The Cancer Financial Experience (CAFÉ) study: randomized controlled trial of a financial navigation intervention to address cancer-related financial hardship

Pharmacy Assistance Programs for Oral Anticancer Drugs: A Narrative Review

Oral anticancer medications (OAMs) are high priced with a significant cost-sharing burden to patients, which can lead to catastrophic financial, psychosocial, and clinical repercussions. Cost-conscious prescribing and inclusion of low-cost alternatives can help mitigate this burden, but cost transparency at the point of prescribing remains a major barrier to doing so. Pharmacy assistance programs, including co-payment cards and patient assistance programs administered by manufacturers and foundation-based grants, remain an essential resource for patients facing prohibitive co-payments for OAMs. However, access to these programs is fraught with complexities, including lack of trained financial navigators, limited transparency on eligibility criteria, onerous documentation burdens, and limits in available funding. Despite these drawbacks and the potential for such programs to incentivize manufacturers to keep list prices high, assistance programs have been demonstrated to improve financial well-being for patients with cancer. The increasing development of integrated specialty pharmacies with dedicated, trained pharmacy staff can help improve and standardize access to such programs, but these services are disproportionately available to patients seen at tertiary care centers. Multistakeholder interventions are needed to mitigate the burden of cost sharing for OAMs, including increased clinician knowledge of financial resources and novel assistance mechanisms, investment of institutions in trained financial navigation services and centralized platforms to identify assistance programs, and policies to cap out-of-pocket spending and improve transparency of rates charged by pharmacy benefit managers to a health plan.

Caregiver costs and financial burden in caregivers of African American cancer survivors

PURPOSE

People with cancer commonly rely on loved ones as informal caregivers during and after treatment. Costs related to caregiving and their association with caregiver financial burden are not well understood.

METHODS

Results include data from 964 caregivers of African American cancer survivors in the Detroit Research on Cancer Survivors (ROCS) cohort. Caregiving costs include those related to medications, logistics (e.g., transportation), and medical bills. Financial burden measures included caregiver financial resources, strain, and difficulty paying caregiving costs. Prevalence ratios (PR) and 95% confidence intervals (CI) of associations between costs and high financial burden were calculated using modified Poisson models controlling for caregiver characteristics.

RESULTS

Caregivers included spouses (36%), non-married partners (8%), family members (48%), and friends (9%). Nearly two-thirds (64%) of caregivers reported costs related to caregiving. Logistical costs were the most common (58%), followed by medication costs (35%) and medical bills (17%). High financial hardship was reported by 38% of caregivers. Prevalence of high financial hardship was 52% (95% CI: 24%, 86%) higher among caregivers who reported any versus no caregiver costs. Associations between caregiver costs and high financial burden were evident for costs related to medications (PR: 1.33, 95% CI: 1.12, 1.58), logistics (PR: 1.57, 95% CI: 1.29, 1.92), and medical bills (PR: 1.57, 95% CI: 1.28, 1.92).

CONCLUSIONS

Most caregivers experienced costs related to caregiving, and these costs were associated with higher prevalence of high caregiver financial burden.

IMPLICATIONS FOR CANCER SURVIVORS

Informal caregivers experience financial hardship related to cancer along with cancer survivors.

Association of financial worry with substance use, mental health, and quality of life in cancer patients

PURPOSE

Financial worry is an under-appreciated negative effect of cancer. The relationship of financial worry and health behaviors in cancer is poorly characterized and has important clinical implications. This study examined the association of financial worry with substance misuse, mood, and quality of life.

METHODS

People with cancer (n = 1473; 6 to 20 months after diagnosis) were recruited from a SEER cancer registry in the Pacific Northwest. Participants completed an online survey assessing financial worry; misuse of cannabis, alcohol, and prescription drugs; tobacco smoking status; quality of life (physical and mental dimensions); anxiety; and depression. Multivariable regressions tested the association of financial worry to each health indicator and outcome.

RESULTS

In adjusted analyses, financial worry was associated with being a current vs. never smoker (odds ratio (OR) = 1.91, 95% confidence interval (CI): 1.01, 3.60), and a positive screen for an anxiety (OR = 3.01, 95% CI: 1.93, 4.68) and depressive (OR = 3.08, 95% CI: 1.89, 5.00) disorder. Financial worry was not associated with cannabis, alcohol, or prescription drug misuse (all ps > 0.05), but was associated with a decrease in physical (β =  - 2.97, 95% CI: - 4.15, - 1.79) and mental (β =  - 5.27, 95% CI: - 6.59, - 3.96) quality of life.

CONCLUSION

Financial worry among cancer survivors is associated with anxiety, depression, and worse quality of life. Of the evaluated substances, there was only an increased odds of current tobacco use with financial worry. Future longitudinal studies should inform the relationships between these factors.

IMPLICATIONS FOR CANCER SURVIVORS

Financial worry and material hardship may both need to be addressed in cancer survivorship.

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.

Cancer treatment-related financial toxicity in Japan: a scoping review

Financial toxicity during cancer survival has been studied mainly in the United States; 47-49% of cancer survivors reported financial hardships and 12-63% reported debt owing to treatment costs. Financial toxicity is influenced by each country's economic status and healthcare system. We aimed to review the evidence on financial toxicity in Japan. A systematic search was performed using PubMed and Ichushi databases. We included English or Japanese peer-reviewed articles that (1) explored the experiences of cancer patients facing financial toxicity due to cancer diagnosis and treatment, (2) were specific to Japan, and (3) focused on the experiences of financial toxicities among cancer patients. Data were extracted focusing on the experiences of patients, families, and healthcare providers. The main themes were synthesized based on a previous study. The search yielded 632 citations from PubMed and 21 from Ichushi, and non-duplicates were identified. Of these, 31 articles were selected for full-text review. Literature was divided into studies describing the following elements: (a) risk factors for financial toxicity, (b) description of financial toxicity, (c) psychological reactions, (d) coping strategies for financial toxicity, and (e) impact on treatment outcomes. Only three studies reported comprehensive financial toxicity scores. Furthermore, treatment costs influenced physicians' treatment decisions, and patients and their families adopted various strategies to cope with treatment costs. Two studies showed that low current income and younger age were high-risk factors. As for utilization of the support system, approximately 70% of the patients used the high-cost medical expense system, 20% used the sickness benefit system, and 40% used the medical expense deduction system. Many cancer patients in Japan suffer from financial toxicity during cancer survival. One reason for this is that the awareness of the system supporting financial toxicity is insufficient and actual utilization is low. It is necessary to actively encourage patients to ask healthcare providers questions, improve the link between patients and the support system, reconstruct the support system design, and improve the method of publicizing the system.

Expanding research on the impact of financial hardship on emotional well-being: guidance of diverse stakeholders to the Emotional Well-Being and Economic Burden of Disease (EMOT-ECON) Research Network

The Emotional Well-Being and Economic Burden (EMOT-ECON) Research Network is one of six research networks funded by the National Institutes of Health (NIH) to advance research about emotional well-being (EWB), and the only one that focuses on addressing how economic burden due to disease or illness affects EWB. The network convened researchers, patients, patient advocates, health care providers and other stakeholders from across the US to discuss the significance of addressing the impact of the economic burden of disease on EWB, the complexity of this prevalent problem for patients and families, and the research gaps that still need to be studied to ultimately develop strategies to reduce the impact of economic burden of disease on EWB and health. Participants identified some important future areas of research as those investigating: (i) prevalent and relevant emotions for patients experiencing economic burden of disease and financial hardship, and how their broader outlook on life is impacted; (ii) constructs and contexts that influence whether the economic burden is stressful; (iii) strategies to deal and cope and their positive or negative effects on EWB and health; and (iv) multi-level and multi-stakeholder interventions to address economic factors (e.g., costs, ability to pay), administrative burdens, education and training, and especially patients' emotional as well as financial status.

"It's just not easy to understand": A mixed methods study of health insurance literacy and insurance plan decision-making in cancer survivors

BACKGROUND

Understanding cancer survivors' health insurance decision-making is needed to improve insurance choice, potentially resulting in reduced financial hardship.

METHODS

This explanatory mixed methods study assessed health insurance decision-making in cancer survivors. Health Insurance Literacy Measure (HILM) captured HIL. Quantitative eye-tracking data collected from two simulated health insurance plan choice sets gauged dwell time (seconds), or interest, in benefits. Dwell time differences by HIL were estimated using adjusted linear models. Qualitative interviews explored survivors' insurance decision-making choices.

RESULTS

Cancer survivors (N = 80; 38% breast cancer) had a median age of 43 at diagnosis (IQR 34-52). When comparing traditional and high-deductible health plans, survivors were most interested in drug costs (median dwell time 58 s, IQR 34-109). When comparing health maintenance organization and preferred provider organization plans, survivors were most interested in test/imaging costs (40s, IQR 14-67). Survivors with low versus high HIL had more interest in deductible (β = 19 s, 95% CI 2-38) and hospitalization costs (β = 14 s, 95% CI 1-27) in adjusted models. Survivors with low versus high HIL more often ranked out-of-pocket (OOP) maximums and coinsurance as the most important and confusing benefits, respectively. Interviews (n = 20) revealed survivors felt alone "to do their own research" about insurance choices. OOP maximums were cited as the deciding factor since it is "how much money is going to be taken out of my pocket." Coinsurance was considered "rather than a benefit, it's a hindrance."

CONCLUSION

Interventions to aid in health insurance understanding and choice are needed to optimize plan choice and potentially reduce cancer-related financial hardship.

Financial toxicity in patients with leukemia undergoing hematopoietic stem cell transplantation: A systematic review

Financial toxicity (FT) is a term used to describe the objective financial burden of cancer care including the associated coping behaviors used by patients and their caregivers. FT has been shown to result in both direct financial burdens and in clinically relevant outcomes, such as non-adherence with care, diminished quality of life, and even decreased overall survival. Much of the data has been described in solid tumors, with limited investigations in the malignant hematology population. Patients with hematologic malignancies undergoing hematopoietic stem cell transplantation (HSCT) face a unique financial burden driven by lengthy hospitalizations and acute and chronic morbidity that have downstream implications on their income and costs. In this review, we discuss the prevalence of FT in patients with leukemia who are eligible for HSCT. We review the impact of FT on financial and clinical outcomes and the role of various interventions that have been studied within this population.