Evidence of the Feasibility and Preliminary Efficacy of Oncology Financial Navigation: A Scoping Review

Implementation strategies of financial navigation and its effects on alleviating financial toxicity among cancer survivors: a systematic review

PURPOSE

This systematic review aims to identify the implementation strategies of financial navigation and systematically synthesise its effects on mitigating financial toxicity among cancer survivors, based on the theoretical framework of implementation science.

METHODS

Medline, Web of Science Core Collection, ScienceDirect and ProQuest Health & Medical Collection databases were searched for studies published before 22 August 2023. We sought original research on financial navigation interventions among adult cancer survivors with financial toxicity in healthcare settings. The Revised Cochrane risk-of-bias tool for randomised trials, 2.0 and the Risk Of Bias In Non-randomised Studies of Interventions-I were used to assess the risk of bias in included studies. In addition, the implementation strategies of the included studies were categorised and collated based on Expert Recommendations for Implementing Change, and the Consolidated Framework for Implementation Research was adopted to explain barriers and facilities for implementation.

RESULTS

In total, 6855 records were screened, yielding 14 full-text articles, which were included (3 randomised clinical trials and 11 non-randomised studies). 'Train and educate stakeholders' (n=13 (92.9%)) and 'use evaluative and iterative strategies' (n=12 (85.7%)) were the most common implementation strategies in financial navigation. The feasibility of financial navigation is relatively high, but generally hindered by the health condition of cancer survivors, low willingness to participate and insufficient number of navigators to cover all participants. After the intervention, three of seven studies reported statistically significant mitigations in patient-reported financial toxicity. In studies reporting statistically significant outcomes, 'adapt and tailor to the context' and 'change infrastructure' were proposed as key corresponding recommendations.

CONCLUSIONS

Financial navigation is a potentially beneficial intervention for lessening the financial toxicity of cancer survivors, but more high-level evidence is needed for further validation. Financial navigation combined with the theoretical framework of implementation science provides a foundation for the future realisation of the leap from knowledge to practice.

PROSPERO REGISTRATION NUMBER

CRD42023469114.

Psychometric Properties of Self-Reported Financial Toxicity Measures in Cancer Survivors: An Overview of Systematic Reviews

AIM(S)

To assess the methodological quality and psychometric properties of self-reported financial toxicity measures for cancer survivors, to offer evidence-based guidance for the selection of these measures in clinical practice, and to supply methodological references for the enhancement and development of related measures in the future.

DESIGN

An overview of systematic reviews.

METHODS

Four academic databases were searched to conduct an overview of systematic reviews published from inception to August 2024. The Overview Quality Assessment Questionnaire (OQAQ) was employed to evaluate the methodological quality of the research included. The consensus-based standards for the selection of health measurement instruments checklist (COSMIN) and the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) system were employed to assess the methodological and psychometric quality of the financial toxicity measures included.

RESULTS

Six systematic reviews satisfied the inclusion criteria. The OQAQ results indicated that six studies exhibited significant methodological quality defects, each receiving a score of 3 points. COST-v1, COST-v2, HARDS, ENRICh, and FinTox were classified as level A. Ten measures were classified as level B, lacking evidence to support content validity and internal consistency as '+'. Seven measures were classified at level C, supported by high-quality evidence indicating certain domains as '-'.

CONCLUSION

COST is advised as the best appropriate measurement standard for research and clinical practice across many global contexts. HARDS and ENRICh were advised to select only after thoroughly evaluating the local socio-economic context. FinTox is particularly suggested for the assessment of severe FT. SFDQ and FIT are advised for selection following an evaluation of therapy alternatives and the cancer's location.

IMPLICATIONS FOR THE PATIENT CARE

Healthcare professionals can implement evidence-based measures in clinical practice to effectively assess the financial toxicity experienced by cancer survivors, offer policy-oriented interventions, and enhance patient-reported outcomes.

Insights From Diverse Perspectives on Social Media Messages to Inform Young Adults With Cancer About Clinical Trials: Focus Group Study

Background

Low rates of adolescent and young adult (YA; aged 15-39 y) clinical trial enrollment (CTE), particularly among underserved groups, have resulted in a lack of standardized cancer treatments and follow-up guidelines for this group that may limit improvement in cancer treatments and survival outcomes for YAs.

Objective

To understand and address unique barriers to CTE, we conducted focus groups to learn about informational, financial, and psychosocial needs of YAs surrounding CTE and identify strategies to address these barriers.

Methods

We conducted 5 focus groups in 2023 among a diverse sample of YA patients from across the United States. An interview guide was developed collaboratively with YA advocates. Specifically, informational needs, financial concerns, and psychosocial issues were explored, and participants were probed to suggest strategies, especially those that leverage technology, to address these barriers. Sessions were audio recorded, transcribed, and coded using direct content analysis. Findings were synthesized through consensus discussions.

Results

We confirmed the previously proposed thematic barriers regarding YA CTE and identified 9 subthemes: awareness, lack of clear and accessible CTE information, fear of the unknown, assumptions about costs, insurance coverage, navigating financial responsibilities, clinical trial discussions, clinical trial misconceptions, and desire for a support network. Throughout, YAs mentioned needs that might be addressed through informational outreach leveraging digital technology, the internet, and social media.

Conclusions

This study expands knowledge of YA perceived barriers to CTE. These findings suggest that leveraging digital technology to disseminate reliable information to address needs may be an effective strategy to improve clinical trial participation in the YA population.

Interventions to Address Cancer-Related Financial Hardship: A Scoping Review and Call to Action

PURPOSE

As oncology practices implement routine screening for financial hardship (FH) and health-related social needs, interventions that address these needs must be implemented. A growing body of literature has reported on FH interventions.

METHODS

We conducted a scoping review of the literature using PubMed, EMBASE, PsychInfo, and CINAHL to identify key studies (2000-2024) reporting on interventions to address cancer-related FH. Full-length manuscripts were included in the review if they detailed a research, quality improvement, or community-based intervention to address at least one element of FH and drew association with an outcome of interest. Studies were categorized by intervention type and qualitatively analyzed to identify critical components, outcomes, and limitations.

RESULTS

Forty-four publications reporting on 43 interventions were included in the final analysis and were categorized as research interventions (n = 20) and real-world programs (n = 20). Studies reporting on financial navigation programs (n = 17) and specialty pharmacy assistance programs (n = 11) were most common; enrolled patients received concrete assistance with direct medical costs and cost-of-living expenses (eg, transportation and food). In addition, several of these programs improved overall patient-reported financial toxicity, decreased appointment no-shows, and improved enrollment in clinical trials.

CONCLUSION

Interventions to address FH are feasible and can address all domains of FH-material, behavioral, and psychosocial. Future research should address the uptake and implementation of these interventions across diverse cancer care delivery settings. Such programs will be an essential part of cancer care delivery until broad social and policy changes can address the underlying factors that contribute to FH in Americans with cancer.

Development and Validation of a Simplified Financial Toxicity Screening Tool for Use in Clinical Practice

PURPOSE

Cancer-related financial toxicity occurs frequently and is a key driver of inequities in access to care and disparities in treatment outcomes. Current practices to screen for financial toxicity are inconsistent because of the lack of a validated and clinically integrated screening tool. This analysis aimed to create and assess an abbreviated version of the validated Comprehensive Score for Financial Toxicity (COST) tool, a measure of financial toxicity used for research purposes, which could easily be added into often-lengthy clinical screening workflows.

METHODS

At an urban comprehensive cancer center with suburban satellite locations, a financial toxicity screening quality improvement project was conducted from June 2022 to August 2023 as part of routine clinical care: 57,526 longitudinal COST surveys were completed by 38,249 patients with cancer. An iterative algorithm selected the items with highest correlation with the total score. Using a separate validation data set, positive and negative predictive values (PPV and NPV, respectively) of the abbreviated tool (two-item) were assessed against the full COST score, with varying risk thresholds.

RESULTS

Inclusion of two COST questions (Q3: "I worry about the financial problems I will have in the future as a result of my illness or treatment"; Q6: "I am satisfied with my current financial situation") yielded a score that had a correlation of 0.922 with the full instrument score. For the two-item scale, PPV ranged from 74% to 91%, and NPV ranged from 91% to 98% when compared with the full COST tool.

CONCLUSION

This analysis of a large data set finds that a simplified COST tool has high predictive value when compared with the full validated measure. An abbreviated COST measure of two questions is suitable for implementation into clinical screening workflows.

Cancer survivor preferences on the timing and content of interventions to mitigate financial toxicity associated with cancer treatment

PURPOSE

Despite growing research on financial toxicity among cancer survivors, large gaps remain in understanding how to intervene to minimize financial toxicity. Uptake and efficacy of interventions mitigating cancer financial toxicity, though promising, remain limited and inconsistent. To date, survivor preferences for financial toxicity interventions are underexplored. This study aimed to evaluate survivor preferences for timing and content of a survivor-facing intervention to address financial toxicity.

METHODS

Adult survivors (N = 105) of colorectal cancer (N = 55) or Non-Hodgkin Lymphoma (N = 50) from three tertiary care centers self-reported demographic and clinical characteristics, comorbidities, mental health, financial impact of cancer (Comprehensive Score for Financial Toxicity scale), and preferences for intervention timing and content. Chi-square tests examined associations between intervention timing and content preferences with financial toxicity score. ANOVAs and correlation analyses described associations between the number of intervention components survivors endorsed and survivors' characteristics.

RESULTS

Regarding intervention timing, 79% of survivors favored intervention before treatment. The most frequently endorsed content was understanding out-of-pocket costs and insurance (48.6%) and applying for aid (39%). Survivors experiencing higher financial toxicity reported greater interest in all intervention components. Survivors with colorectal cancer (p = .018), < 65 years (p = .019), higher financial toxicity (p < .001), greater life-altering (p < .001) and care-altering (p = .014) coping behaviors, and poorer mental health (p = .008) endorsed more intervention components.

CONCLUSIONS

Actionable insights to improve financial toxicity interventions may be to offer assistance earlier than currently provided (i.e. before treatment) and to include certain topics currently rarely offered (e.g., stress management, budget development support) in line with survivors' preferences.

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.

Influence of age on financial toxicity in cancer patients

Objective

The aim of this study was to assess the level of financial toxicity (FT) experienced by the following three age groups of cancer patients in China: young working-aged patients (age < 40 years), middle-aged patients (40-64 years), and older patients (≥ 65 years).

Methods

The data used for this study were collected via a cross-sectional survey conducted in China. FT was assessed using the Comprehensive Score for Financial Toxicity (COST). ANOVA was used to examine the differences in FT status between age groups. Multivariate linear regression models were employed to assess the association between age and FT, adjusted by socioeconomic and other clinical characteristics.

Results

A total of 556 cancer patients completed the survey. Approximately 54.3% of the participants were male and 45.7% were female. The majority (61.5%) were aged 40-64 years, while 27.7% were aged 65 or older. The mean FT scores for young patients (< 40 years), middle-aged patients (40-64 years), and older patients (≥ 65 years) were 16.7, 12.8, and 12.4, respectively. The results of the regression analysis revealed that, without adjusting for background characteristics, young patients had significantly higher mean COST scores. This suggests they experienced lower levels of FT compared to patients in other age groups. Stratified analysis revealed that, for older patients, only educational level and type of insurance scheme were significant factors in predicting the COST score.

Conclusions

This study provides empirical evidence for developing targeted interventions and policies to reduce the FT for patients in different age groups. Given that FT is complicated, a longitudinal study should be conducted to explore the long-term impact of FT on cancer patients' quality of life and well-being.

"It was kind of a nightmare, it really was:" financial toxicity among rural women cancer survivors

PURPOSE

The purpose of this study was to examine how rural women cancer survivors experience and manage financial toxicity.

METHODS

A qualitative descriptive design was used to explore experiences of financial toxicity among rural women who received cancer treatment. We conducted qualitative interviews with 36 socioeconomically diverse rural women cancer survivors.

RESULTS

Participants were categorized into three groups: (1) survivors who struggled to afford basic living expenses but did not take on medical debt; (2) survivors who took on medical debt but were able to meet their basic needs; and (3) survivors who reported no financial toxicity. The groups differed by financial and job security and insurance type. We describe each group and, for the first two groups, the strategies they used to manage financial toxicity.

CONCLUSIONS

Financial toxicity related to cancer treatment is experienced differently by rural women cancer survivors depending on financial and job security and insurance type. Financial assistance and navigation programs should be tailored to support rural patients experiencing different forms of financial toxicity.

IMPLICATIONS FOR CANCER SURVIVORS

Rural cancer survivors with financial security and private insurance may benefit from policies aimed at limiting patient cost-sharing and financial navigation to help patients understand and maximize their insurance benefits. Rural cancer survivors who are financially and/or job insecure and have public insurance may benefit from financial navigation services tailored to rural patients that can assist with living expenses and social needs.

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.

Evaluation of a Conference on Cancer-Related Financial and Legal Issues: A Potential Resource to Counter Financial Toxicity

This study describes the conception, development, and growth of the Triage Cancer Conference hosted by Triage Cancer, a national nonprofit organization providing free legal and financial education to the cancer community. We conducted a retrospective analysis of post-conference participant surveys. Descriptive statistics were calculated for participant demographics, and acceptability, feasibility, and appropriateness were evaluated. From 2016-2021, 1239 participants attended the conference and completed post-conference surveys. Participants included social workers (33%), nurses (30%), and cancer patients/survivors (21%), with representation from over 48 states. Among those who reported race, 16% were Black, and 7% were Hispanic. For acceptability, more than 90% of participants felt that the conference content, instructors, and format were suitable and useful. For feasibility, more than 90% of participants felt that the material was useful, with 93-96% reporting that they were likely to share the information and 98% reporting that they would attend another triage cancer event. Appropriateness was also high, with >80-90% reporting that the sessions met the pre-defined objectives. Triage Cancer fills an important gap in mitigating financial toxicity, and formal evaluation of these programs allows us to build evidence of the role and impact of these existing resources. Future research should focus on adding validated patient-reported outcomes, longer-term follow-up, and ensuring inclusion and evaluation of outcome metrics among vulnerable populations.

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.

Experiences of financial toxicity among caregivers of cancer patients: a meta-synthesis of qualitative studies

OBJECTIVES

The purpose of this study was to explore the experience of financial toxicity among caregivers of cancer patients and to provide recommendations for subsequent intervention strategies.

METHODS

Computer searches of PubMed, EmBase, The Cochrane Library, Web of Science, CINAHL (EBSCO), CNKI, Wanfang database, and SinoMed for qualitative studies experience of financial toxicity among caregivers cancer patients. The search time frame was from the establishment of the database to May 2023. The quality of included studies was assessed using the Qualitative Research Checklist from the Joanna Briggs Institute (JBI) Reviewer's Manual. The meta-synthesis was integrated following the meta-aggregation method proposed by the Joanna Briggs Institute (JBI) and reported following the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) guidelines.

RESULTS

A total of nine studies were included, distilling 25 qualitative findings into nine new categories and synthesizing three synthesized findings: caregivers have strong negative experiences that affect their family relationships, daily work and life; caregivers use different strategies to cope with financial toxicity; needs and expectations of caregivers coping with financial toxicity.

CONCLUSIONS

Financial toxicity among caregivers of cancer patients affects their daily lives. Receiving timely recognition of this financial burden and providing assistance to enhance their coping skills are crucial in mitigating its impact. Healthcare professionals should focus on the financial toxicity experienced by caregivers of people with cancer, address their supportive needs, and develop a comprehensive support system to improve caregivers' coping abilities and quality of life.

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.

The long-term financial experiences of adolescent and young adult cancer survivors

BACKGROUND

Cancer-related financial hardship can negatively impact financial well-being and may prevent adolescent and young adult (AYA) cancer survivors (ages 15-39) from gaining financial independence. This analysis explored the financial experiences following diagnosis with cancer among AYA survivors.

METHODS

We conducted a cross-sectional, anonymous survey of a national sample of AYAs recruited online. The Comprehensive Score for Financial Toxicity (COST) and InCharge Financial Distress/Financial Well-Being Scale (IFDFW) assessed financial hardship (cancer-related and general, respectively), and respondents reported related financial consequences and financial coping behaviors (both medical and non-medical).

RESULTS

Two hundred sixty-seven AYA survivors completed the survey (mean 8.3 years from diagnosis). Financial hardship was high: mean COST score was 13.7 (moderate-to-severe financial toxicity); mean IFDFW score was 4.3 (high financial stress). Financial consequences included post-cancer credit score decrease (44%), debt collection contact (39%), spending more than 10% of income on medical expenses (39%), and lacking money for basic necessities (23%). Financial coping behaviors included taking money from savings (55%), taking on credit card debt (45%), putting off major purchases (45%), and borrowing money (42%). In logistic regression models, general financial distress was associated with increased odds of experiencing financial consequences and engaging in both medical- and non-medical-related financial coping behaviors.

DISCUSSION

AYA survivors face long-term financial hardship after cancer treatment, which impacts multiple domains, including their use of healthcare and their personal finances. Interventions are needed to provide AYAs with tools to navigate financial aspects of the healthcare system; connect them with resources; and create systems-level solutions to address healthcare affordability.

IMPLICATIONS FOR CANCER SURVIVORS

Survivorship care providers, particularly those who interact with AYA survivors, must be attuned to the unique risk for financial hardships facing this population and make efforts to increase access available interventions.

Using Real-World Data to Explore the Impact of One-Time Financial Grants Among Young Adult Cancer Survivors

Young adult (YA) cancer survivors experience worse financial outcomes than older survivors. This analysis used data from Expect Miracles Foundation to explore the impact of one-time financial grants on financial well-being and access to health care. Among 300 respondents, the average grant was $1526 (standard deviation = $587; range $300-$3000). Respondents reported improved ability to pay expenses (t = 4.45, p < 0.001), increased financial decision-making power (t = 2.79, p = 0.06), decreased medical debt impact (t = 2.1, p = 0.04), improved transportation access (t = 2.38, p = 0.02), and fewer challenges in accessing care (t = 3.0, p = 0.005) 6 months after receiving a financial grant. Financial assistance offers YAs an opportunity to meet medical and nonmedical expenses.

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.

Administrative Burden Associated with Cost-Related Delays in Care in U.S. Cancer Patients

BACKGROUND

U.S. cancer patients engage in administrative tasks to pay for their healthcare. This study investigated the relationship between payment tasks and timely access to cancer care.

METHODS

We analyzed online survey data from 510 U.S. cancer patients and survivors to understand the relationship between administrative payment tasks and cost-related delays and nonadherence. Two-part modelling was used to determine if, and to what extent, there was a relationship between administrative burden and cost-related delays/nonadherence.

RESULTS

Younger patients (≤44 years) reported more payment tasks and cost-related delays/nonadherence than older patients (≥ 55 years); African American patients reported more payment tasks and cost-related delays/nonadherence than white patients. After accounting for age, race/ethnicity, education, and out-of-pocket costs, patients who reported engaging in more tasks had greater log odds of delaying/forgoing care [b = 0.18; 95% confidence interval (CI), 0.12-0.24]. Cost-related delays/nonadherence increased by 32% for every unit increase in administrative payment burden (b = 0.32; 95% CI, 0.18-0.46).

CONCLUSIONS

Administrative payment burden increased the odds of cost-related delays and nonadherence by 49%, taking the form of delayed or skipped doctor appointments, tests and bloodwork, and prescription fulfillment. Younger patients and those identifying as African American were more likely to engage in payment tasks and to delay or forgo care due to cost. Administrative burdens can disrupt access to care and traditionally underserved patient populations are disproportionately exposed to these hardships.

IMPACT

Reducing the complexity of healthcare through universal, human-centered design could reduce burdens and increase access.

Assessing the pre-implementation context for financial navigation in rural and non-rural oncology clinics

Background

Financial navigation (FN) is an evidence-based intervention designed to address financial toxicity for cancer patients. FN's success depends on organizations' readiness to implement and other factors that may hinder or support implementation. Tailored implementation strategies can support practice change but must be matched to the implementation context. We assessed perceptions of readiness and perceived barriers and facilitators to successful implementation among staff at nine cancer care organizations (5 rural, 4 non-rural) recruited to participate in the scale-up of a FN intervention. To understand differences in the pre-implementation context and inform modifications to implementation strategies, we compared findings between rural and non-rural organizations.

Methods

We conducted surveys (n = 78) and in-depth interviews (n = 73) with staff at each organization. We assessed perceptions of readiness using the Organizational Readiness for Implementing Change (ORIC) scale. In-depth interviews elicited perceived barriers and facilitators to implementing FN in each context. We used descriptive statistics to analyze ORIC results and deductive thematic analysis, employing a codebook guided by the Consolidated Framework for Implementation Research (CFIR), to synthesize themes in barriers and facilitators across sites, and by rurality.

Results

Results from the ORIC scale indicated strong perceptions of organizational readiness across all sites. Staff from rural areas reported greater confidence in their ability to manage the politics of change (87% rural, 76% non-rural) and in their organization's ability to support staff adjusting to the change (96% rural, 75% non-rural). Staff at both rural and non-rural sites highlighted factors reflective of the Intervention Characteristics (relative advantage) and Implementation Climate (compatibility and tension for change) domains as facilitators. Although few barriers to implementation were reported, differences arose between rural and non-rural sites in these perceived barriers, with non-rural staff more often raising concerns about resistance to change and compatibility with existing work processes and rural staff more often raising concerns about competing time demands and limited resources.

Conclusions

Staff across both rural and non-rural settings identified few, but different, barriers to implementing a novel FN intervention that they perceived as important and responsive to patients' needs. These findings can inform how strategies are tailored to support FN in diverse oncology practices.

Financial Toxicity Order Set: Implementing a Simple Intervention to Better Connect Patients With Resources

PURPOSE

Financial toxicity of cancer treatment is well described in the literature, including characterizations of its risk factors, manifestations, and consequences. There is, however, limited research on interventions, particularly those at the hospital level, to address the issue.

METHODS

From March 1, 2019, to February 28, 2022, a multidisciplinary team conducted a three-cycle Plan-Do-Study-Act (PDSA) process to develop, test, and implement an electronic medical record (EMR) order set to directly refer patients to a hospital-based financial assistance program. The cycles included an assessment of the efficacy of our current practice in connecting patients experiencing financial hardship with assistance, the development and piloting of the EMR referral order, and the broad implementation of the order set across our institution.

RESULTS

In PDSA cycle 1, we found that approximately 25% of patients at our institution experienced some form of financial hardship, but most patients were not connected to available resources because of our referral mechanism. In PDSA cycle 2, the pilot referral order set was deemed feasible and received positive feedback. Over the 12-month study period (March 1, 2021-February 28, 2022) of PDSA cycle 3, 718 orders were placed for 670 unique patients across interdisciplinary providers from 55 treatment areas. These referrals resulted in at least $850,000 in US dollars (USD) in financial aid in 38 patients (mean = $22,368 USD).

CONCLUSION

The findings from our three-cycle PDSA quality improvement project demonstrate the feasibility and efficacy of interdisciplinary efforts to develop a hospital-level financial toxicity intervention. A simple referral mechanism can empower providers to connect patients in need with available resources.

Building Organizational Capacity to Deliver Oncology Financial Advocacy

Background

Cancer-related financial hardship is linked to poor health outcomes and early mortality. Oncology financial advocacy (OFA) aims to prevent cancer-related financial hardship in oncology settings by assessing patients' needs and connecting them to available financial resources. Despite promising evidence, OFA remains underutilized.

Objectives

Describe oncology financial advocates' perceptions about the challenges to and opportunities for implementing oncology financial advocacy (OFA) in community cancer centers.

Methods

Nine virtual focus groups were conducted with 45 oncology financial advocates. Focus group transcripts were analyzed using template-based thematic analysis informed by the Consolidated Framework for Implementation Research (CFIR); two study team members coded each transcript and all six team members identified emergent themes.

Results

Salient themes were identified across all five domains of the CFIR framework: (1) intervention characteristics: participants described challenges of adapting OFA to meet the needs of the medical system instead of needs of the patients; (2) outer setting: growing awareness of health and cancer disparities could bring more attention to and investment in OFA; (3) inner setting: programs are under-resourced to assist all at-risk patients, staffing, technology integration, and network/communication workflows are needed; (4) characteristics of individuals: advocates believe strongly in the effectiveness and would like to see their credibility enhanced with professional certification; (5) process: implementation strategies that target the engagement of leadership, key stakeholders, and patients to increase program reach are needed.

Conclusions

OFA cannot reach all at-risk patients because of understaffing, poor communication between departments, and a lack of understanding OFA as an intervention among colleagues, key stakeholders, and patients. To reach full implementation, advocates need assistance in making the case for more resources, research on patient outcomes, professional certification, and the use of policy to incentivize financial advocacy as a standard of care in medicine.

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

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

Facing financial barriers to healthcare: patient-informed adaptation of a conceptual framework for adults with a history of cancer

Background

Cancer-related financial hardship is associated with negative clinical outcomes, which may be partially explained by cost-related delayed or forgone care in response to financial barriers. We sought to understand patient experiences facing financial barriers to medical care following a cancer diagnosis.

Methods

We conducted virtual, semi-structured interviews in Fall 2022 with 20 adults with a history of cancer who had experienced cancer-related financial hardship in the prior year. We used template analysis within a pragmatic paradigm, combining constructivist and critical realist theoretical perspectives, to analyze interview transcripts and adapt an existing conceptual framework of financial barriers to care.

Results

The majority of interviewees identified as women (70%), non-Hispanic white (60%), and reported an annual household income of <$48,000 (60%). As interviewees sought to overcome financial barriers, they described substantial frustration at the limitations and complexities of United States health and social care systems, resulting in a reliance on a fragmented, uncertain resource landscape. The administrative burden resulting from bureaucratic systems and the advocacy responsibilities required to navigate them ultimately fell on interviewees and their caregivers. Thus, participants described their ability to overcome financial barriers as being influenced by individual and interpersonal factors, such as social support, comfort asking for help, time, prior experience navigating resources, and physical and mental health. However, participants noted health system organizational factors, such as whether all new patients proactively met with a social worker or financial navigator, as having the potential to lessen the administrative and financial burden experienced.

Conclusion

We present an adapted conceptual framework outlining multi-level factors influencing patient experiences coping with financial barriers to medical care. In addition to influencing whether a patient ultimately delays or forgoes care due to cost, financial barriers also have the potential to independently affect patient mental, physical, and financial health.

Coverage and Cost-of-Care Links: Addressing Financial Toxicity Among Patients With Hematologic Cancer and Their Caregivers

PURPOSE

This study examined the feasibility, acceptability, and preliminary effectiveness of an oncology financial navigation (OFN) intervention, Coverage and Cost-of-Care Links (CC Links), among patients with hematologic cancer and their caregivers who are at increased risk of experiencing financial toxicity (FT).

METHODS

All patients who presented to the Division of Hematology and Bone and Marrow Transplant (BMT) at an National Cancer Institute-designated cancer center between April 2021 and January 2022 were screened for FT during inpatient and outpatient visits. Patients who screened positive for FT and met the inclusion criteria were recruited to participate in CC Links that provided financial navigation and assistance via a financial navigator. Caregivers of patients undergoing BMTs were also recruited to participate. Primary outcomes were defined as improvements in FT, distress, and physical and mental quality of life.

RESULTS

Fifty-four patients and 32 caregivers completed the intervention and pre-/postintervention surveys. CC Links resulted in statistically significant decreases in the Comprehensive Score for FT for both patients (|t| = 2.42, P = .019) and caregivers (|t| = 2.43, P = .021) and total FT (|t| = 2.13, P = .041) and material conditions scores (|t| = 2.25, P = .031) for caregivers only. Only 27% of eligible patients participated in the study, whereas 100% of eligible caregivers participated. The majority of participants rated the intervention highly for acceptability (89%) and appropriateness (88%). An average of $2,500 (USD) in financial benefits was secured per participant via CC Links.

CONCLUSION

CC Links was effective in decreasing FT among patients with hematologic cancer and their caregivers while demonstrating high acceptability and appropriateness ratings.

Implementation of Systematic Financial Screening in an Outpatient Breast Oncology Setting

PURPOSE

Implementation of routine financial screening is a critical step toward mitigating financial toxicity. We evaluated the feasibility, sustainability, and acceptability of systematic financial screening in the outpatient breast oncology clinic at a large, urban cancer center.

METHODS

We developed and implemented a stakeholder-informed process to systematically screen for financial hardship and worry. A 2-item assessment in English or Spanish was administered to patients through the electronic medical record portal or using paper forms. We evaluated completion rates and mode of completion. Through feedback from patients, clinicians, and staff, we identified strategies to improve completion rates and acceptability.

RESULTS

From March, 2021, to February, 2022, 3,500 patients were seen in the breast oncology clinic. Of them, 39% (n = 1,349) responded to the screening items, either by paper or portal, 12% (n = 437) preferred not to answer, and the remaining 49% (n = 1,714) did not have data in their electronic health record, meaning they were not offered screening or did not complete the paper forms. Young adults (18-39 years) were more likely to respond compared with patients 70 years or older (61% v 30%, P < .01). English-preferring patients were more likely to complete the screening compared with those who preferred Spanish (46% v 28%, P < .01). Non-Hispanic White patients were more likely to respond compared with Non-Hispanic Black patients and with Hispanic patients (46% v 39% v 32%, P < .01). Strategies to improve completion rates included partnering with staff to facilitate paper form administration, optimizing patient engagement with the portal, and clearly communicating the purpose of the screening.

CONCLUSION

Systematic financial screening is feasible, and electronic data capture facilitates successful implementation. However, inclusive procedures that address language and technology preferences are needed to optimize screening.

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

Financial toxicity describes the adverse impact patients experience from the monetary and time costs of cancer care. The financial burden patients experience comes from substantially increased out-of-pocket spending that often occurs concurrent with reduced income due to sick leave from work. Financial toxicity is common affecting approximately half of patients with a gynecological cancer depending on the validated instrument used for measurement. Financial toxicity is experienced by patients in three domains: economic hardship affecting patients' material conditions (i.e., medical debt), psychological response (i.e., distress), and health-related coping behaviors that patients adopt (i.e., foregoing care due to costs). Higher financial toxicity among cancer patients has been associated with decreased quality of life, impaired adherence to recommended care, and worse overall survival. In this review, we describe the current literature on financial toxicity, including how it can be assessed with validated tools, the downstream impact on patients, risk factors, and employment concerns of survivors. Whenever possible, we highlight data from research featuring patients with gynecologic cancer specifically. We also review studies with interventions aimed to mitigate financial toxicity and offer the reader real world examples of interventions currently being used. Lastly, we provide an overview of health policy developments relevant to financial toxicity and advocate for innovation in the development and implementation of strategies to decrease the financial toxicity patients experience following a diagnosis of gynecologic cancer.

Sources of informal financial support among adolescent and young adult cancer survivors: a mixed methods analysis from the HIAYA CHAT study

PURPOSE

The purpose of this exploratory sequential mixed methods study was to describe the sources of informal financial support used by adolescent and young adult (AYA) cancer survivors and how financial toxicity and demographic factors were associated with different types and magnitudes of informal financial support.

METHODS

This analysis is part of a larger health insurance literacy study that included pre-trial interviews and a randomized controlled trial (RCT) for AYA cancer survivors. Eligible study participants were 18 years of age, diagnosed with cancer as an AYA (15-39 years), insured, and for the RCT sample less than 1 year from diagnosis. Interview audio was transcribed, quality checked, and thematically analyzed. RCT baseline and follow-up surveys captured informal financial support use. Chi-squared and Fisher's exact tests were used to assess differences in informal financial support type use and frequency by financial toxicity and AYA demographics.

RESULTS

A total of N = 24 and N = 86 AYAs participated in pre-trial interviews and the RCT respectively. Interview participants reported a variety of informal financial support sources including savings, community, family/friends, and fundraisers. However, only half of participants reported their informal financial support to be sufficient. High financial toxicity was associated with the most types of informal financial support and a higher magnitude of use. The lowest income group accessed informal financial supports less frequently than higher income groups.

CONCLUSION

Our study demonstrates that AYA survivors experiencing financial toxicity frequently turn to informal sources of financial support and the magnitude is associated with financial toxicity. However, low-income survivors, and other at-risk survivors, may not have access to informal sources of financial support potentially widening inequities.

Defining the Role of the Modern Oncology Provider in Mitigating Financial Toxicity

Financial toxicity, the cumulative financial hardships resulting from cancer diagnosis and treatment, is a growing problem in the United States. With the proliferation of costly novel therapeutics and improved cancer survival, financial toxicity will remain a major issue in cancer care delivery. Frontline oncology providers serve as gatekeepers in the medical system and, as such, could play essential roles in recognizing and addressing financial toxicity. Providers and health systems could help mitigate financial toxicity through routine financial toxicity screening, financial navigation, and advocacy. Specific strategies include developing and implementing financial screening instruments that can be integrated in electronic medical records and establishing team-based financial navigation programs to help patients with out-of-pocket medical costs, nonmedical spending, and insurance optimization. Finally, providers should continue to advocate for policies and legislation that decrease cost and promote value-based care. In this review, we examine opportunities for provider engagement in these areas and highlight gaps for future research.

Core functions of a financial navigation intervention: An in-depth assessment of the Lessening the Impact of Financial Toxicity (LIFT) intervention to inform adaptation and scale-up in diverse oncology care settings

Background

Lessening the Impact of Financial Toxicity (LIFT) is an intervention designed to address financial toxicity (FT) and improve cancer care access and outcomes through financial navigation (FN). FN identifies patients at risk for FT, assesses eligibility for financial support, and develops strategies to cope with those costs. LIFT successfully reduced FT and improved care access in a preliminary study among patients with high levels of FT in a single large academic cancer center. Adapting LIFT requires distinguishing between core functions (components that are key to its implementation and effectiveness) and forms (specific activities that carry out core functions). Our objective was to complete the first stage of adaptation, identifying LIFT core functions.

Methods

We reviewed LIFT's protocol and internal standard-operating procedures. We then conducted 45-90 min in-depth interviews, using Kirk's method of identifying core functions, with key LIFT staff (N = 8), including the principal investigators. Interviews focused on participant roles and intervention implementation. Recorded interviews were transcribed verbatim. Using ATLAS.ti and a codebook based on the Model for Adaptation Design and Impact, we coded interview transcripts. Through thematic analysis, we then identified themes related to LIFT's intervention and implementation core functions. Two report back sessions with interview participants were incorporated to further refine themes.

Results

Six intervention core functions (i.e., what makes LIFT effective) and five implementation core functions (i.e., what facilitated LIFT's implementation) were identified to be sufficient to reduce FT. Intervention core functions included systematically cataloging knowledge and tracking patient-specific information related to eligibility criteria for FT relief. Repeat contacts between the financial navigator and participant created an ongoing relationship, removing common barriers to accessing resources. Implementation core functions included having engaged sites with the resources and willingness necessary to implement FN. Developing navigators' capabilities to implement LIFT-through training, an established case management system, and connections to peer navigators-were also identified as implementation core functions.

Conclusion

This study adds to the growing evidence on FN by characterizing intervention and implementation core functions, a critical step toward promoting LIFT's implementation and effectiveness.

Lessening the Impact of Financial Toxicity (LIFT): a protocol for a multi-site, single-arm trial examining the effect of financial navigation on financial toxicity in adult patients with cancer in rural and non-rural settings

BACKGROUND

Almost half of the patients with cancer report cancer-related financial hardship, termed "financial toxicity" (FT), which affects health-related quality of life, care retention, and, in extreme cases, mortality. This increasingly prevalent hardship warrants urgent intervention. Financial navigation (FN) targets FT by systematically identifying patients at high risk, assessing eligibility for existing resources, clarifying treatment cost expectations, and working with patients and caregivers to develop a plan to cope with cancer costs. This trial seeks to (1) identify FN implementation determinants and implementation outcomes, and (2) evaluate the effectiveness of FN in improving patient outcomes.

METHODS

The Lessening the Impact of Financial Toxicity (LIFT) study is a multi-site Phase 2 clinical trial. We use a pre-/post- single-arm intervention to examine the effect of FN on FT in adults with cancer. The LIFT trial is being conducted at nine oncology care settings across North Carolina in the United States. Sites vary in geography (five rural, four non-rural), size (21-974 inpatient beds), and ownership structure (governmental, non-profit). The study will enroll 780 patients total over approximately 2 years. Eligible patients must be 18 years or older, have a confirmed cancer diagnosis (any type) within the past 5 years or be living with advanced disease, and screen positive for cancer-related financial distress. LIFT will be delivered by full- or part-time financial navigators and consists of 3 components: (1) systematic FT screening identification and comprehensive intake assessment; (2) connecting patients experiencing FT to financial support resources via trained oncology financial navigators; and (3) ongoing check-ins and electronic tracking of patients' progress and outcomes by financial navigators. We will measure intervention effectiveness by evaluating change in FT (via the validated Comprehensive Score of Financial Toxicity, or COST instrument) (primary outcome), as well as health-related quality of life (PROMIS Global Health Questionnaire), and patient-reported delayed or forgone care due to cost. We also assess patient- and stakeholder-reported implementation and service outcomes post-intervention, including uptake, fidelity, acceptability, cost, patient-centeredness, and timeliness.

DISCUSSION

This study adds to the growing evidence on FN by evaluating its implementation and effectiveness across diverse oncology care settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04931251. Registered on June 18, 2021.

Financial Assistance Processes and Mechanisms in Rural and Nonrural Oncology Care Settings

PURPOSE

Patients with cancer are at heightened risk of experiencing financial hardship. Financial navigation (FN) is an evidence-based approach for identifying and addressing patient and caregiver financial needs. In preparation for the implementation of a multisite FN intervention, we describe existing processes (ie, events and actions) and mechanisms (ie, how events work together) connecting patients to financial assistance, comparing rural and nonrural practices.

METHODS

We conducted in-depth, semistructured interviews with stakeholders (ie, administrators, providers, and staff) at each of the 10 oncology care sites across a single state (five rural and five nonrural practices). We developed process maps for each site and analyzed stakeholder perspectives using thematic analysis. After reporting findings back to stakeholders, we synthesized themes and process maps across rural and nonrural sites separately.

RESULTS

Eighty-three stakeholders were interviewed. We identified six core elements of existing financial assistance processes across all sites: distress screening (including financial concerns), referrals, resource connection points, and pharmaceutical, insurance, and community/foundation resources. Processes differed by rurality; however, facilitators and barriers to identifying and addressing patient financial needs were consistent. Open communication between staff, providers, patients, and caregivers was a primary facilitator. Barriers included insufficient staff resources, challenges in routinely identifying needs, inadequate preparation of patients for anticipated medical costs, and limited tracking of resource availability and eligibility.

CONCLUSION

This study identified a clear need for systematic implementation of oncology FN to equitably address patient and caregiver financial hardship. Results have informed our current efforts to implement a multisite FN intervention, which involves comprehensive financial toxicity screening and systematization of intake and referrals.