Financial stress and strain associated with terminal cancer--a review of the evidence

Measurement of the major ignored burden of multiple myeloma, pernicious anaemia and of other haematological conditions on partners and family members: A cross-sectional study

BACKGROUND

Having a haematological condition can adversely affect the quality of life (QoL) of family members/partners of patients. It is important to measure this often ignored burden in order to implement appropriate supportive interventions.

OBJECTIVE

To measure current impact of haematological conditions on the QoL of family members/partners of patients, using the Family Reported Outcome Measure-16 (FROM-16).

METHODS

A cross-sectional study, recruited online through patient support groups, involved UK family members/partners of people with haematological conditions completing the FROM-16.

RESULTS

183 family members/partners (mean age = 60.5 years, SD = 13.2; females = 62.8%) of patients (mean age = 64.1, SD = 12.8; females = 46.4%) with 12 haematological conditions completed the FROM-16. The FROM-16 mean total score was 14.0 (SD = 7.2), meaning 'a moderate effect on QoL'. The mean FROM-16 scores of family members of people with multiple myeloma (mean = 15.8, SD = 6.3, n = 99) and other haematological malignancies (mean = 13.9, SD = 7.8, n = 29) were higher than of people with pernicious anaemia (mean = 10.7, SD = 7.5, n = 47) and other non-malignant conditions (mean = 11, SD = 7.4, n = 56, p < .01). Over one third (36.1%, n = 183) of family members experienced a 'very large effect' (FROM-16 score>16) on their quality of life.

CONCLUSIONS

Haematological conditions, in particular those of malignant type, impact the QoL of family members/partners of patients. Healthcare professionals can now, using FROM-16, identify those most affected and should consider how to provide appropriate holistic support within routine practice.

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

BACKGROUND

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

AIM

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

DESIGN

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

DATA SOURCES

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS AND DISCUSSION

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

A proactive financial navigation intervention in patients with newly diagnosed gastric and gastroesophageal junction adenocarcinoma

PURPOSE

Many cancer patients and caregivers experience financial hardship, leading to poor outcomes. Gastric and gastroesophageal junction (GEJ) cancer patients are particularly at risk for financial hardship given the intensity of treatment. This pilot randomized study among gastric/GEJ cancer patients and caregivers tested a proactive financial navigation (FN) intervention to obtain a signal of efficacy to inform a larger, more rigorous randomized study.

METHODS

We tested a 3-month proactive FN intervention among gastric/GEJ cancer patients and caregivers compared to usual care. Caregiver participation was optional. The primary endpoint was incidence of financial hardship, defined as follows: accrual of debt, income decline of ≥ 20%, or taking loans to pay for treatment. Data from participant surveys and documentation by partner organizations delivering the FN intervention was analyzed and outcomes were compared between study arms.

RESULTS

Nineteen patients and 12 caregivers consented. Primary FN resources provided included insurance navigation, budget planning, and help with out-of-pocket medical expenses. Usual care patients were more likely to experience financial hardship (50% vs 40%) and declines in quality of life (37.5% vs 0%) compared to intervention patients. Caregivers in both arms reported increased financial stress and poorer quality of life over the study period.

CONCLUSIONS

Proactive financial navigation has potentially positive impacts on financial hardship and quality of life for cancer patients and more large-scale randomized interventions should be conducted to rigorously explore the impact of similar interventions. Interventions that have the potential to lessen caregiver financial stress and burden need further exploration.

TRIAL REGISTRATION

TRN: NCT03986502, June 14, 2019.

Financial hardship for patients with cancer and caregivers at end of life in the USA: narrative review

BACKGROUND

Patients and their families face financial hardship during cancer treatment, which may intensify at end of life (EOL) due to increased symptoms and care needs. We undertook a narrative literature review to describe the current understanding of the causes, impacts and factors associated with financial hardship at EOL. We identify gaps in research, policy and clinical practice and propose steps to mitigate financial hardship for patients and caregivers at EOL.

METHODS

We conducted a Medline search to identify US studies since 2000 that examined EOL financial hardship for patients with cancer and their caregivers.

RESULTS

Twenty-seven adult and four paediatric studies met review criteria. Adults with cancer and their caregivers face significant financial hardship at EOL and in bereavement, especially due to employment changes and informal caregiving time costs. Financial hardship may be higher for younger caregivers and for patients who are uninsured, low income, rural, with high symptom burdens or with certain cancer types. The few paediatric studies showed high financial hardship and employment impact lasting well beyond a child's death.

CONCLUSIONS

There is limited literature examining financial hardship at EOL in the USA, especially in paediatrics. Priorities for future research include longitudinal studies in diverse populations of patients with cancer and informal caregivers using standardised financial hardship measures. Policies to address financial hardship at EOL, especially with hospice care, should include insurance coverage for family caregiving and medical leave policies. There is need for increased financial hardship screening at EOL and in bereavement and a need for financial navigation interventions.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

What affects the direct economic burden of non-communicable diseases on middle-aged and older adult people in Shaanxi Province?

Non-communicable diseases (NCDs) are the leading cause of death worldwide. NCDs affect the health status and the quality of life. In addition, continuous NCDs treatment expenses place a heavy economic burden on families and cause huge economic losses to the society. The prevention and treatment of NCDs and reduction of their economic burden are key public health issues. Considering middle-aged and older adult people as the focus, their basic socio-demographic characteristics and health behavior status of this group, and a pooled cross-sections regression model was then used to analyze the main factors affecting the direct economic burden. The results showed that from 2013 to 2018, the prevalence of NCDs among the middle-aged and older adult people in Shaanxi province as well as the direct economic burden of NCDs increased. The effect factors primarily included sex, age, employment status, income level, type of medical insurance, urban or rural residency, level of the health care-providing institutions, visiting times of 2-week, and length of hospital stay. Several measures can be taken to control the onset of NCDs and reduce their direct economic burden.

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.

Psychosocial Interventions at the End-of-Life: A Scoping Review

BACKGROUND

The integration of holistic and effective end-of-life (EOL) care into cancer management has increasingly become a recognized field. People living with terminal cancer and their caregivers face a unique set of emotional, spiritual, and social stressors, which may be managed by psychosocial interventions.

OBJECTIVES

This study aimed to explore the types and characteristics of psychosocial interventions at the EOL for adult cancer patients and their caregivers and to identify gaps in the current literature.

METHODS

A systematic search was conducted through MEDLINE (Ovid) and CINAHL from January 1, 2011, to January 31, 2021, retrieving 2453 results. A final 15 articles fulfilled the inclusion criteria, reviewed by 2 independent reviewers. Ten percent of the original articles were cross-checked against study eligibility at every stage by 2 experienced researchers.

RESULTS

Most interventions reported were psychotherapies, with a predominance of meaning or legacy-related psychotherapies. Most interventions were brief, with significant caregiver involvement. Most studies were conducted in high-income, English-speaking populations.

CONCLUSION

There is robust, although heterogeneous, literature on a range of psychosocial interventions at the EOL. However, inconsistencies in the terminology used surrounding EOL and means of outcome assessment made the comparison of interventions challenging.

IMPLICATION FOR PRACTICE

Future studies will benefit from increased standardization of study design, EOL terminology, and outcome assessment to allow for a better comparison of intervention efficacy. There is a need for increased research in psychosocial interventions among middle- to low-income populations exploring social aspects, intimacy, and the impact of COVID-19.

Heterogeneity of financial toxicity and associated risk factors for older cancer survivors in China

In China, older cancer survivors may show heterogeneity in financial toxicity (FT). We aimed to identify FT profiles among older Chinese cancer survivors and examine the association between FT profiles and individual characteristics. We used a latent profile analysis to categorize participants and a multinomial logistic regression to examine the associations. We identified three distinct FT profiles: high, moderate, and low. Participants aged 65-69 years, with a monthly household income ≥ 5,000 CNY and a high school education or above were more likely to be classified into the moderate than high FT profile, a monthly household income ≥ 5,000 CNY increased the likelihood of being in the low FT profile and living alone negatively affected the odds of being in the low FT profile. The findings identified heterogeneity in FT among this population, may help identify high-risk groups, and may enable early intervention.

Developing a Conceptual Framework for Socioeconomic Impact Research in European Cancer Patients: A 'Best-Fit' Framework Synthesis

BACKGROUND

Multiple studies have indicated a socioeconomic impact of cancer and cancer care on patients and their families. Existing instruments designed to measure this impact lack consensus in their conceptualization of the issue. Further, various terminologies have been used in the literature (e.g., financial burden, financial hardship, financial stress) without clear definitions and consistent conceptual background. Based on a targeted review of existing models addressing the socioeconomic impact of cancer, our goal was to develop a comprehensive framework from a European perspective.

METHOD

A 'best-fit' framework synthesis was applied. First, we systematically identified existing models to generate a priori concepts. Second, we systematically identified relevant European qualitative studies and coded their results against these a priori concepts. Inclusion and exclusion criteria were predefined and applied thoroughly in these processes. Thematic analysis and team discussions were applied to finalize the (sub)themes in our proposed conceptual framework. Third, we examined model structures and quotes from qualitative studies to explore relationships among (sub)themes. This process was repeated until no further change in (sub)themes and their relationships emerged.

RESULT

Eighteen studies containing conceptual models and seven qualitative studies were identified. Eight concepts and 20 sub-concepts were derived from the included models. After coding the included qualitative studies against the a priori concepts and following discussions among team members, seven themes and 15 sub-themes were included in our proposed conceptual framework. Based on the identified relationships, we categorized themes into four groups: causes, intermediate consequences, outcomes and risk factors.

CONCLUSION

We propose a Socioeconomic Impact Framework based on a targeted review and synthesis of existing models in the field and adapted to the European perspective. Our work contributes as an input to a European consensus project on socioeconomic impact research by an Organization European Cancer Institute (OECI) Task Force.

A Policy-Ready Public Health Guidebook of Strategies and Indicators to Promote Financial Well-Being and Address Financial Strain in Response to COVID-19

INTRODUCTION

The COVID-19 pandemic has adversely affected the financial well-being of populations globally, escalating concerns about links with health care and overall well-being. Governments and organizations need to act quickly to protect population health relative to exacerbated financial strain. However, limited practice- and policy-relevant resources are available to guide action, particularly from a public health perspective, that is, targeting equity, social determinants of health, and health-in-all policies. Our study aimed to create a public health guidebook of strategies and indicators for multisectoral action on financial well-being and financial strain by decision makers in high-income contexts.

METHODS

We used a multimethod approach to create the guidebook. We conducted a targeted review of existing theoretical and conceptual work on financial well-being and strain. By using rapid review methodology informed by principles of realist review, we collected data from academic and practice-based sources evaluating financial well-being or financial strain initiatives. We performed a critical review of these sources. We engaged our research-practice team and government and nongovernment partners and participants in Canada and Australia for guidance to strengthen the tool for policy and practice.

RESULTS

The guidebook presents 62 targets, 140 evidence-informed strategies, and a sample of process and outcome indicators.

CONCLUSION

The guidebook supports action on the root causes of poor financial well-being and financial strain. It addresses a gap in the academic literature around relevant public health strategies to promote financial well-being and reduce financial strain. Community organizations, nonprofit organizations, and governments in high-income countries can use the guidebook to direct initiative design, implementation, and assessment.

Caregiving burdens of family members of patients living with hepatocellular carcinoma

BACKGROUND

Caregiving burden is common among family caregivers (FCs). In Taiwan, no reports have compared caregiving burden according to disease stage, or explored the comprehensive factors of caregiving burden in the FCs of patients with hepatocellular carcinoma (HCC).

AIM

The aim of the study was to investigate caregiving burden at different diagnosis stages and its potential predictors in the FCs of patients with hepatocellular carcinoma.

METHODS

This descriptive, cross-sectional study included 192 FCs. Caregiving burden was measured using the Caregiver Reaction Assessment tool. The predictive factors of caregiving burden in the FCs of patients with HCC were identified using a linear regression model.

RESULTS

The global caregiving burden had no significant differences between the four disease stages. The lack of family support and impact on schedule were significantly higher at the terminal stage than at the earlier stage. The risk factors of caregiving burden were high depression, high financial demand, heavy caregiving tasks, advanced age and frequent patient contact, which obtained a variance of 47.8% in the regression model.

CONCLUSION

Healthcare providers need to proactively identify and assess FCs with risk factors of caregiving burden and provide appropriate interventions specific to individual needs at different disease stages.

Social Determinants of Mental, Physical, and Oral Health of Middle-Aged and Older African Americans in South Los Angeles

BACKGROUND

A growing body of research suggests that financial difficulties could weaken the protective effects of socioeconomic status (SES) indicators, including education and income, on the health status of marginalized communities, such as African Americans.

AIM

We investigated the separate and joint effects of education, income, and financial difficulties on mental, physical, and oral self-rated health (SRH) outcomes in African American middle-aged and older adults.

METHODS

This cross-sectional study enrolled 150 middle-aged and older African Americans residing in South Los Angeles. Data on demographic factors (age and gender), socioeconomic characteristics (education, income, and financial difficulties), and self-rated health (mental, physical, and oral health) were collected. Three linear regression models were used to analyze the data.

RESULTS

Higher education and income were associated with a lower level of financial strain in a bivariate analysis. However, according to multivariable models, only financial difficulties were associated with poor mental, physical, and oral health. As similar patterns emerged for all three health outcomes, the risk associated with financial difficulties seems robust.

CONCLUSIONS

According to our multivariable models, financial strain is a more salient social determinant of health within African American communities than education and income in economically constrained urban environments such as South Los Angeles. While education and income lose some protective effects, financial strain continues to deteriorate the health of African American communities across domains.

Bureaucracy and burden: An Intersectionality-Based Policy Analysis of social welfare policy with consequences for carers of people with life-limiting illness

BACKGROUND

For informal carers of people with life-limiting illness, social welfare policy related to income support and housing has been associated with varied psychosocial issues, yet remains relatively under-explored. An intersectional approach offers potential to illuminate diverse experiences and implications.

AIM

To explore the way in which caring in the context of life-limiting illness is framed within welfare policy, to articulate inequities encountered by carers, and to identify policy and practice recommendations.

DESIGN

The Intersectionality-Based Policy Analysis (IBPA) Framework was used to situate findings of a broader qualitative study.

SETTING/PARTICIPANTS

Data were collected via semi-structured interviews with participants who were bereaved carers (n = 12), welfare workers (n = 14) and palliative care workers (n = 7), between November 2018 and April 2020, in an Australian region associated with socioeconomic disadvantage. Five elements of IBPA were applied to the products of analysis of this data.

RESULTS

Use of the IBPA Framework revealed that representations of carers and causes of their welfare needs in policy were underpinned by several assumptions; including that caring and grieving periods are temporary or brief, and that carers have adequate capacity to navigate complex systems. Policy and processes had differentiated consequences for carers, with those occupying certain social locations prone to accumulating disadvantage.

CONCLUSIONS

This intersectional analysis establishes critical exploration of the framing and consequences of welfare policy for carers of people with life-limiting illness, presented in a novel conceptual model. Implications relate to intersectoral development of structural competency, responsiveness to structurally vulnerable carers in clinical practice, and needed policy changes.

Prevalence and factors associated with demoralization in palliative care patients: A cross-sectional study from Hong Kong

OBJECTIVES

Although demoralization is common among palliative care patients, it has not yet been examined empirically in the Hong Kong Chinese context. This study aims to examine (1) the prevalence of demoralization among community-dwelling palliative care patients in Hong Kong; (2) the percentage of palliative care patients who are demoralized but not depressed and vice versa; and (3) the association of socio-demographic factors, particularly family support, with demoralization.

METHOD

A cross-sectional study targeting community-living palliative care patients in Hong Kong was conducted. A total of 54 patients were recruited by a local hospice and interviewed for completing a questionnaire which included measures of demoralization, depression, perceived family support, and demographic information.

RESULTS

The prevalence of demoralization was 64.8%. Although there was overlap between demoralization and depression (52.8% meeting the criteria of both), 7.5% of depressed patients were not demoralized, and 13.2% of demoralized patients were not depressed. Participants who were not single and had more depressive symptoms and less family support had a significantly higher demoralization level.

SIGNIFICANCE OF RESULTS

This is the first study which reports the prevalence of demoralization in Hong Kong. Demoralization was found common in community-living palliative care patients receiving medical social work services in Hong Kong. This study provides evidence of the importance of differentiating the constructs between demoralization and depression. It also provides an implication that those who are married, more depressed, and have the least family support could be the most vulnerable group at risk of demoralization. We recommend that early assessment of demoralization among palliative care patients be considered.

"My Cancer Is Worth Only Fifteen Weeks"? A Critical Analysis of the Lived Experiences of Financial Toxicity and Cancer in Canada

BACKGROUND

Cancer patients experience financial hardship due to rising expenses related to cancer treatment and declining income levels associated with reduced employability. Employment Insurance Sick Benefits (EI-SB) is a social income support program which provides temporary income replacement to Canadians when they fall ill. Although EI-SB is designed to maintain continuity of income during an illness, little is known about the perspectives of cancer patients who receive EI-SB. This knowledge can inform the development of public policies which are responsive to the needs and priorities of cancer patients.

METHODS

We conducted a theory-informed thematic analysis of data collected from twenty semi-structured interviews with participants who were receiving care in a cancer centre in Cape Breton, Nova Scotia and had received EI-SB. A coding framework was developed using Taplin and colleagues' intermediate outcomes of patient care across the cancer care continuum. Interpretation of findings was guided by the synergies of oppression theoretical lens.

RESULTS

Three overarching themes describe the experiences of cancer patients receiving social income support: Economic exclusion, in which the structure of the labour market and social welfare system determine access to workplace benefits and continuity of reasonable income; financial toxicity, a vicious cycle of financial burden and increasing financial distress; and constrained choices, where cancer influences employability and lowered income influences the need to be employed.

CONCLUSION

Cancer patients need income support programs that are tailored to match their healthcare priorities. In addition, policies which strengthen working conditions and facilitate a reintegration to work when possible will be important in addressing the structural drivers of income insecurity experienced by cancer patients.

Influence of financial burden on withdrawal or change of cancer treatment in Japan: results of a bereavement survey

PURPOSE

This study aimed to examine the effect of financial burden of cancer treatment from diagnosis to end-of-life on treatment withdrawal or change in Japan.

METHODS

This study was part of a nationwide survey of bereaved family members of cancer patients in Japan (J-HOPE2016 study). Questions regarding withdrawal or change of cancer treatment (stratified according to whether the treatment was recommended by physicians or based on the patients' request), financial difficulties in coping with cancer treatment expenses, and the participants' socioeconomic background were asked. Descriptive analyses were performed, and logistic regression was used to examine the factors related to withdrawal or change of cancer treatment.

RESULTS

In total, 510 (60%) questionnaires were returned. Approximately 7.5% of participants reported withdrawal or change of cancer treatment for financial reasons. Financial difficulties in coping with cancer treatment expenses such as using up all or a portion of one's savings (OR = 2.14, 95% CI = 1.14-4.04, p = 0.018/ OR = 3.45, 95% CI = 1.52-7.81, p = 0.003) and subjective financial burden (OR = 2.54, 95% CI = 1.25-5.14, p = 0.010/OR = 3.89, 95% CI = 1.68-9.00, p = 0.002) were significantly related to withdrawal or change of cancer treatment (recommended by physicians/based on patient request).

CONCLUSION

Fewer participants reported withdrawal or change of cancer treatment than in previous studies, which might reflect the characteristics of the Japanese healthcare system. However, there are patients in Japan who withdraw or change cancer treatment for financial reasons. Medical staff should consider financial toxicity as a serious side effect and assist patients in their decision-making regarding treatment while taking into account their socioeconomic backgrounds.

Caring and Grieving in the Context of Social and Structural Inequity: Experiences of Australian Carers With Social Welfare Needs

Caring for and bereavement following the death of someone with a life-limiting illness may precipitate social welfare needs related to income support and housing. Nevertheless, carer experiences of welfare policy and institutions have not received significant attention. This qualitative study explored experiences of carers who navigated social welfare policy while caring for someone with a life-limiting illness, and in bereavement. In-depth interviews were conducted with 12 bereaved carers in an area associated with socioeconomic disadvantage. Carers differentially encountered precariousness, with some experiencing structural vulnerability. These positionalities appeared to be shaped by policy and process-related burdens, perceptions of the welfare state, and degrees of legitimisation or disenfranchisement of forms of capital and coping orientations. Recommendations that may improve carer experience were identified. Implications relate to the need for an expanded conceptualisation of vulnerability in health and welfare practice, policy that authentically validates caring and grieving, and upstream strategies that address inequity.

A Scoping Review of Behavioral Interventions Addressing Medical Financial Hardship

Little information has been compiled across studies about existing interventions to mitigate issues of medical financial hardship, despite growing interest in health care delivery. The purpose of this qualitative systematic scoping review was to examine content and outcomes of interventions to address medical financial hardship. PRISMA guidelines were applied to present results using PubMed, Scopus, and CINAHL, published between January 1980 and August 2020. Additional studies were identified through reference lists of selected papers. Included studies focused on mitigating medical financial hardship from out-of-pocket (OOP) health care expenses as an intervention strategy with at least 1 evaluation component. Screening 2412 articles identified 339 articles for full-text review, 12 of which met inclusion criteria. Variation was found regarding targets and outcome measurement of intervention. Primary outcomes were in the following categories: financial outcomes (eg, OOP expenses), behavioral outcomes, psychosocial, health care utilization, and health status. No included studies reported significant reduction in OOP expenses, perceptions of financial burden/toxicity, or health status. However, changes were observed for behavioral outcomes (adherence to treatment, patient needs addressed), some psychosocial outcomes (mental health symptoms, perceived support, patient satisfaction), and care utilization such as routine health care. No patterns were observed in the achievement of outcomes across studies based on intensity of intervention. Few rigorous studies exist in this emerging field, and studies have not shown consistent positive effects. Future research should focus on conceptual clarity of the intervention, align outcome measurement and achieve consensus around outcomes, and employ rigorous study designs, measurement, and outcome follow-up.

A conceptual framework for understanding financial burden during serious illness

Life-threatening illness is associated with financial burden among families. During this time, care-related expenses often increase. The concept of financial burden has not fully been explored nor conceptually described in the literature. Our study coalesces the empirical literature on financial burden into a more comprehensive multidimensional theoretical framework to understand financial burden among patients and families dealing with serious illness. Using Jabareen's phased approach for building conceptual frameworks, we synthesized the existing scientific literature (including existing measures of financial burden) to construct an empirically derived model. Definitions of financial burden are overlapping with similarities, but also inconsistencies. Many studies have focused more on objective and operational definitions, than subjective and conceptual aspects. Regarding measures for financial burden, many studies have only used a few items. The financial burden is dependent on the illness trajectories and duration. By considering multidimensionality, we illustrate potential financial burden factors (objective, coping, and subjective). Although anticipation and expectations about future financial issues are important, patients and caregivers generally experience objective aspects of burden, followed by subjective impressions of burden. Coping skills likely reduce subjective burden. Based on the results, we redefine the financial burden among patients with life-threatening illness and caregivers.

Patient Safety in Palliative and End-of-Life Care: A Text Mining Approach and Systematic Review of Definitions

BACKGROUND

Patient safety has gained an increasing profile as a crucial element of healthcare. However, not only is there little evidence on the relevance of the term in the palliative and end-of-life care literature but also a lack of a precise and uniform definition.

METHOD

With a text mining approach occurrence of the term patient safety was determined in all available abstracts of 10 palliative and end-of-life care journals. Furthermore, 4 electronic databases (MEDLINE, EMBASE, CINAHL and PSYCINFO) were searched supplemented by hand-searching of relevant literature to identify and conceptualize published definitions of patient safety in the palliative and end-of-life care context. Publications were independently assessed against inclusion criteria by 2 authors.

RESULTS

Our search of 14,351 abstracts yielded 41 hits for "patient safety" ranking 2,345 in the list of most commonly encountered tokens. We identified 11 definitions of patient safety stemming from 11 publications. Definitions differed with regard to the concept of process or outcome. They also allowed distinctive perspectives on the extent to which patient care influences patient safety. Lastly, exact wording led to discrepancies in the understanding of unsafe care and generalizability of definitions.

CONCLUSION

Our results indicate that patient safety has gradually gained importance in palliative and end-of-life care. However, as key elements of definientia varied considerably no consensus definition could be identified. Nevertheless, a universal definition would help to facilitate communication and exchange of information among individuals and organizations involved in palliative and end-of-life care.

Systematic review of financial burden assessment in cancer: Evaluation of measures and utility among adolescents and young adults and caregivers

The cost of cancer care is rising and represents a stressor that has significant and lasting effects on quality of life for many patients and caregivers. Adolescents and young adults (AYAs) with cancer are particularly vulnerable. Financial burden measures exist but have varying evidence for their validity and reliability. The goal of this systematic review is to summarize and evaluate measures of financial burden in cancer and describe their potential utility among AYAs and their caregivers. To this end, the authors searched PubMed, Embase, the Cochrane Library, CINAHL, and PsycINFO for concepts involving financial burden, cancer, and self-reported questionnaires and limited the results to the English language. They discarded meeting abstracts, editorials, letters, and case reports. The authors used standard screening and evaluation procedures for selecting and coding studies, including consensus-based standards for documenting measurement properties and study quality. In all, they screened 7250 abstracts and 720 full-text articles to identify relevant articles on financial burden. Eighty-six articles met the inclusion criteria. Data extraction revealed 64 unique measures for assessing financial burden across material, psychosocial, or behavioral domains. One measure was developed specifically for AYAs, and none were developed for their caregivers. The psychometric evidence and study qualities revealed mixed evidence of methodological rigor. In conclusion, several measures assess the financial burden of cancer. Measures were primarily designed and evaluated in adult patient populations with little focus on AYAs or caregivers despite their increased risk of financial burden. These findings highlight opportunities to adapt and test existing measures of financial burden for AYAs and their caregivers.

Income loss after a cancer diagnosis in Germany: An analysis based on the socio-economic panel survey

BACKGROUND AND AIMS

Cancer treatments often require intensive use of healthcare services and limit patients' ability to work, potentially causing them to become financially vulnerable. The present study is the first attempt to measure, on the German national level, the magnitude of absolute income loss after a cancer diagnosis.

METHODS

This study analyzes data from the Socio-Economic Panel (SOEP) survey, one of the largest and most comprehensive household surveys in Germany, consisting of approximately 20,000 individuals, who are traced annually. The empirical strategy consists of ordinary least squares (OLS) and multinomial logistic estimators to measure changes in job income, work status, working hours, and pension as a result of reporting a cancer diagnosis for the period between 2009 and 2015. Sample consistency checks were conducted to limit measurement error biases.

RESULTS

Our results show that job incomes dropped between 26% and 28% within the year a cancer diagnosis was reported. The effect persisted for two years after the diagnosis and was no longer observable after four years. The finding was linked to an increased likelihood of unemployment and a reduction of working hours by 24%. Pension levels, on the other hand, were not affected by a cancer diagnosis.

CONCLUSIONS

These findings suggest that many cancer patients are exposed to financial hardship in Germany, particularly when the cancer diagnosis occurs during their working age and before requirements to obtain a pension are met. Further research seems warranted to identify particularly vulnerable patient groups.

What constitutes a palliative care need in people with serious illnesses across Africa? A mixed-methods systematic review of the concept and evidence

BACKGROUND

Clarity on what constitutes a palliative care need is essential to ensure that health systems and clinical services deliver an appropriate response within Universal Health Coverage.

AIM

To synthesise primary evidence from Africa for palliative care needs among patients and families with serious illness.

DESIGN

We conducted a mixed methods systematic review with sequential synthesis design. The protocol was registered with PROSPERO (CRD42019136606) and included studies were quality assessed using Mixed Method Appraisal Tool.

DATA SOURCES

Six global literature databases and Three Africa-specific databases were searched up to October 2020 for terms related to palliative care, serious illnesses and Africa. Palliative care need was defined as multidimensional problems, symptoms, distress and concerns which can benefit from palliative care.

RESULTS

Of 7810 papers screened, 159 papers met eligibility criteria. Palliative care needs were mostly described amongst patients with HIV/AIDS (n = 99 studies) or cancer (n = 59), from East (n = 72) and Southern (n = 89) Africa. Context-specific palliative care needs included managing pregnancy and breastfeeding, preventing infection transmission (physical); health literacy needs, worry about medical bills (psychological); isolation and stigma, overwhelmed families needing a break, struggling to pay children's school fees and selling assets (social and practical needs); and rites associated with cultural and religious beliefs (spiritual).

CONCLUSIONS

Palliative care assessment and care must reflect the context-driven specific needs of patients and families in Africa, in line with the novel framework. Health literacy is a crucial need in this context that must be met to ensure that the benefits of palliative care can be achieved at the patient-level.

Social welfare needs of bereaved Australian carers: Implications of insights from palliative care and welfare workers

An individual and psychological emphasis has influenced practice and research on bereavement following informal care provision in the context of life-limiting illness. Consideration of the potential for bereavement to be shaped by intersecting social and structural inequities is needed; and should include an understanding of interactions with government institutions and social policy. This qualitative study employed interpretive description to explore the way in which palliative care workers and welfare sector workers perceive and approach experiences and needs of bereaved carers receiving government income support or housing assistance in Western Sydney, an area associated with recognised socioeconomic disadvantage. A total of 21 palliative care workers within a public health service and welfare workers from two government social welfare services participated in in-depth interviews. Data were analysed using framework analysis. Participants highlighted social welfare policy and related interactions that may impact bereavement, potentially related to financial, housing and employment precariousness. Personal, interpersonal and structural factors perceived to shape the navigation of welfare needs were explored, alongside needed professional and structural changes envisioned by workers. With limited forms of capital, vulnerably positioned carers may encounter difficulties that heighten their precariousness in bereavement. Transactional organisational cultures alongside health and welfare agencies that function in a siloed manner appear to contribute to structural burden for carers, following death due to life-limiting illness. Palliative care and welfare workers also associated elements of their work with bereaved carers with their own experiences of helplessness, frustration and distress. Findings point to a need for the development of interagency strategies in addition to policy underpinned by more nuanced understandings of vulnerability in bereavement, post-caring.

Development, Practice Patterns, and Early Clinical Outcomes of a Multidisciplinary Liver Cancer Clinic

Multidisciplinary care has been associated with improved survival in patients with primary liver cancers. We report the practice patterns and real world clinical outcomes for patients presenting to the Johns Hopkins Hospital (JHH) multidisciplinary liver clinic (MDLC). We analyzed hepatocellular carcinoma (HCC, n = 100) and biliary tract cancer (BTC, n = 76) patients evaluated at the JHH MDLC in 2019. We describe the conduct of the clinic, consensus decisions for patient management based on stage categories, and describe treatment approaches and outcomes based on these categories. We describe subclassification of BCLC stage C into 2 parts, and subclassification of cholangiocarcinoma into 4 stages. A treatment consensus was finalized on the day of MDLC for the majority of patients (89% in HCC, 87% in BTC), with high adherence to MDLC recommendations (91% in HCC, 100% in BTC). Among patients presenting for a second opinion regarding management, 28% of HCC and 31% of BTC patients were given new therapeutic recommendations. For HCC patients, at a median follow up of 11.7 months (0.7-19.4 months), median OS was not reached in BCLC A and B patients. In BTC patients, at a median follow up of 14.2 months (0.9-21.1 months) the median OS was not reached in patients with resectable or borderline resectable disease, and was 11.9 months in patients with unresectable or metastatic disease. Coordinated expert multidisciplinary care is feasible for primary liver cancers with high adherence to recommendations and a change in treatment for a sizeable minority of patients.

[Individual financial burden following a cancer diagnosis from the perspective of social services in Germany]

BACKGROUND

In addition to physical, psychological and social effects, economic effects and the associated financial burden of a cancer diagnosis may also gain in importance during prolonged disease progression. Counselling by social services is an important factor in coping with this burden.

METHODS

People employed in social work in oncology were invited to participate in a survey. The survey comprises 16 items on the perception of financial burdens, changes in the relevance of the topic, risk factors and current counselling practice.

RESULTS

81% of the respondents reported that the financial burden arising from a cancer diagnosis is a relevant topic of consultation for at least half of the patients. For 55%, this topic has become more important in recent years, which is due to higher survival rates, an increased number of younger patients, and poorer social security and working conditions.

DISCUSSION AND CONCLUSION

Despite comprehensive insurance coverage, the financial burden of cancer patients has also gained in importance in Germany and must be increasingly taken into account in everyday social service counselling. Due to numerous risk factors and complex reasons, further measures are required to enable the early identification of risk constellations and to improve the situation of those affected.

The Use of the Intensive Longitudinal Methods to Study Financial Well-Being: A Scoping Review and Future Research Agenda

Financial well-being is a positive financial condition that has an objective (e.g., income) and a subjective (e.g., financial satisfaction) side. Much research has examined financial well-being using cross-sectional and classic longitudinal designs. More recently, researchers have begun to examine financial well-being using intensive longitudinal designs, collecting data in a repeated (at least five measurements) and intensive (short time interval between measurements) way. The goal of the current study was to systematically review all published research on financial well-being using intensive longitudinal methods, summarize themes from this work, and suggest future research directions. Searching three databases (Scopus, PsycINFO, Econpapers), we found nine articles that respected inclusion and exclusion criteria. From each selected article, we extracted information about (1) research field diffusion, (2) data collection methods, (3) financial well-being's definition and operationalization, (4) research questions addressed and (5) data analysis. Findings showed that most of the studies adopted an interval-contingent research design, collecting data once a day; that both the objective and subjective sides of the construct were assessed, and that, most of the time, the construct was conceptualized as financial stress (lack of financial well-being). Different kinds of research questions were addressed across studies and these were often analyzed using multilevel analysis. In the discussion section, future research directions are suggested.

Measures of financial burden for families dealing with serious illness: A systematic review and analysis

BACKGROUND

Many families coping with serious illness report experiencing financial burden, which negatively impacts coping and quality of life. Financial burden, however, is a complex construct that has been inconsistently operationalized in the literature.

AIM

To review the available literature to identify, and describe the properties of, measurement tools or scales used to assess financial burden, including financial stress and strain, for families dealing with serious illness.

DESIGN

A systematic review.

DATA SOURCES

Six databases were searched for articles published between 2006 and 2020. The review included studies in English, that reported empirical data, and used at least one measure of financial burden. To obtain a full copy of measures, an environmental scan was conducted.

RESULTS

A total of 31 measures were included. Only five of the total were designed for patient self-report, 23 of the total were designed for caregiver report. Whereas 11 measures relied on a single-item, 17 were multi-item. The remaining measures provided no information about target population and items. The most popular measures-based on Google Scholar citations-tended to only include one financial burden item. Given the complexity of financial burden, and its subjective and objective aspects, the utility of these single item measures remains questionable. Also, although patients may experience financial burden, there is a lack of patient-reported measures.

CONCLUSION

To measure financial burden, we identified a need to develop and test multi-item measures, measures appropriate for patient populations and greater attention to the temporal aspects of self-report assessments.

Caring precariously: An interpretive description of palliative care and welfare worker perspectives on end of life carers navigating social welfare

BACKGROUND

Caring at end-of-life is associated with financial burden, economic disadvantage, and psychosocial sequelae. Health and social welfare systems play a significant role in coordinating practical resources and support in this context. However, little is known about social policy and interactions with public institutions that shape experiences of informal carers with social welfare needs at end-of-life.

AIM

To explore ways in which palliative care and welfare sector workers perceive and approach experiences and needs of the carers of people with life-limiting illnesses who receive government income support or housing assistance, in an area of recognised socioeconomic disadvantage.

DESIGN

An interpretive descriptive study employed in-depth, qualitative interviews to explore participants' reflections on working with carers of someone with a life-limiting illness. Data were analysed using the framework approach.

SETTING/PARTICIPANTS

Twenty-one workers employed within three public services in Western Sydney were recruited.

RESULTS

Workers articulated understandings of welfare policy and its consequences for carers at end-of-life, including precariousness in relation to financial and housing circumstances. Identified resources and barriers to the navigation of social welfare needs by carers were categorised as personal, interpersonal and structural.

CONCLUSIONS

Caring at end-of-life while navigating welfare needs was seen to be associated with precariousness by participants, particularly for carers positioned in vulnerable social locations. Findings highlighted experiences of burdensome system navigation, inconsistent processes and inequity. Further exploration of structural determinants of experience is needed, including aspects of palliative care and welfare practice and investment in inter-agency infrastructure for supporting carers at end-of-life.

Rapid rise in the cost of targeted cancer therapies for Medicare patients with solid tumors from 2006 to 2015

BACKGROUND

Inflation-adjusted cancer costs in the United States have increased 40% in the last decade, leading to increasing financial burden on both payers and patients. Patients under 65 show substantial increases in utilization of expensive targeted therapy anticancer agents; however, patients aged 65+ account for the majority of new malignancies. Utilization and cost trends for these emerging agents have not been examined in detail in the Medicare population.

PATIENTS AND METHODS

Retrospective prevalent cohort analysis of patients 65+ with any stage of invasive lung, breast, colorectal, or prostate cancer, receiving systemic therapy drawn from the United States Medicare 5% fee-for-service sample claims (2005-2015). Yearly trends in utilization and associated costs were modeled with adjustment for inflation, demographics, and comorbidities.

RESULTS

Among Medicare beneficiaries with fee-for-service and Part D enrollment who were receiving some type of systemic anticancer therapy, there were 9230 patients with colorectal, 32,738 patients with breast, and 16,278 patients with lung cancers identified from 2006 to 2015, and 19,295 patients with prostate cancer from 2009 to 2015. The share of cancer costs to Medicare attributable to targeted therapies, increased dramatically for prostate cancer (1.7% to 19.4%), lung cancer (6.7% to 19.4%), colorectal cancer (11.7% to 22.2%), and breast cancer (15.8% to 25.5%). Although the proportion of patients receiving targeted therapies remained stable, mean per-patient cancer costs increased dramatically from 2006 to 2015 for patients with lung or prostate cancer receiving targeted therapy and for patients with breast cancer receiving non-hormonal targeted therapies. Targeted agents for these cancers showed substantial inflation-adjusted price growth over this time period.

Invited Commentary: Reckoning With the Relationship Between Stressors and Suicide Attempts in a Time of COVID-19

The coronavirus disease 2019 (COVID-19) pandemic presents a unique set of risk exposures for populations, which might lead to an increase in suicide. While large-scale traumatic events are known to increase psychological disorders, thus far the science has not shown a clear link between these events and suicide. In this issue of the Journal, Elbogen et al. (Am J Epidemiol. 2020;189(11):1266-1274) used representative data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) to show that 4 dimensions of financial strain-financial debt/crisis, unemployment, past homelessness, and lower income-are associated with subsequent suicide attempts. There are 3 main lessons we can take from Elbogen et al.: First, with populations facing record-breaking unemployment, economic recession, and reduced wages, we can anticipate an increase in suicide in the wake of the COVID-19 pandemic. Second, these data show the centrality of financial stressors, marking the current moment as distinct from other disasters or large-scale trauma. Third, the data teach us that financial stressors are linked and cumulative. In this way, Elbogen et al. provide a sobering harbinger of the potential effects on suicide of the collective stressors borne by the COVID-19 pandemic and other mass traumatic events that are accompanied by substantial financial stressors.

Economic Strain Deteriorates While Education Fails to Protect Black Older Adults Against Depressive Symptoms, Pain, Self-rated Health, Chronic Disease, and Sick Days

Background

A large body of empirical evidence on Minorities' Diminished Returns (MDRs) suggests that educational attainment shows smaller health effects for Blacks compared to Whites. At the same time, economic strain may operate as a risk factor for a wide range of undesired mental and physical health outcomes in Black communities.

Aim

The current study investigated the combined effects of education and economic strain on the following five health outcomes in Black older adults in underserved areas of South Los Angeles: depressive symptoms, number of chronic diseases, pain intensity, self-rated health, and sick days.

Methods

This cross-sectional study included 619 Black older adults residing in South Los Angeles. Data on demographic factors (age and gender), socioeconomic characteristics, economic strain, health insurance, living arrangement, marital status, health behaviors, depressive symptoms, pain intensity, number of chronic diseases, sick days, and self-rated health were collected. Five linear regressions were used to analyze the data.

Results

Although high education was associated with less economic strain, it was the economic strain, not educational attainment, which was universally associated with depressive symptoms, pain intensity, self-rated health, chronic diseases, and sick days, independent of covariates. Similar patterns emerged for all health outcomes suggesting that the risk associated with economic strain and lack of health gain due to educational attainment are both robust and independent of type of health outcome.

Conclusion

In economically constrained urban environments, economic strain is a more salient social determinant of health of Black older adults than educational attainment. While education loses some of its protective effects, economic strain deteriorates health of Black population across domains. There is a need for bold economic and social policies that increase access of Black communities to cash at times of emergency. There is also a need to improve the education quality in the Black communities.

The experience of financial stress among emerging adult cancer survivors

Objective: The experience of cancer-related financial stress was examined within the developmental context of emerging adulthood.Methodological approach: This study is a secondary analysis of data drawn from two samples of testicular or hematologic cancer survivors. In-depth interviews from 52 emerging adult (EA) cancer survivors, ages 18-29, were coded by combining thematic analysis with an abductive approach.Findings: Emergent themes included some common to most age groups, including worries about medical costs and availability of health insurance, as well as specific age-related concerns, such as fertility preservation. Financial stress appeared to interrupt developmental tasks of emerging adulthood, including completing an education, establishing independence, and managing relationships. Surprisingly, financial stress was experienced as a benefit for some participants.Conclusion: Financial stress affects EA cancer survivors in unique ways. To provide support, health professionals should consider survivors' developmental life stage to understand their financial stress, and ultimately, to improve quality of life.

Measuring financial toxicity incurred after treatment of head and neck cancer: Development and validation of the Financial Index of Toxicity questionnaire

BACKGROUND

The treatment of head and neck cancer (HNC) may cause significant financial toxicity to patients. Herein, the authors have presented the development and validation of the Financial Index of Toxicity (FIT) instrument.

METHODS

Items were generated using literature review and were based on expert opinion. In item reduction, items with factor loadings of a magnitude <0.3 in exploratory factor analysis and inverse correlations (r < 0) in test-retest analysis were eliminated. Retained items constituted the FIT. Reliability tests included internal consistency (Cronbach α) and test-retest reliability (intraclass correlation). Validity was tested using the Spearman rho by comparing FIT scores with baseline income, posttreatment lost income, and the Financial Concerns subscale of the Social Difficulties Inventory. Responsiveness analysis compared change in income and change in FIT between 12 and 24 months.

RESULTS

A total of 14 items were generated and subsequently reduced to 9 items comprising 3 domains identified on exploratory factor analysis: financial stress, financial strain, and lost productivity. The FIT was administered to 430 patients with HNC at 12 to 24 months after treatment. Internal consistency was good (α = .77). Test-retest reliability was satisfactory (intraclass correlation, 0.70). Concurrent validation demonstrated mild to strong correlations between the FIT and Social Difficulties Inventory Money Matters subscale (Spearman rho, 0.26-0.61; P < .05). FIT scores were found to be inversely correlated with baseline household income (Spearman rho, -0.34; P < .001) and positively correlated with lost income (Spearman rho, 0.24; P < .001). Change in income was negatively correlated with change in FIT over time (Spearman rho, -0.25; P = .04).

CONCLUSIONS

The 9-item FIT demonstrated internal and test-retest reliability as well as concurrent and construct validity. Prospective testing in patients with HNC who were treated at other facilities is needed to further establish its responsiveness and generalizability.

The patient-level effect of the cost of Cancer care - financial burden in German Cancer patients

BACKGROUND

Financial toxicity of cancer has so far been discussed primarily in the US health care system and is associated with higher morbidity and mortality. In European health care systems, the socio-economic impact of cancer is poorly understood. This study investigates the financial burden and patient-reported outcomes of neuroendocrine (NET) or colorectal (CRC) cancer patients at a German Comprehensive Cancer Center.

METHODS

This prospective cross-sectional study surveyed 247 advanced stage patients (n = 122 NET/n = 125 CRC) at the National Center for Tumor Diseases, in Germany about cancer-related out-of-pocket costs, income loss, distress, and quality of life. Multiple linear regression analysis was performed to demonstrate the effects of economic deterioration on patients' quality of life and distress.

RESULTS

81% (n = 199) of the patients reported out-of-pocket costs, and 37% (n = 92) income loss as a consequence of their disease. While monthly out-of-pocket costs did not exceed 200€ in 77% of affected patients, 24% of those with income losses reported losing more than 1.200€ per month. High financial loss relative to income was significantly associated with patients' reporting a worse quality of life (p < .05) and more distress (p < .05).

CONCLUSIONS

Financial toxicity in third-party payer health care systems like Germany is caused rather by income loss than by co-payments. Distress and reduced quality of life due to financial problems seem to amplify the burden that already results from a cancer diagnosis and treatment. If confirmed at a broader scale, there is a need for targeted support measures at the individual and system level.

COVID-19-Related Economic Anxiety Is As High as Health Anxiety: Findings from the USA, the UK, and Israel

As the COVID-19 outbreak peaks, millions of individuals are losing their income, and economic anxiety is felt worldwide. In three different countries (the USA, the UK, and Israel: N = 1200), the present study addresses four different sources of anxiety: health-related anxiety, economic-related anxiety, daily routine-change anxiety, and anxiety generated by social isolation. We hypothesized that, economic anxiety would have a similar or greater effect, compared to health anxiety. Results show that in all three countries, the levels of economic and health anxiety were essentially equal, and both surpassed routine-change and isolation anxiety. Although the COVID-19 crisis originated in the health field, this study emphasizes the need to move from a generalized concept of anxiety to specific types of distress, most notably economic anxiety. Economic anxiety results in serious mental and physical health problems and should be attended to by clinical professionals and by policy makers.

Equity and the financial costs of informal caregiving in palliative care: a critical debate

Background

Informal caregivers represent the foundation of the palliative care workforce and are the main providers of end of life care. Financial pressures are among the most serious concerns for many carers and the financial burden of end of life caregiving can be substantial.

Methods

The aim of this critical debate paper was to review and critique some of the key evidence on the financial costs of informal caregiving and describe how these costs represent an equity issue in palliative care.

Results

The financial costs of informal caregiving at the end of life can be significant and include carer time costs, out of pocket costs and employment related costs. Financial burden is associated with a range of negative outcomes for both patient and carer. Evidence suggests that the financial costs of caring are not distributed equitably. Sources of inequity are reflective of those influencing access to specialist palliative care and include diagnosis (cancer vs non-cancer), socio-economic status, gender, cultural and ethnic identity, and employment status. Effects of intersectionality and the cumulative effect of multiple risk factors are also a consideration.

Conclusions

Various groups of informal end of life carers are systematically disadvantaged financially. Addressing these, and other, determinants of end of life care is central to a public health approach to palliative care that fully recognises the value of carers. Further research exploring these areas of inequity in more depth and gaining a more detailed understanding of what influences financial burden is required to take the next steps towards meeting this aspiration. We will address the conclusions and recommendations we have made in this paper through the work of our recently established European Association of Palliative Care (EAPC) Taskforce on the financial costs of family caregiving.

Prevalence, Risk Factors, and Outcomes of Financial Stress in Survivors of Critical Illness

OBJECTIVES

Little is known about the experience of financial stress for patients who survive critical illness or their families. Our objective was to describe the prevalence of financial stress among critically ill patients and their families, identify clinical and demographic characteristics associated with this stress, and explore associations between financial stress and psychologic distress.

DESIGN

Secondary analysis of a randomized trial comparing a coping skills training program and an education program for patients surviving acute respiratory failure and their families.

SETTING

Five geographically diverse hospitals.

PARTICIPANTS

Patients (n = 175) and their family members (n = 85) completed surveys within 2 weeks of arrival home and 3 and 6 months after randomization.

MEASUREMENTS AND MAIN RESULTS

We used regression analyses to assess associations between patient and family characteristics at baseline and financial stress at 3 and 6 months. We used path models and mediation analyses to explore relationships between financial stress, symptoms of anxiety and depression, and global mental health. Serious financial stress was high at both time points and was highest at 6 months (42.5%) among patients and at 3 months (48.5%) among family members. Factors associated with financial stress included female sex, young children at home, and baseline financial discomfort. Experiencing financial stress had direct effects on symptoms of anxiety (β = 0.260; p < 0.001) and depression (β = 0.048; p = 0.048).

CONCLUSIONS

Financial stress after critical illness is common and associated with symptoms of anxiety and depression. Our findings provide direction for potential interventions to reduce this stress and improve psychologic outcomes for patients and their families.

Methods for measuring financial toxicity after cancer diagnosis and treatment: a systematic review and its implications

Patients experiencing financial distress as a side-effect of cancer are not only reported in the United States, but also in third-party payer healthcare systems in Europe. Since validated survey instruments are a prerequisite for robust and comparable results, we aimed to compile and classify available instruments to enable both a better understanding of the underlying construct of financial toxicity and to facilitate further studies that are adjustable to various healthcare systems. We did a systematic literature search on studies that provide data on perceived cancer-related financial distress experienced by adult patients using PubMed, CINAHL and Web of Science databases up to 2018. We analyzed all detected instruments, items domains and questions with regard to their wording, scales and the domains of financial distress covered. Among 3298 records screened, 41 publications based on 40 studies matched our inclusion criteria. Based on the analysis of 352 different questions we identified 6 relevant subdomains that represent perceptions of and reactions to experienced financial distress: (i) active financial spending, (ii) use of passive financial resources, (iii) psychosocial responses, (iv) support seeking, (v) coping with care or (vi) coping with ones' lifestyle. We found an inconsistent coverage and use of these domains that makes it difficult to compare and quantify the prevalence of financial distress. Moreover, some existing instruments do not reflect relevant domains for patients in third-party payer systems. There is neither a consistent understanding of the construct of financial burden nor do available instruments cover all relevant aspects of a patients' distress perception. We encourage using the identified six domains to further develop survey instruments and adjust them to different health systems.

Substance Use among Economically Disadvantaged African American Older Adults; Objective and Subjective Socioeconomic Status

Purpose. This study investigated the effects of objective and subjective socioeconomic status (SES) indicators on two health behaviors, cigarette smoking and alcohol drinking, among African American older adults. Methods. This community-based study recruited 619 economically disadvantaged African American older adults (age ≥ 65 years) residing in South Los Angeles. Structured face-to-face interviews were conducted to collect data. Data on demographic factors (age and gender), subjective SES (financial difficulties), objective SES (educational attainment), living arrangement, marital status, healthcare access (insurance), and health (number of chronic medical conditions, self-rated health, sick days, depression, and chronic pain) and health behaviors (cigarette smoking and alcohol drinking) were collected from participants. Logistic regressions were used to analyze the data. Results. High financial difficulties were associated with higher odds of smoking cigarettes and drinking alcohol, independent of covariates. Educational attainment did not correlate with our outcomes. Similar patterns emerged for cigarette smoking and alcohol drinking. Conclusion. Subjective SES indicators such as financial difficulties may be more relevant than objective SES indicators such as educational attainment to health risk behaviors such as cigarette smoking and alcohol drinking among African American older adults in economically constrain urban environments. Smoking and drinking may serve as coping mechanisms with financial difficulty, especially among African American older adults. In line with the minorities' diminished returns (MDR) theory, and probably due to discrimination against racial minorities, educational attainment has a smaller protective effect among economically disadvantaged African American individuals against health risk behaviors.

Chronic Respiratory Disease and Health-Related Quality of Life of African American Older Adults in an Economically Disadvantaged Area of Los Angeles

Background. Most of the attention of policy makers, program planners, clinicians, and researchers in the area of physical health disparities among African American older adults has been traditionally focused on cardiometabolic disease and cancer. Among a long list of chronic medical conditions, chronic respiratory conditions (CRCs), such as asthma, chronic bronchitis, and emphysema, have received less attention. Purpose. This study investigated whether CRCs contribute to physical and mental health-related quality of life (HRQoL) of African American older adults who live in economically disadvantaged urban areas, and whether these effects are due to demographic factors, socioeconomic status (SES), health behaviors, and comorbid medical and mental conditions. Methods. This community-based study recruited 617 African American older adults (age ≥ 65 years) from Service Planning Areas (SPA) 6, an economically disadvantaged area in South Los Angeles. Structured face-to-face interviews were used to collect data on demographic factors (age and gender), SES (educational attainment and financial difficulty), living arrangements, marital status, health behaviors (cigarette smoking and alcohol drinking), health (CRC, number of comorbid medical conditions, depressive symptoms, and pain intensity), and physical and mental HRQoL (Physical and Mental Component Summary Scores; PCS and MCS; SF-12). Linear regressions were used to analyze the data. Results. The presence of CRCs was associated with lower PCS and MCS in bivariate analysis. The association between CRCs and PCS remained significant above and beyond all confounders. However, the association between CRCs and MCS disappeared after controlling for confounders. Conclusion. For African American older adults living in economically disadvantaged urban areas, CRCs contribute to poor physical HRQoL. Evaluation and treatment of CRCs in African American older adults may be a strategy for reduction of disparities in HRQoL in this population. As smoking is the major modifiable risk factor for CRCs, there is a need to increase accessibility of smoking cessation programs in economically disadvantaged urban areas. More research is needed on the types, management, and prognosis of CRCs such as asthma, chronic bronchitis, and emphysema in African American older adults who reside in low-income and resource limited urban areas.

Depression in caregivers of patients with breast cancer: A cross-sectional study from a cancer research center in South India

CONTEXT

Existing literature suggests an alarming rate of depression in cancer caregivers, which is comparable to or even higher than in patients themselves. There are no studies on depression among caregivers of breast cancer from India.

AIMS

The aim is to study the prevalence and determinants of depression in caregivers of breast cancer.

SETTINGS AND DESIGN

This is a cross-sectional study of 384 patient-caregiver dyads at a cancer research center in South India.

MATERIALS AND METHODS

Based on the International Classification of Diseases, 10^th Revision Diagnostic Criteria for Research depression was diagnosed, and the severity of depression was assessed using the Hamilton rating scale for depression. A semi-structured pro forma was used to collect the clinical data under patient, caregivers, and care characteristics.

RESULTS

The prevalence of depression in caregivers was 52.5%. Among them, 35% had mild depression, 16% had moderate depression, and 2% had severe depression. Spousal caregivers, those who resided with the patient, those providing financial support and those with noncaring domestic responsibilities appeared as vulnerable determinants in univariate analysis. However, multivariate analysis did not support the same.

CONCLUSION

Depression is common among caregivers of patients with breast cancer. There is a need for focused interventions for this group, which may improve the outcome of the patient as well.

Cigarette Smoking among Economically Disadvantaged African-American Older Adults in South Los Angeles: Gender Differences

The current study aims to explore gender differences in the risk of cigarette smoking among African-American (AA) older adults who live in economically disadvantaged urban areas of southern Los Angeles. This cross-sectional study enrolled 576 older AA adults (age range between 65 and 96 years) who were residing in Service Planning Area 6 (SPA 6), one of the most economically challenged areas in southern Los Angeles. All participants had cardiometabolic disease (CMD). Data were collected using structured face-to-face interviews. Demographic factors (age and gender), socioeconomic status (educational attainment and financial difficulty), health (number of comorbid medical conditions and depressive symptoms), and health behaviors (current alcohol drinking and current smoking) were measured. Logistic regressions were used to analyze the data without and with interaction terms between gender and current drinking, depressive symptoms, and financial difficulty. AA men reported more smoking than AA women (25.3% versus 9.3%; p < 0.05). Drinking showed a stronger association with smoking for AA men than AA women. Depressive symptoms, however, showed stronger effects on smoking for AA women than AA men. Gender did not interact with financial difficulty with regard to current smoking. As AA older men and women differ in psychological and behavioral determinants of cigarette smoking, gender-specific smoking cessation interventions for AA older adults who live in economically deprived urban areas may be more successful than interventions and programs that do not consider gender differences in determinants of smoking. Gender-tailored smoking cessation programs that address drinking for AA men and depression for AA women may help reduce the burden of smoking in AA older adults in economically disadvantaged urban areas. Given the non-random sampling, there is a need for replication of these findings in future studies.

Socioeconomic position and use of healthcare in the last year of life: A systematic review and meta-analysis

BACKGROUND

Low socioeconomic position (SEP) is recognized as a risk factor for worse health outcomes. How socioeconomic factors influence end-of-life care, and the magnitude of their effect, is not understood. This review aimed to synthesise and quantify the associations between measures of SEP and use of healthcare in the last year of life.

METHODS AND FINDINGS

MEDLINE, EMBASE, PsycINFO, CINAHL, and ASSIA databases were searched without language restrictions from inception to 1 February 2019. We included empirical observational studies from high-income countries reporting an association between SEP (e.g., income, education, occupation, private medical insurance status, housing tenure, housing quality, or area-based deprivation) and place of death, plus use of acute care, specialist and nonspecialist end-of-life care, advance care planning, and quality of care in the last year of life. Methodological quality was evaluated using the Newcastle-Ottawa Quality Assessment Scale (NOS). The overall strength and direction of associations was summarised, and where sufficient comparable data were available, adjusted odds ratios (ORs) were pooled and dose-response meta-regression performed. A total of 209 studies were included (mean NOS quality score of 4.8); 112 high- to medium-quality observational studies were used in the meta-synthesis and meta-analysis (53.5% from North America, 31.0% from Europe, 8.5% from Australia, and 7.0% from Asia). Compared to people living in the least deprived neighbourhoods, people living in the most deprived neighbourhoods were more likely to die in hospital versus home (OR 1.30, 95% CI 1.23-1.38, p < 0.001), to receive acute hospital-based care in the last 3 months of life (OR 1.16, 95% CI 1.08-1.25, p < 0.001), and to not receive specialist palliative care (OR 1.13, 95% CI 1.07-1.19, p < 0.001). For every quintile increase in area deprivation, hospital versus home death was more likely (OR 1.07, 95% CI 1.05-1.08, p < 0.001), and not receiving specialist palliative care was more likely (OR 1.03, 95% CI 1.02-1.05, p < 0.001). Compared to the most educated (qualifications or years of education completed), the least educated people were more likely to not receive specialist palliative care (OR 1.26, 95% CI 1.07-1.49, p = 0.005). The observational nature of the studies included and the focus on high-income countries limit the conclusions of this review.

CONCLUSIONS

In high-income countries, low SEP is a risk factor for hospital death as well as other indicators of potentially poor-quality end-of-life care, with evidence of a dose response indicating that inequality persists across the social stratum. These findings should stimulate widespread efforts to reduce socioeconomic inequality towards the end of life.

Assessing patients' experiences of cancer care across the treatment pathway: a mapping review of recent psychosocial cancer care publications

PURPOSE

Patients are a critical source of information about the quality of the components of cancer care that contributes to optimal psychosocial outcomes. Recently published research was examined to determine the: (1) proportion of studies that examined at least one of 14 components of cancer care, (2) the proportion of studies that included multiple components of care, and (3) the phase of the cancer care pathway in which data collection occurred (i.e. pre-, during and post-treatment).

METHODS

MEDLINE was searched to retrieve all data-based publications indexed for two international psychosocial cancer care journals (Supportive Care in Cancer and Psycho-Oncology) over a 2-year period. A total of 333 publications yielded 214 eligible publications that were assessed against the 14 components of care for which measurement by healthcare providers at multiple phases during cancer care is recommended. Publications were coded based on the: (1) specific component/s of care focused upon in the research, (2) number of components examined and (3) timing of data collection.

RESULTS

The most frequently assessed component of care was physical and psychosocial screening (n = 198, 93%). Most studies (n = 187, 87%) examined a single component of care. No studies assessed all 14 components. Only seven studies (2.1%) examined components of care across multiple phases of the care pathway.

CONCLUSIONS

Recently published studies have examined limited segments of patients' experiences of cancer care. To improve psychosocial outcomes among people living with and beyond cancer, there should be a greater focus on patients' experiences across multiple components and the whole care pathway.

Cancer-related financial hardship among head and neck cancer survivors: Risk factors and associations with health-related quality of life

OBJECTIVE

Cancer survivors are susceptible to financial hardship. In head and neck cancer (HNC) survivors, we investigated (a) predictors for cancer-related financial hardship and (b) associations between financial hardship and health-related quality of life (HRQoL).

METHODS

We conducted a cross-sectional study in HNC survivors identified from the National Cancer Registry Ireland. HRQoL was based on the Functional Assessment for Cancer Therapy General (FACT-G) plus Head and Neck Module (FACT-HN). Objective cancer-related financial hardship (financial stress) was assessed as household ability to make ends meet due to cancer and subjective financial hardship (financial strain) as feelings about household financial situation due to cancer. Modified Poisson regression was used to identify predictors for financial hardship. Bootstrap linear regression was used to estimate associations between hardship and FACT domain scores.

RESULTS

Pre-diagnosis retirement (relative risk [RR] 0.50, 95% confidence interval [CI] 0.37-0.67), pre-diagnosis financial stress (RR 1.85, 95% CI 1.58-2.15), and treatment were significantly associated with objective financial hardship. Predictors of subjective financial hardship were similar: aged greater than or equal to 65 years, pre-diagnosis financial stress, and treatment. Participants with objective financial hardship reported significantly lower physical (coefficient -3.45, 95% CI -4.39 to -2.44), emotional (-2.01, 95% CI -2.83 to -1.24), functional (-2.56, 95% CI -3.77 to -1.33) and HN-specific HRQoL (-3.55, 95% CI -5.04 to -2.23). Physical, emotional, and functional HN-specific HRQoL were also significantly lower in participants with subjective financial hardship.

CONCLUSION

Cancer-related financial hardship is common and associated with worse HRQoL among HNC survivors. This supports the need for services and supports to address financial concerns among HNC survivors.

Targeted composite value-based endpoints in platinum-sensitive recurrent ovarian cancer

OBJECTIVES

FDA-approved treatments for platinum-sensitive recurrent ovarian cancer (PSROC) include bevacizumab and PARP inhibitors (PARPi); clinical decisions regarding therapy must be made prior to initiating chemotherapy. Using the American Society of Clinical Oncology (ASCO) and European Society of Medical Oncology (ESMO) value frameworks, we assessed relative values of concurrent/maintenance biologic therapies in PSROC.

METHODS

Value scores were calculated for key maintenance therapies based on randomized controlled trials: bevacizumab (OCEANS, GOG 213); olaparib (Study 19, SOLO2); niraparib (NOVA); rucaparib (ARIEL3). Personalized value scorecards were constructed for patients with germline/somatic-BRCA mutations, homologous recombination deficiency (HRD), and wild-type BRCA (wBRCA). ASCO value scores assess clinical benefit, toxicity, long-term survival, symptom palliation, treatment-free interval, and quality of life (QOL). ESMO value scores assess clinical benefit, toxicity, and QOL.

RESULTS

ASCO scores were highest for maintenance PARPi in germline/somatic-BRCA mutation cohorts: olaparib (SOLO2) = 47, (Study 19) = 62; niraparib = 50; rucaparib = 54. HRD cohorts had slightly lower scores: niraparib = 46; rucaparib = 37. wBRCA cohorts had the lowest scores: niraparib = 26; rucaparib = 26; and olaparib (Study 19) = 32, as did patients receiving bevacizumab (OCEANS) = 35, (GOG 213) = 26. ESMO scores demonstrated high-value for maintenance PARPi in germline/somatic-BRCA mutation cohorts and low-value for bevacizumab and PARPi in wBRCA cohorts.

CONCLUSIONS

The value of maintenance PARPi therapy depends heavily on BRCA status, with the highest value scores in germline/somatic-BRCA mutation cohorts. Personalized value scorecards provide a visual aid to assess the harm-benefit balance of maintenance PARPi for PSROC.