Financial toxicity in cancer care: origins, impact, and solutions

Financial struggles and coping with the aftermath of breast cancer care: An ethnographic study in Vietnam

Breast cancer, the most common cancer diagnosed among women, disproportionately affects low- and middle-income countries (LMICs). Based on an ethnographic study conducted in Central Vietnam in 2019, including observation and interviews with 33 women patients, we investigate how women and their families managed the financial burden of breast cancer care. Our findings suggest that in a context where health-related risk protection is poorly organised and out-of-pocket expenses are burdensome, despite the presence of universal health coverage, patients must rely heavily on informal arrangements to finance their treatment. They proactively researched available information and undertook extensive and ramified work to prove their deservingness for some types of assistance, including strategically disclosing their cancer status or using tactics to accelerate the process of applying for state welfare. Affected families must make hard calculations to prioritise the pressing health need of a member diagnosed with cancer and in many circumstances, forfeited the education of their young children. We offer theoretical understanding of 'patient work' beyond the routine management of the biological aspects of an illness. In addition, we demonstrate how engaging in those various coping practices can reinforce one's vulnerability to a vicious cycle of illness and poverty and amplify socio-economic inequalities among the affected community and the larger society. We argue this situation, if not tackled urgently and appropriately, can impede the progress towards achieving Sustainable Development Goal 3 (Good Health and Wellbeing) and Goal 10 (Reduced Inequalities) in LMICs amidst the non-communicable disease epidemic.

Timing of parathyroidectomy after kidney transplantation: A cost-effectiveness analysis

INTRODUCTION

Parathyroidectomy is the definitive treatment for tertiary hyperparathyroidism post-kidney transplantation. However, cinacalcet-based medical management is increasingly used as an alternative. The financial consequences of each treatment remain unclear. We aimed to identify the most cost-effective strategy for managing hyperparathyroidism from the kidney transplantation recipient's perspective.

METHODS

We constructed a patient-level discrete event simulation model to compare parathyroidectomy and cinacalcet-based medical management. The effects of hyperparathyroidism on allograft survival and all-cause mortality were considered in the discrete event simulation model with a time horizon of 15 years. Our base case was a 55-year-old kidney transplantation recipient with persistent hyperparathyroidism and hypercalcemia. The primary outcome was the cost-effectiveness measured by cost per quality-adjusted life years.

RESULTS

The monthly out-of-pocket cost of cinacalcet ranged from $12 to $288, depending on insurance coverage, with a base case cost of $150. Our base case analysis showed that parathyroidectomy was the dominant treatment with lesser cost ($1,315 vs $7,147) and greater effectiveness (3.17 quality-adjusted life years and 2.92 quality-adjusted life years) than cinacalcet. One-way sensitivity analysis on the cinacalcet treatment duration showed that parathyroidectomy became more cost-effective at 9 months. Two-way sensitivity analysis on the cost of cinacalcet and the duration of treatment with cinacalcet showed that as the monthly cost of cinacalcet increases, the expense of cinacalcet-based medical management quickly exceeds the cost of parathyroidectomy.

CONCLUSION

Parathyroidectomy becomes more cost-effective for kidney transplantation recipients with tertiary hyperparathyroidism when they require cinacalcet-based medical management for more than 9 months. As part of shared decision-making, it is important to discuss the financial costs involved in treating tertiary hyperparathyroidism.

Financial toxicity in early-phase cancer clinical trial participants

BACKGROUND

Little is known about financial toxicity in early-phase clinical trial (EP-CT) participants. This study sought to describe financial toxicity in EP-CT participants and assess associations with patient characteristics and patient-reported outcomes (PROs).

METHODS

Prospectively enrolled EP-CT participants from were followed from April 2021 through January 2023. Participants completed the Comprehensive Score for Financial Toxicity (<26 = financial toxicity) at time of treatment. Quality of life (QOL), symptoms, coping, and resource concerns were surveyed. Associations of financial toxicity with patient characteristics, PROs, and clinical outcomes were explored.

RESULTS

Of 261 eligible patients, 197 completed baseline assessments (75.5%, median age = 63.4 years [31.8-88.6], 57.4% female). Most common cancers were gastrointestinal (33.0%) and breast (20.8%). More than one third (34.0%) of patients reported financial toxicity. Patients with financial toxicity were more likely to be <65 years (70.2% vs 48.5%, p = .004), unemployed (45.5% vs 16.9%, p < .001), not have attended college (53.1% vs 26.4%, p = .002), and have income <$60,000 (59.7% vs 25.4%, p < .001). In adjusted models, patients with financial toxicity reported lower QOL (B = -6.66, p = .004) and acceptance (B = -0.78, p = .002), and increased self-blame (B = 0.87, p < .001). They were more likely to have concerns regarding housing (10.6% vs 2.3%, p = .025), bills (31.8% vs 3.8%, p < .001), food (9.1% vs 0.8%, p = .006), and employment (21.2% vs 1.5%, p < .001). There was no difference in time on trial (hazard ratio, 1.03; p = .860) or survival (hazard ratio, 1.16; p = .496).

CONCLUSIONS

More than one third of EP-CT participants reported financial toxicity. Factors associated with financial toxicity and demonstrated novel associations among financial toxicity with QOL, coping, and resource concerns were identified, highlighting the need to address financial toxicity among this population.

The Impact of Long COVID on Employment and Well-Being: A Qualitative Study of Patient Perspectives

BACKGROUND

Exploring the experiences of Long COVID patients who face challenges with employment may inform improvements in how healthcare systems can provide holistic care for this patient population.

OBJECTIVE

Understand perspectives about the impact of Long COVID on employment and well-being among patients seeking healthcare for Long COVID.

DESIGN

Qualitative study involving one-on-one interviews.

PARTICIPANTS

Eligible participants were 18 years of age or older, spoke English, self-reported as doing well in daily life before having COVID-19, and reported that COVID-19 was still having a significant impact on their life three or more months following an acute infection.

APPROACH

Participants were recruited from a post-COVID recovery clinic at an academic medical center. Interviews were conducted from August to September 2022.

KEY RESULTS

Among all participants (N = 21), most described that they were not able to work at a capacity equivalent to their norm pre-COVID-19. For those who continued working after their COVID-19 infection, the effort and energy required for work left little capacity to participate in other life activities and made it difficult to attend recommended healthcare appointments. Participants reported financial impacts of changes in employment including loss of income and changes in insurance, which were compounded by high healthcare costs. Changes in employment resulted in emotional repercussions including feelings of loss of self-identity and fear of judgement at work. Participants discussed issues surrounding access to strategies to address challenges posed by the impact of Long COVID on employment, including strategies learned from healthcare providers to cope with Long COVID symptoms at work and efforts to seek disability benefits or workplace accommodations.

CONCLUSIONS

Patients with Long COVID may face significant challenges due to changes in their ability to work. Healthcare providers can support these patients by connecting them to financial assistance resources, facilitating appropriate mental health treatment, and expediting workplace accommodation requests.

Financial Toxicity in Patients With Chronic Pancreatitis

OBJECTIVES

Patients with chronic illnesses are susceptible to the financial burden of disease-related treatment costs. Financial toxicity is well researched in cancer and several chronic diseases. This review explores the financial challenges faced by patients with chronic pancreatitis and the impact of financial hardship on their well-being.

MATERIALS AND METHODS

We performed a review of the published literature to summarize the body of existing research and to identify knowledge gaps related to the financial burden experienced by patients with chronic pancreatitis.

RESULTS

Research on financial burden, cost-coping behaviors, cost-related nonadherence to prescribed medications, and social vulnerabilities in people with chronic pancreatitis is sparse. No studies have assessed the suitability and validity of instruments measuring subjective financial toxicity in a patient population with chronic pancreatitis.

CONCLUSIONS

There is a critical need for further studies of financial toxicity in the patient population with chronic pancreatitis, considering that if the sources of financial burden can be identified, opportunities emerge to dampen or mitigate their impact on patients with chronic pancreatitis.

A Systematic Review of Interventions Targeting Cancer-Related Financial Hardship: Current Evidence and Implications

BACKGROUND

Despite an increasing emphasis on alleviating financial hardship in cancer care delivery, limited knowledge of evidence-based and effective interventions is available.

OBJECTIVE

This systematic review aimed to identify gaps in the literature and provide insights for future evidence-based interventions targeting financial hardship from both micro and macro perspectives.

METHODS

We comprehensively searched the PubMed, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, and PsycINFO databases from inception to October 2022. Studies examining the effect of an intervention on mitigating cancer-related financial hardship were included.

RESULTS

A total of 24 studies were included. Findings indicate that the most significant positive changes were in the material conditions domain from the micro perspective of financial hardship. From the macro perspective, positive effects were shown for improving access to care, affordability of care, healthcare utilization, and healthcare equity of interventions at the provider or care team level, the community healthcare environment level, and the healthcare system and policy level. Notably, significant heterogeneity was observed among interventions and outcome measurements.

CONCLUSIONS

This is the first comprehensive systematic review of interventions targeting cancer-related financial hardship from both micro and macro perspectives. No consistently positive effect of the interventions on all domains was reported. Multidisciplinary approaches and higher-level hierarchical and evidence-based interventions are needed to address financial hardship.

IMPLICATIONS FOR PRACTICE

Health practitioners should screen and manage financial hardship using a standard and comprehensive measurement at the dyadic level of cancer survivors and caregivers.

Financial toxicity in breast cancer patients receiving regional nodal irradiation: Variation by cancer subtype

BACKGROUND

We evaluated sociodemographic and clinical predictors of financial toxicity (FT) among patients with breast cancer with higher risk clinical factors warranting regional nodal irradiation (RNI).

METHODS

Among 183 participants in a clinical trial of conventional vs. hypofractionated treatment with RNI, 125 (68 %) completed a pilot survey of FT measured using the validated Economic Strain and Resilience in Cancer (ENRICh) instrument, scored from 0 (minimal) to 10 (severe) FT. Associations with predictors were evaluated using Pearson correlation coefficients and Kruskal Wallis, Mann-Whitney U, and Jonckheere-Terpstra tests. Predictors of severe FT (ENRICh≥5) were tested using multivariable logistic regression with odds ratios converted to relative risks (RR).

RESULTS

Of the sample, all received RNI, 92 % chemotherapy, 67 % axillary dissection, 26 % mastectomy without reconstruction, and 32 % mastectomy with reconstruction. At a median follow up of 1.48 years, median FT score was 2.13 (IQR 0.93-4.6), with 20.8 % of patients experiencing severe FT. Unadjusted worse FT score was associated with younger age (P = 0.003), Hispanic ethnicity (P = 0.006), lower income (P = 0.02), shorter interval from diagnosis to FT assessment (P = 0.02), and chemotherapy receipt (P = 0.05), but not with breast surgery type (P = 0.42), axillary surgery type (P = 0.33), or pathologic T (P = 0.68) or N stage (P = 0.47). In multivariable analysis, triple negative subtype was the sole clinical factor predicting severe FT (RR = 3.38; 95 % CI 1.48-4.99; P = 0.01).

CONCLUSION

Among patients with breast cancer receiving RNI, triple negative subtype was associated with severe FT, suggesting that tumor receptor subtype may help identify a key breast cancer subpopulation for early FT intervention.

Self-Reported Financial Difficulties Among Patients with Multiple Myeloma and Chronic Lymphocytic Leukemia Treated at U.S. Community Oncology Clinics (Alliance A231602CD)

Objectives

To estimate the proportion and correlates of self-reported financial difficulty among patients with multiple myeloma (MM) or chronic lymphocytic leukemia (CLL).

Setting

23 U.S. community and minority oncology practice sites affiliated with the National Cancer Institute Community Oncology Research Program (NCORP).

Participants

521 patients (≥18 years) with MM or CLL were consented and 416 responded to a survey (completion rate=79.8%). Respondents had a MM diagnosis (74.0%), an associate degree or higher (53.4%), were White (89.2%), insured (100%) and treated with clinician-administered drugs (68.0%).

Interventions

Observational, prospective, protocol-based survey administered in 2019-2020.

Primary and secondary outcome measures

Financial difficulty was assessed using a single-item standard measure, the EORTC QLQC30: "Has your physical condition or medical treatment caused you financial difficulties in the past year?" and using an 'any-or-none' composite measure of 22 items assessing financial difficulty, worries and the use of cost-coping strategies. Multivariable logistic regression models assessed the association between financial difficulty, diagnosis, and socioeconomic and treatment characteristics.

Results

16.8% reported experiencing financial difficulty using the single-item measure and 60.3% using the composite measure. Most frequently endorsed items in the composite measure were financial worry about having to pay large medical bills related to cancer and difficulty paying medical bills. Financial difficulty using the single-item measure was associated with having MM versus CLL (adjusted odds ratio [aOR], 0.34; 95% CI, 0.13-0.84; P=.02), having insurance other than Medicare (aOR, 2.53; 95% CI, 1.37-4.66; P=.003), being non-White (aOR, 2.21; 95% CI, 1.04-4.72; P=.04), and having a high school education or below (aOR, 0.36; 95% CI, 0.21-0.64; P=.001). Financial difficulty using the composite measure was associated with having a high school education or below (aOR, 0.62; 95% CI, 0.41-0.94; P=.03).

Conclusions

U.S. patients with blood cancer report financial difficulty, especially those with low socio-economic status. Evidence-based and targeted interventions are needed.

Effects of a reminiscence therapy-involved program on anxiety, depression, and the quality of life in cancer patients: a meta-analysis of randomized controlled trials

Objective

Reminiscence therapy is increasingly being utilized for cancer patients to address psychological pressure and enhance their quality of life. This meta-analysis aimed to comprehensively evaluate the effect of a reminiscence therapy-involved program (RTIP) on anxiety, depression, and quality of life in cancer patients.

Methods

A systematic literature search was conducted in the Web of Science, PubMed, Embase, and Cochrane Library databases until December 2023 to screen randomized control trials (RCTs) comparing the effect of RTIP and control care.

Results

A total of 16 RCTs published from 2013 to 2023 were included, with 1,963 cancer patients undergoing RTIP with or without control care (RTIP group, N = 984) or control care (control group, N = 979). The results showed the the anxiety score [standardized mean differences (SMD) = -0.539; 95% confidence interval (CI) = -0.700, -0.378; P < 0.001], anxiety rate [relative risk (RR) = 0.736; 95% CI: 0.627, 0.865; P < 0.001], depression score (SMD = -0.664; 95% CI: -0.967, -0.361; P < 0.001), and depression rate (RR = 0.632; 95% CI = 0.532, 0.750; P < 0.001) were significantly reduced in the RTIP group compared to the control group. Furthermore, overall quality of life was increased in the RTIP group than in the control group (SMD = 0.501; 95% CI: 0.314, 0.689; P < 0.001). In digestive system cancer patients, anxiety/depression scores and rates were reduced, and the overall quality of life was elevated in the RTIP group in comparison with the control group (all P < 0.050). The quality of evidence was generally high, with a low risk of bias in most studies and no publication bias in any outcomes (all P > 0.050).

Conclusion

RTIP attenuates anxiety and depression and improves the quality of life in cancer patients, benefitting their overall health condition.

Systematic Review Registration

This meta-analysis was registered at PROSPERO with registration number CRD42024563266.

Interventions to mitigate cancer-related medical financial hardship: A systematic review and meta-analysis

BACKGROUND

This study systematically reviewed interventions mitigating financial hardship in patients with cancer and assessed effectiveness using a meta-analytic method.

METHODS

PubMed, Cochrane, Scopus, CINAHL, and Web of Science were searched for articles published in English during January 2000-April 2023. Two independent reviewers selected prospective clinical trials with an intervention targeting and an outcome measuring financial hardship. Quality appraisal and data extraction were performed independently by two reviewers using a quality assessment tool. A random-effects model meta-analysis was performed. Reporting followed the preferred reporting items for systematic review and meta-analyses guidelines.

RESULTS

Eleven studies (2211 participants; 55% male; mean age, 59.29 years) testing interventions including financial navigation, financial education, and cost discussion were included. Financial worry improved in only 27.3% of 11 studies. Material hardship and cost-related care nonadherence remained unchanged in the two studies measuring these outcomes. Four studies (373 participants; 37% male, mean age, 55.88 years) assessed the impact of financial navigation on financial worry using the comprehensive score of financial toxicity (COST) measure (score range, 0-44; higher score = lower financial worry) and were used for meta-analysis. There was no significant change in the mean of pooled COST score between post- and pre-intervention (1.21; 95% confidence interval, -6.54 to 8.96; p = .65). Adjusting for pre-intervention COST, mean change of COST significantly decreased by 0.88 with every 1-unit increase in pre-intervention COST (p = .02). The intervention significantly changed COST score when pre-intervention COST was ≤14.5.

CONCLUSION

A variety of interventions have been tested to mitigate financial hardship. Financial navigation can mitigate financial worry among high-risk patients.

Varying the intensity of cystoscopic surveillance for high-risk non-muscle-invasive bladder cancer

OBJECTIVES

To compare the clinical, economic, and health utility outcomes associated with alternative cystoscopic surveillance regimens for high-risk non-muscle-invasive bladder cancer (HRNMIBC).

PATIENTS AND METHODS

We performed real-world clinical data-driven microsimulations of a hypothetical cohort of 100 000 patients diagnosed with HRNMIBC at age 70 years. The cohort was simulated to undergo alternative surveillance regimens recommended by five guidelines, and two hypothetical regimens-surveillance intensity escalation and de-escalation-which had a surveillance intensity moderately higher and lower, respectively, than the guideline-recommended regimens. We evaluated the 10-year cumulative incidence of muscle-invasive bladder cancer (MIBC), cancer-specific survival (CSS), overall survival (OS), and cost-effectiveness from a United States healthcare payer perspective.

RESULTS

The guideline-recommended surveillance regimens led to an estimated 10-year cumulative incidence of MIBC ranging from 11.0% to 11.6%, CSS 95.0% to 95.2%, and OS 69.7% to 69.8%. Surveillance intensity escalation resulted in a 10-year cumulative incidence of MIBC of 10.5% (95% confidence interval [CI] 10.3-10.7%), CSS of 95.4% (95% CI 95.2-95.5%), and OS of 69.9% (95% CI 69.6-70.1%), vs 11.9% (95% CI 11.7-12.1%), 94.9% (95% CI 94.8-95.1%), and 69.6% (95% CI 69.3-69.9%), respectively, from surveillance intensity de-escalation. By increasing surveillance intensity, the number-needed-to-treat to prevent one additional MIBC progression over 10 years was ≥80, and ≥257 to avoid one additional cancer-related mortality. Compared to surveillance intensity de-escalation, higher-intensity regimens incurred an incremental cost of ≥$336 000 per incremental quality-adjusted life year gained, which well exceeded conventional willingness-to-pay thresholds, ≥$686 000 per additional MIBC progression prevented, and ≥$2.2 million per additional cancer-related mortality avoided.

CONCLUSION

In microsimulations testing a wide range of cystoscopic surveillance intensity for patients newly diagnosed with HRNMIBC, moderate surveillance de-escalation appears associated with an insignificant change in 10-year OS and furthermore is cost-effective vs higher-intensity surveillance regimens. These results suggest that moderate surveillance de-escalation can reduce costs of care without compromising life expectancy for many patients.

Influence of Financial Toxicity on the Quality of Life in Lung Cancer Patients Undergoing Immunotherapy: The Mediating Effect of Self-Perceived Burden

Purpose

The purpose of this study is to understand the level of quality of life (QOL) of lung cancer patients receiving immunotherapy and to clarify the potential mediating role of self-perceived burden (SPB) in the relationship between financial toxicity (FT) and QOL.

Patients and Methods

A convenience sample of 342 lung cancer patients receiving immunotherapy was recruited from a cancer hospital from October 2022 to April 2023 for this cross-sectional study. The participants were requested to complete the following structured questionnaires: a sociodemographic and clinical questionnaire, the Functional Assessment of Cancer Therapy-Lung (FACT-L), the Self-Perceived Burden Scale (SPBS) and the COmprehensive Score for Financial Toxicity (COST). The data were subjected to Pearson correlation analysis and bootstrapping analysis in structural equation modelling.

Results

The total FACT-L score was 79.90±15.84 points in 322 lung cancer patients receiving immunotherapy. FT (β = 0.37, P < 0.01) and SPB (β = -0.27, P < 0.01) had a direct effect on QOL. In addition, SPB partly mediated the association between FT and QOL, and the standardized indirect effect was 0.19, accounting for 33.9% of the total effect.

Conclusion

The present study revealed that there is still much room for improvement in the QOL of lung cancer patients during immunotherapy. A greater financial burden resulted in a greater self-perceived burden and was thus associated with inferior QOL. It is imperative for oncology nurses to routinely assess QOL, FT or risk and SPB for lung cancer patients undergoing immunotherapy as well as to assist those patients in understanding the potential financial risk of each choice and help them take more active roles in their routine clinical care.

Cancer Survivors' Experience of Care and Financial Toxicity: Results From a National Survey

PURPOSE

Financial toxicity (FT) can adversely affect quality of life, treatment adherence, and clinical outcomes. Patient experience of care (PEC) captures patient's perspectives on interactions with health care providers (HCPs) and systems, but the impact of PEC on FT is unknown. This study examined the relationship between PEC and FT.

METHODS

We used data from the 2016-2017 Medical Expenditure Panel Survey (MEPS) Experience with Cancer Survivorship Supplement. PEC was assessed by patient-reported frequencies of their HCPs providing explanations that were easy to understand, listening carefully, showing respect, and spending enough time with the patient. FT was assessed by nine items to measure material, psychological, and behavioral FT. Analyses were performed using multivariable logistic regression controlling for sociodemographic and clinical characteristics and weighted to produce nationally representative estimates and account for survey nonresponse.

RESULTS

Data from 1,068 individuals diagnosed with cancer at age >18 years were assessed. A total of 30% reported material FT, 35% reported psychological FT, and 27% reported behavioral FT. Examining PEC, 64% of respondents indicated that HCPs always explained things, 60% always listened, 66% always showed respect, and 57% always spent adequate time with them. Odds of psychological FT were significantly (P < .05) lower among patients reporting HCPs always (v never/sometimes) listened to them (odds ratio [OR], 0.37 [95% CI, 0.19 to 0.70]), showed them respect (OR, 0.36 [95% CI, 0.16 to 0.81]), and spent enough time with them (OR, 0.47 [95% CI, 0.26 to 0.86]). Significant associations with PEC were also found with MEPS psychological FT items on worry about paying medical bills, family's financial stability, and keeping job/income because of cancer.

CONCLUSION

Worry/anxiety regarding costs can be a major factor affecting individuals diagnosed with cancer. Improving patient-provider interactions to enhance patient experience of care may reduce psychological financial toxicity.

Prevalence of current suicidal thoughts and lifetime suicide attempts in individuals with cancer and other chronic diseases in Germany: Evidence for differential associations from a representative community cohort

BACKGROUND

Research indicates an elevated risk for suicidal thoughts and behaviors (STBs) among individuals with cancer, but community-based studies on the prevalence of STBs in comparison to the general population and other chronic diseases are lacking.

METHODS

Data was drawn from the representative population-based, prospective Gutenberg Health Study (GHS). Participants (N = 12,382; age: M = 59.5, SD = 10.8; 48.9 % women) completed highly standardized medical assessments and validated questionnaires such as the PHQ-9. In addition to prevalence estimates (stratified by STBs and gender), logistic regression models were calculated (controlling for confounders).

RESULTS

The sample included 1910 individuals with cancer, 8.2 % of whom reported current suicidal thoughts and 2.0 % reported lifetime suicide attempts. There was neither a significant association between a cancer diagnosis and suicidal thoughts (p = .077) nor suicide attempts (p = .17) in models adjusting for age, gender, and income. Other chronic diseases were linked to suicidal thoughts and attempts only in men.

LIMITATIONS

Although the investigation of the two kinds of STB are a strength of the study, the items' different time frames complicate comparisons. In addition, the cross-sectional design limits the ability to understand observed relationships and to identify periods of risk.

CONCLUSION

This study expands the evidence base regarding the vulnerability to STBs in individuals with cancer, including long-term survivors. It highlights their heterogeneity, differential risk factors underlying suicidal thoughts and attempts, and the relevance of other (contextual) factors shaping an individual's susceptibility to suicidal crises.

Developing national cancer survivorship standards to inform quality of care in the United States using a consensus approach

PURPOSE

To develop United States (US) standards for survivorship care that informs (1) essential health system policy and process components and (2) evaluation of the quality of survivorship care.

METHODS

The National Cancer Institute and the Department of Veterans Affairs led a review to identify indicators of quality cancer survivorship care in the domains of health system policy, process, and evaluation/assessment. A series of three virtual consensus meetings with survivorship care and research experts and advocates was conducted to rate the importance of the indicators and refine the top indicators. The final set of standards was developed, including ten indicators in each domain.

RESULTS

Prioritized items were survivor-focused, including processes to both assess and manage physical, psychological, and social issues, and evaluation of patient outcomes and experiences. Specific indicators focused on developing a business model for sustaining survivorship care and collecting relevant business metrics (e.g., healthcare utilization, downstream revenue) to show value of survivorship care to health systems.

CONCLUSIONS

The National Standards for Cancer Survivorship Care can be used by health systems to guide development of new survivorship care programs or services or to assess alignment and enhance services in existing survivorship programs. Given the variety of settings providing care to survivors, it is necessary for health systems to adapt these standards based on factors including age-specific needs, cancer types, treatments received, and health system resources.

IMPLICATIONS FOR CANCER SURVIVORS

With over 18 million cancer survivors in the United States, many of whom experience varied symptoms and unmet needs, it is essential for health systems to have a comprehensive strategy to provide ongoing care. The US National Standards for Survivorship Care should serve as a blueprint for what survivors and their families can anticipate after a cancer diagnosis to address their needs.

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

Background

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

Method

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

Result

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

Conclusion

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

The Impact of Structural and Meso-Level Factors on Caregiver Coping Abilities When Supporting a Child with Cancer: A Qualitative Study

Family caregivers of children diagnosed with cancer often experience periods of significant stress. We provide an in-depth examination of the impacts of structural (health care and leave policies) and meso-level (organizations and communities/social networks) factors on caregiver coping during childhood cancer treatment. We conducted a secondary analysis of a comprehensive qualitative dataset examining the impacts of structural and meso-level factors on caregiver coping from in-depth, semi-structured interviews with 49 caregivers representing 38 unique cases of childhood cancer. Using a modified grounded theory approach, transcripts were analyzed using inductive thematic analysis. Caregivers experienced multiple and often intersecting structural and meso-level factors, both facilitating and impeding their ability to cope during their child's cancer treatment. Our analysis revealed the following themes: having few out-of-pocket medical expenses, access to paid time off from employment, and support from one's health system, organizations, or community/social networks fostered caregiver coping. Significant financial burdens due to cancer treatment, having to take unpaid leave from employment, remaining employed regardless of one's circumstances, and lack of support from one's health system, organizations, or community/social networks hindered caregiver coping. Our findings point to several policies that may ease caregiver burden and facilitate caregiver coping during childhood cancer treatment.

Financial Toxicity in Cancer Supportive Care: An International Survey

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Exploring the economic toxicity experiences and coping styles of patients with colorectal cancer fistula in Jiangsu province, China: a qualitative study

OBJECTIVES

In recent years, economic toxicity has significantly affected the physical and mental health as well as the quality of life of patients with colorectal cancer. However, this issue has not garnered adequate attention from healthcare professionals. This study aims to investigate the experiences of economic toxicity and coping strategies among patients with colorectal cancer fistula. The findings are intended to inform the development of suitable and effective intervention programmes to address economic toxicity within this patient population.

DESIGN

A descriptive phenomenological approach was employed in this qualitative research, using a semistructured method for data collection and analysis of interview data. Traditional content analysis methods were applied, encompassing coding, categorisation and theme distillation. Data analysis continued until thematic saturation was achieved, with no new themes emerging.

SETTING

Nanjing Medical University Lianyungang Clinical Medical College.

PARTICIPANTS

A total of 21 patients with colorectal cancer fistula were selected as interview subjects through purposive sampling. The selection took place from May 2022 to May 2023, involving patients during their stay at a tertiary hospital in Lianyungang city, Jiangsu province, China.

RESULTS

In total, three pieces and eight subthemes were distilled: subjective feelings (worries about treatment costs, concerns about uncertainty about the future, worries about daily life), coping styles (coping alone, unwillingness to help, prepurchased insurance, dealing with illness, giving up treatment, inability to afford costs) and needs and aspirations (need for health policies, need for social support).

CONCLUSIONS

Patients with colorectal cancer fistulae experience economic toxicity, leading to significant impairment in both physical and mental health. Despite employing various coping strategies, healthcare professionals must prioritise addressing the economic toxicity issue in patients. Implementing rational and effective interventions can greatly assist patients in effectively managing economic toxicity.

"Let him die. He caused it": A qualitative study on cancer stigma in Tanzania

Cancer stigma presents a critical barrier to care seeking, contributing to delayed presentation and poor cancer outcomes worldwide. The burden of cancer in Tanzania is on the rise, with cancer being the third-leading cause of death in the country. Despite rising incidence and poor outcomes of cancer, cancer-related stigma interventions have received low prioritization. There is a need for sound research that focuses on understanding attitudes driving stigma, its impact on care-seeking and treatment adherence, and intervention models to reduce stigma. We used a cross-sectional qualitative study design. We administered three open-ended qualitative questions to 140 adults newly diagnosed with cancer in Moshi, Tanzania. The questions explored common attitudes toward people with cancer, the perceived impact of cancer-related stigma on care engagement, and ideas for reducing cancer stigma. Patients were recruited during routine appointments at the Cancer Center at Kilimanjaro Christian Medical Center. Data were analyzed using a team-based, applied thematic approach and NVivo 12 software. All participants described stigma as a significant challenge for treatment and receiving support from their social networks. Perceptions of financial burden, misconceptions about cancer, such as the belief that it is contagious, and fear of death, were common attitudes driving cancer stigma. Most participants feared that symptoms would prevent them from being able to work and that the cost of cancer care would drive away loved ones. Stigma was not a ubiquitous response, as some participants reported increased care and social support from family members after a cancer diagnosis. Experiences of stigma contributed to feelings of shame, fear of burdening the family, reduced resources to access treatment, and disengagement from care. Common substitutes to medical therapies included religious interventions and traditional medicine, perceived as less expensive and less stigmatizing. Many participants felt they would benefit from improved financial support, professional counseling, and education for families and communities to reduce stigmatizing attitudes and enhance social support. There is a need for intervention studies focused on improving cancer literacy, community advocacy to reduce cancer stigma, and increasing emotional and practical support for people with cancer and their families. There is also a clear need for policy efforts to make cancer care more affordable and accessible to reduce the financial burden on patients and families.

National survey of patient perspectives on cost discussions among recipients of copay assistance

BACKGROUND

Individuals with cancer and other medical conditions often experience financial concerns from high costs-of-care and may utilize copay assistance programs (CAP). We sought to describe CAP recipients' experiences/preferences for cost discussions with clinicians.

METHODS

We conducted a national, cross-sectional electronic-survey from 10/2022 to 11/2022 of CAP recipients with cancer or autoimmune conditions to assess patient perspectives on cost discussions. We used multivariable logistic regression models to explore associations of patient perspectives on cost discussions with patient characteristics and patient-reported outcomes (eg, financial toxicity, depression/anxiety, and health literacy).

RESULTS

Among 1,566 participants, 71% had cancer and 29% had autoimmune conditions. Although 62% of respondents desired cost discussions, only 32% reported discussions took place. Additionally, 52% of respondents wanted their doctor to consider out-of-pocket costs when deciding the best treatment, and 61% of respondents felt doctors should ensure patients can afford treatment prescribed. Participants with depression symptoms were more likely to want doctors to consider out-of-pocket costs (OR = 1.54, P = .005) and to believe doctors should ensure patients can afford treatment (OR = 1.60, P = .005). Those with severe financial toxicity were more likely to desire cost discussions (OR = 1.65, P < .001) and want doctors to consider out-of-pocket costs (OR = 1.52, P = .001). Participants with marginal/inadequate health literacy were more likely to desire cost discussions (OR = 1.37, P = .01) and believe doctors should ensure patients can afford treatment (OR = 1.30, P = .036).

CONCLUSIONS

In this large sample of CAP recipients with cancer and autoimmune conditions, most reported a desire for cost discussions, but under one-third reported such discussions took place.

Impact of Financial Costs on Patients' Fertility Preservation Decisions: An Examination of Qualitative Data from Female Young Adults with Cancer and Oncology Providers

Purpose: To examine the impact of financial costs on fertility preservation decisions among female young adults (YAs) with cancer. Methods: Female YAs (N = 18; aged 21-36) with a history of cancer and oncology providers (N = 12) were recruited from an National Cancer Institute-designated comprehensive cancer center in a state without insurance coverage for fertility preservation. YAs and providers completed individual interviews and a brief online assessment. Qualitative description using thematic analysis was used to identify, analyze, and report common themes. Descriptive statistics was used to characterize the sample. Results: Female YAs and oncology providers highlighted the critical role that high out-of-pocket costs play in YAs' fertility preservation decisions along with the value that enhanced insurance coverage for fertility preservation would have for increasing female YAs' access to and utilization of fertility preservation. Although providers were concerned about preservation costs for their patients, they reported that their concerns did not impact whether they referred interested female YAs to reproductive specialists. Oncology providers expressed concern about inequities in utilization of fertility preservation for female and racially/ethnically minoritized YAs that were exacerbated by the high out-of-pocket fertility preservation costs. Conclusion: Cost is a significant barrier to fertility preservation for female YA cancer patients. Female YAs of reproductive age may benefit from decision support tools to assist with balancing the cost of fertility preservation with their values and family building goals. Policy-relevant interventions may mitigate cost barriers and improve access to care.

Addressing Financial Toxicity in Head and Neck Cancer-A Crucial Imperative

This Viewpoint calls for consideration of the financial costs of head and neck cancer care when choosing treatment strategies for patients who may face severe financial stress or insolvency due to cancer treatment.

Domains and Categories of Needs in Long-Term Follow-Up of Adult Cancer Survivors: A Scoping Review of Systematic Reviews

The number of long-term cancer survivors increases continually. Understanding their needs is crucial to ensure an adequate follow-up. The aim of our study was to summarize the current literature concerning needs and what influences these needs. A scoping review of systematic reviews was conducted according to the recommendations of the Joanna Briggs Institute. Four electronic databases were searched. Of 414 retrieved papers, 11 met the eligibility criteria. Needs were aggregated into six domains (health-related information, health system, mental, practical, relationship and physical) and 15 categories. The lack of adequate information and the lack of access and/or continuity of supportive care were the most prominent needs. Female gender, younger age, a low level of family and/or social support, and higher educational level were identified as risk factors. Employment and relationship status can affect the needs both in a positive and negative way. The weeks or months after the end of the treatments are particularly critical, and needs can be emphasized during this period. The experience of cancer could also lead to positive changes. The variety of needs affects the quality of life of cancer survivors. Needs assessments should be systematically provided to ensure a better awareness of health professionals and to allow an individual, holistic, and integrated follow-up.

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.

The impact of humanitarian aid on financial toxicity among cancer patients in Northwest Syria

INTRODUCTION

The ongoing crisis in Syria has divided the country, leading to significant deterioration of the healthcare infrastructure and leaving millions of people struggling with poor socioeconomic conditions. Consequently, the affordability of healthcare services for the population has been compromised. Cancer patients in Northwest Syria have faced difficulties in accessing healthcare services, which increased their financial distress despite the existence of humanitarian health and aid programs. This study aimed to provide insights into how humanitarian assistance can alleviate the financial burdens associated with cancer treatment in conflict-affected regions.

MATERIALS AND METHODS

This research employed a quantitative, quasi-experimental design with a pre-test-post-test approach, focusing on evaluating the financial toxicity among cancer patients in Northwest Syria before and after receiving humanitarian aid. The study used purposeful sampling to select participants and included comprehensive demographic data collection. The primary tool for measuring financial toxicity was the Comprehensive Score for Financial Toxicity (FACIT-COST) tool, administered in Arabic. Data analysis was conducted using SPSS v25, employing various statistical tests to explore relationships and impacts.

RESULTS

A total of 99 cancer patients were recruited in the first round of data collection, out of whom 28 patients affirmed consistent receipt of humanitarian aid throughout the follow-up period. The results of the study revealed that humanitarian aid has no significant relationship with reducing the financial toxicity experienced by cancer patients in Northwest Syria. Despite the aid efforts, many patients continued to face significant financial distress.

CONCLUSION

The research findings indicate that current humanitarian assistance models might not sufficiently address the complex financial challenges faced by cancer patients in conflict zones. The research emphasizes the need for a more comprehensive and integrated approach in humanitarian aid programs. The study highlights the importance of addressing the economic burdens associated with cancer care in conflict settings and calls for a re-evaluation of aid delivery models to better serve the needs of chronic disease patients. The findings suggest a need for multi-sectoral collaboration and a systemic approach to improve the overall effectiveness of humanitarian assistance in such contexts.

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

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

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.

Integrating Palliative Care Into the Management of Genitourinary Malignancies

Palliative care (PC) plays a critical role in managing the difficulties associated with genitourinary malignancies. Its primary aim is to improve the overall health of patients, provide support to both patients and their caregivers, and help individuals to navigate the complex decisions about treatment and end-of-life care. PC takes a holistic approach to patient care, recognizing that genitourinary malignancies affect multiple aspects of a person's life. By addressing physical, emotional, social, and spiritual needs, PC aims to provide comprehensive support that is consistent with the patient's values and preferences. The goal is to optimize comfort, minimize distress, and enhance the patient's quality of life throughout the course of the illness. PC is not a one-off intervention, but an ongoing source of support. This article aims to provide a thorough overview of the critical elements involved in addressing the challenges posed by genitourinary cancers, emphasizing the importance of palliative interventions. We will highlight the multifaceted aspects of care and explore strategies to optimize the overall well-being of patients throughout the course of treatment for genitourinary malignancies.

Financial Toxicity in Radiation Oncology

Financial toxicity details the financial burden patients face due to a variety of medical costs. Cancer patients, especially those receiving radiation therapy, are at a much higher risk of experiencing economic hardships than healthy people or people with other conditions. There are a variety of risk factors associated with financial toxicity as well as numerous tools to assess the toxicity experienced by patients. In this review article, we present a concise overview of contributors, risk factors, case studies, tools, impacts, and potential interventions of financial toxicity.

Cost effectiveness of immunotherapy combination therapies for endometrial cancer

Over the past five years (2019-2023), several new targeted therapies and immunotherapy has been approved in treating relapsed cervical, ovarian, and endometrial cancers. Concurrently, there has been growing recognition of financial toxicity associated with cancer care during this time period. As such, we reviewed FDA approvals from 2019 to 2013 and identified the following approvals in gynecologic oncology: pembrolizumab plus lenvatinib, pembrolizumab for recurrent endometrial cancer that is MSI-H/dMMR, tisotumab vedotin, dostarlimab as single-agent therapy, and dostarlimab plus chemotherapy. We focused on approvals for endometrial cancer, and conducted a cost-effectiveness analysis for combination options approved in treating recurrent or advanced endometrial cancer (i.e. pembrolizumab plus lenvatinib versus placebo; dostarlimab plus chemotherapy versus placebo), and found neither regimen was cost-effective at a willingness-to-pay of $100,000 per Equal Value of Life Years Gained (evLYG). While these costs may not necessarily be translated to an individual patient, these costs are absorbed by healthcare systems and insurance providers on a larger scale with downstream effects on individuals contributing to healthcare costs a whole.

COVID-19 and health care-related financial toxicity in the United States: Evidence from the 2022 National Health Interview Survey

BACKGROUND

Despite the common perception of the socioeconomic burden of the COVID-19 pandemic, quantification of the relationship between COVID-19 and indicators of health care-related financial toxicity in the general population has been limited. This study aimed to provide estimates of these relationships in a nationally representative sample of the US adult population.

METHODS

Using the data on 27,480 adults from the 2022 National Health Interview Survey, we fitted multivariable logistic regression models to assess the differential risks of financial toxicity as manifested by the financial hardship in paying medical bills, delayed and forgone medical care, and medication nonadherence, by COVID-19 diagnosis, severity, and duration of symptoms.

RESULTS

We found that compared to individuals not having COVID-19, individuals with severe symptoms of COVID-19 were 1.86, 1.50, 1.76, and 1.77 times more likely to experience financial hardship, delay medical care, forgo medical care, and skip/delay/take less medication, respectively. Similarly, individuals with symptoms lasting for 3 or more months were 1.94, 1.65, 1.87, and 2.20 times more likely to experience these measures of financial toxicity, respectively.

CONCLUSIONS

The estimates of the relationship between COVID-19 and financial toxicity will facilitate effective communications for policy actions aimed at alleviating the burden of the COVID-19 pandemic.

Identifying the supportive care needs of people affected by non-muscle invasive bladder cancer: An integrative systematic review

PURPOSE

To understand supportive care needs among people with non-muscle invasive bladder cancer (NMIBC).

METHODS

An integrative systematic review was reported using the Preformed Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines. Seven electronic databases were searched for relevant studies, including all quantitative, qualitative, and mixed methods studies, irrespective of research design. The review process was managed by Covidence systematic review software. Two reviewer authors independently performed data extraction using eligibility criteria. Quality appraisal was conducted, and a narrative synthesis was performed.

RESULTS

A total of 1129 articles were screened, of which 21 studies met the inclusion criteria. The findings revealed that the frequency of supportive care needs reported by NMIBC participants included psychological/emotional (16/21:76%), physical (16/21:76%), practical (8/21:38%), interpersonal/intimacy (7/21:33%), family-related (7/21:33%), health system/information (5/21:23%), social (4/21:19%), patient-clinician communication (3/21:14%), spiritual (1/21:5%) and daily needs (1/21:5%).

CONCLUSION

People affected by NMIBC experience anxiety, depression, uncertainty, and fear of recurrence. The physical symptoms reported included urinary issues, pain, sleeping disorders and fatigue. These supportive care needs persist throughout the participants' treatment trajectory and can impact their quality of life.

IMPLICATIONS FOR CANCER SURVIVORS

Identifying supportive care needs within the NMIBC population will help inform future interventions to provide patient-centred care to promote optimal well-being and self-efficacy for people diagnosed with NMIBC.

Financial burden faced by breastfeeding mothers caring for children diagnosed with cancer in Ghana; an exploratory qualitative study

BACKGROUND

When children are diagnosed of cancer, parents face varied financial issues. Among some of the identifiable factors that cause financial challenges among breastfeeding mothers include the high cost of childhood cancer care. The high cost of childhood cancer care could impede the sustainability of access to prompt care. There is paucity of literature on the financial burdens faced by breastfeeding mothers with children diagnosed with cancer in Ghana. Therefore, this study sought to explore the financial burden faced by mothers with breastfeeding children diagnosed with cancer.

METHODS

The study employed qualitative exploratory descriptive design. One-on-one interviews were conducted among 13 mothers with breastfeeding children diagnosed of cancer. Permission was sought for data to be recorded, transcribed concurrently and inductive content analysis done.

RESULTS

Three main themes emerged after data analysis: High cost (sub-themes; expensive medications, laboratory investigation fees, and cost of mothers' feeding), Public support (sub-themes; appeal for funds, national health insurance scheme) and Self-financing (loans, personal savings). Most of the breastfeeding mothers narrated that high cost of childhood cancer care generated financial distress to them. They shared that the cost involved in purchasing their children's cancer medications, paying for laboratory investigations and feeding themselves to produce adequate breastmilk to feed their children were challenging. Some of the mothers self-financed the cost of their children's cancer care through loans and personal savings.

CONCLUSION

Government and other stakeholders should allocate annual budget and funds towards childhood cancer care to lessen the financial burden breastfeeding mothers caring for children with cancer experience.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Suffering and adjustment: a grounded theory of the process of coping with financial toxicity among young women with breast cancer

PURPOSE

To explore the process of coping with financial toxicity among young women with breast cancer and formulate a grounded theory that serves as a foundation for creating intervention strategies aimed at supporting cancer survivors.

METHODS

A qualitative study using the Corbin and Strauss variant of grounded theory. A series of in-depth interviews were carried out with young women with breast cancer (n = 29) using the theoretical sampling method. We analyzed data by coding core categories in the patients' coping processes and developing theory around these categories. Data collection and analysis were performed simultaneously.

RESULTS

A substantial theory of the process of coping with financial toxicity among young female breast cancer survivors was constructed. Two core concepts, suffering and adjustment, were identified. Young women with breast cancer suffered from financial toxicity, which was related to risk factors, coping resources, and unmet needs. To overcome financial toxicity, young women with breast cancer adjusted by reshaping consumption concept, re-dividing of family functions, re-planning of occupation career, and rebuilding life confidence.

CONCLUSION

This qualitative study constructed a theory delineating the coping strategies employed by young women with breast cancer in response to financial toxicity, offering profound insights into the intricacies of cancer-related financial toxicity. Identifying risk factors, enhancing coping resources, and meeting unmet needs would be helpful to patients' adjustment to financial stress.

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

BACKGROUND

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Hospital- and county-level characteristics explain geographic variability in prices of cancer-related procedures: Implications for policy and interventions

BACKGROUND

Healthcare costs in the U.S. are high and variable, which can hinder access and impact health outcomes across communities. This study examined hospital- and county-level characteristics to identify factors that explain geographic variation in prices for four cancer-related procedures.

METHODS

Data sources included Turquoise Health, which compiles publicly-available price data from U.S. hospitals. We examined list prices for four procedures: abdominal ultrasound, diagnostic colonoscopy, brain MRI, and pelvis CT scan, which we linked to characteristics of hospitals (e.g., number of beds) and counties (e.g., metropolitan status). We used multilevel linear regression models to assess multivariable relationships between prices and hospital- and county-level characteristics. Supplementary analyses repeated these models using procedures prices for commercial insurance plans.

RESULTS

For each procedure, list prices varied across counties (intraclass correlation: abdominal ultrasound = 23.2%; colonoscopy = 17.1%; brain MRI = 37.2%; pelvis CT = 50.9%). List prices for each procedure were associated with hospital ownership (all p < 0.001) and percent of population without health insurance (all p < 0.05). For example, list prices for abdominal ultrasound were higher for proprietary versus Government-owned hospitals (β = 539.10, 95% confidence interval [CI]: 256.12, 822.08, p < 0.001) and for hospitals in counties with more uninsured residents (β = 23.44, 95% CI: 2.55, 44.33, p = 0.03). Commercial insurance prices were negatively associated with metropolitan status.

CONCLUSIONS

Prices for cancer-related healthcare procedures varied substantially, with considerable heterogeneity associated with county location as well as county-level social determinants of health (e.g., health insurance coverage). Interventions and policy changes are needed to alleviate the financial burden of cancer care among patients, including geographic variation in prices for cancer-related procedures.

Care Delivery Interventions for Individuals with Cancer: A Literature Review and Focus on Gastrointestinal Malignancies

BACKGROUND

Gastrointestinal malignancies represent a particularly challenging condition, often requiring a multidisciplinary approach to management in order to meet the unique needs of these individuals and their caregivers.

PURPOSE

In this literature review, we sought to describe care delivery interventions that strive to improve the quality of life and care for patients with a focus on gastrointestinal malignancies.

CONCLUSION

We highlight patient-centered care delivery interventions, including patient-reported outcomes, hospital-at-home interventions, and other models of care for individuals with cancer. By demonstrating the relevance and utility of these different care models for patients with gastrointestinal malignancies, we hope to highlight the importance of developing and testing new interventions to address the unique needs of this population.

Factors Associated with Delaying and Forgoing Care Due to Cost among Long-term, Appalachian Cancer Survivors in Rural North Carolina

Background

Little research exists on delayed and forgone health and mental health care due to cost among rural cancer survivors.

Methods

We surveyed survivors in 7 primarily rural, Appalachian counties February to May 2020. Univariable analyses examined the distribution and prevalence of delayed/forgone care due to cost in the past year by independent variables. Chi-square or Fisher's tests examined bivariable differences. Logistic regressions assessed the odds of delayed/forgone care due to cost.

Results

Respondents (n=428), aged 68.6 years on average (SD: 12.0), were 96.3% non-Hispanic white and 49.8% female; 25.0% reported delayed/forgone care due to cost. The response rate was 18.5%. The proportion of delayed/forgone care for those aged 18-64 years was 46.7% and 15.0% for those aged 65+ years (P<0.0001). Females aged 65+ years (OR: 2.00; CI: 1.02-3.93) had double the odds of delayed/forgone care due to cost compared to males aged 65+ years.

Conclusion

About one in four rural cancer survivors reported delayed/forgone care due to cost, with rates approaching 50% in survivors aged <65 years.

Impact

Clinical implications indicate the need to: 1) ask about the impact of care costs, and 2) provide supportive services to mitigate effects of treatment costs, particularly for younger and female survivors.

Interventions for financial toxicity among cancer survivors: A scoping review

INTRODUCTION

Financial toxicity impairs cancer survivors' material condition, psychological wellbeing and quality of life. This scoping review aimed to identify interventions for reducing cancer-related financial toxicity (FT), and to summarize their main findings.

METHODS

A systematic search was performed in PubMed, Web of Science, EMBASE, CINAHL, Clinical Trials, China National Knowledge Internet, Wanfang and SinoMed from January 2010 to September 2022 following the PRISMA-ScR checklist.

RESULTS

From 2842 identified articles, a total of 15 were included in this review. Existing interventions can be classified into four types: financial navigation, financial counseling, insurance education and others. Previous interventions preliminarily affirmed the feasibility, satisfaction, and improvement in financial worries and knowledge. However, the effectiveness on FT was controversial.

CONCLUSIONS

Previous interventions affirmed the feasibility and primary effect of these interventions. Studies with more rigorous design are needed to evaluate the effectiveness and generalizability of interventions on FT across diverse healthcare systems.

Financial toxicity among cancer patients, survivors and their families in the United Kingdom: a scoping review

BACKGROUND

The aim of this scoping review was to identify key research gaps and priorities in order to advance policy and practice for people living with cancer in the UK.

METHODS

The review adhered to PRISMA guidelines for scoping review. We searched MEDLINE, EMBASE, Scopus, Web of Science and Google Scholar on 16 July 2022. There were no restrictions in terms of study design and publication time; gray literature was included. The key words, 'financial' or 'economic', were combined with each of the following words 'hardship/stress/burden/distress/strain/toxicity/catastrophe/consequence/impact.'

RESULTS

29/629 studies/reports published during 1982-2022 were eligible to be included in the review. No study conducted a comprehensive inquiry and reported all aspects of financial toxicity (FT) or used a validated measure of FT. The most three commonly reported outcomes related to financial hardship were financial well-being (24/29), benefit/welfare (17/29) and mental health status (16/29).

CONCLUSIONS

It is evident that FT is experienced by UK cancer patients/survivors and that the issue is under-researched. There is an urgent need for further research including rigorous studies which contribute to a comprehensive understanding about the nature and extent of FT, disparities in experience, the impacts of FT on outcomes and potential solutions to alleviate FT and related problems.

Real-World Clinical Outcomes of Bevacizumab-awwb Biosimilar versus Bevacizumab Reference Product in Patients with Metastatic Colorectal Cancer

BACKGROUND

Bevacizumab-awwb was the first biosimilar approved for cancer treatment in the USA. Limited information is available on the real-world comparative safety and effectiveness of bevacizumab biosimilars, especially for indications granted approval through extrapolation.

OBJECTIVE

To evaluate the real-world outcomes of patients with metastatic colorectal cancer (mCRC) initiated on bevacizumab-awwb versus bevacizumab reference product.

PATIENTS AND METHODS

This was an observational, longitudinal cohort study of US adult patients with mCRC from four integrated care delivery systems who were newly initiated on bevacizumab-awwb between 1 July 2019 and 30 March 2020 or bevacizumab reference product between 1 July 2015 and 30 June 2018. Patients were followed until 1 year after treatment initiation, end of plan membership, or death, whichever occurred first. The primary outcome of overall survival (OS) was analyzed using a binary non-inferiority test with lower margin of 10% and adjusted Cox proportional hazards regression analysis to assess all-cause mortality if non-inferiority was met. Secondary outcomes included counts of doses received, treatment duration, all-cause hospitalizations, and incidence of serious adverse events.

RESULTS

A total of 1445 patients initiated on either bevacizumab-awwb (n = 239) or bevacizumab reference product (n = 1206) were included in the analysis. The mean overall age was 60 ± 13 years, 46% of patients were female, and 51% were white. The OS rate was 72.8% and 73.1% for patients receiving bevacizumab-awwb and bevacizumab reference product, respectively (p < 0.01 for non-inferiority). The adjusted hazard ratio for mortality was 1.01 (0.77-1.33, p = 0.93). There were no statistically significant differences in secondary outcomes between the study groups.

CONCLUSIONS

These findings suggest that bevacizumab-awwb is as effective and safe as bevacizumab reference product for the real-world treatment of mCRC.

Financial toxicity in thyroid cancer survivors

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Availability and accessibility of services to address financial toxicity described by Australian lung cancer patients and healthcare professionals

PURPOSE

Although the financial burden and impact of a cancer diagnosis has been widely described in international literature, less understood is the availability and accessibility of services to ameliorate this need. This study reports the experiences of Australian lung cancer patients and health professionals delivering care, regarding factors that exacerbate and mitigate financial stress, and availability and accessibility of services to support people following a cancer diagnosis.

METHODS

Qualitative semi-structured interviews with twenty-three lung cancer patients attending two metropolitan tertiary health services and eleven health professionals delivering care were undertaken during July-August 2021.

RESULTS

Neither health service systematically screened for financial toxicity nor routinely provided information regarding potential financial impacts during consultations. Patients experienced lengthy delays in accessing welfare supports, provoking financial stress and worry. Health professionals reported limited resources and referral services to support patients with financial need; this was especially problematic for patients with lung cancer. They described its psychological impact on patients and their family members or carers and warned of its impact on ability to adhere to treatment.

CONCLUSION

Available and accessibility of services addressing financial toxicity in Australian lung cancer patients is inadequate. Although financial stress is a common, distressing problem, health professionals feel hampered in their ability to help due to limited service availability. Left unaddressed, financial toxicity can impact treatment adherence, directly influencing health outcomes, and increase risk of poverty, amplifying social inequities. Findings highlight opportunity for actionable interventions like financial consent and routine screening and discussion of financial toxicity across care pathways.

Preventing Future Harm: Identifying the Drivers of an Unsafe Discharge to Improve Safety on an Inpatient Oncology Service

Cancer Morbidity, Mortality, and Improvement Rounds is a series of articles intended to explore the unique safety risks experienced by oncology patients through the lens of quality improvement, systems and human factors engineering, and cognitive psychology. For purposes of clarity, each case focuses on a single theme, although, as is true for all medical incidents, there are almost always multiple, overlapping, contributing factors. The quality improvement paradigm used here, which focuses on root cause analyses and opportunities to improve care delivery systems, was previously outlined in this journal.This article describes the care of a young patient with aggressive breast cancer, declining performance status, and multiple hospital admissions who died shortly after being discharged home without essential medications or an adequate plan for follow-up. The patient's death due to her malignancy was unavoidable, but she had inadequate resources before her death, leading to avoidable suffering. This outcome resulted from a series of minor errors attributable to inadequate handoffs, challenges establishing realistic goals of care, and hierarchy within and between medical teams that resulted in major lapses at the time of discharge. We explore these issues and discuss how this case led to the establishment of programs designed to empower health care providers and increase engagement of outpatient oncologists at critical points of patients' disease courses.