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Jia S, Cheung DST, Ho MH, Takemura N, Feng Y, Lin CC. A Systematic Review of Interventions Targeting Cancer-Related Financial Hardship: Current Evidence and Implications. Cancer Nurs 2024:00002820-990000000-00287. [PMID: 39190807 DOI: 10.1097/ncc.0000000000001393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2024]
Abstract
BACKGROUND Despite an increasing emphasis on alleviating financial hardship in cancer care delivery, limited knowledge of evidence-based and effective interventions is available. OBJECTIVE This systematic review aimed to identify gaps in the literature and provide insights for future evidence-based interventions targeting financial hardship from both micro and macro perspectives. METHODS We comprehensively searched the PubMed, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, and PsycINFO databases from inception to October 2022. Studies examining the effect of an intervention on mitigating cancer-related financial hardship were included. RESULTS A total of 24 studies were included. Findings indicate that the most significant positive changes were in the material conditions domain from the micro perspective of financial hardship. From the macro perspective, positive effects were shown for improving access to care, affordability of care, healthcare utilization, and healthcare equity of interventions at the provider or care team level, the community healthcare environment level, and the healthcare system and policy level. Notably, significant heterogeneity was observed among interventions and outcome measurements. CONCLUSIONS This is the first comprehensive systematic review of interventions targeting cancer-related financial hardship from both micro and macro perspectives. No consistently positive effect of the interventions on all domains was reported. Multidisciplinary approaches and higher-level hierarchical and evidence-based interventions are needed to address financial hardship. IMPLICATIONS FOR PRACTICE Health practitioners should screen and manage financial hardship using a standard and comprehensive measurement at the dyadic level of cancer survivors and caregivers.
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Affiliation(s)
- Shumin Jia
- Author Affiliations: School of Nursing, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
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Gharzai LA, Liu YA, Sun Z, Mady LJ, Mohn M, Larson A, Kircher S, Yanez B, Carlos RC, Pottow J, Jagsi R, Sadigh G. Financial Toxicity Screening Preferences in Patients With Breast Cancer. JCO Oncol Pract 2024:OP2400415. [PMID: 39288337 DOI: 10.1200/op.24.00415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Revised: 07/18/2024] [Accepted: 08/15/2024] [Indexed: 09/19/2024] Open
Abstract
PURPOSE Financial toxicity is an important issue in cancer that affects quality of life and treatment adherence. Screening can identify patients at risk but consensus on appropriate timing or methods is lacking. METHODS We sent an anonymous survey to e-mail subscribers of a nationwide breast cancer-specific philanthropic organization in July 2023 asking about financial toxicity screening preferences. Frequencies, percentages, and medians were calculated for categorical and continuous variables. RESULTS Of 5,774 potential participants, 738 respondents with a confirmed cancer diagnosis participated (12.7% response rate). Participants were 93% female (n = 690), had a median age of 50 years (IQR, 44-57), were 57% non-Hispanic White (n = 418), 20% Black/African-American (n = 149), 9.2% Hispanic (n = 68). 93% confirmed a breast cancer diagnosis (n = 689), and 54% were currently undergoing treatment (n = 400). Most indicated not being asked about financial stressors by (58%, n = 425) and not receiving assistance from their care team (68%, n = 498). Most preferred for providers to reach out regarding financial needs (83%, n = 615). Most wished for these discussions to take place early (when first diagnosed [45%, n = 334] or when treatment selected [37%, n = 275]) and to be asked frequently (each appointment [42%, n = 312] or once per month [36%, n = 268]). Participants felt most comfortable discussing financial needs with a social worker or patient/financial navigator (92%, n = 679), in person (75%, n = 553), or via telephone (65%, n = 479). CONCLUSION Patients in this sample primarily consisting of women with breast cancer desired financial screening to occur early, often, and to be initiated by their providers. Patient preferences can inform optimal implementation of financial toxicity screening practices. Continued work refining best practices for financial toxicity screening should incorporate these patient preferences.
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Affiliation(s)
- Laila A Gharzai
- Department of Radiation Oncology, Northwestern University, Chicago, IL
- Department of Medical Social Sciences, Northwestern University, Chicago, IL
| | - Yingzhe Alex Liu
- Department of Biostatistics, Northwestern University, Chicago, IL
| | - Zequn Sun
- Department of Biostatistics, Northwestern University, Chicago, IL
| | - Leila J Mady
- Department of Otolaryngology, Johns Hopkins University, Baltimore, MD
| | - Michelle Mohn
- Department of Social Work, Northwestern University, Chicago, IL
| | - Alexis Larson
- Department of Radiation Oncology, Northwestern University, Chicago, IL
| | - Sheetal Kircher
- Division of Medical Oncology, Department of Internal Medicine, Northwestern University, Chicago, IL
| | - Betina Yanez
- Department of Medical Social Sciences, Northwestern University, Chicago, IL
| | - Ruth C Carlos
- Department of Radiology, University of Michigan, Ann Arbor, MI
| | - John Pottow
- University of Michigan Law School, Ann Arbor, MI
| | - Reshma Jagsi
- Department of Radiation Oncology, Emory University, Atlanta, GA
| | - Gelareh Sadigh
- Department of Radiology, University of California Irvine, Irvine, CA
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Jung J, Mukherjee K, Brown M, Sadigh G. Association between financial hardship and psychological burden and the role of social and mental health support: An observational study. Medicine (Baltimore) 2024; 103:e38871. [PMID: 38996144 PMCID: PMC11245238 DOI: 10.1097/md.0000000000038871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 06/19/2024] [Indexed: 07/14/2024] Open
Abstract
We aimed to assess the association between medical financial hardship and psychological burden and the moderating role of social and mental health support. 2021 United States National Health Interview Survey was used. Financial hardship was defined as having financial worry, material hardship, or cost-related care nonadherence. Psychological burden was measured using perceived general health status, satisfaction with life, and serious psychological distress (SPD). Of 29,370 included adults, 49% experienced financial hardship in the last 12 months. Financial hardship was associated with a higher psychological burden (odds ratio [OR], 3.58; 95% confidence interval [CI], 2.43-5.47 for SPD). Eleven percent received counseling/therapy from mental health professionals, and 90% had experienced frequent social support. Frequent social support was associated with lower financial hardship (OR, 0.71; 95% CI, 0.63-0.80) and psychological burden (OR, 0.28; 95% CI, 0.19-0.42 for SPD). Previous mental health support was associated with higher financial hardship (OR,1.40; 95% CI, 1.28-1.54) and psychological burden (OR, 9.75; 95% CI, 6.97-13.94 for SPD). Those experiencing financial hardship had lower odds of SPD if they received mental health support in the last 12 months (OR, 0.57; 95% CI, 0.39-0.85). Future interventions should also focus on improving social support and mental health for patients as a way of mitigating medical financial hardship.
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Affiliation(s)
- Jinho Jung
- School of Medicine, University of California, Irvine, Irvine, CA
- Department of Radiological Sciences, University of California, Irvine, Orange, CA
| | - Kumar Mukherjee
- School of Pharmacy, Philadelphia College of Osteopathic Medicine, Suwanee, GA
| | | | - Gelareh Sadigh
- Department of Radiological Sciences, University of California, Irvine, Orange, CA
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Nwachukwu C, Makhnoon S, Person M, Muthukrishnan M, Kazmi S, Anderson LD, Kaur G, Kapinos KA, Williams EL, Fatunde O, Sadeghi N, Robles F, Basey A, Hulsey T, Pruitt SL, Gerber DE. Transferring care to enhance access to early-phase cancer clinical trials: Protocol to evaluate a novel program. Contemp Clin Trials Commun 2024; 39:101292. [PMID: 38623454 PMCID: PMC11016932 DOI: 10.1016/j.conctc.2024.101292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 02/14/2024] [Accepted: 03/26/2024] [Indexed: 04/17/2024] Open
Abstract
Involving diverse populations in early-phase (phase I and II) cancer clinical trials is critical to informed therapeutic development. However, given the growing costs and complexities of early-phase trials, trial activation and enrollment barriers may be greatest for these studies at healthcare facilities that provide care to the most diverse patient groups, including those in historically underserved communities (e.g., safety-net healthcare systems). To promote diverse and equitable access to early-phase cancer clinical trials, we are implementing a novel program for the transfer of care to enhance access to early-phase cancer clinical trials. We will then perform a mixed-methods study to determine perceptions and impact of the program. Specifically, we will screen, recruit, and enroll diverse patients from an urban, integrated safety-net healthcare system to open and active early-phase clinical trials being conducted in a university-based cancer center. To evaluate this novel program, we will: (1) determine program impact and efficiency; and (2) determine stakeholder experience with and perceptions of the program. To achieve these goals, we will conduct preliminary cost analyses of the program. We will also conduct surveys and interviews with patients and caregivers to elucidate program impact, challenges, and areas for improvement. We hypothesize that broadening access to early-phase cancer trials conducted at experienced centers may improve equity and diversity. In turn, such efforts may enhance the efficiency and generalizability of cancer clinical research.
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Affiliation(s)
- Chika Nwachukwu
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA
- Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Sukh Makhnoon
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA
- O'Donnell School of Public Health, UT Southwestern Medical Center, Dallas, TX, USA
| | - Marieshia Person
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA
| | - Meera Muthukrishnan
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA
- O'Donnell School of Public Health, UT Southwestern Medical Center, Dallas, TX, USA
| | - Syed Kazmi
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA
- Division of Hematology-Oncology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Larry D. Anderson
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA
- Division of Hematology-Oncology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Gurbakhash Kaur
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA
- Division of Hematology-Oncology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Kandice A. Kapinos
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA
- O'Donnell School of Public Health, UT Southwestern Medical Center, Dallas, TX, USA
- RAND Corporation, Arlington, VA, USA
| | - Erin L. Williams
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA
| | - Oluwatomilade Fatunde
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA
| | - Navid Sadeghi
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA
- Division of Hematology-Oncology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
- Parkland Health, Dallas, TX, USA
| | - Fabian Robles
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA
- Parkland Health, Dallas, TX, USA
| | - Alice Basey
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA
- Patient Advocate Program, Office of Community Outreach, Engagement, and Equity, Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA
| | - Thomas Hulsey
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA
- Patient Advocate Program, Office of Community Outreach, Engagement, and Equity, Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA
| | - Sandi L. Pruitt
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA
- O'Donnell School of Public Health, UT Southwestern Medical Center, Dallas, TX, USA
| | - David E. Gerber
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA
- O'Donnell School of Public Health, UT Southwestern Medical Center, Dallas, TX, USA
- Division of Hematology-Oncology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
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Rieder SM, Burgess E, Rutledge T, Sussman A, Boyce T, Pankratz VS, Kano M. Critical decisions: A mixed-methods study of decision-making among diverse gynecologic cancer patients considering therapeutic clinical trial enrollment. Gynecol Oncol 2024; 184:103-110. [PMID: 38301308 DOI: 10.1016/j.ygyno.2024.01.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 01/16/2024] [Accepted: 01/20/2024] [Indexed: 02/03/2024]
Abstract
OBJECTIVE Participation in therapeutic clinical trials does not reflect the diversity of gynecologic cancer patients, limiting access to novel therapeutics and generalizability of results. Reasons for inequities in participation among historically underrepresented populations remain undertheorized, as studies have shown equal willingness to participate among groups. We sought to apply a precarity framework to conceptualize the factors that impact patients' desire to enroll, to improve equity in gynecologic oncology clinical trial participation. METHODS Gynecologic cancer patients at a single tertiary care facility in the Southwestern United States who discussed participation in therapeutic clinical trial with their oncology provider from 2020 to 2021 were identified. Enrolled participants completed surveys and qualitative interviews regarding treatment experiences and decision-making. Oncology providers completed parallel surveys at the time of their patient's enrollment. Descriptive statistics and thematic coding were used to analyze data. RESULTS 30 patients were enrolled and participated in surveys and interviews. No differences were found in quantitative data assessing shared decision-making and patient-centered communication between those who enrolled and those who did not. Qualitative data demonstrated that patients who declined trial enrollment expressed concerns regarding uncertainty and loss of control, independence in decision-making, and significant resource challenges and financial toxicity of cancer treatment. CONCLUSIONS We identified a constellation of factors that contribute to desire to enroll in clinical trials, that we describe using the framework of precarity. Through identification of precarious patients and mitigation of burdens, we anticipate improved enrollment and retention in therapeutic clinical trials among diverse gynecologic oncology patients.
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Affiliation(s)
- Stephanie Margrit Rieder
- University of New Mexico Comprehensive Cancer Center, Albuquerque, NM, USA; Department of Obstetrics and Gynecology, University of New Mexico School of Medicine, Albuquerque, NM, USA.
| | - Ellen Burgess
- University of New Mexico Comprehensive Cancer Center, Albuquerque, NM, USA
| | - Teresa Rutledge
- University of New Mexico Comprehensive Cancer Center, Albuquerque, NM, USA; Department of Obstetrics and Gynecology, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Andrew Sussman
- University of New Mexico Comprehensive Cancer Center, Albuquerque, NM, USA; Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Tawny Boyce
- University of New Mexico Comprehensive Cancer Center, Albuquerque, NM, USA
| | | | - Miria Kano
- University of New Mexico Comprehensive Cancer Center, Albuquerque, NM, USA; Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA
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Alacevich C, Abi Nehme AM, Lee JH, Li D, Mobley EM, Close JL, George TJ, LeLaurin JH, Hong YR, Shenkman EA, Gutter MS, Salloum RG. A point-of-care pilot randomized intervention to connect patients with cancer-induced financial toxicity to telehealth financial counseling. Cancer Causes Control 2024; 35:393-403. [PMID: 37794203 PMCID: PMC10872295 DOI: 10.1007/s10552-023-01794-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 09/06/2023] [Indexed: 10/06/2023]
Abstract
PURPOSE Elevated costs of cancer treatment can result in economic and psychological "financial toxicity" distress. This pilot study assessed the feasibility of a point-of-care intervention to connect adult patients with cancer-induced financial toxicity to telehealth-delivered financial counseling. METHODS We conducted a three-armed parallel randomized pilot study, allocating newly referred patients with cancer and financial toxicity to individual, group accredited telehealth financial counseling, or usual care with educational material (1:1:1). We assessed the feasibility of recruitment, randomization, retention, baseline and post-intervention COmprehensive Score for Financial Toxicity (COST), and Telehealth Usability Questionnaire (TUQ) scores. RESULTS Of 382 patients screened, 121 were eligible and enrolled. 58 (48%) completed the intervention (9 individual, 9 group counseling, 40 educational booklet). 29 completed follow-up surveys: 45% female, 17% African American, 79% white, 7% Hispanic, 55% 45-64 years old, 31% over 64, 34% lived in rural areas, 24% had cancer stage I, 21% II, 7% III, 31% IV. Baseline characteristics were balanced across arms, retention status, surveys completion. Mean (SD) COST was 12.4 (6.1) at baseline and 16.0 (8.4) post-intervention. Mean (SD) COST score differences were 6.3 (11.6) after individual counseling, 5.8 (8.5) after group counseling, and 2.5 (6.4) after usual care. Mean TUQ score among nine counseling participants was 5.5 (0.9) over 7.0. Non-parametric comparisons were not statistically meaningful. CONCLUSION Recruitment and randomization were feasible, while study retention presented challenges. Nine participants reported good usability and satisfaction with telehealth counseling. Larger-scale trials focused on improving participation, retention, and impact of financial counseling among patients with cancer are justified.
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Affiliation(s)
- Caterina Alacevich
- Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, USA.
| | - Anna Maria Abi Nehme
- Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, USA
| | - Ji-Hyun Lee
- Department of Biostatistics, University of Florida, Gainesville, USA
- Division of Quantitative Sciences, University of Florida Health Cancer Center, Gainesville, USA
| | - Derek Li
- Department of Biostatistics, University of Florida, Gainesville, USA
- Division of Quantitative Sciences, University of Florida Health Cancer Center, Gainesville, USA
| | - Erin M Mobley
- Department of Surgery, University of Florida, Jacksonville, USA
| | - Julia L Close
- Division of Hematology and Oncology, University of Florida, Gainesville, USA
| | - Thomas J George
- Division of Hematology and Oncology, University of Florida, Gainesville, USA
| | - Jennifer H LeLaurin
- Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, USA
| | - Young-Rock Hong
- Health Services Research, Management and Policy, University of Florida, Gainesville, USA
| | - Elizabeth A Shenkman
- Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, USA
| | - Michael S Gutter
- Department of Family, Youth and Community Sciences, University of Florida, Gainesville, USA
- Department of Agricultural and Applied Economics, Virginia Tech, Blacksburg, USA
| | - Ramzi G Salloum
- Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, USA
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Donzo MW, Nguyen G, Nemeth JK, Owoc MS, Mady LJ, Chen AY, Schmitt NC. Effects of socioeconomic status on enrollment in clinical trials for cancer: A systematic review. Cancer Med 2024; 13:e6905. [PMID: 38169154 PMCID: PMC10807561 DOI: 10.1002/cam4.6905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 11/07/2023] [Accepted: 12/21/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND To achieve equitable access to cancer clinical trials (CCTs), patients must overcome structural, clinical, and attitudinal barriers to trial enrollment. The goal of this systematic review was to study the relationship between socioeconomic status (SES), assessed either by direct or proxy measures, and CCT enrollment. METHODS The review team and medical librarian developed search strategies for each database to identify studies for this systematic review, which was conducted according to PRISMA guidelines. Inclusion criteria were as follows: studies published in relevant scientific journals between January 2000 and July 2022, primary sources, English literature, and studies conducted in the US. Sixteen studies fulfilled the inclusion criteria and were reviewed. The risk of bias assessment was conducted independently by two reviewers using the Newcastle Ottawa scale. RESULTS The initial search yielded 4070 citations, and 16 studies were included in our review. Four of the studies included used patient reported annual income as a measure of SES, while the remaining 12 studies used patient zip code as a proxy measurement of SES. Consistent with our hypothesis, 13 studies showed a positive association between high SES (patient-reported or proxy measurement) and CCT enrollment. Two studies showed a negative association, and one study showed no relationship. CONCLUSIONS The existing literature suggests that low SES is associated with lower participation in CCT. The small number of studies identified on this topic highlights the need for additional research on SES and other barriers to CCT participation.
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Affiliation(s)
- Maja Wichhart Donzo
- Department of Otolaryngology – Head and Neck SurgeryEmory University School of MedicineAtlantaGeorgiaUSA
- The Winship Cancer Institute at Emory UniversityAtlantaGeorgiaUSA
| | - Grace Nguyen
- Department of Otolaryngology – Head and Neck SurgeryEmory University School of MedicineAtlantaGeorgiaUSA
- The Winship Cancer Institute at Emory UniversityAtlantaGeorgiaUSA
| | - John K. Nemeth
- Woodruff Health Sciences Center LibraryEmory UniversityAtlantaGeorgiaUSA
| | - Maryanna S. Owoc
- University of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
| | - Leila J. Mady
- Department of Otolaryngology – Head and Neck SurgeryJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Amy Y. Chen
- Department of Otolaryngology – Head and Neck SurgeryEmory University School of MedicineAtlantaGeorgiaUSA
- The Winship Cancer Institute at Emory UniversityAtlantaGeorgiaUSA
| | - Nicole C. Schmitt
- Department of Otolaryngology – Head and Neck SurgeryEmory University School of MedicineAtlantaGeorgiaUSA
- The Winship Cancer Institute at Emory UniversityAtlantaGeorgiaUSA
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Sears-Smith M, Knight TG. Financial Toxicity in Patients with Hematologic Malignancies: a Review and Need for Interventions. Curr Hematol Malig Rep 2023; 18:158-166. [PMID: 37490228 DOI: 10.1007/s11899-023-00707-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2023] [Indexed: 07/26/2023]
Abstract
INTRODUCTION Financial toxicity is a developing research area to quantify the financial stress experienced by patients and caregivers, as well as the mechanisms by which they manage the costs associated with treatment and the very real harms that this stress can inflict upon cancer care. Patients with blood malignancies experience increased costs associated with their diagnosis due to possible inpatient admissions for treatment, frequent office visits, and even more frequent lab evaluations and testing. PURPOSE OF REVIEW Multiple studies have examined the causes and effects of financial toxicity on patient care and outcomes, and there have been several validated tools developed to identify patients experiencing or at risk for financial harm. DISCUSSION However, few studies to date have focused on implementing successful interventions to assist in mitigating financial difficulties for patients diagnosed with hematologic malignancies and their families. In this review, we examine the current literature with an emphasis on levels of care, including providers, systems, and policies. Specifically, we discuss published interventions including physician education about treatment costs, financial navigation in cancer centers, and novel institutional multidisciplinary review of patients' financial concerns. We also discuss the urgent need for societal and governmental interventions to lessen financial distress experienced by these highly vulnerable blood cancer patients.
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Affiliation(s)
- Megan Sears-Smith
- Levine Cancer Institute, Atrium Health, 1020 Morehead Medical Drive, Charlotte, NC, 28204, USA
| | - Thomas G Knight
- Levine Cancer Institute, Atrium Health, 1021 Morehead Medical Drive, LCI Building 2, Suite 60100, Charlotte, NC, 28204, USA.
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Luiten-Apirana P, Gendi M, Bernard J, Li Z, Edge R, Gellert B, Miller A, Mury M, Sansey N, Jasicki L, Stolp S. The Clinical Trials Assistance Pilot: reducing the financial burden of cancer clinical trials for patients in regional New South Wales. AUST HEALTH REV 2023; 47:607-613. [PMID: 37605341 DOI: 10.1071/ah22249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 08/09/2023] [Indexed: 08/23/2023]
Abstract
Objective This study investigated whether the provision of financial assistance to patients living in regional New South Wales influenced patients' decisions to participate in a cancer clinical trial (cancer treatment or supportive care) and resulted in improved psychosocial outcomes. Methods Administrative data were collected from participants, including demographics, travel distances and the value of financial support provided. Qualitative interviews were then conducted with a subset of consenting patients who received financial assistance for a clinical trial. Results Sixty-four patients with cancer received financial support for a clinical trial, 27 (42%) of whom were interviewed. Participants whose distance to a trial site was over 400 km received almost three times as much financial support (M = A$3194.20, s.d. = A$1597.60) as participants whose distance to a trial site was between 50 and 100 km (M = A$1116.29, s.d. = $A1311.23). Half of participants indicated that receiving financial assistance influenced their decision to participate in a clinical trial, and most indicated the support alleviated the financial burden of clinical trial participation. Conclusions The provision of financial assistance to patients living in regional areas may reduce inequities in cancer clinical trial participation and improve psychosocial outcomes.
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Affiliation(s)
| | - Monica Gendi
- Cancer Council NSW, 153 Dowling Street, Woolloomooloo, NSW, Australia
| | - Jai Bernard
- Cancer Council NSW, 153 Dowling Street, Woolloomooloo, NSW, Australia
| | - Zhicheng Li
- Cancer Council NSW, 153 Dowling Street, Woolloomooloo, NSW, Australia
| | - Rhiannon Edge
- Cancer Council NSW, 153 Dowling Street, Woolloomooloo, NSW, Australia
| | - Bradley Gellert
- Cancer Council NSW, 153 Dowling Street, Woolloomooloo, NSW, Australia
| | - Annie Miller
- Cancer Council NSW, 153 Dowling Street, Woolloomooloo, NSW, Australia
| | - Maria Mury
- Cancer Institute NSW, 1 Reserve Road, St Leonards, NSW, Australia
| | - Niki Sansey
- Cancer Institute NSW, 1 Reserve Road, St Leonards, NSW, Australia
| | - Lindsey Jasicki
- Cancer Institute NSW, 1 Reserve Road, St Leonards, NSW, Australia
| | - Sean Stolp
- Cancer Council NSW, 153 Dowling Street, Woolloomooloo, NSW, Australia
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Hastert TA, Nair M, Eggly S. Providers' communication-related concerns in helping patients address the financial impact of cancer. PATIENT EDUCATION AND COUNSELING 2023; 114:107860. [PMID: 37421848 DOI: 10.1016/j.pec.2023.107860] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 06/14/2023] [Accepted: 06/16/2023] [Indexed: 07/10/2023]
Abstract
OBJECTIVES This study describes the communication-related concerns of oncology providers in addressing financial issues with patients. METHODS We conducted semi-structured interviews with 17 providers (9 clinicians, 5 social workers/navigators, 3 attorneys) who addressed financial concerns with cancer patients and analyzed resulting transcripts using qualitative thematic analysis. Interview topics included cost-related concerns of patients, resources providers used, and unmet needs related to addressing financial issues. Here we present codes and content related to a cross-cutting cost communication, stratified by provider discipline. RESULTS Communication-related issues varied by provider type. Clinicians identified lack of information, lack of time, and the need for additional support as major barriers to effective cost discussions. Social workers/navigators expressed the importance of establishing a relationship before discussing costs and on the need to revisit cost concerns over time to meet patients' changing needs. The attorneys endorsed the need for more and earlier cost communication to prevent financial hardship. CONCLUSION Communication concerns and strategies were central to providers' experiences of addressing cancer patient cost concerns. PRACTICE IMPLICATIONS Understanding the experiences of diverse oncology providers can inform the development and implementation of interventions to prevent and mitigate financial hardship in people with cancer.
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Affiliation(s)
- Theresa A Hastert
- Department of Oncology, Wayne State University School of Medicine, Detroit, MI, USA; Population Studies and Disparities Research Program, Karmanos Cancer Institute, Detroit, MI, USA.
| | - Mrudula Nair
- Department of Public Health Sciences, Henry Ford Medical Group, Detroit, MI, USA
| | - Susan Eggly
- Department of Oncology, Wayne State University School of Medicine, Detroit, MI, USA; Population Studies and Disparities Research Program, Karmanos Cancer Institute, Detroit, MI, USA
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11
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Pail O, Knight TG. Financial toxicity in patients with leukemia undergoing hematopoietic stem cell transplantation: A systematic review. Best Pract Res Clin Haematol 2023; 36:101469. [PMID: 37353293 DOI: 10.1016/j.beha.2023.101469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 04/06/2023] [Accepted: 04/11/2023] [Indexed: 06/25/2023]
Abstract
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.
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Affiliation(s)
- Orrin Pail
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
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12
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Acuña-Villaorduña A, Baranda JC, Boehmer J, Fashoyin-Aje L, Gore SD. Equitable Access to Clinical Trials: How Do We Achieve It? Am Soc Clin Oncol Educ Book 2023; 43:e389838. [PMID: 37146264 DOI: 10.1200/edbk_389838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
The mismatch between the study populations participating in oncology clinical trials and the composition of the targeted cancer population requires urgent amelioration. Regulatory requirements can mandate that trial sponsors enroll diverse study populations and ensure that regulatory revue prioritizes equity and inclusivity. A variety of projects directed at increasing accrual of underserved populations to oncology clinical trials emphasize best practices: broadened eligibility requirements for trials, simplification of trial procedures, community outreach through patient navigators, decentralization of clinical trial procedures and institution of telehealth, and funding to offset costs of travel and lodging. Substantial improvement will require major changes in culture in the educational and professional practice, research, and regulatory communities and will require major increases in public, corporate, and philanthropic funding.
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Affiliation(s)
- Ana Acuña-Villaorduña
- Cancer Immunotherapy Program, Tisch Cancer Institute, Mount Sinai School of Medicine, New York, NY
| | | | - Jessica Boehmer
- Oncology Center of Excellence (OCE), US Food and Drug Administration, Silver Spring, MD
| | - Lola Fashoyin-Aje
- Office of Oncologic Diseases, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD
| | - Steven D Gore
- Early Therapeutics Clinical Trial Network, Investigational Drug Branch, Cancer Therapy Evaluation Program, National Cancer Institute, Shady Grove, MD
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13
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Chapman-Davis E, Webster EM, Hines JF. Achieving diversity in clinical trial enrollment by reducing burden and increasing value: A patient-centered approach. Gynecol Oncol 2023; 172:A1-A2. [PMID: 37197889 DOI: 10.1016/j.ygyno.2023.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Affiliation(s)
| | - Emily M Webster
- Division of Gynecologic Oncology, Weill Cornell Medicine, New York, NY, USA
| | - Jeffrey F Hines
- University of Connecticut Health Center, Farmington, CT, USA
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14
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Medina SP, Zhang S, Nieves E, Dornsife DL, Johnson R, Spicer D, Borno HT. Experiences of a Multiethnic Cohort of Patients Enrolled in a Financial Reimbursement Program for Cancer Clinical Trials. JCO Oncol Pract 2023; 19:e801-e810. [PMID: 36800640 DOI: 10.1200/op.22.00429] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
PURPOSE Financial reimbursement programs (FRPs) offset out-of-pocket (OOP) expenses from therapeutic clinical trial (TCT) participation. The study explores patients' experience in TCTs after enrollment in a FRP at two academic medical centers, including barriers and opportunities to improve trial participation. METHODS From May 2019 to January 2020, adults diagnosed with cancer and eligible for TCTs and FRP were recruited from the Improving Patient Access to Cancer Clinical Trials randomized trial at the University of California San Francisco and University of Southern California. Patients with income ≤ 700% of national poverty guidelines were eligible. Semistructured interviews were conducted in patients' preferred language. Qualitative analysis was performed by site and preferred language by two independent coders. RESULTS Of 65 trial patients, 53 participated (38%, University of California San Francisco; 62%, USC). The median age was 59 (IQR, 46-65) years, and 58% were female. Nearly half (49%) identified as Latinx/Hispanic compared with 32% non-Hispanic White, 10% Asian, 4% Black, 1% Native American, and 4% Others. A third were non-English speakers, 42% had college education or more, and 55% were retired/unemployed. Most common malignancies were gastrointestinal (42%), breast (19%), and genitourinary (13%), and 66% had metastatic disease. Patients experienced long travel time (1-4.5 hours) among 57% and financial toxicity from OOP costs (68%). High acceptability of the FRP was reported (81%). Although 30% of patients reported willingness to discuss finances of cancer treatment/trial with physicians, majority (87%) preferred discussion with social workers or TCT staff. Proposed modifications to TCTs included decentralization, recruitment strategies, voucher structure, and established rates for OOP expenses. CONCLUSION Patients' experience with TCTs reveal financial and logistical stressors that may be lessened by the Improving Patient Access to Cancer Clinical Trial reimbursement program. FRPs may address inequities in clinical trial access among low-income and diverse populations.
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Affiliation(s)
| | - Sylvia Zhang
- Helen Diller Family Comprehensive Cancer Center, UCSF, San Francisco, CA
| | - Elena Nieves
- Department of Medicine and Division of Oncology, USC, Los Angeles, CA
| | | | | | - Darcy Spicer
- Department of Medicine and Division of Oncology, USC, Los Angeles, CA
| | - Hala T Borno
- Department of Medicine, UCSF, San Francisco, CA.,Helen Diller Family Comprehensive Cancer Center, UCSF, San Francisco, CA.,Division of Hematology/Oncology, UCSF, San Francisco, CA.,Trial Library, Inc, San Francisco, CA
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15
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Patel KB, Turner K, Alishahi Tabriz A, Gonzalez BD, Oswald LB, Nguyen OT, Hong YR, Jim HSL, Nichols AC, Wang X, Robinson E, Naso C, Spiess PE. Estimated Indirect Cost Savings of Using Telehealth Among Nonelderly Patients With Cancer. JAMA Netw Open 2023; 6:e2250211. [PMID: 36626174 PMCID: PMC9856804 DOI: 10.1001/jamanetworkopen.2022.50211] [Citation(s) in RCA: 38] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
IMPORTANCE Patients with cancer typically have greater financial hardships and time costs than individuals without cancer. The COVID-19 pandemic has exacerbated this, while posing substantial challenges to delivering cancer care and resulting in important changes in care-delivery models, including the rapid adoption of telehealth. OBJECTIVE To estimate patient travel, time, and cost savings associated with telehealth for cancer care delivery. DESIGN, SETTING, AND PARTICIPANTS An economic evaluation of cost savings from completed telehealth visits from April 1, 2020, to June 30, 2021, in a single-institution National Cancer Institute-Designated Comprehensive Cancer Center. All patients aged 18 to 65 years who completed telehealth visits within the designated time frame and had a Florida mailing address documented in their electronic medical record were included in the study cohort. Data were analyzed from April 2020 to June 2021. MAIN OUTCOMES AND MEASURES The main outcome was estimated patient cost savings from telehealth, which included 2 components: costs of travel (defined as roundtrip distance saved from car travel) and potential loss of productivity due to the medical visit (defined as loss of income from roundtrip travel plus loss of income from in-person clinic visits). Two different models with a combination of 2 different mileage rates ($0.56 and $0.82 per mile) and census tract-level median hourly wages were used. RESULTS The study included 25 496 telehealth visits with 11 688 patients. There were 4525 (3795 patients) new or established visits and 20 971 (10 049 patients) follow-up visits. Median (IQR) age was 55.0 (46.0-61.0) years among the telehealth visits, with 15 663 visits (61.4%) by women and 18 360 visits (72.0%) by Hispanic non-White patients. According to cost models, the estimated mean (SD) total cost savings ranged from $147.4 ($120.1) at $0.56/mile to $186.1 ($156.9) at $0.82/mile. For new or established visits, the mean (SD) total cost savings per visit ranged from $176.6 ($136.3) at $0.56/mile to $222.8 ($177.4) at $0.82/mile, and for follow-up visits, the mean (SD) total cost savings per visit was $141.1 ($115.3) at $0.56/mile to $178.1 ($150.9) at $0.82/mile. CONCLUSIONS AND RELEVANCE In this economic evaluation, telehealth was associated with savings in patients time and travel costs, which may reduce the financial toxicity of cancer care. Expansion of telehealth oncology services may be an effective strategy to reduce the financial burden among patients with cancer.
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Affiliation(s)
- Krupal B. Patel
- Department of Head and Neck and Endocrine Oncology, Moffitt Cancer Center, Tampa, Florida
- Department of Otolaryngology, Head and Neck Surgery, University of South Florida, Tampa
| | - Kea Turner
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida
| | - Amir Alishahi Tabriz
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida
| | - Brian D. Gonzalez
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida
| | - Laura B. Oswald
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida
| | - Oliver T. Nguyen
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida
| | - Young-Rock Hong
- Department of Health Services Research, Management and Policy, College of Public Health and Health Professions, University of Florida, Gainesville
| | - Heather S. L. Jim
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida
| | - Anthony C. Nichols
- Department of Otolaryngology, Head and Neck Surgery, Western University, London, Ontario, Canada
| | - Xuefeng Wang
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, Tampa, Florida
| | - Edmondo Robinson
- Department of Internal and Hospital Medicine, Moffitt Cancer Center, Tampa, Florida
- Center for Digital Health, Moffitt Cancer Center, Tampa, Florida
| | - Cristina Naso
- Virtual Health Program, Moffitt Cancer Center, Tampa, Florida
| | - Philippe E. Spiess
- Virtual Health Program, Moffitt Cancer Center, Tampa, Florida
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, Florida
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16
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McGarvey N, Gitlin M, Fadli E, Chung KC. Out-of-pocket cost by cancer stage at diagnosis in commercially insured patients in the United States. J Med Econ 2023; 26:1318-1329. [PMID: 37907436 DOI: 10.1080/13696998.2023.2254649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 08/30/2023] [Indexed: 11/02/2023]
Abstract
AIMS Out-of-pocket (OOP) costs may constitute a substantial financial burden to patients diagnosed with cancer. Earlier stage diagnosis and treatment of cancers may promote decreased morbidity and mortality, subsequently also lowering costs. To better understand costs experienced by patients with cancer, OOP costs by stage post-diagnosis were estimated. MATERIALS AND METHODS A retrospective analysis was conducted using Optum's de-identified Integrated Claims-Clinical dataset with Enriched Oncology, which includes data from commercially insured members (June 1, 2015-July 31, 2020). Mean annual and cumulative OOP costs (co-pay + co-insurance + deductible) (2020 USD) were reported through a 3-year period post-cancer diagnosis among adult commercially insured members (not including Medicare Advantage members) diagnosed with staged breast, cervical, colorectal, lung, ovarian, or prostate cancer between January 1, 2016 and June 30, 2020 with continuous enrollment for ≥1-month post-diagnosis. RESULTS A total of 7,494 eligible members were identified who were diagnosed with breast, cervical, colorectal, lung, ovarian, or prostate cancer. A greater proportion of OOP costs were incurred in year 1 post-diagnosis but remained relatively high through year 3 post-diagnosis. Cumulative mean OOP costs were as high as $35,243 (lung stage IV) per commercially insured patient by year 3 post-diagnosis and were generally higher among those diagnosed at later stages (III/IV) than those diagnosed at earlier stages (I/II) across all cancers. LIMITATIONS Generalizability of these results is limited to those with commercial health insurance coverage. Additionally, cancer staging was dependent on accuracy of staging as recorded in the electronic medical record and as determined by Optum's proprietary algorithm using natural language processing. CONCLUSION Cumulative mean OOP costs among commercially insured patients during the 3-year period post-cancer diagnosis were substantial and generally higher among those with later stage cancer diagnoses. Diagnosis of cancer at earlier stages may allow for more timely treatment and lessen patient OOP costs.
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Affiliation(s)
| | | | - Ela Fadli
- BluePath Solutions, Los Angeles, CA, USA
| | - Karen C Chung
- GRAIL LLC, a subsidiary of Illumina Inc. currently held separate from Illumina Inc. under the terms of the Interim Measures Order of the European Commission dated 29 October 2021, Menlo Park, CA, USA
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17
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Gerber DE, Tiro JA, McNeill LH, Williams EL, Zhu H, Lee SJC, Leavey PJ, Sadeghi N, Kapinos KA, Dornsife DL, Nguyen V, Wileyto EP, Guerra CE. Enhancing access to and diversity in cancer clinical trials through a financial reimbursement program: Protocol to evaluate a novel program. Contemp Clin Trials 2022; 121:106922. [PMID: 36096281 DOI: 10.1016/j.cct.2022.106922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 09/05/2022] [Accepted: 09/06/2022] [Indexed: 01/27/2023]
Abstract
As clinical trials have become more complex, with increasing numbers of required procedures and clinic visits, gaining access to promising new treatments has become even more challenging for many individuals. To address these barriers, we implemented a financial reimbursement and outreach program designed to increase the number and diversity of participants in cancer clinical trials at centers in Dallas, Houston, and Philadelphia. As endorsed by U.S. Food and Drug Administration (FDA) and the Texas and Pennsylvania State Legislatures, the program provides financial reimbursement for non-clinical costs (e.g., travel, lodging) to patients on cancer clinical trials with household income up to 700% the Federal poverty rate. The research study described here, centered at the Dallas site, evaluates program impact by assessing (1) numbers and diversity of patients enrolled to cancer clinical trials before and after program implementation; (2) characteristics of patients offered participation in the program who do versus do not enroll; (3) characteristics of patients enrolled in the program who do versus do not complete the reimbursement process. To evaluate perceived barriers and facilitators of program participation, we will conduct semi-structured interviews and administer the Comprehensive Score for Financial Toxicity Patient Reported Outcome Measure (COST PROM) and the Short Assessment of Health Literacy (SAHL). This program will examine how reimbursement of non-clinical costs can improve access to cancer clinical trials, with the eventual goal of increasing trial enrollment, diversity, representativeness, and generalizability.
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Affiliation(s)
- David E Gerber
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA; Division of Hematology-Oncology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA; Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX, USA.
| | - Jasmin A Tiro
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA; Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX, USA.
| | - Lorna H McNeill
- Department of Health Disparities Research, Division of Cancer Prevention and Population Sciences, MD Anderson Cancer Center, Houston, TX, USA.
| | - Erin L Williams
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA.
| | - Hong Zhu
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA; Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX, USA.
| | - Simon J Craddock Lee
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA; Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX, USA.
| | - Patrick J Leavey
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA; Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX, USA; Children's Health, Dallas, TX, USA.
| | - Navid Sadeghi
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA; Division of Hematology-Oncology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA; Parkland Health and Hospital System, Dallas, TX, USA.
| | - Kandice A Kapinos
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA; Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX, USA; RAND Corporation, Santa Monica, CA, USA.
| | | | - Vivian Nguyen
- Abramson Cancer Center and the Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - E Paul Wileyto
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Carmen E Guerra
- Abramson Cancer Center and the Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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18
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Różyńska J. The ethical anatomy of payment for research participants. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2022; 25:449-464. [PMID: 35610403 PMCID: PMC9427899 DOI: 10.1007/s11019-022-10092-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 05/04/2022] [Indexed: 11/18/2022]
Abstract
In contrast to most publications on the ethics of paying research subjects, which start by identifying and analyzing major ethical concerns raised by the practice (in particular, risks of undue inducement and exploitation) and end with a set of-more or less well-justified-ethical recommendations for using payment schemes immune to these problems, this paper offers a systematic, principle-based ethical analysis of the practice. It argues that researchers have a prima facie moral obligation to offer payment to research subjects, which stems from the principle of social beneficence. This principle constitutes an ethical "spine" of the practice. Other ethical principles of research ethics (respect for autonomy, individual beneficence, and justice/fairness) make up an ethical "skeleton" of morally sound payment schemes by providing additional moral reasons for offering participants (1) recompense for reasonable expenses; and (2a) remuneration conceptualized as a reward for their valuable contribution, provided (i) it meets standards of equality, adequacy and non-exploitation, and (ii) it is not overly attractive (i.e., it does not constitute undue inducement for participation or retention, and does not encourage deceptive behaviors); or (2b) remuneration conceptualized as a market-driven price, provided (i) it is necessary and designed to help the study achieve its social and scientific goals, (ii) it does not reinforce wider social injustices and inequalities; (iii) it meets the requirement of non-exploitation; and (iv) it is not overly attractive. The principle of justice provides a strong ethical reason for not offering recompenses for lost wages (or loss of other reasonably expected profits).
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Affiliation(s)
- Joanna Różyńska
- Center for Bioethics and Biolaw, Faculty of Philosophy, University of Warsaw, Krakowskie Przedmiescie 3, 00-047, Warsaw, Poland.
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19
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Smith GL, Banegas MP, Acquati C, Chang S, Chino F, Conti RM, Greenup RA, Kroll JL, Liang MI, Pisu M, Primm KM, Roth ME, Shankaran V, Yabroff KR. Navigating financial toxicity in patients with cancer: A multidisciplinary management approach. CA Cancer J Clin 2022; 72:437-453. [PMID: 35584404 DOI: 10.3322/caac.21730] [Citation(s) in RCA: 91] [Impact Index Per Article: 45.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 03/15/2022] [Accepted: 04/13/2022] [Indexed: 12/21/2022] Open
Abstract
Approximately one-half of individuals with cancer face personal economic burdens associated with the disease and its treatment, a problem known as financial toxicity (FT). FT more frequently affects socioeconomically vulnerable individuals and leads to subsequent adverse economic and health outcomes. Whereas multilevel systemic factors at the policy, payer, and provider levels drive FT, there are also accompanying intervenable patient-level factors that exacerbate FT in the setting of clinical care delivery. The primary strategy to intervene on FT at the patient level is financial navigation. Financial navigation uses comprehensive assessment of patients' risk factors for FT, guidance toward support resources, and referrals to assist patient financial needs during cancer care. Social workers or nurse navigators most frequently lead financial navigation. Oncologists and clinical provider teams are multidisciplinary partners who can support optimal FT management in the context of their clinical roles. Oncologists and clinical provider teams can proactively assess patient concerns about the financial hardship and employment effects of disease and treatment. They can respond by streamlining clinical treatment and care delivery planning and incorporating FT concerns into comprehensive goals of care discussions and coordinated symptom and psychosocial care. By understanding how age and life stage, socioeconomic, and cultural factors modify FT trajectory, oncologists and multidisciplinary health care teams can be engaged and informative in patient-centered, tailored FT management. The case presentations in this report provide a practical context to summarize authors' recommendations for patient-level FT management, supported by a review of key supporting evidence and a discussion of challenges to mitigating FT in oncology care. CA Cancer J Clin. 2022;72:437-453.
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Affiliation(s)
- Grace L Smith
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Matthew P Banegas
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, San Diego, California
| | - Chiara Acquati
- Graduate College of Social Work, University of Houston, Houston, Texas
- Department of Health Disparities Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Shine Chang
- Department of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Fumiko Chino
- Department of Radiation Oncology, Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Rena M Conti
- Department of Markets, Public Policy, and Law, Boston University School of Business, Boston, Massachusetts
| | - Rachel A Greenup
- Division of Surgical Oncology, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Juliet L Kroll
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Margaret I Liang
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Maria Pisu
- Department of Internal Medicine, The University of Alabama, Birmingham, Alabama
| | - Kristin M Primm
- Department of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michael E Roth
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Veena Shankaran
- Seattle Cancer Care Alliance/University of Washington Medicine and Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - K Robin Yabroff
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
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20
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Sidana S, Allmer C, Larson MC, Dueck A, Yost K, Warsame R, Thanarajasingam G, Cerhan JR, Paludo J, Rajkumar SV, Habermann TM, Nowakowski GS, Lin Y, Gertz MA, Witzig T, Dispenzieri A, Gonsalves WI, Ansell SM, Thompson CA, Kumar SK. Patient Experience in Clinical Trials: Quality of Life, Financial Burden, and Perception of Care in Patients With Multiple Myeloma or Lymphoma Enrolled on Clinical Trials Compared With Standard Care. JCO Oncol Pract 2022; 18:e1320-e1333. [PMID: 35580285 PMCID: PMC9377715 DOI: 10.1200/op.21.00789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
PURPOSE Patients' concerns regarding clinical trial (CT) participation include apprehension about side effects, quality of life (QoL), financial burden, and quality of care. METHODS We prospectively evaluated the experience of patients with multiple myeloma or lymphoma who were treated on CTs (CT group, n = 35) versus patients treated with standard approaches (non-CT group, n = 88) focusing on QoL, financial burden of care, and patients' perception of quality of care over a 1-year period. RESULTS There were no significant differences in any of the patient-reported outcomes in CT versus non-CT groups. We observed an initial decline in overall QoL in the first 3 months across both groups, driven primarily by physical and functional well-being. QoL gradually improved and was above baseline by month 12. Patients reported highest improvement in the functional well-being subdomain. Patients in both groups reported high satisfaction with the quality of care received, and there were no differences in overall satisfaction, communication with team, or access to care. At baseline, 16%-19% of patients reported financial burden, which increased to a peak of 33% in the CT group and to 49% in the non-CT group over the course of 1 year. There was no significant difference in financial burden in the two groups overall. Most of the patients reported getting all the care that was deemed medically necessary in both groups. However, a significant proportion of patients reported having to make other kinds of financial sacrifices because of their cancer (CT group: 33% of patients at baseline and 21%-40% over 1 year; non-CT group: 19% at baseline and 25%-36% over 1 year). CONCLUSION Patients treated on CTs reported comparable QoL and quality of care with the non-CT group. A high proportion of patients reported financial burden over time in both groups. Our findings can serve as a guide to educate patients regarding CT participation and highlight the need to address the significant financial burden experienced by patients with cancer.
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Affiliation(s)
- Surbhi Sidana
- Division of BMT and Cellular Therapy, Stanford University School of Medicine, Stanford, CA,Division of Hematology, Mayo Clinic, Rochester, MN
| | - Cristine Allmer
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | - Melissa C. Larson
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | - Amylou Dueck
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | | | | | | | - James R. Cerhan
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | - Jonas Paludo
- Division of Hematology, Mayo Clinic, Rochester, MN
| | | | | | | | - Yi Lin
- Division of Hematology, Mayo Clinic, Rochester, MN
| | | | | | | | | | | | | | - Shaji K. Kumar
- Division of Hematology, Mayo Clinic, Rochester, MN,Shaji K. Kumar, MD, Division of Hematology, Mayo Clinic, 200 First St SW, Rochester, MN 55905; e-mail:
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21
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Bradley CJ, Simon K, Winkfield K, Moy B. Enhancing Health Equity Through Cancer Health Economics Research. J Natl Cancer Inst Monogr 2022; 2022:74-78. [PMID: 35788369 DOI: 10.1093/jncimonographs/lgab018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/10/2021] [Indexed: 11/14/2022] Open
Abstract
Cancer displays some of the largest health-equity concerns of all diseases. This paper draws attention to how health economics research can assess strategies to reduce or even eliminate health disparities and provides pivotal examples of existing research as well as areas for future contributions. The paper also highlights critical data limitations that currently restrain the impact health economics research could have. We then explore new areas of inquiry where economic research is sparse but could have an important impact on health equity, particularly in topics involving Medicare and Medicaid policies that expand reimbursement and generosity of coverage. Health economics studies are notably absent from policies and practices surrounding clinical trials, representing an opportunity for future research. We urge health economics researchers to consider experiments, interventions, and assessments through primary data collection; we further encourage the formulation of multidisciplinary teams to ensure that health economics skills are well melded with other areas of expertise. These teams are needed to maximize novelty and rigor of evidence. As policies are promulgated to address disparities in cancer, involvement of economics in a multidisciplinary context can help ensure that these policies do not have unintended impacts that may deepen inequities.
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Affiliation(s)
- Cathy J Bradley
- Colorado School of Public Health, Department of Health Systems, Management and Policy and University of Colorado Cancer Center, University of Colorado Anschutz, Aurora, CO, USA
| | - Kosali Simon
- O'Neill School of Public and Environmental Affairs, Indiana University, Bloomington, IN, USA
| | - Karen Winkfield
- Meharry-Vanderbilt Alliance, Wake Forest University, Winston-Salem, NC, USA
| | - Beverly Moy
- Department of Medicine, Harvard Medical School, Breast Oncology Program, Massachusetts General Hospital Cancer Center, Boston, MA, USA
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22
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Corrigan KL, Fu S, Chen YS, Kaiser K, Roth M, Peterson SK, Shih YCT, Jagsi R, Giordano SH, Volk RJ, Robin Yabroff K, Banegas MP, Acquati C, Conti RM, Ma HY, Ku K, Nancy You Y, Smith GL. Financial toxicity impact on younger versus older adults with cancer in the setting of care delivery. Cancer 2022; 128:2455-2462. [PMID: 35417565 PMCID: PMC9177670 DOI: 10.1002/cncr.34220] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 02/21/2022] [Accepted: 03/09/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Young adults and other working-age adults with cancer are at risk for cancer-related financial toxicity (FT), including material hardships, depletion of coping resources, and psychological burden. This study compares FT domains in young adults (18-39 years old) (YAs), other working-age adults (40-64 years old), and older adults (≥65 years old) receiving cancer care. METHODS A total of 311 adults were surveyed using the multi-domain Economic Strain and Resilience in Cancer instrument measuring FT (0-10 score indicating least to greatest FT; score ≥5 severe FT). Participants were receiving ambulatory care from March-September 2019. Associations of age with overall FT and material hardship, coping resource depletion, and psychological burden FT domains were tested using Kruskal-Wallis and χ2 tests and multivariable generalized linear models with gamma distribution. RESULTS YAs (median age, 31.5 years) comprised 9.6% of the sample; other working-age adults comprised 56.9%. Overall, material, coping, and psychological FT scores were worse in younger age adults versus older adults (P < .001 in all multivariable models). Compared with older adults, younger age adults demonstrated worse material hardship (median scores, 3.70 vs 4.80 vs 1.30 for YAs, other working-age, and older adults, respectively; P < .001), coping resource depletion (4.50 vs 3.40 vs 0.80; P < .001), and psychological burden (6.50 vs 7.00 vs 1.00; P < .001). Fifty percent of YAs had severe overall FT versus 40.7% of other working-age adults and 9.6% of older adults (P < .001). CONCLUSIONS Younger age adults with cancer bore disproportionate FT. Interventions to address unmet needs are critical components for addressing FT in this population.
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Affiliation(s)
- Kelsey L. Corrigan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Shuangshuang Fu
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ying-Shiuan Chen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kelsey Kaiser
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Michael Roth
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Susan K. Peterson
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ya-Chen T. Shih
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Reshma Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI
| | - Sharon H. Giordano
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Robert J. Volk
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Mathew P. Banegas
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, San Diego, CA
| | - Chiara Acquati
- Graduate College of Social Work, University of Houston, Houston, TX
- Department of Health Disparities Research, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Rena M. Conti
- Department of Markets, Public Policy, and Law, Boston University School of Business, Boston, MA
| | - Hilary Y. Ma
- Department of General Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kimberly Ku
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Y. Nancy You
- Department of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Grace L. Smith
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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23
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Perni S, Azoba C, Gorton E, Park ER, Chabner BA, Moy B, Nipp RD. Financial Toxicity, Symptom Burden, Illness Perceptions, and Communication Confidence in Cancer Clinical Trial Participants. JCO Oncol Pract 2022; 18:e1427-e1437. [PMID: 35666957 DOI: 10.1200/op.21.00697] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Cancer clinical trial (CCT) participants are at risk for experiencing adverse associations from financial toxicity, but these remain understudied. METHODS From July 2015 to July 2017, we prospectively enrolled CCT participants referred for financial assistance and a group of patients matched by age, sex, cancer type, trial, and trial phase. We assessed financial burden of cancer care, cost concerns about CCTs, physical (Edmonton Symptom Assessment Scale [ESAS]) and psychologic (Patient Health Questionnaire-4 [PHQ-4]) symptoms, illness perceptions (Brief Illness Perception Questionnaire), and communication confidence (Perceived Efficacy in Patient-Physician Interactions). Adjusting for age, sex, race, performance status, marital status, income, insurance, and disease status, we examined associations of financial burden and cost concerns with patients' symptoms, illness perceptions, and communication confidence. RESULTS Of 198 patients, 112 (56.6%) reported financial burden and 82 (41.4%) reported cost concerns. Higher ESAS-total (odds ratio [OR] = 1.03; 95% CI, 1.01 to 1.06; P = .001), PHQ-4 depression (OR = 1.58; 95% CI, 1.20 to 2.08; P < .001), PHQ-4 anxiety (OR = 1.26; 95% CI, 1.02 to 1.55; P = .025), and more negative illness perceptions (OR = 1.04; 95% CI, 1.00 to 1.07; P = .029) were associated with financial burden, but not communication confidence (OR = 0.98; 95% CI, 0.02 to 1.05; P = .587). Higher ESAS-total (OR = 1.03; 95% CI, 1.01 to 1.05; P = .004), PHQ-4 depression (OR = 1.36; 95% CI, 1.08 to 1.71; P = .03), PHQ-4 anxiety (OR = 1.26; 95% CI, 1.03 to 1.53; P = .018), more negative illness perceptions (OR = 1.06; 95% CI, 1.02 to 1.10; P = .001), and decreased communication confidence (OR = 0.93; 95% CI, 0.86 to 1.00; P = .029) were associated with cost concerns. CONCLUSION In this study of CCT participants, greater symptom burden, more negative illness perceptions, and lower communication confidence were associated with financial toxicity, underscoring the importance of addressing these issues when seeking to alleviate adverse associations of financial toxicity.
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Affiliation(s)
- Subha Perni
- Harvard Radiation Oncology Program, Massachusetts General Hospital and Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA.,Department of Radiation Oncology, Massachusetts General Hospital Cancer Center, Boston, MA
| | - Chukwuma Azoba
- St George's University School of Medicine, True Blue, Grenada
| | - Emily Gorton
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Elyse R Park
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA
| | - Bruce A Chabner
- Division of Hematology/Oncology, Massachusetts General Hospital Cancer Center, Boston, MA
| | - Beverly Moy
- Division of Hematology/Oncology, Massachusetts General Hospital Cancer Center, Boston, MA
| | - Ryan D Nipp
- Division of Hematology/Oncology, Massachusetts General Hospital Cancer Center, Boston, MA
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24
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Kushnir I, Clemons M, Fergusson D, Bossé D, Reaume MN. Attitudes towards open-label versus placebo-control designs in oncology randomized trials: A survey of medical oncologists. J Eval Clin Pract 2022; 28:495-499. [PMID: 35191169 PMCID: PMC9302988 DOI: 10.1111/jep.13669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 01/24/2022] [Accepted: 01/25/2022] [Indexed: 11/30/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Randomized trials are considered the gold standard when assessing the efficacy of new therapeutic agents. In clinical situations where no standard of care therapy is approved, randomized trials usually compare experimental agents to either a placebo or an open-label nonintervention arm (i.e., best supportive care). We surveyed Canadian medical oncologists to understand their attitudes towards each design. METHODS Members of the Canadian Association of Medical Oncologists were invited to participate in an anonymous online survey. Standardized case scenarios were used to determine participants' attitudes regarding the role of open-label versus placebo-controlled trials. RESULTS A total of 322 medical oncologists and trainees were invited to participate and 86 responded (response rate 27%). Fifty-one (59%) believed that open-label trials are an acceptable alternative to placebo-controlled design when investigating a therapeutic agent in the adjuvant setting. Thirty-eight (49%) deemed it acceptable to compare the investigational agent to an open-label arm instead of a placebo to assess progression-free survival in the metastatic setting. Twenty-eight (38%) of respondents felt that open-label design was acceptable when assessing the quality of life endpoint. Most physicians were unsure whether the US Food and Drug Administration require a placebo-controlled arm in oncology trials. CONCLUSION Canadian medical oncologists participating in this survey are divided in their opinions regarding the acceptability of an open-label design in randomized-controlled trials, where no standard therapy is approved. Clearer guidance from regulatory bodies on the adequacy of different trial designs is needed.
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Affiliation(s)
- Igal Kushnir
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital, The University of Ottawa and the Ottawa Hospital Cancer Centre, Ottawa, Ontario, Canada.,Meir Medical Center, Institute of Oncology, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mark Clemons
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital, The University of Ottawa and the Ottawa Hospital Cancer Centre, Ottawa, Ontario, Canada.,The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Dean Fergusson
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Dominick Bossé
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital, The University of Ottawa and the Ottawa Hospital Cancer Centre, Ottawa, Ontario, Canada
| | - Martin Neil Reaume
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital, The University of Ottawa and the Ottawa Hospital Cancer Centre, Ottawa, Ontario, Canada
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25
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Oyer RA, Hurley P, Boehmer L, Bruinooge SS, Levit K, Barrett N, Benson A, Bernick LA, Byatt L, Charlot M, Crews J, DeLeon K, Fashoyin-Aje L, Garrett-Mayer E, Gralow JR, Green S, Guerra CE, Hamroun L, Hardy CM, Hempstead B, Jeames S, Mann M, Matin K, McCaskill-Stevens W, Merrill J, Nowakowski GS, Patel MI, Pressman A, Ramirez AG, Segura J, Segarra-Vasquez B, Hanley Williams J, Williams JE, Winkfield KM, Yang ES, Zwicker V, Pierce LJ. Increasing Racial and Ethnic Diversity in Cancer Clinical Trials: An American Society of Clinical Oncology and Association of Community Cancer Centers Joint Research Statement. J Clin Oncol 2022; 40:2163-2171. [PMID: 35588469 DOI: 10.1200/jco.22.00754] [Citation(s) in RCA: 70] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
A concerted commitment across research stakeholders is necessary to increase equity, diversity, and inclusion (EDI) and address barriers to cancer clinical trial recruitment and participation. Racial and ethnic diversity among trial participants is key to understanding intrinsic and extrinsic factors that may affect patient response to cancer treatments. This ASCO and Association of Community Cancer Centers (ACCC) Research Statement presents specific recommendations and strategies for the research community to improve EDI in cancer clinical trials. There are six overarching recommendations: (1) clinical trials are an integral component of high-quality cancer care, and every person with cancer should have the opportunity to participate; (2) trial sponsors and investigators should design and implement trials with a focus on reducing barriers and enhancing EDI, and work with sites to conduct trials in ways that increase participation of under-represented populations; (3) trial sponsors, researchers, and sites should form long-standing partnerships with patients, patient advocacy groups, and community leaders and groups; (4) anyone designing or conducting trials should complete recurring education, training, and evaluation to demonstrate and maintain cross-cultural competencies, mitigation of bias, effective communication, and a commitment to achieving EDI; (5) research stakeholders should invest in programs and policies that increase EDI in trials and in the research workforce; and (6) research stakeholders should collect and publish aggregate data on racial and ethnic diversity of trial participants when reporting results of trials, programs, and interventions to increase EDI. The recommendations are intended to serve as a guide for the research community to improve participation rates among people from racial and ethnic minority populations historically under-represented in cancer clinical trials. ASCO and ACCC will work at all levels to advance the recommendations in this publication.
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Affiliation(s)
- Randall A Oyer
- Penn Medicine Lancaster General Health Ann B Barshinger Cancer Institute, Lancaster, PA
| | | | - Leigh Boehmer
- Association of Community Cancer Centers, Rockville, MD
| | | | - Kathryn Levit
- American Society of Clinical Oncology, Alexandria, VA
| | - Nadine Barrett
- Duke Clinical and Translational Science Institute, Raleigh, NC
| | - Al Benson
- Northwestern University, Evanston, IL
| | | | - Leslie Byatt
- University of New Mexico Comprehensive Cancer Center, Albuquerque, NM
| | | | | | - Kyle DeLeon
- American Cancer Society Cancer Action Network, Washington, DC
| | - Lola Fashoyin-Aje
- US Food and Drug Administration Oncology Center of Excellence, Silver Spring, MD
| | | | | | - Sybil Green
- American Society of Clinical Oncology, Alexandria, VA
| | - Carmen E Guerra
- University of Pennsylvania Raymond and Ruth Perelman School of Medicine, Philadelphia, PA
| | - Leila Hamroun
- ChristianaCare Oncology Patient Advocates for Clinical Trials, Newark, DE
| | - Claudia M Hardy
- University of Alabama at Birmingham O'Neal Comprehensive Cancer Center, Birmingham, AL
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Eddy S Yang
- University of Alabama at Birmingham Comprehensive Cancer Center, Birmingham, AL
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26
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Kroll JL, Kim S, Cho D, Weathers SP, Chen AB, Smith G, Bruera E, Milbury K. Financial distress and its associated burden in couples coping with an advanced cancer. Support Care Cancer 2022; 30:4485-4495. [PMID: 35112209 DOI: 10.1007/s00520-021-06758-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 12/13/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE In efforts to understand financial distress (FD) associated with advanced cancer care from the perspective of both patients with incurable disease and their spousal caregivers, we assessed FD in both members of the couple, identified symptom and quality of life (QOL) correlates, and examined the potential role of illness communication. METHODS Patients undergoing treatment for stage III/IV lung cancer or a grade III/IV primary brain tumor and their spousal caregivers (n = 76 dyads) completed measures of somatic and affective symptoms including FD, physical and mental QOL, and ease of engaging in illness communication. Patients and caregivers additionally rated their perception of each other's symptoms, including FD. RESULTS FD was endorsed by both patients (any FD 62.7%; high FD 24%) and spousal caregivers (any FD 64.7%; high FD 32.3%). Self-reported FD was significantly correlated (partial r = .52, p < .001) within couples. FD was associated with greater symptoms of anxiety (r = .29, p = .01; r = .31, p = .01), depression (r = 29, p = 01; r = .39, p = .001), and poorer physical QOL(r = - .25, p = .03; r = - .25, p = .001) for patients and caregivers, respectively. For patients, FD was additionally associated with poorer mental QOL(r = - .44, p < .001). Caregivers accurately perceived patient FD, yet patients tended to underreport their caregiver's FD by almost an entire point (t = 2.8, p = .007). A 3-way interaction (FD X role X illness communication) revealed (b = .40, p = .041) that illness communication moderated the association between FD and physical QOL for spouses so that spouses who reported less ease of illness communication demonstrated a stronger association between financial distress and physical QOL (b = - 2.08, p < .001) than those reporting greater ease of engaging in illness communication (b = .49, p = .508). CONCLUSION In the advanced cancer setting, FD is prevalent in both patients and their spousal caregivers and associated with psychological distress and poor physical QOL. Results suggest that optimal FD assessment should include patients and spouses, and spouse's ease of engaging with illness communication may be a potential target for future intervention studies.
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Affiliation(s)
- Juliet L Kroll
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, 1155 Pressler, Houston, TX, 77005, USA.
| | - Seokhun Kim
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, 1155 Pressler, Houston, TX, 77005, USA
| | - Dalnim Cho
- Department of Health Disparities Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Shiao-Pei Weathers
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Aileen B Chen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Grace Smith
- Department of Health Disparities Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation & Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kathrin Milbury
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, 1155 Pressler, Houston, TX, 77005, USA
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27
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Young MJ, Bodien YG, Edlow BL. Ethical Considerations in Clinical Trials for Disorders of Consciousness. Brain Sci 2022; 12:211. [PMID: 35203974 PMCID: PMC8870384 DOI: 10.3390/brainsci12020211] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 01/28/2022] [Accepted: 01/28/2022] [Indexed: 11/30/2022] Open
Abstract
As the clinical trial landscape for patients with disorders of consciousness (DoC) expands, consideration of associated ethical challenges and opportunities is of ever-increasing importance. Responsible conduct of research in the vulnerable population of persons with DoC, including those with coma, vegetative state/unresponsive wakefulness syndrome (VS/UWS), minimally conscious state (MCS), covert cortical processing (CCP), and cognitive motor dissociation (CMD), demands proactive deliberation of unique ethical issues that may arise and the adoption of robust protections to safeguard patients, surrogates, and other key stakeholders. Here we identify and critically evaluate four central categories of ethical considerations in clinical trials involving participants with DoC: (1) autonomy, respect for persons and informed consent of individuals with liminal consciousness; (2) balancing unknown benefits and risks, especially considering the epistemological gap between behavior and consciousness that complicates ordinary ascription of subjective states; (3) disclosure to surrogates and clinical teams of investigational results pertaining to consciousness; and (4) justice considerations, including equitable access to clinical trial enrollment across communities and geographies. We outline guiding principles and research opportunities for clinicians, neuroethicists, and researchers engaged in DoC clinical trials to advance ethical study design and deployment in this complex yet crucial area of investigation.
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Affiliation(s)
- Michael J. Young
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, MA 02114, USA; (Y.G.B.); (B.L.E.)
| | - Yelena G. Bodien
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, MA 02114, USA; (Y.G.B.); (B.L.E.)
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Charlestown, MA 02114, USA
| | - Brian L. Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, MA 02114, USA; (Y.G.B.); (B.L.E.)
- Athinoula A. Martinos Center for Biomedical Imaging, Harvard Medical School, Massachusetts General Hospital, Charlestown, MA 02114, USA
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28
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Shah K, Zafar SY, Chino F. Role of financial toxicity in perpetuating health disparities. Trends Cancer 2022; 8:266-268. [PMID: 35034866 DOI: 10.1016/j.trecan.2021.12.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 12/14/2021] [Accepted: 12/15/2021] [Indexed: 11/17/2022]
Abstract
Rising costs of cancer care drive patient financial toxicity (FT) that perpetuates known health disparities in access and quality cancer treatment. This Review discusses how FT is a barrier to cancer research and treatment, and discusses potential solutions to improve affordability and reduce healthcare disparities for our patients.
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Affiliation(s)
- Kanan Shah
- New York University Grossman School of Medicine, New York, NY, USA
| | - S Yousuf Zafar
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Fumiko Chino
- Department of Radiation Oncology, Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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29
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Yabroff KR, Shih YCT, Bradley CJ. Treating the Whole Patient With Cancer: The Critical Importance of Understanding and Addressing the Trajectory of Medical Financial Hardship. J Natl Cancer Inst 2022; 114:335-337. [PMID: 34981116 PMCID: PMC8902336 DOI: 10.1093/jnci/djab211] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 11/02/2021] [Indexed: 01/07/2023] Open
Affiliation(s)
- K Robin Yabroff
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA, USA
- Correspondence to: K. Robin Yabroff, PhD, American Cancer Society, 3380 Chastain Meadows Pkwy NW Suite 200, Kennesaw, GA 30144, USA (e-mail: )
| | - Ya-Chen Tina Shih
- Section of Cancer Economics and Policy, Department of Health Services Research, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cathy J Bradley
- Colorado School of Public Health Administration, Department of Health Systems, Management & Policy, University of Colorado Comprehensive Cancer Center, Aurora, CO, USA
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30
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Chow R, Lage DE, Williams GR, Sedrak MS, Greer JA, Temel JS, Nipp RD. Representation and Outcomes of Older Adults in Practice-Changing Oncology Trials in the Era of Novel Therapies: A Guideline Appraisal. J Natl Compr Canc Netw 2022; 20:37-44. [PMID: 34991068 PMCID: PMC9271368 DOI: 10.6004/jnccn.2021.7055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 04/28/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Older adults account for 70% of cancer-related deaths, but previous studies have shown that they are underrepresented in cancer clinical trials. We sought to analyze the representation and outcomes of older adults in trials conducted in the era of novel targeted therapy and immunotherapy. METHODS We searched the 2020 NCCN Clinical Practice Guidelines in Oncology and retrieved trials from the past 10 years leading to category 1 recommendations in the first-line metastatic setting for the 5 most common causes of cancer death. We categorized trials by cancer type, single-agent versus multiagent approach, and therapeutic class. We described the percentage of older adults (according to each trial's definition) and used a Mantel-Haenszel random-effects meta-analysis model to compare overall and progression-free survival by age. RESULTS We identified 30 trials consisting of 24,416 patients. Across all trials, 44% of enrolled patients were older adults. Representation of older adults by cancer type within trials was 49% prostate cancer, 38% pancreatic cancer, 37% breast cancer, and 34% non-small cell lung cancer. Representation of older adults also varied by therapeutic class: 20% received immunotherapy, 44% received cytotoxic chemotherapy, 54% received targeted/hormonal therapy, and 34% received combination therapy (P<.001 for all comparisons). For each year since 2010, the percentage of older adults enrolled in trials increased by 1.9%, although this difference was not significant. We observed no difference in overall or progression-free survival between older and younger adults. In our analysis of practice-changing clinical trials, we found that 44% of clinical trial participants were older adults. Trials that included immunotherapy or a combination of therapeutic classes had a lower representation of older adults (<40%). CONCLUSIONS We found that >40% of patients in practice-changing trials are older adults. Although they remain underrepresented in clinical trials compared with the general population, older adults in practice-changing trials seem to be better represented than in previously reported analyses of cooperative group trials.
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Affiliation(s)
- Ronald Chow
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Daniel E. Lage
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Grant R. Williams
- Division of Hematology and Oncology, Department of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Mina S. Sedrak
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Joseph A. Greer
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jennifer S. Temel
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Ryan D. Nipp
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
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31
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Patel MR, Jagsi R, Resnicow K, Smith SN, Hamel LM, Su C, Griggs JJ, Buchanan D, Isaacson N, Torby M. A Scoping Review of Behavioral Interventions Addressing Medical Financial Hardship. Popul Health Manag 2021; 24:710-721. [PMID: 33989065 PMCID: PMC8713277 DOI: 10.1089/pop.2021.0043] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Minal R. Patel
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
- Rogel Cancer Center, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Reshma Jagsi
- Rogel Cancer Center, Michigan Medicine, Ann Arbor, Michigan, USA
- Department of Radiation Oncology, Michigan Medicine, Ann Arbor, Michigan, USA
- Center for Bioethics and Social Sciences Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Kenneth Resnicow
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
- Rogel Cancer Center, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Shawna N. Smith
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Lauren M. Hamel
- Wayne State University School of Medicine/Karmanos Cancer Institute, Detroit, Michigan, USA
| | - Christopher Su
- Rogel Cancer Center, Michigan Medicine, Ann Arbor, Michigan, USA
- Department of Internal Medicine-Hematology and Oncology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Jennifer J. Griggs
- Rogel Cancer Center, Michigan Medicine, Ann Arbor, Michigan, USA
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
- Department of Internal Medicine-Hematology and Oncology, Michigan Medicine, Ann Arbor, Michigan, USA
- Michigan Oncology Quality Consortium, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Diamond Buchanan
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Nicole Isaacson
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Michelle Torby
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
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Accelerating cancer clinical trial recruitment through a financial reimbursement program integrated with patient navigation: an interrupted time series analysis. J Cancer Policy 2021; 30:100305. [DOI: 10.1016/j.jcpo.2021.100305] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 08/27/2021] [Accepted: 08/31/2021] [Indexed: 11/21/2022]
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Abrams HR, Durbin S, Huang CX, Johnson SF, Nayak RK, Zahner GJ, Peppercorn J. Financial toxicity in cancer care: origins, impact, and solutions. Transl Behav Med 2021; 11:2043-2054. [PMID: 34850932 DOI: 10.1093/tbm/ibab091] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Financial toxicity describes the financial burden and distress that can arise for patients, and their family members, as a result of cancer treatment. It includes direct out-of-pocket costs for treatment and indirect costs such as travel, time, and changes to employment that can increase the burden of cancer. While high costs of cancer care have threatened the sustainability of access to care for decades, it is only in the past 10 years that the term "financial toxicity" has been popularized to recognize that the financial burdens of care can be just as important as the physical toxicities traditionally associated with cancer therapy. The past decade has seen a rapid growth in research identifying the prevalence and impact of financial toxicity. Research is now beginning to focus on innovations in screening and care delivery that can mitigate this risk. There is a need to determine the optimal strategy for clinicians and cancer centers to address costs of care in order to minimize financial toxicity, promote access to high value care, and reduce health disparities. We review the evolution of concerns over costs of cancer care, the impact of financial burdens on patients, methods to screen for financial toxicity, proposed solutions, and priorities for future research to identify and address costs that threaten the health and quality of life for many patients with cancer.
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Affiliation(s)
- Hannah R Abrams
- Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Sienna Durbin
- Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Cher X Huang
- Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | | | - Rahul K Nayak
- Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Greg J Zahner
- Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Jeffrey Peppercorn
- Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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Perez EA, Jaffee EM, Whyte J, Boyce CA, Carpten JD, Lozano G, Williams RM, Winkfield KM, Bernstein D, Poblete S. Analysis of Population Differences in Digital Conversations About Cancer Clinical Trials: Advanced Data Mining and Extraction Study. JMIR Cancer 2021; 7:e25621. [PMID: 34554099 PMCID: PMC8498899 DOI: 10.2196/25621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 06/11/2021] [Accepted: 06/13/2021] [Indexed: 11/27/2022] Open
Abstract
Background Racial and ethnic diversity in clinical trials for cancer treatment is essential for the development of treatments that are effective for all patients and for identifying potential differences in toxicity between different demographics. Mining of social media discussions about clinical trials has been used previously to identify patient barriers to enrollment in clinical trials; however, a comprehensive breakdown of sentiments and barriers by various racial and ethnic groups is lacking. Objective The aim of this study is to use an innovative methodology to analyze web-based conversations about cancer clinical trials and to identify and compare conversation topics, barriers, and sentiments between different racial and ethnic populations. Methods We analyzed 372,283 web-based conversations about cancer clinical trials, of which 179,339 (48.17%) of the discussions had identifiable race information about the individual posting the conversations. Using sophisticated machine learning software and analyses, we were able to identify key sentiments and feelings, topics of interest, and barriers to clinical trials across racial groups. The stage of treatment could also be identified in many of the discussions, allowing for a unique insight into how the sentiments and challenges of patients change throughout the treatment process for each racial group. Results We observed that only 4.01% (372,283/9,284,284) of cancer-related discussions referenced clinical trials. Within these discussions, topics of interest and identified clinical trial barriers discussed by all racial and ethnic groups throughout the treatment process included health care professional interactions, cost of care, fear, anxiety and lack of awareness, risks, treatment experiences, and the clinical trial enrollment process. Health care professional interactions, cost of care, and enrollment processes were notably discussed more frequently in minority populations. Other minor variations in the frequency of discussion topics between ethnic and racial groups throughout the treatment process were identified. Conclusions This study demonstrates the power of digital search technology in health care research. The results are also valuable for identifying the ideal content and timing for the delivery of clinical trial information and resources for different racial and ethnic groups.
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Affiliation(s)
- Edith A Perez
- Division of Hematology and Oncology, Mayo Clinic, Jacksonville, FL, United States
| | - Elizabeth M Jaffee
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, United States
| | | | - Cheryl A Boyce
- Ohio Commission on Minority Health, Columbus, OH, United States
| | - John D Carpten
- Institute of Translational Genomics, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Guillermina Lozano
- Department of Genetics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | | | - Karen M Winkfield
- Meharry-Vanderbilt Alliance, Vanderbilt University Medical Center, Nashville, TN, United States
| | | | - Sung Poblete
- Stand Up To Cancer, Los Angeles, CA, United States
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Deshields TL, Wells-Di Gregorio S, Flowers SR, Irwin KE, Nipp R, Padgett L, Zebrack B. Addressing distress management challenges: Recommendations from the consensus panel of the American Psychosocial Oncology Society and the Association of Oncology Social Work. CA Cancer J Clin 2021; 71:407-436. [PMID: 34028809 DOI: 10.3322/caac.21672] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 03/17/2021] [Accepted: 03/22/2021] [Indexed: 12/11/2022] Open
Abstract
Distress management (DM) (screening and response) is an essential component of cancer care across the treatment trajectory. Effective DM has many benefits, including improving patients' quality of life; reducing distress, anxiety, and depression; contributing to medical cost offsets; and reducing emergency department visits and hospitalizations. Unfortunately, many distressed patients do not receive needed services. There are several multilevel barriers that represent key challenges to DM and affect its implementation. The Consolidated Framework for Implementation Research was used as an organizational structure to outline the barriers and facilitators to implementation of DM, including: 1) individual characteristics (individual patient characteristics with a focus on groups who may face unique barriers to distress screening and linkage to services), 2) intervention (unique aspects of DM intervention, including specific challenges in screening and psychosocial intervention, with recommendations for resolving these challenges), 3) processes for implementation of DM (modality and timing of screening, the challenge of triage for urgent needs, and incorporation of patient-reported outcomes and quality measures), 4) organization-inner setting (the context of the clinic, hospital, or health care system); and 5) organization-outer setting (including reimbursement strategies and health-care policy). Specific recommendations for evidence-based strategies and interventions for each of the domains of the Consolidated Framework for Implementation Research are also included to address barriers and challenges.
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Affiliation(s)
- Teresa L Deshields
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, Illinois
| | - Sharla Wells-Di Gregorio
- Department of Internal Medicine, Division of Palliative Medicine, The Ohio State University Wexner Medical Center, James Cancer Hospital, Columbus, Ohio
| | - Stacy R Flowers
- Department of Family Medicine, Boonshoft School of Medicine, Wright State University, Dayton, Ohio
| | - Kelly E Irwin
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ryan Nipp
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Lynne Padgett
- Department of Psychology, Veterans Affairs Medical Center, Washington, District of Columbia
| | - Brad Zebrack
- School of Social Work, University of Michigan, Ann Arbor, Michigan
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Bharucha AE, Rhodes CT, Boos CM, Keller DA, Dispenzieri A, Oldenburg RP. Increased Utilization of Virtual Visits and Electronic Approaches in Clinical Research During the COVID-19 Pandemic and Thereafter. Mayo Clin Proc 2021; 96:2332-2341. [PMID: 34481597 PMCID: PMC8255101 DOI: 10.1016/j.mayocp.2021.06.022] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/14/2021] [Accepted: 06/28/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To assess the impact of the COVID-19 pandemic on clinical research and the use of electronic approaches to mitigate this impact. METHODS We compared the utilization of electronic consenting, remote visits, and remote monitoring by study monitors in all research studies conducted at Mayo Clinic sites (Arizona, Florida, and Minnesota) before and during the COVID-19 pandemic (ie, between May 1, 2019 and December 31, 2020). Participants are consented through a participant-tracking system linked to the electronic health record. RESULTS Between May 2019, and December 2020, there were 130,800 new consents across every modality (electronic and paper) to participate in a non-trial (107,176 [82%]) or a clinical trial (23,624 [18%]). New consents declined from 5741 in February 2020 to 913 in April 2020 but increased to 11,864 in November 2020. The mean (standard deviation [SD]) proportion of electronic consent increased from 22 (2%) before to 45 (20%) during the pandemic (P=.001). Mean (SD) remote electronic consenting increased from 0.3 (0.5%) to 29 (21%) (P<.001). The mean (SD) number of patients with virtual visits increased from 3.5 (2.4%) to 172 (135%) (P=.003) per month between pre-COVID (July 2019 to February 2020) and post-COVID (March to December 2020) periods. Virtual visits used telemedicine (68%) or video (32%). Requests for remote monitor access to complete visits increased from 44 (17%) per month between May 2019 and February 2020 to 111 (74%) per month between March and December 2020 (P=.10). CONCLUSION After a sharp early decline, the enrollment of new participants and ongoing study visits recovered during the COVID-19 pandemic. This recovery was accompanied by the increased use of electronic tools.
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Affiliation(s)
- Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.
| | - Cathi T Rhodes
- Research Systems Operations, Mayo Clinic, Scottsdale, AZ
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Galsky MD, Balar AV, Black PC, Campbell MT, Dykstra GS, Grivas P, Gupta S, Hoimes CJ, Lopez LP, Meeks JJ, Plimack ER, Rosenberg JE, Shore N, Steinberg GD, Kamat AM. Society for Immunotherapy of Cancer (SITC) clinical practice guideline on immunotherapy for the treatment of urothelial cancer. J Immunother Cancer 2021; 9:e002552. [PMID: 34266883 PMCID: PMC8286774 DOI: 10.1136/jitc-2021-002552] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2021] [Indexed: 12/12/2022] Open
Abstract
A number of immunotherapies have been developed and adopted for the treatment of urothelial cancer (encompassing cancers arising from the bladder, urethra, or renal pelvis). For these immunotherapies to positively impact patient outcomes, optimal selection of agents and treatment scheduling, especially in conjunction with existing treatment paradigms, is paramount. Immunotherapies also warrant specific and unique considerations regarding patient management, emphasizing both the prompt identification and treatment of potential toxicities. In order to address these issues, the Society for Immunotherapy of Cancer (SITC) convened a panel of experts in the field of immunotherapy for urothelial cancer. The expert panel developed this clinical practice guideline (CPG) to inform healthcare professionals on important aspects of immunotherapeutic treatment for urothelial cancer, including diagnostic testing, treatment planning, immune-related adverse events (irAEs), and patient quality of life (QOL) considerations. The evidence- and consensus-based recommendations in this CPG are intended to give guidance to cancer care providers treating patients with urothelial cancer.
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Affiliation(s)
- Matthew D Galsky
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Arjun V Balar
- Perlmutter Cancer Center, New York University Langone Medical Center, New York, New York, USA
| | - Peter C Black
- Department of Urologic Sciences, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Matthew T Campbell
- Department of Genitourinary Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gail S Dykstra
- Bladder Cancer Advocacy Network (BCAN), Bethesda, Maryland, USA
- Dykstra Research, Seattle, Washington, USA
| | - Petros Grivas
- Department of Medicine, Division of Oncology, University of Washington, Seattle, Washington, USA
- Seattle Cancer Care Alliance, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Shilpa Gupta
- Department of Hematology and Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio, USA
| | - Christoper J Hoimes
- Department of Medicine, Duke Cancer Institute, Duke University, Durham, North Carolina, USA
| | - Lidia P Lopez
- Division of Hematology-Oncology, Department of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Joshua J Meeks
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- The Jesse Brown VA Medical Center, Chicago, Illinois, USA
| | - Elizabeth R Plimack
- Department of Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | - Jonathan E Rosenberg
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Deparment of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Neal Shore
- Carolina Urologic Research Center, Myrtle Beach, South Carolina, USA
| | - Gary D Steinberg
- Department of Urology and Perlmutter Cancer Center, NYU Langone Medical Center, New York, New York, USA
| | - Ashish M Kamat
- Department of Urology under Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Huey RW, George GC, Phillips P, White R, Fu S, Janku F, Karp DD, Naing A, Piha-Paul S, Subbiah V, Tsimberidou AM, Pant S, Yap TA, Rodon J, Meric-Bernstam F, Shih YCT, Hong DS. Patient-Reported Out-of-Pocket Costs and Financial Toxicity During Early-Phase Oncology Clinical Trials. Oncologist 2021; 26:588-596. [PMID: 33783054 DOI: 10.1002/onco.13767] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 03/18/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Clinical trials are an important therapeutic option for patients with cancer. Although financial burden in cancer treatment is well documented, the financial burden associated with clinical trials is not well understood. PATIENTS AND METHODS We conducted a survey regarding economic burden and financial toxicity in patients with cancer enrolled in phase I clinical trials for >1 month. Financial toxicity score was assessed using the Comprehensive Score for Financial Toxicity survey. Patients also reported monthly out-of-pocket (OOP) costs. RESULTS Two hundred and thirteen patients completed the survey (72% non-Hispanic White; 45% with annual income ≤$60,000; 50% lived >300 miles from the clinic; 37% required air travel). Forty-eight percent of patients had monthly OOP costs of at least $1,000. Fifty-five percent and 64% of patients reported unanticipated medical and nonmedical expenses, respectively. Worse financial toxicity was associated with yearly household income <$60,000 (odds ratio [OR]: 2.7; p = .008), having unanticipated medical costs (OR: 3.2; p = .024), and living >100 miles away from the clinical trial hospital (OR: 2.3; p = .043). Non-White or Hispanic patients (OR: 2.5; p = .011) and patients who were unemployed or not working outside the home (OR: 2.5; p = .016) were more likely to report high unanticipated medical costs. CONCLUSION Among patients with cancer participating in clinical trials, economic burden is high, and most of patients' OOP costs were nonmedical costs. Financial toxicity is disproportionally higher in patients with lower income and those who travel farther, and unexpected medical costs were more common among non-White or Hispanic patients. OOP costs can be substantial and are often unexpected for patients. IMPLICATIONS FOR PRACTICE The financial burden of cancer treatment is well documented, but there are limited data regarding the financial burden associated with cancer clinical trials. This study surveyed 213 patients enrolled in early-phase clinical trials. Monthly out-of-pocket costs were at least $1000 for nearly half of patients. Worse financial toxicity was associated with income <$60,000 and living farther away from the hospital. Racial/ethnic minorities had higher rates of unanticipated medical costs. These data help to quantify the high financial burden for patients and may reveal a cause of disparities in clinical trial enrollment for underrepresented populations.
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Affiliation(s)
- Ryan W Huey
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Goldy C George
- Department of Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Penny Phillips
- Clinical Center for Targeted Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Revenda White
- Clinical Center for Targeted Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Siqing Fu
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Filip Janku
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Daniel D Karp
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Aung Naing
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sarina Piha-Paul
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Vivek Subbiah
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Apostolia M Tsimberidou
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Shubham Pant
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Timothy A Yap
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jordi Rodon
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Funda Meric-Bernstam
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ya-Chen Tina Shih
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - David S Hong
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Vahl JM, von Witzleben A, Welke C, Doescher J, Theodoraki MN, Brand M, Schuler PJ, Greve J, Hoffmann TK, Laban S. Influence of travel burden on tumor classification and survival of head and neck cancer patients. Eur Arch Otorhinolaryngol 2021; 278:4535-4543. [PMID: 33877433 DOI: 10.1007/s00405-021-06816-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 04/09/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Cancer patients have to overcome various barriers to obtain diagnostics and treatment at head and neck cancer centers. Travel distance to a specialized hospital may result in psychosocial and financial distress, thus interfering with diagnostics, treatment, and follow-up care. In this study, we have aimed to analyze the association of travel distance with cTNM status, UICC stage at primary diagnosis, and survival outcomes of head and neck cancer (HNC) patients. METHODS We have analyzed data of 1921 consecutive HNC patients diagnosed between 2014 and 2019 at the head and neck cancer center of the Comprehensive Cancer Center Ulm (CCCU), Germany. Postal code-based travel distance calculation in kilometers, TNM status, and UICC stage were recorded at initial diagnosis. The assembly of travel distance-related groups (short, intermediate, long-distance) has been investigated. Moreover, group-related survival and recurrence analysis have been performed. RESULTS In contrast to observations from overseas, no association of travel distance and higher cTNM status or UICC stage at primary diagnosis has been observed. Furthermore, no significant differences for recurrence-free survival and overall survival by travel distance were detected. CONCLUSION In southern Germany, travel distance to head and neck cancer centers seems to be tolerable. Travel burden is not synonymous with travel distance alone but also involves sociodemographic, monetary, and disease-specific aspects as well as accessibility to proper infrastructure of transport and health care system.
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Affiliation(s)
- J M Vahl
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Frauensteige 12, 89075, Ulm, Germany.
| | - A von Witzleben
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Frauensteige 12, 89075, Ulm, Germany
| | - C Welke
- Clinical Cancer Registry Comprehensive Cancer Center Ulm, Ulm University Medical Center, 89081, Ulm, Germany
| | - J Doescher
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Frauensteige 12, 89075, Ulm, Germany
| | - M N Theodoraki
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Frauensteige 12, 89075, Ulm, Germany
| | - M Brand
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Frauensteige 12, 89075, Ulm, Germany
| | - P J Schuler
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Frauensteige 12, 89075, Ulm, Germany
| | - J Greve
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Frauensteige 12, 89075, Ulm, Germany
| | - T K Hoffmann
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Frauensteige 12, 89075, Ulm, Germany
| | - S Laban
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Frauensteige 12, 89075, Ulm, Germany
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Ver Hoeve ES, Ali-Akbarian L, Price SN, Lothfi NM, Hamann HA. Patient-reported financial toxicity, quality of life, and health behaviors in insured US cancer survivors. Support Care Cancer 2021; 29:349-358. [PMID: 32361832 PMCID: PMC9208736 DOI: 10.1007/s00520-020-05468-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Accepted: 04/13/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE Fighting cancer is a costly battle, and understanding the relationship between patient-reported financial toxicity (FT) and health outcomes can help inform interventions for post-treatment cancer survivors. METHODS Stages I-III solid tumor, insured US cancer survivors (N = 103) completed a survey addressing FT (as measured by the standardized COST measure) and clinically relevant health outcomes (including health-related quality of life [HRQOL] and adherence to recommended survivorship health behaviors). Univariate and multivariate analyses were used to assess demographic and disease-specific correlates of FT, and to assess the predictive value of FT on HRQOL and adherence to survivorship health behaviors. RESULTS Approximately 18% of respondents noted FT levels associated with significant financial burden. In univariate analyses, after correcting for multiple comparisons, greater FT was associated with unpartnered status, non-retirement, and lower level of educational attainment. Greater FT was also significantly associated with HRQOL components of anxiety, fatigue, pain, physical functioning, and social functioning. FT was not significantly associated with any measured survivorship health behaviors. In multivariate analyses, FT was found to be a meaningful predictor of patient-reported anxiety, fatigue, physical functioning, and social functioning above and beyond theoretically and statistically relevant demographic characteristics. CONCLUSIONS Although overall levels of FT were lower among cancer survivors in this sample, as compared with active treatment patients assessed in previous studies, financial burden continued to be a concern for a significant minority of cancer survivors and was associated with components of reduced HRQOL. Further research is needed to understand FT among underinsured survivors and those treated in community oncology settings. IMPLICATIONS FOR CANCER SURVIVORS Incorporation of FT assessment into survivorship care planning could enhance clinical assessment of survivors' FT vulnerability, help address the dynamic and persistent challenges of survivorship, and help identify those most in need of intervention across the cancer care continuum.
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Affiliation(s)
- Elizabeth S Ver Hoeve
- Department of Psychology, University of Arizona, 1503 E University Blvd., Tucson, AZ, USA.
| | - Leila Ali-Akbarian
- University of Arizona Cancer Center, 3838 N Campbell Ave., Tucson, AZ, USA
| | - Sarah N Price
- Department of Psychology, University of Arizona, 1503 E University Blvd., Tucson, AZ, USA
| | - Nurhyikmah M Lothfi
- Department of Psychology, University of Arizona, 1503 E University Blvd., Tucson, AZ, USA
| | - Heidi A Hamann
- Departments of Psychology and Family and Community Medicine, University of Arizona, 1503 E University Blvd., Tucson, AZ, USA
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Arastu A, Patel A, Mohile SG, Ciminelli J, Kaushik R, Wells M, Culakova E, Lei L, Xu H, Dougherty DW, Mohamed MR, Hill E, Duberstein P, Flannery MA, Kamen CS, Pandya C, Berenberg JL, Aarne V, Liu Y, Loh KP. Assessment of Financial Toxicity Among Older Adults With Advanced Cancer. JAMA Netw Open 2020; 3:e2025810. [PMID: 33284337 PMCID: PMC8184122 DOI: 10.1001/jamanetworkopen.2020.25810] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Importance Financial toxicity (FT), unintended and unanticipated financial burden experienced by cancer patients undergoing cancer care, is associated with negative consequences and increased risk of mortality. Older patients (≥70 years) with cancer are at risk for FT, yet data are limited on FT and whether oncologists discuss FT with their patients. Objective To examine the prevalence of FT in older adults with advanced cancer, its association with health-related quality of life (HRQoL), and cost conversations between oncologists and patients. Design, Setting, and Participants This cross-sectional secondary analysis was performed on baseline data from the Improving Communication in Older Cancer Patients and Their Caregivers study, a cluster randomized trial from 31 community oncology practices across the US that was conducted from October 29, 2014, to April 28, 2017. Participants included 536 patients with advanced cancer who answered 3 questions regarding financial toxicity. Data were analyzed from September 1, 2019, to May 1, 2020. Exposure Older patients undergoing cancer care treatments. Main Outcomes and Measures The main outcome looked at FT and its association with HRQoL. Three questions were used to identify patients 70 years or older experiencing FT. Multivariable linear regression models were used to assess the independent associations of FT with HRQoL. A single audio-recorded clinic transcript was analyzed within 4 weeks of enrollment for patients with FT. The framework method was used to identify frequency and themes related to cost conversations. Results This study evaluated 536 patients 70 years or older with advanced cancer. Ninety-eight patients (18.3%) reported FT; mean (SD) age was 76.4 (5.4) years; 59 (60.2%) were female, 14 (14.3%) were Black/African American, 91 (92.9%) were not employed, and 29 (29.6%) had Medicare as their sole insurance coverage. On multivariate regression analyses, FT was associated with higher levels of depression (β = 0.81; 95% CI, 0.15-1.48), anxiety (β = 1.67; 95% CI, 0.74-2.61), and distress (β = 0.73; 95% CI, 0.08-1.39) and lower HRQoL (β = -5.30; 95% CI, -8.92 to -1.69). Among those who reported FT, 49% had a conversation with their health care professional about costs. Most conversations (79%) were initiated by oncologists or patients. Four themes were generated from cost conversations: statements regarding cost of care, ability to afford medical prescriptions, indirect consequences associated with inability to work and provide for family, and cost burden in nontreatment domains. Conclusions and Relevance In this study, among older adults with advanced cancer, FT is associated with worse HRQoL. Almost half of conversations among patients reporting FT demonstrated costs are being actively discussed. Resources and interventions are needed to manage FT.
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Affiliation(s)
- Asad Arastu
- Department of Medicine, Oregon Health and Science University Hospital, Portland, Oregon, USA
| | - Arpan Patel
- James P Wilmot Cancer Institute, Division of Hematology/Oncology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Supriya Gupta Mohile
- James P Wilmot Cancer Institute, Division of Hematology/Oncology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Joseph Ciminelli
- Department of Biostatistics, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Ramya Kaushik
- University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Megan Wells
- James P Wilmot Cancer Institute, Division of Hematology/Oncology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Eva Culakova
- Department of Surgery, Cancer Control, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Lianlian Lei
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Huiwen Xu
- Department of Surgery, Cancer Control, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | | | - Mostafa R. Mohamed
- James P Wilmot Cancer Institute, Division of Hematology/Oncology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Elaine Hill
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Paul Duberstein
- Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, Piscataway, New Jersey, USA
| | - Marie Anne Flannery
- School of Nursing, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Charles Stewart Kamen
- James P Wilmot Cancer Institute, Division of Hematology/Oncology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Chintan Pandya
- Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Jeffrey L. Berenberg
- Hawaii National Cancer Institute Community Oncology Research Program (MU-NCORP), Honolulu, Hawaii, USA
| | - Valerie Aarne
- James P Wilmot Cancer Institute, Division of Hematology/Oncology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Yang Liu
- Department of Neurosurgery, University of Rochester, Rochester, New York, USA
| | - Kah Poh Loh
- James P Wilmot Cancer Institute, Division of Hematology/Oncology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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Likhitsup A, Parikh ND. Economic Implications of Hepatocellular Carcinoma Surveillance and Treatment: A Guide for Clinicians. PHARMACOECONOMICS 2020; 38:5-24. [PMID: 31573053 DOI: 10.1007/s40273-019-00839-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The incidence of hepatocellular carcinoma (HCC) is increasing worldwide, with significant morbidity and associated costs. Treatment allocation depends on the stage of diagnosis; however, resource utilization can be significant across all stages. We aimed to summarize the available data on the cost effectiveness of surveillance of and treatments for HCC in the context of current treatment guidelines. We performed a focused review of studies investigating the economic burden and cost effectiveness of HCC surveillance treatment modalities published between January 2000 and January 2019. The overall economic burden of HCC is increasing in the USA and in several countries worldwide due to its rising incidence and the proliferation of therapies. Liver transplantation is a cost-effective strategy for early-stage HCC treatment in selected patients. In settings where liver transplantation is not available or in patients awaiting transplant, ablative or locoregional therapies are cost effective with increases in quality-adjusted life-years. First-line therapy with sorafenib for advanced stage HCC is cost effective in the treatment of compensated cirrhosis. The cost effectiveness of recently approved systemic therapies for advanced HCC require further investigation. Existing studies have shown that guideline-recommended surveillance techniques and several available therapies for the treatment of HCC are cost effective; however, there are limitations in the literature, including reliance on suboptimal modeling with incomplete/simplified model structure or inadequate inputs. With increasing therapeutic options in patients with HCC, understanding their relative value is critical in designing HCC treatment algorithms.
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Affiliation(s)
- Alisa Likhitsup
- Division of Gastroenterology and Hepatology, University of Missouri, Kansas City, MO, USA
| | - Neehar D Parikh
- Division of Gastroenterology and Hepatology, University of Michigan, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109, USA.
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Park HSM. Cancer Clinical Trial Enrollment: OK Doc, but What's in It for Me? J Natl Compr Canc Netw 2019; 17:1404-1405. [PMID: 31693990 DOI: 10.6004/jnccn.2019.7365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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