points (IQR, 2-6). Only 13% of the sample had the same COST scores at both assessments; 38% had an improved score and 50% had a worsened score. Only, seven of the 12 patients (58%) interviewed reported changes to one or more of the constructs in the conceptual model of financial toxicity. Most commonly, changes to out-of-pocket medical costs were reported (5/12). Changes to nonmedical expenses (n = 2) and subjective financial distress without changes to objective financial burden (n = 2) were also reported.

CONCLUSION

Additional research is needed to explicate changes in COST scores over time.

Age-related differences in employment, insurance, and financial hardship among colorectal cancer patients: a report from the ColoCare Study

PURPOSE

Employment and financial hardships are common issues for working-age colorectal cancer patients. We surveyed colorectal cancer survivors to investigate employment, insurance, and financial outcomes by age at diagnosis.

METHODS

Cross-sectional survey of six ColoCare Study sites regarding employment, insurance, and financial hardship outcomes. Eligible participants were 1 to 5 years from colorectal cancer diagnosis. Diagnosis age (18-49, 50-64, 65+ years) with outcomes of interest were compared using chi-square and t-tests. Multivariable logistic and Poisson regressions were fit to examine association of demographic factors with any material/psychological hardship (yes/no) and the count of hardships.

RESULTS

N = 202 participants completed the survey (age: 18-49 (n = 42, 20.8%), 50-64 (n = 79, 39.1%), 65+ (n = 81, 40.1%)). Most diagnosed age < 65 worked at diagnosis (18-49: 83%; 50-64: 64%; 65+ : 14%, p < 0.001) and continued working after diagnosis (18-49: 76%; 50-64: 59%; 65+ : 13%; p < 0.001). Participants age 18-49 reported cancer-related difficulties with mental (81.3%) and physical (89%) tasks at work more than those working in the older age groups (45%-61%). In regression models, among those reporting any hardship, the rates of material and psychological hardships were higher among those age 18-64 (Incidence Rate Ratios (IRR) range 1.5-2.3 vs. age 65+) and for those with < college (IRR range 1.3-1.6 vs. college +).

CONCLUSIONS

Younger colorectal cancer patients are more likely to work after a cancer diagnosis and during cancer treatment, but report higher levels of financial hardship than older patients.

IMPLICATIONS FOR CANCER SURVIVORS

Younger colorectal cancer patients may encounter financial hardship, thus may feel a need to work during and after treatment.

Burden of Financial Hardship Among Breast Cancer Survivors in Maharashtra, India

INTRODUCTION

Improved breast cancer treatments have increased survival rates, but prolonged and costly therapies strain survivors financially. This study addresses the dearth of research on financial difficulties among breast cancer survivors (BCS) in India.

METHODS

A mixed-methods study was employed; we assessed financial hardship (FH) using the Comprehensive Score for Financial Toxicity-Functional Assessment of Chronic Illness Therapy (COST-FACIT), a validated 12-item questionnaire. The minimum score represents FH (FH was categorized based on scores <27).

RESULTS

Out of 80 surveyed BCS, 60% experienced FH and had a median age of 48 years (40.5-56.5 years). Factors such as occupation, education, income, expenditures, insurance coverage, and impact on savings exhibited significant associations with FH. With only one-third having health insurance and 43.8% self-funding treatment, this research sheds light on the urgent need for targeted support and policies to alleviate the financial burdens faced by BCS in the Indian context.

CONCLUSION

Financial hardship harms the mental and physical health of BCS. Collaborative efforts among policymakers, healthcare professionals, and insurers are crucial to establishing a compassionate healthcare system that addresses both immediate health and long-term financial concerns.

Financial Hardship and Age-Related Decrements in Kidney Function Among Black and White Adults in the Midlife in the United States Study

OBJECTIVE

This analysis examined if financial hardship was associated with age-related decrements in kidney function using a material-psychosocial-behavioral framework. We also tested if this association was mediated by comorbidity of cardiometabolic risk factors (obesity, elevated blood pressure, and insulin resistance).

METHODS

Data from 1361 non-Hispanic Black and White adults (ages 26-94 years; non-Hispanic Black = 258) were obtained from the Wave 3 and Refresher phases of the Midlife in the United States project. Kidney function was based on serum creatinine-based estimated glomerular filtration rate (eGFR; Chronic Kidney Disease Epidemiology Collaboration formula without race adjustment). Financial hardship was evaluated in three domains: material (income to poverty line ratio, health insurance coverage, and public/government financial assistance), psychological (perceived financial status, control over financial status, and perceived financial strains), and behavioral responses (financial adjustment/coping such as sold possessions and cutting back on spending).

RESULTS

More severe financial hardship (overall score and in each domain) was associated with age-related decrements in eGFR, even after adjusting for sociodemographic, education, and health-related covariates. The association between financial hardship and age-related decrements in eGFR was conditional on sex but not race. Finally, cardiometabolic risk factors mediated the association between financial hardship and age-related decrements in eGFR.

CONCLUSIONS

These findings affirm the negative effects of financial hardship on age-related decrements in renal clearance. In addition to incorporating traditionally used indicators of SES, such as education and income, future research on social hallmarks of aging should also consider the role of financial hardship on the aging process and age-related diseases.

Mapping the supportive care needs and quality of life of adult survivors of childhood cancer at a comprehensive cancer center in the Middle East

Assessing unmet needs is crucial to achieving quality care and patient satisfaction. Between September and December 2021, we assessed unmet supportive care needs in a consecutive sample of adult survivors of childhood cancer at KHCC (King Hussien Cancer Center). Two hundred and ninety-seven adult survivors of childhood cancer completed the study questionnaire. The average needs score across all domains was 24.80 (SD = 19.65), with the financial domain scoring the highest 30.39 (SD = 31.95) and sexuality scoring the lowest 7.67 (SD = 19.67). Using a multivariate linear regression model, female gender was independently associated with significantly high scores in all need domains (p < 0.001), except for sexuality. Monthly income, comorbidities, socioeconomic challenges, time since diagnosis, and age at diagnosis have emerged as predictors of needs in many domains. Mean quality of life (QoL) was significantly and inversely associated with the mean score in multiple domains: psychological (p < 0.001), sexuality (p = 0.038), financial (p < 0.001), and overall needs (p = 0.004). Following a content analysis of qualitative data, educational difficulties, and work-related challenges were identified as other unmet needs. Cancer experiences during childhood significantly influence supportive care needs in adulthood. There is a need for more tailored studies assessing different populations of cancer survivors and avoiding the one-size-fits-all survivorship care.

Financial hardship experience in middle- and older-aged patients with advanced lung cancer

PURPOSE

Advancements in medical treatments have resulted in increased medical costs for cancer patients. More than half of the patients with advanced lung cancer reported unmet financial needs. The purpose of this study is to examine the differences in the prevalence and correlates of financial hardship between middle- and older-aged patients with advanced lung cancer, and its impact on multiple health-related outcomes.

METHODS

This study presents a cross-sectional analysis involving 226 patients with advanced lung cancer, who were enrolled in a randomized controlled trial conducted between 2018 and 2020. Data collection was performed through self-reported questionnaires and electronic medical records. Multivariable logistic and linear regression models were adopted for analysis.

RESULTS

58.0% reported experiencing financial hardships. Middle-aged participants who were single and had a lower education level were more likely to experience financial difficulties. However, males and higher performance status were associated with a lower likelihood of experiencing financial difficulties among older-aged participants. Financial hardship was significantly associated with anxiety (p < 0.001), depression (p < 0.001), sleep disturbances (p < 0.001), quality of life, global health status (p = 0.002), functional scale score (p < 0.001), symptom scale score (p < 0.001), and lung cancer-specific scale score (p < 0.001).

CONCLUSIONS

More than half of the patients with advanced lung cancer experienced financial hardships caused by cancer or its treatment, with a higher prevalence reported in middle-aged patients. Different sociodemographic and clinical variables correlated with financial hardship in middle- and older-aged participants, respectively. More attention should be paid to middle-aged patients with advanced lung cancer, particularly during routine assessments.

Comparison of Financial Hardship and Healthcare Utilizations Associated with Cancer in the United States Medicare Programs during the COVID-19 Pandemic

BACKGROUND

In the United States, Medicare beneficiaries diagnosed with cancer often face significant financial challenges due to the expensive nature of cancer treatments and increased cost-sharing responsibilities. However, there is limited knowledge regarding the financial hardships and healthcare utilizations faced by those enrolled in Medicare Advantage (MA) compared to those in traditional fee-for-service Medicare (TM) during the COVID-19 pandemic. Our study aims to investigate the subjective financial hardships experienced by individuals enrolled in TM and MA and to determine whether these two Medicare programs exhibit differences in healthcare utilization during the pandemic.

METHODS

We utilized data from the 2020-2022 National Health Interview Survey (NHIS), focusing on nationally representative samples of cancer survivors aged 65 or older. Financial hardship was categorized into three distinct groups: material (e.g., problems with medical bills), psychological (e.g., worry about paying), and behavioral (e.g., delayed care due to cost). Healthcare utilization included wellness visits (preventive care), emergency care services, hospitalizations, and telehealth. We used survey design-adjusted analysis to compare the study outcomes between MA and TM.

RESULTS

Among a weighted sample of 4.4 million Medicare beneficiaries with cancer (mean age: 74.9), 76% were enrolled in MA plans. Cancer survivors with a college degree (59.3% vs. 49.8%) and high family income (38.2% vs. 31.1%) were more likely to enroll in MA plans. There were no significant differences in any material, psychological, or behavioral financial hardship domains between beneficiaries with MA and TM plans except forgone counseling due to cost. For healthcare utilization measures, cancer survivors in MA were more likely than those in TM to have flu vaccination (77.2% vs. 70.1%) and experience lower hospitalizations (16.0% vs. 20.0%). However, there were no differences in other health service utilizations between MA and TM.

CONCLUSION

While no significant differences were observed in any materialized, psychological, or behavioral financial hardships, older cancer survivors enrolled in MA plans were more likely to receive vaccinations and lower hospitalization rates during COVID-19. Although other preventive or primary care visits (i.e., wellness visits) were higher, their difference did not reach statistical significance. As MA grows in popularity, it is essential to consistently monitor and evaluate the performance and outcomes of Medicare plans for cancer survivors as we navigate the post-pandemic landscape.

Financial hardship after cancer: revision of a conceptual model and development of patient-reported outcome measures

Aim: This qualitative study refined a conceptual model of financial hardship and developed measures corresponding to model constructs. Methods: Eighteen women with breast cancer recruited through a comprehensive cancer center completed interviews. A qualitative framework analysis was conducted of the interviews. Results: Participants experienced varying levels of financial hardship. Protective factors included good health insurance, work accommodations and social support. Participants worried about cancer care costs and employment. Programs for alleviating financial hardship had high administrative burdens. Four preliminary financial hardship measures were developed: coping, impacts, depression and worry. Conclusion: Reducing administrative barriers to benefits could reduce financial hardship after cancer. More research is needed on the effects of out-of-network/formulary care and denials of coverage and to validate the measures.

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

BACKGROUND

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

METHODS

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

RESULTS AND DISCUSSION

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

Financial hardship and neighborhood socioeconomic disadvantage in long-term childhood cancer survivors

BACKGROUND

Long-term survivors of childhood cancer face elevated risk for financial hardship. We evaluate whether childhood cancer survivors live in areas of greater deprivation and the association with self-reported financial hardships.

METHODS

We performed a cross-sectional analysis of data from the Childhood Cancer Survivor Study between 1970 and 1999 and self-reported financial information from 2017 to 2019. We measured neighborhood deprivation with the Area Deprivation Index (ADI) based on current zip code. Financial hardship was measured with validated surveys that captured behavioral, material and financial sacrifice, and psychological hardship. Bivariate analyses described neighborhood differences between survivors and siblings. Generalized linear models estimated effect sizes between ADI and financial hardship adjusting for clinical factors and personal socioeconomic status.

RESULTS

Analysis was restricted to 3475 long-term childhood cancer survivors and 923 sibling controls. Median ages at time of evaluation was 39 years (interquartile range [IQR] = 33-46 years and 47 years (IQR = 39-59 years), respectively. Survivors resided in areas with greater deprivation (ADI ≥ 50: 38.7% survivors vs 31.8% siblings; P < .001). One quintile increases in deprivation were associated with small increases in behavioral (second quintile, P = .017) and psychological financial hardship (second quintile, P = .009; third quintile, P = .014). Lower psychological financial hardship was associated with individual factors including greater household income (≥$60 000 income, P < .001) and being single (P = .048).

CONCLUSIONS

Childhood cancer survivors were more likely to live in areas with socioeconomic deprivation. Neighborhood-level disadvantage and personal socioeconomic circumstances should be evaluated when trying to assist childhood cancer survivors with financial hardships.

Financial-legal navigation reduces financial toxicity of pediatric, adolescent, and young adult cancers

BACKGROUND

Pediatric, adolescent, and young adult patients with cancer and their caregivers are at high risk of financial toxicity, and few evidence-based oncology financial and legal navigation programs exist to address it. We tested the feasibility, acceptability, and preliminary effectiveness of Financial and Insurance Navigation Assistance, a novel interdisciplinary financial and legal navigation intervention for pediatric, adolescent and young adult patients and their caregivers.

METHODS

We used a single-arm feasibility and acceptability trial design in a pediatric hematology and oncology clinic and collected preintervention and postintervention surveys to assess changes in financial toxicity (3 domains: psychological response/Comprehensive Score for Financial Toxicity [COST], material conditions, and coping behaviors); health-related quality of life (Patient-Reported Outcomes Measurement Information System Physical and Mental Health, Anxiety, Depression, and Parent Proxy scales); and perceived feasibility, acceptability, and appropriateness.

RESULTS

In total, 45 participants received financial navigation, 6 received legal navigation, and 10 received both. Among 15 adult patients, significant improvements in FACIT-COST (P = .041) and physical health (P = .036) were noted. Among 46 caregivers, significant improvements were noted for FACIT-COST (P < .001), the total financial toxicity score (P = .001), and the parent proxy global health score (P = .0037). We were able to secure roughly $335 323 in financial benefits for 48 participants. The intervention was rated highly for feasibility, acceptability, and appropriateness.

CONCLUSIONS

Integrating financial and legal navigation through Financial and Insurance Navigation Assistance was feasible and acceptable and underscores the benefit of a multidisciplinary approach to addressing financial toxicity.

CLINICALTRIALS.GOV REGISTRATION

NCT05876325.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Financial difficulties experienced by patients with gastrointestinal stromal tumours (GIST) in the Netherlands: data from a cross-sectional multicentre study

PURPOSE

This study aims to (1) explore the prevalence of patient-reported financial difficulties among GIST patients, differentiating between those currently undergoing tyrosine kinase inhibitor (TKI) treatment and those who are not; (2) investigate associations between financial difficulties and sociodemographic and clinical characteristics, work, cancer-related concerns, anxiety and depression and (3) study the impact of financial difficulties on health-related quality of life.

METHODS

A cross-sectional study was conducted among Dutch GIST patients diagnosed between 2008 and 2018, who were invited to complete a one-time survey between September 2020 and June 2021. Patients completed nine items of the EORTC item bank regarding financial difficulties, seven work-related questions, the Hospital Anxiety and Depression Scale, Cancer Worry Scale and EORTC QLQ-C30.

RESULTS

In total, 328 GIST patients participated (response rate 63.0%), of which 110 (33.8%) were on TKI treatment. Patients currently treated with TKIs reported significantly more financial difficulties compared to patients not on TKIs (17.3% vs 8.7%, p = 0.03). The odds of experiencing financial difficulties was 18.9 (95% CI 1.7-214.7, p = 0.02) times higher in patients who were less able to work due to their GIST diagnosis. Patients who experienced financial difficulties had significantly lower global quality of life and functioning, and more frequently reported psychological symptoms as compared to patients who did not report financial difficulties.

CONCLUSION

Even in a country where the costs of TKIs and follow-up care are covered by health insurance, financial difficulties can be present in GIST patients, especially in patients on TKI treatment, and may negatively influence the quality of life.

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.

Financial Burden of Hepatocellular Carcinoma Screening in Patients With Cirrhosis

BACKGROUND

The overall value of hepatocellular carcinoma screening is defined by the balance of benefits and harms. Studies have only reported physical harms with none describing financial harms.

METHODS

We conducted a multicenter pragmatic randomized clinical trial of hepatocellular carcinoma screening outreach among 2872 patients with cirrhosis from March 2018 to April 2021. Patients with positive or indeterminate results and matched patients with negative results completed surveys at baseline and at follow-up measuring financial harms via Cancer Self-Administered Questionnaire and financial burden via Comprehensive Score for Financial Toxicity Functional Assessment of Chronic Illness Therapy. Univariable and multivariable longitudinal regression analyses were performed to compare changes in financial harms across groups: true positive, true negative, false positive, and indeterminate. Semistructured interviews were conducted in a subset of patients, sampled by center and test result.

RESULTS

Of 311 patients who completed at least 1 follow-up survey (75% response rate), 37 had true positive, 133 true negative, 64 false positive, and 77 indeterminate results. Financial harms increased in true positive and false positive patients with no significant changes noted among those with true negative or indeterminate results. At follow-up, 21.8% of patients reported moderate-severe financial burden, which was not significantly associated with test results. Semistructured interviews revealed variation in the frequency and severity of financial harms based on test results, with increased harm in those with false positive results.

CONCLUSIONS

Financial harms of hepatocellular carcinoma screening vary by test result and can pose a barrier that must be considered when determining the optimal screening program.

Dedicated financial hardship screening adds value to routine distress screening among gynecologic cancer patients

OBJECTIVES

To evaluate existing distress screening to identify patients with financial hardship (FH) compared to dedicated FH screening and assess patient attitudes toward FH screening.

METHODS

We screened gynecologic cancer patients starting a new line of therapy. Existing screening included: (1) Moderate/severe distress defined as Distress Thermometer score ≥ 4, (2) practical concerns identified from Problem Checklist, and (3) a single question assessing trouble paying for medications. FH screening included: (1) Comprehensive Score for Financial Toxicity (COST) tool and (2) 10-item Financial Needs Checklist to guide referrals. FH was defined as COST score < 26. We calculated sensitivity (patients with moderate/severe distress + FH over total patients with FH) and specificity (patients with no/mild distress + no FH over total patients with no FH) to assess the extent distress screening could capture FH. Surveys and exit interviews assessed patient perspectives toward screening.

RESULTS

Of 364 patients screened for distress, average age was 62 years, 25% were Black, 45% were Medicare beneficiaries, 32% had moderate/severe distress, 15% reported ≥1 practical concern, and 0 reported trouble paying for medications. Most (n = 357, 98%) patients also completed FH screening: of them, 24% screened positive for FH, 32% reported ≥1 financial need. Distress screening had 57% sensitivity and 77% specificity for FH. Based on 79 surveys and 43 exit interviews, FH screening was acceptable with feedback to improve the timing and setting of screening.

CONCLUSIONS

Dedicated FH screening was feasible and acceptable, but sensitivity was low. Importantly, 40% of women with FH would not have been identified with distress screening alone.

Understanding the financial cost of cancer clinical trial participation

BACKGROUND

Though financial hardship is a well-documented adverse effect of standard-of-care cancer treatment, little is known about out-of-pocket costs and their impact on patients participating in cancer clinical trials. This study explored the financial effects of cancer clinical trial participation.

METHODS

This cross-sectional analysis used survey data collected in December 2022 and May 2023 from individuals with cancer previously served by Patient Advocate Foundation, a nonprofit organization providing social needs navigation and financial assistance to US adults with a chronic illness. Surveys included questions on cancer clinical trial participation, trial-related financial hardship, and sociodemographic data. Descriptive and bivariate analyses were conducted using Cramer's V to estimate the in-sample magnitude of association. Associations between trial-related financial hardship and sociodemographics were estimated using adjusted relative risks (aRR) and corresponding 95% confidence intervals (CI) from modified Poisson regression models with robust standard errors.

RESULTS

Of 650 survey respondents, 18% (N = 118) reported ever participating in a cancer clinical trial. Of those, 47% (n = 55) reported financial hardship as a result of their trial participation. Respondents reporting trial-related financial hardship were more often unemployed or disabled (58% vs. 43%; V = 0.15), Medicare enrolled (53% vs. 40%; V = 0.15), and traveled >1 h to their cancer provider (45% vs. 17%; V = 0.33) compared to respondents reporting no hardship. Respondents who experienced trial-related financial hardship most often reported expenses from travel (reported by 71% of respondents), medical bills (58%), dining out (40%), or housing needs (40%). Modeling results indicated that respondents traveling >1 h vs. ≤30 min to their cancer provider had a 2.2× higher risk of financial hardship, even after adjusting for respondent race, income, employment, and insurance status (aRR = 2.2, 95% CI 1.3-3.8). Most respondents (53%) reported needing $200-$1000 per month to compensate for trial-related expenses. Over half (51%) of respondents reported less willingness to participate in future clinical trials due to incurred financial hardship. Notably, of patients who did not participate in a cancer clinical trial (n = 532), 13% declined participation due to cost.

CONCLUSION

Cancer clinical trial-related financial hardship, most often stemming from travel expenses, affected almost half of trial-enrolled patients. Interventions are needed to reduce adverse financial participation effects and potentially improve cancer clinical trial participation.

Forgoing physician visits due to cost: regional clustering among cancer survivors by age, sex, and race/ethnicity

BACKGROUND

Innovative treatments have improved cancer survival but also increased financial hardship for patients. While demographic factors associated with financial hardship among cancer survivors are known in the USA, the role of geography is less clear.

METHODS

We evaluated prevalence of forgoing care due to cost within 12 months by US Census region (Northeast, North Central/Midwest [NCMW], South, West) by demographic factors (age, sex, race/ethnicity) among 217,981 cancer survivors aged 18 to 82 years from the 2015-2019 Behavioral Risk Factor Surveillance System survey. We summarized region- and group-specific prevalence of forgoing physician visits due to cost and used multilevel logistic regression models to compare regions.

RESULTS

The prevalence of forgoing physician visits due to cost was highest in the South (aged < 65 years: 19-38%; aged ≥ 65: 4-21%; adjusted odds ratios [OR], NCMW versus South, OR: 0.63 [0.56-0.71]; Northeast versus South, OR: 0.63 [0.55-0.73]; West versus South, OR: 0.73 [0.64-0.84]). Across the USA, including regions with broad Medicaid expansion, younger, female, and persons of color most often reported cost-related forgoing physician visits.

CONCLUSION

Forgoing physician visits due to cost among cancer survivors is regionally clustered, raising concerns for concentrated poor long-term cancer outcomes. Underlying factors likely include variation in regional population compositions and contextual factors, such as Medicaid expansion and social policies. Disproportionate cost burden among survivors of color in all regions highlight systemic barriers, underscoring the need to improve access to the entire spectrum of care for cancer survivors, and especially for those most vulnerable.

High Financial Hardship among Patients with Advanced Ovarian Cancer

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

Financial hardship among siblings of long-term survivors of childhood cancer: A Childhood Cancer Survivor Study report

BACKGROUND

Siblings of children with cancer may experience adverse household economic consequences, but their financial outcomes in adulthood are unknown.

METHODS

A total of 880 siblings (aged 18-64 years) of adult-aged childhood cancer survivors were surveyed to estimate the prevalence of financial hardship by three established domains (behavioral, material, and psychological). For individual financial hardship items matching the contemporaneous National Health Interview Survey or Behavioral Risk Factor Surveillance System, siblings were compared with the general population by calculating adjusted prevalence odds ratios (ORs) to sample-weighted responses. Multivariable logistic regression models examined associations between sibling characteristics and each hardship domain and between sibling hardship and survivors' cancer/treatment characteristics.

RESULTS

Behavioral, material, and psychological hardship was reported by 24%, 35%, and 28%, respectively. Compared with national survey respondents, siblings were more likely to report worries about medical bills (OR, 1.14; 95% confidence interval [CI], 1.06-1.22), difficulty affording nutritious foods (OR, 1.79; 95% CI, 1.54-2.07), and forgoing needed medical care (OR, 1.38; 95% CI, 1.10-1.73), prescription medications (OR, 2.52; 95% CI, 1.99-3.20), and dental care (OR, 1.34; 95% CI, 1.15-1.57) because of cost. Sibling characteristics associated with reporting financial hardship in one or more domains included female sex, older age, chronic health conditions, lower income, not having health insurance, high out-of-pocket medical expenditures, and nonmedical/nonhome debt. No survivor cancer/treatment characteristics were associated with sibling financial hardship.

CONCLUSIONS

Adult siblings of childhood cancer survivors were more likely to experience financial hardship compared with the general population. Childhood cancer may adversely affect entire households, with potentially lasting implications.

Toward identification and intervention to address financial toxicity and unmet health-related social needs among adolescents and emerging adults with cancer and their caregivers: A cross-cultural perspective

PURPOSE

We qualitatively explored the unique needs and preferences for financial toxicity screening and interventions to address financial toxicity among adolescents and emerging adults (younger AYAs: 15-25 years) with cancer and their caregivers.

METHODS

We recruited English- or Spanish-speaking younger AYAs who were treated for cancer within the past 2 years and their caregivers. Semi-structured interviews were conducted to explore preferences for screening and interventional study development to address financial toxicity. The data were coded using conventional content analysis. Codes were reviewed with the study team, and interviews continued until saturation was reached; codes were consolidated into categories and themes during consensus discussions.

RESULTS

We interviewed 17 participants; nine were younger AYAs. Seven of the 17 preferred to speak Spanish. We identified three cross-cutting themes: burden, support, and routine, consistent, and clear. The burden came in the form of unexpected costs such as transportation to appointments, as well as emotional burdens such as AYAs worrying about how much their family sacrificed for their care or caregivers worrying about the AYA's physical and financial future. Support, in the form of familial, community, healthcare institution, and insurance, was critical to mitigating the effects of financial toxicity in this population. Participants emphasized the importance of meeting individual financial needs by routinely and consistently asking about financial factors and providing clear guidance to navigate these needs.

CONCLUSION

Younger AYAs and their caregivers experience significant financial challenges and unmet health-related social needs during cancer treatment and often rely on key supports to alleviate these unmet needs. When developing interventions to mitigate financial toxicity, clinicians and health systems should prioritize clear, consistent, and tailorable approaches to support younger AYA cancer survivors and their families.

Association of Medicare eligibility with access to and affordability of care among older cancer survivors

PURPOSE

Older cancer survivors have substantial needs for ongoing care, but they may encounter difficulties accessing care due to cost concerns. We examined whether near-universal insurance coverage through Medicare-a key source of health insurance coverage in this population-is associated with improvements in care access and affordability among older cancer survivors around age 65.

METHODS

In a nationally representative sample of cancer survivors (aged 50-80) from 2006-2018 National Health Interview Survey, we employed a quasi-experimental, regression discontinuity design to estimate changes in insurance coverage, delayed/skipped care due to cost, and worries about or problems paying medical bills at age 65.

RESULTS

Medicare coverage sharply increased from 8.3% at age 64 to 98.2% at age 65, ensuring near-universal insurance coverage (99.5%). Medicare eligibility at age 65 was associated with reductions in delayed/skipped care due to cost (discontinuity, - 5.7 percentage points or pp; 95% CI, - 8.1, - 3.3; P < .001), worries about paying for medical bills (- 7.7 pp; 95% CI, - 12.0, - 3.2; P = .001), and problems paying medical bills (- 3.2 pp; 95% CI, - 6.1, - 0.2; P = .036). However, a sizable proportion reported any access or affordability problems (29.7%) between ages 66 and 80.

CONCLUSIONS

Near-universal Medicare coverage at age 65 was associated with a reduction-but not elimination-of access and affordability problems among cancer survivors.

IMPLICATIONS FOR CANCER SURVIVORS

These findings reaffirm the role of Medicare in improving access and affordability for older cancer survivor and highlight opportunities for reforms to further alleviate financial burden of care in this population.

Financial Toxicity and Health-Related Quality of Life Profile of Patients With Hematologic Malignancies Treated in a Universal Health Care System

PURPOSE

We investigated the association of financial toxicity (FT) with the health-related quality of life (HRQoL) profile of patients with hematologic malignancies treated in a universal health care system.

METHODS

We did a secondary analysis of six multicenter studies enrolling patients with hematologic malignancies. FT was evaluated using the financial difficulties item of the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30). Multivariable linear regression models were used to assess the mean differences in HRQoL scores between patients with or without FT, while adjusting for key potential confounding factors. We also examined the prevalence of clinically important problems and symptoms by the experience of FT, using established thresholds for the EORTC QLQ-C30. Multivariable binary logistic regression analysis was performed to explore the risk factors associated with FT.

RESULTS

Overall, 1,847 patients were analyzed, of whom 441 (23.9%) reported FT. We observed statistically and clinically relevant worse scores for patients with FT compared with those without FT for all the EORTC QLQ-C30 scales. The three largest clinically relevant mean differences between patients with and without FT were observed in pain (∆ = 19.6 [95% CI, 15.7 to 23.5]; P < .001), social functioning (∆ = -18.9 [95% CI, -22.5 to -15.2]; P < .001), and role functioning (Δ = -17.7 [95% CI, -22.1 to -13.3]; P < .001). Patients with FT tended to report a higher prevalence of clinically important problems and symptoms across all EORTC QLQ-C30 scales. In the univariable and multivariable analyses, the presence of FT was associated with the presence of comorbidities, an Eastern Cooperative Oncology Group performance status ≥1, and not receiving a salary.

CONCLUSION

Patients with hematologic malignancies treated in the setting of a universal health care system who experience FT have a worse HRQoL profile compared with those without FT.

Financial Toxicity in Radiation Oncology: Impact for Our Patients and for Practicing Radiation Oncologists

With rising costs of diagnosis, treatment, and survivorship, financial burdens on patients with cancer and negative effects from high costs, called financial toxicity (FT), are growing. Research suggests that FT may be experienced by more than half of working-age cancer survivors and a similar proportion may incur debt or avoid recommended prescription medications due to treatment costs. As FT can lead to worse physical, psychological, financial, and survival outcomes, there is a discrete need to identify research gaps around this issue that constrain the development and implementation of effective screening and innovative care delivery interventions. Prior research, including within a radiation oncology-specific context, has sought to identify the scope of FT among patients with cancer, develop assessment tools to evaluate patient risk, quantify financial sacrifices, and qualify care compromises that occur when cancer care is unaffordable. FT is a multifactorial problem and potential solutions should be pursued at all levels of the health care system (patient-provider, institutional, and systemic) with specific regard for patients' individual/local contexts. Solutions may include selecting alternative treatment schedules, discussing financial concerns with patients, providing financial navigation services, low-cost transportation options, and system-wide health policy shifts. This review summarizes existing FT research, describes tools developed to measure FT, and suggests areas for intervention and study to help improve FT and outcomes for radiation oncology patients.

Health-related quality of life among patients with esophageal, gastric, and colorectal cancer at Kenyatta National Hospital

BACKGROUND

Despite the advancement of modern treatment approaches, several studies indicated a diminished health-related quality of life (HRQoL) in patients with gastrointestinal cancer. However, there is insufficient data about the HRQoL of gastrointestinal cancer patients in Kenya.

AIMS

The study aimed to investigate HRQoL and its determinants in gastrointestinal cancer patients at Kenyatta National Hospital.

METHODS

A cross-sectional study was employed among 160 esophageal, 103 gastric, and 96 colorectal cancer patients. The patient list, identified by unique hospital identification numbers, was obtained from records. Eligibility was assessed based on predetermined criteria, and the hospital identification numbers were reshuffled. Study participants were then randomly selected daily during the data collection period. Data were collected using a researcher-administered European Organization for Research and Treatment of Cancer quality of life questionnaire. The data entry and analysis were carried out using Statistical Package for the Social Sciences 26.0 statistical software. A bivariate and multivariate binary logistic regression analysis was employed to investigate determinants of HRQoL at a 0.05 level of significance.

RESULTS

Most esophageal (N = 118, 73.7%), gastric (N = 75, 72.8%), and colorectal (N = 72, 75%) cancer patients had poor overall HRQoL. In the social (p = .04) and cognitive (p = .02) domain of HRQoL, esophageal cancer patients had a significantly lower mean score as compared to gastric cancer patients. Colorectal cancer patients had the highest mean score in physical functioning (p = .01) as compared with gastric cancer patients. Nonetheless, gastric cancer patients had the highest mean score in emotional functioning domains of quality of life as compared to esophageal (p = .04) and colorectal (p < .001) cancer patients The study revealed a low mean HRQoL score in the majority of the symptom domains of quality of life. A statistically significant difference in all domains of HRQoL was not observed in various treatment modalities of gastrointestinal cancer. Advanced-stage (stages III and IV) and co-morbidities were significant determinants of poor HRQoL.

CONCLUSIONS

The overall HRQoL of gastrointestinal cancer patients was poor. Advanced-stage cancer and co-morbidities were significant determinants of poor HRQoL. Therefore, intensification of routine monitoring of the disease and the treatments should be actively implemented to improve the HRQoL.

Importance of Patient Health Insurance Coverage and Out-of-Pocket Costs for Genomic Testing in Oncologists' Treatment Decisions

PURPOSE

Use of genomic testing, especially multimarker panels, is increasing in the United States. Not all tests and related treatments are covered by health insurance, which can result in substantial patient out-of-pocket (OOP) costs. Little is known about oncologists' treatment decisions with respect to patient insurance coverage and OOP costs for genomic testing.

METHODS

We identified 1,049 oncologists who used multimarker tumor panels from the 2017 National Survey of Precision Medicine in Cancer Treatment. Separate multivariable ordinal logistic regressions examined associations of oncologist-, practice-, and area-level characteristics and oncologists' ratings of importance (very, somewhat, or a little/not important) of insurance coverage and OOP costs for genomic testing in treatment decisions, adjusting for oncologist years of experience, sex, race and ethnicity, specialty, use of next-generation sequencing (NGS) tests, region, tumor boards, patient insurance mix, and area-level socioeconomic characteristics.

RESULTS

Among oncologists, 47.3%, 32.7%, and 20.0% reported that patient insurance coverage for genomic testing was very, somewhat, or a little/not important, respectively, in treatment decisions. In addition, 56.9%, 28.0%, and 15.2% reported that OOP costs for testing were very, somewhat, or a little/not important, respectively. In adjusted analyses, oncologists who used NGS tests were more likely to report patient insurance and OOP costs as important (odds ratio [OR], 2.00 [95% CI, 1.16 to 3.45] and OR, 2.12 [95% CI, 1.22 to 3.68], respectively) in treatment decisions compared with oncologists who did not use these tests, as were oncologists who treated solid tumors, rather than only hematological cancers. More years of experience and higher percentages of Medicaid or self-paid/uninsured patients in the practice were associated with reporting insurance coverage (OR, 1.43 [95% CI, 1.09 to 1.89]) and OOP costs (OR, 1.51 [95% CI, 1.13 to 2.01]) as important. Oncologists in practices with molecular tumor boards for genomic tests were less likely to report coverage (OR, 0.63 [95% CI, 0.47 to 0.85]) and OOP costs (OR, 0.72 [95% CI, 0.53 to 0.97]) as important than their counterparts in practices without these tumor boards.

CONCLUSION

Most oncologists rate patient health insurance and OOP costs for genomic tests as important considerations in subsequent treatment recommendations. Modifiable factors associated with these ratings can inform interventions to support patient-physician decision making about care.

A point-of-care pilot randomized intervention to connect patients with cancer-induced financial toxicity to telehealth financial counseling

PURPOSE

Elevated costs of cancer treatment can result in economic and psychological "financial toxicity" distress. This pilot study assessed the feasibility of a point-of-care intervention to connect adult patients with cancer-induced financial toxicity to telehealth-delivered financial counseling.

METHODS

We conducted a three-armed parallel randomized pilot study, allocating newly referred patients with cancer and financial toxicity to individual, group accredited telehealth financial counseling, or usual care with educational material (1:1:1). We assessed the feasibility of recruitment, randomization, retention, baseline and post-intervention COmprehensive Score for Financial Toxicity (COST), and Telehealth Usability Questionnaire (TUQ) scores.

RESULTS

Of 382 patients screened, 121 were eligible and enrolled. 58 (48%) completed the intervention (9 individual, 9 group counseling, 40 educational booklet). 29 completed follow-up surveys: 45% female, 17% African American, 79% white, 7% Hispanic, 55% 45-64 years old, 31% over 64, 34% lived in rural areas, 24% had cancer stage I, 21% II, 7% III, 31% IV. Baseline characteristics were balanced across arms, retention status, surveys completion. Mean (SD) COST was 12.4 (6.1) at baseline and 16.0 (8.4) post-intervention. Mean (SD) COST score differences were 6.3 (11.6) after individual counseling, 5.8 (8.5) after group counseling, and 2.5 (6.4) after usual care. Mean TUQ score among nine counseling participants was 5.5 (0.9) over 7.0. Non-parametric comparisons were not statistically meaningful.

CONCLUSION

Recruitment and randomization were feasible, while study retention presented challenges. Nine participants reported good usability and satisfaction with telehealth counseling. Larger-scale trials focused on improving participation, retention, and impact of financial counseling among patients with cancer are justified.

Predictors of Financial Toxicity Risk Among Patients Undergoing Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy (CRS-HIPEC)

BACKGROUND

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is the preferred treatment for select patients with peritoneal malignancies. However, the procedure is resource intensive and costly. This study aimed to determine the risk of financial toxicity for patients undergoing CRS-HIPEC.

PATIENTS AND METHODS

We performed a retrospective cohort study of patients undergoing CRS-HIPEC at a single institution from 2016 to 2022. We utilized insurance status, out-of-pocket expenditures, and estimated post-subsistence income to determine risk of financial toxicity. A multivariable logistic regression was used to determine risk factors for financial toxicity.

RESULTS

Our final study cohort consisted of 163 patients. Average age was 58 [standard deviation 10] years, and 52.8% (n = 86) were male. A total of 52 patients (31.9%) were at risk of financial toxicity. A total of 36 patients (22.1%) were from the lower income quartiles (first or second) and 127 patients (77.9%) were from the higher income quartiles (third or fourth). A total of 47 patients (29%) were insured by Medicare, and 116 patients (71%) had private insurance. The median out-of-pocket expenditure across the study cohort was $3500, with a median of $5000 ($3341-$7350) for the at-risk group and $3341 ($2500-$4022) for the not at-risk group (p < 0.001). Risk factors for financial toxicity included high out-of-pocket expenditures and a lower income quartile.

CONCLUSIONS

An estimated one-third of patients undergoing CRS-HIPEC at our institution were at risk for financial toxicity. Several preoperative factors were associated with an increased risk and could be utilized to identify patients who might benefit from interventions.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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