Time to add screening for financial hardship as a quality measure?

Reducing financial toxicity in bladder cancer care

PURPOSE OF REVIEW

Financial toxicity is a significant concern for many individuals with bladder cancer, which is, overall, the most expensive malignancy, per patient. Financial toxicity, defined as the harmful effects of treatment costs on an individual's quality of life, is associated with worse outcomes and decreased quality of life. Awareness of the objective and subjective factors that contribute to financial toxicity, and ways to mitigate their effects on patients, is essential to reduce the burden of bladder cancer care. This commentary aims to discuss the elements contributing to financial toxicity amongst bladder cancer patients, identify at-risk populations, and review current and potential strategies for mitigating financial burden.

RECENT FINDINGS

Bladder cancer is becoming more expensive as the use of novel therapies increases. Early data suggest how some of these novel treatments or changes in treatment delivery may impact costs. Potential innovative strategies for cost reduction include blue light cystoscopy, intravesical gemcitabine-docetaxel rather than BCG for high-risk nonmuscle-invasive patients, home BCG therapy, and surveillance guideline optimization. However, there is still much work to be done on the potential impacts of these treatment on financial toxicity. While there is a paucity of data on treatment changes to reduce financial toxicity, and cost data can be hard to access, clinicians can still reduce the financial burden of cancer care. Awareness, financial toxicity screening, cost communication, and/or early referral to financial navigators or other similar resources have the potential to reduce financial burden. Despite mounting evidence, these tools/techniques are largely underutilized.

SUMMARY

Many individuals with bladder cancer face significant financial toxicity, with the potential for this to worsen in the setting of rising treatment costs. Novel diagnostic and treatment modifications may reduce financial toxicity. However, awareness, screening, cost discussions, and utilization of financial navigators are tools/techniques that are currently available and should be used to reduce financial burden.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

IMPLICATIONS FOR PRACTICE

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

Financial Toxicity Screening Preferences in Patients With Breast Cancer

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.

Addressing financial toxicity in cancer treatment-An opportunity for the 340B drug pricing program

Cancer treatment has become increasingly expensive, partially due to the use of specialty drugs. The costs of these drugs are often passed down to patients, who may face the consequences of paying for more than they can afford, leading to financial toxicity. The 340B drug pricing program is a health care policy that may provide an opportunity to mitigate the financial consequences of cancer care. The 340B program requires manufacturers to sell outpatient drugs at a discount to hospitals caring for a significant number of socioeconomically disadvantaged individuals. The program intended for hospitals to use savings from discounted purchases to expand their safety net to vulnerable patients. Some studies have shown that participating hospitals do this by offering more charity and discounted care, whereas others have demonstrated that hospitals fail to sufficiently expand their safety net. A potential flaw of the program is the lack of guidance from governing bodies on how hospitals should use savings from discounted purchases. There has been growing discussion among stakeholders to reform the 340B program given the mixed findings of its effectiveness. With the rising costs of specialty drugs and associated prevalence of financial toxicity in patients with cancer, there is an opportunity to address these issues through reform that improves the program. Directing hospitals to offer specific safety net opportunities, such as passing along discounted drug prices to vulnerable populations, could help the growing number of patients who are financially burdened by medications at the core of the 340B program.

"I Just Had to Do What I Had to Do": Characterizing Direct and Indirect Prostate Cancer Treatment Costs for Black Survivors and Their Caregivers

Introduction. Financial hardship is prevalent among Black prostate cancer survivors and exacerbates health disparities. Characterizing and sharing cost information with patients can facilitate well-informed treatment decision making. Our research explored the direct and indirect costs associated with prostate cancer treatment among Black men and their caregivers. Direct costs included out-of-pocket and insurance-related fees, and indirect costs included the unforeseen costs of care, including patient time, caregiver time, lost wages, and transportation. Methods. We conducted semi-structured interviews with Black prostate cancer survivors and their caregivers to learn about the experience of direct and indirect costs. The interview guide and data analysis were informed by the Measures of Financial Wellbeing framework to gain a better understanding of the material, behavioral, and psychosocial aspects of care-related costs. Guided by a qualitative descriptive approach, we used inductive and deductive coding for our thematic analysis. Results. Eleven prostate cancer survivors with a median age of 68 y (interquartile range [IQR] 62.0-71.5 y) and 11 caregivers with a median age of 64 y (IQR 58.5-70.5 y) participated. We grouped themes into 3 domains and their intersections (i.e., material, behavioral, psychosocial). Participants reported their work and insurance had a significant influence on their finances, treatment costs required rearranging of household budgets, and the weight of indirect costs varied. Ultimately, participants emphasized the significant impact of care costs and the adjustments needed to adapt to them. Discussion. The complexities of material, behavioral, and psychosocial domains of direct and indirect costs of prostate cancer are critical to address when supporting those diagnosed with prostate cancer when making preference-sensitive treatment decisions. The interconnectedness between indirect costs highlights the wide-ranging impact financial well-being has on prostate cancer survivors and caregivers.

Highlights

Direct and indirect costs have a wide-ranging impact on the material, behavioral, and psychosocial aspects of financial well-being of Black prostate cancer survivors and their caregivers.These results emphasize the need for sharing cost information to support medical decision making.Future research should focus on the design of cost-sharing interventions that target the complexities of direct and indirect costs collectively, rather than separately.

Cancer diagnosis and treatment in working-age adults: Implications for employment, health insurance coverage, and financial hardship in the United States

The rising costs of cancer care and subsequent medical financial hardship for cancer survivors and families are well documented in the United States. Less attention has been paid to employment disruptions and loss of household income after a cancer diagnosis and during treatment, potentially resulting in lasting financial hardship, particularly for working-age adults not yet age-eligible for Medicare coverage and their families. In this article, the authors use a composite patient case to illustrate the adverse consequences of cancer diagnosis and treatment for employment, health insurance coverage, household income, and other aspects of financial hardship. They summarize existing research and provide nationally representative estimates of multiple aspects of financial hardship and health insurance coverage, benefit design, and employee benefits, such as paid sick leave, among working-age adults with a history of cancer and compare them with estimates among working-age adults without a history of cancer from the most recently available years of the National Health Interview Survey (2019-2021). Then, the authors identify opportunities for addressing employment and health insurance coverage challenges at multiple levels, including federal, state, and local policies; employers; cancer care delivery organizations; and nonprofit organizations. These efforts, when informed by research to identify best practices, can potentially help mitigate the financial hardship associated with cancer.

Financial Burden of Hepatocellular Carcinoma Screening in Patients With Cirrhosis

BACKGROUND

The overall value of hepatocellular carcinoma screening is defined by the balance of benefits and harms. Studies have only reported physical harms with none describing financial harms.

METHODS

We conducted a multicenter pragmatic randomized clinical trial of hepatocellular carcinoma screening outreach among 2872 patients with cirrhosis from March 2018 to April 2021. Patients with positive or indeterminate results and matched patients with negative results completed surveys at baseline and at follow-up measuring financial harms via Cancer Self-Administered Questionnaire and financial burden via Comprehensive Score for Financial Toxicity Functional Assessment of Chronic Illness Therapy. Univariable and multivariable longitudinal regression analyses were performed to compare changes in financial harms across groups: true positive, true negative, false positive, and indeterminate. Semistructured interviews were conducted in a subset of patients, sampled by center and test result.

RESULTS

Of 311 patients who completed at least 1 follow-up survey (75% response rate), 37 had true positive, 133 true negative, 64 false positive, and 77 indeterminate results. Financial harms increased in true positive and false positive patients with no significant changes noted among those with true negative or indeterminate results. At follow-up, 21.8% of patients reported moderate-severe financial burden, which was not significantly associated with test results. Semistructured interviews revealed variation in the frequency and severity of financial harms based on test results, with increased harm in those with false positive results.

CONCLUSIONS

Financial harms of hepatocellular carcinoma screening vary by test result and can pose a barrier that must be considered when determining the optimal screening program.

Dedicated financial hardship screening adds value to routine distress screening among gynecologic cancer patients

OBJECTIVES

To evaluate existing distress screening to identify patients with financial hardship (FH) compared to dedicated FH screening and assess patient attitudes toward FH screening.

METHODS

We screened gynecologic cancer patients starting a new line of therapy. Existing screening included: (1) Moderate/severe distress defined as Distress Thermometer score ≥ 4, (2) practical concerns identified from Problem Checklist, and (3) a single question assessing trouble paying for medications. FH screening included: (1) Comprehensive Score for Financial Toxicity (COST) tool and (2) 10-item Financial Needs Checklist to guide referrals. FH was defined as COST score < 26. We calculated sensitivity (patients with moderate/severe distress + FH over total patients with FH) and specificity (patients with no/mild distress + no FH over total patients with no FH) to assess the extent distress screening could capture FH. Surveys and exit interviews assessed patient perspectives toward screening.

RESULTS

Of 364 patients screened for distress, average age was 62 years, 25% were Black, 45% were Medicare beneficiaries, 32% had moderate/severe distress, 15% reported ≥1 practical concern, and 0 reported trouble paying for medications. Most (n = 357, 98%) patients also completed FH screening: of them, 24% screened positive for FH, 32% reported ≥1 financial need. Distress screening had 57% sensitivity and 77% specificity for FH. Based on 79 surveys and 43 exit interviews, FH screening was acceptable with feedback to improve the timing and setting of screening.

CONCLUSIONS

Dedicated FH screening was feasible and acceptable, but sensitivity was low. Importantly, 40% of women with FH would not have been identified with distress screening alone.

The Growing Burden of Cancer in Adolescent and Young Adults in Asia: A Call to Action

Recent estimates suggest that the lower middle income countries in Asia carry the heaviest burden of cancer among adolescents and young adults (AYAs) (defined as age 15-39 years). A larger proportion of the population in Asia is aged 15-39 compared with the developed countries. This age group is different from the pediatric or the adult group in terms of physical, social, psychological, and financial needs. Cancer incidence, disability, survivorship needs, financial toxicity, psychosocial issues, and so on are underestimated in this group, and available literature is scarce. Global data show an increasing trend of adult-onset cancers such as colorectal, breast, pancreas, and lung in the AYA population. Data suggest that the disease biology and prognosis are different in this group; however, further research is needed. An ESMO/SIOPE/SIOP Asia survey on the care of AYA cancer patients in Asia found a suboptimal availability of AYA specialized centers in the region and identified several unmet needs including lack of training, clinical trials, and high rates of treatment abandonment. There is an urgent need for cancer care systems in Asia to develop specialized services to be able to cater to this growing burden. Training and research in this area also need to be upscaled with the goal of establishing a sustainable infrastructure and quality services to ensure that this vulnerable group receives appropriate care. Management guidelines and national health policies should consider giving special attention to this group as the World Health Assembly reinforces the inclusion of children and adolescents in cancer control programs.

A Financial Toxicity Screening and Care Coordination Quality Improvement Program in a Gynecology Oncology Urban Practice

Background

Educating a multidisciplinary team on financial toxicity (FT) risk, screening, and care coordination is an approach to addressing gaps in care among newly diagnosed patients with stage III or IV cancer.

Objective

The goal of this quality improvement project (QIP) was to supply an education program for the multidisciplinary team providing insights for the following objectives: (1) Increase the rate of FT screening where there was no baseline screening, (2) Increase referrals for resource care coordination among patients experiencing FT, and (3) Evaluate the relationship between FT and selected demographic identifiers during the 8-week project.

Methods

The Plan-Do-Study-Act (PDSA) model was adopted for learning and leading the change during the QIP, focusing on the COmprehensive Score for financial Toxicity (COST) and resource care coordination for newly diagnosed participants with stage III or IV gynecologic cancer.

Results

Of the 42 (80.75%) participants consenting to the QIP, 61.90% had COST scores below 23, with 100% (26) of the participants receiving referrals for resource care coordination. On average, 6.50 patients enter the practice for care, with 50% (3.25) reporting FT. At this rate, 162.50 patients were experiencing FT in a 50-week year and were not receiving resource care coordination. However, because some patients did not consent to the QIP, the average FT (Yes) count could potentially be between 199.50 to 225.00 patients in a 50-week year, leading to a potential 62.50 with FT (or 28% of 225.00) not receiving referrals. Age was the main driver for FT COST Score in this QIP. Many variables were unobserved in this QIP and could impact the FT COST Score. However, separate modeling reveals that age alone explains approximately 15% of FT COST scores' observed changes. Controlling for more variables may refine the model, but it seems unlikely by the data analysis that age would disappear as a driver of change in the FT COST score.

Conclusion

Developing a multidisciplinary education program focusing on a structured QIP-PDSA plan can be an example of standardizing an FT screening and care coordination program. The QIP team successfully incorporated a PDSA model roadmap screening program to identify the participants experiencing FT and promptly referred 100% for resource care coordination.

Cancer-Related Financial Hardship Screening as Part of Practice Transformation

BACKGROUND

Data on financial hardship, an "adverse event" in individuals with cancer, are needed to inform policy and supportive care interventions and reduce adverse economic outcomes.

METHODS

Lay navigator-led financial hardship screening was piloted among University of Alabama at Birmingham oncology patients initiating treatment in October 2020. Financial hardship screening, including reported financial distress and difficulty, was added to a standard-of-care treatment planning survey. Screening feasibility and completion and proportions of reported financial distress and difficulty were calculated overall and by patient race and rurality. The risk of financial distress by patient sociodemographics was estimated.

RESULTS

Patients who completed a treatment planning survey (N=2741) were 18% Black, Indigenous, or persons of color (BIPOC) and 16% rural dwelling. The majority of patients completed financial hardship screening (90%), surpassing the target feasibility completion rate of 75%. The screening revealed 34% of patients were experiencing financial distress, including 49% of BIPOC and 30% of White patients. Adjusted models revealed BIPOC patients had a 48% higher risk of financial distress compared with those who were White (risk ratio 1.48, 95% CI, 1.31-1.66). Large differences in reported financial difficulties were seen comparing patients who were BIPOC and White (utilities: 33% vs. 10%, upfront medical payments: 44% vs. 23%, transportation: 28% vs. 12%, respectively).

CONCLUSIONS

The collection of patient-reported financial hardship data via routine clinical care was feasible and identified racial inequities at treatment initiation. Efforts to collect patient economic data should support the design, implementation, and evaluation of patient-centered interventions to improve equity and reduce the impact of financial hardship.

Financial Toxicity Monitoring in a Randomized Controlled Trial of Patient-Reported Outcomes During Cancer Treatment (Alliance AFT-39)

PURPOSE

Financial toxicity (FT) affects 20% of cancer survivors and is associated with poor clinical outcomes. No large-scale programs have been implemented to mitigate FT. We evaluated the effect of monthly FT screening as part of a larger patient-reported outcomes (PROs) digital monitoring intervention.

METHODS

PRO-TECT (AFT-39) is a cluster-randomized trial of patients undergoing systemic therapy for metastatic cancer. Practices were randomly assigned 1:1 to digital symptom monitoring (PRO practices) or usual care (control practices). Digital monitoring consisted of between-visit online or automated telephone patient surveys about symptoms, functioning, and FT (single-item screening question from Functional Assessment of Chronic Illness Therapy-COmprehensive Score for financial Toxicity) for up to 1 year, with automated alerts sent to practice nurses for concerning survey scores. Clinical team actions in response to alerts were not mandated. The primary outcome of this planned secondary analysis was development or worsening of financial difficulties, assessed via the European Organisation for Research and Treatment of Cancer QLQ-C30 financial difficulties measure, at any time compared with baseline. A randomly selected subset of patients and nurses were interviewed about their experiences with the intervention.

RESULTS

One thousand one hundred ninety-one patients were enrolled (593 PRO; 598 control) at 52 US community oncology practices. Overall, 30.2% of patients treated at practices that received the FT screening intervention developed, or experienced worsening of, financial difficulties, compared with 39.0% treated at control practices (P = .004). Patients and nurses interviewed stated that FT screening identified patients for financial counseling who otherwise would be reluctant to seek, or unaware of the availability of, assistance.

CONCLUSION

In this report of a secondary outcome from a randomized clinical trial, FT screening as part of routine digital patient monitoring with PROs reduced the development, or worsening, of financial difficulties among patients undergoing systemic cancer therapy.

Anticipatory Guidance: Developing a Patient Navigation Pathway to Reduce the Financial Toxicity of Cancer

Background

Healthcare providers have an influential role in the experience of financial toxicity among their cancer patients, yet patients commonly report unmet needs and dissatisfaction regarding communication with their providers about financial concerns.

Aims

The purpose of this study is to develop a novel financial navigation pathway that leverages existing patient financial services and resources with corresponding patient-centered, community-informed strategies, via study participants, that may be utilized in routine care to reduce financial hardship among cancer patients.

Methods

We conducted in-depth interviews (n=50) with 34 cancer patients and 16 cancer care professionals at a National Cancer Institute designated comprehensive cancer center located in a dense urban area of the US between December2022 to June 2023.

Results

Content analyses resulted in emergent themes and representative quotations on experiences of financial hardship within the material, behavioral, and psychosocial domains. Investigators used emergent themes to develop financial strategies and construct a financial navigation pathway to screen patients for and intervene upon the financial toxicity of cancer in routine care.

Conclusion

This study followed an innovative approach by constructing a financial navigation pathway tool that follows the oncological workflow at a National Cancer Institute designated comprehensive cancer center. Future research is needed to test the tool's impact on financial toxicity, cancer outcomes, and other health-related outcomes, and to better understand how much patient navigation is needed to bring about meaningful change.

Financial toxicity in cancer patients and subsequent risk of repeat acute care utilization

Background

Acute care (AC) visits by cancer patients are costly sources of healthcare resources and can exert a financial burden of oncology care both for individuals with cancer and healthcare systems. We sought to identify whether cancer patients who reported more severe initial financial toxicity (FT) burdens shouldered excess risks for acute care utilization.

Methods

In 225 adult patients who participated in the Economic Strain and Resilience in Cancer (ENRICh) survey study of individuals receiving ambulatory cancer care between March and September 2019, we measured the baseline FT (a multidimensional score of 0-10 indicating the least to most severe global, material, and coping FT burdens). All AC visits, including emergency department (ED) and unplanned hospital admissions, within 1-year follow-up were identified. The association between the severity of FT and the total number of AC visits was tested using Poisson regression models.

Results

A total of 18.6% (n = 42) of patients had any AC visit, comprising 64.3% hospital admissions and 35.7% ED visits. Global FT burden was associated with the risk of repeat AC visits within 1-year follow-up (RR = 1.17, 95% CI 1.07-1.29, P < 0.001 for every unit increase), even after adjusting for sociodemographic and disease covariates. When examining subdimensions of FT, the burden of depleted FT coping resources (coping FT) was strongly associated with the risk of repeat AC visits (RR = 1.27, 95% CI 1.15-1.40, P < 0.001) while material FT burden showed a trend toward association (RR = 1.07, 95% CI 0.99-1.15, P = 0.07).

Conclusion

In this prospective study of acute oncology care utilization outcomes among adult cancer patients, FT was a predictor of a higher burden of acute care visits. Patients with severely depleted material and also practical and social coping resources were at particular risk for repeated visits. Future studies are needed to identify whether early FT screening and intervention efforts may help to mitigate urgent acute care utilization burdens.

The impact of government reimbursement negotiation on targeted anticancer medicines use and cost in China: A cohort study based on national health insurance data

Background

High prices of targeted anticancer medicines (TAMs) result in financial toxicity for patients and the health insurance system. How national price negotiation and reimbursement policy affect the accessibility of TAMs for cancer patients remains unknown.

Methods

In this population-based cohort study, we used national health insurance claims data in 2017 and identified adult patients with cancer diagnoses for which price-negotiated TAMs were indicated. We estimated the half-month prevalence of price-negotiated TAMs use before and after the policy implementation in September 2017. We calculated direct medical costs, out-of-pocket (OOP) costs, and the proportion of OOP cost for each cancer patient to measure their financial burden attributable to TAMs use. We performed segmented linear and multivariable logistic regression to analyse the policy impact.

Results

We included 39 391 of a total 118 655 cancer beneficiaries. After September 2017, the prevalence of price-negotiated TAMs use increased from 1.4%-2.1% to 2.9%-3.1% (P = 0.005); TAMs users' daily medical costs increased from US$261.3 to US$292.5 (P < 0.001), while median daily OOP costs (US$68.2 vs US$65.7; P = 0.134) and OOP costs as a proportion of daily medical costs persisted (28.5% vs 28.5%; P = 0.995). Compared with resident beneficiaries, the relative probability of urban employee beneficiaries on TAMs uses decreased after the policy (adjusted odds ratio (aOR) = 2.4 vs aOR = 2.2).

Conclusions

The government price negotiation and reimbursement policy improved patient access to TAMs and narrowed disparities among insurance schemes. China's approach to promoting the affordability of expensive medicines provides valuable experience for health policy decision-makers.

Knowledge, Attitudes, and Resources of Frontline Oncology Support Personnel Regarding Financial Burden in Patients With Cancer

PURPOSE

Financial navigation services support patients with cancer and address the direct and indirect financial burden of cancer diagnosis and treatment. These services are commonly delivered through a variety of frontline oncology support personnel (FOSP) including navigators, social workers, supportive care providers, and other clinic staff, but the perspective of FOSPs is largely absent from current literature on financial burden in oncology. We surveyed a national sample of FOSPs to understand their perspectives on patient financial burden, resource availability, and barriers and facilitators to assisting patients with cancer-related financial burden.

METHODS

We used Qualtrics online survey software and recruited participants using multiple professional society and interest group mailing lists. Categorical responses were described using frequencies, distributions of numeric survey responses were described using the median and IQR, and two open-ended survey questions were categorized thematically using a priori themes, allowing additional emergent themes.

RESULTS

Two hundred fourteen FOSPs completed this national survey. Respondents reported a high awareness of patient financial burden and felt comfortable speaking to patients about financial concerns. Patient assistance resources were commonly available, but only 15% described resources as sufficient for the observed needs. A substantial portion of respondents reported moral distress related to this lack of resources.

CONCLUSION

FOSPs, who already have requisite knowledge and comfort in discussing patient financial needs, are a critical resource for mitigating cancer-related financial burden. Interventions should leverage this resource but prioritize transparency and efficiency to reduce the administrative and emotional toll on the FOSP workforce and reduce the risk of burnout.

Financial toxicity among adolescent and young adult cancer survivors: A systematic review of educational attainment, employment, and income

PURPOSE

To identify, evaluate and summarize the evidence on educational attainment, employment status and income of AYAs surviving cancer.

METHODS

A search of six databases for articles published between 01/01/2010 and 03/31/2022 was performed. Articles with an AYA survivorship population, quantitative design and a cancer-free comparator group were included. Data extraction was conducted, and quality appraisal was completed using ROBINS-I. Results were summarized using a narrative synthesis.

RESULTS

A total of 2801 articles were identified, of which 12 were included. Among the limited evidence, educational attainment did not differ from cancer-free peers. Survivors were more likely to be unemployed, have lower incomes and require social security for income supplementation. Evidence suggested that females, diagnosis of brain cancer and the presence of late-effects were among the risk factors for severe outcomes.

CONCLUSIONS

Limited socioeconomic evidence exists for AYAs surviving cancer. Long-lasting financial toxicities occur and highlights a need for further investigation.

Financial Hardship in Adult Survivors of Childhood Cancer in the Era After Implementation of the Affordable Care Act: A Report From the Childhood Cancer Survivor Study

PURPOSE

To estimate the prevalence of financial hardship among adult survivors of childhood cancer compared with siblings and identify sociodemographic, cancer diagnosis, and treatment correlates of hardship among survivors in the era after implementation of the Affordable Care Act.

METHODS

A total of 3,555 long-term (≥ 5 years) survivors of childhood cancer and 956 siblings who completed a survey administered in 2017-2019 were identified from the Childhood Cancer Survivor Study. Financial hardship was measured by 21 survey items derived from US national surveys that had been previously cognitively tested and fielded. Principal component analysis (PCA) identified domains of hardship. Multiple linear regression examined the association of standardized domain scores (ie, scores divided by standard deviation) with cancer and treatment history and sociodemographic characteristics among survivors.

RESULTS

Survivors were more likely than siblings to report hardship in ≥ 1 item (63.4% v 53.7%, P < .001). They were more likely to report being sent to debt collection (29.9% v 22.3%), problems paying medical bills (20.7% v 12.8%), foregoing needed medical care (14.1% v 7.8%), and worry/stress about paying their rent/mortgage (33.6% v 23.2%) or having enough money to buy nutritious meals (26.8% v 15.5%); all P < .001. Survivors reported greater hardship than siblings in all three domains identified by principal component analysis: behavioral hardship (mean standardized domain score 0.51 v 0.35), material hardship/financial sacrifices (0.64 v 0.46), and psychological hardship (0.69 v 0.44), all P < .001. Sociodemographic (eg,

CONCLUSION

Survivors of childhood cancer were more likely to experience financial hardship than siblings. Correlates of hardship can inform survivorship care guidelines and intervention strategies.

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Key Words Collapse

MESH Headings

• United States
• Adult
• Humans
• Child
• Neoplasms/therapy
• Cancer Survivors
• Patient Protection and Affordable Care Act
• Financial Stress
• Cost of Illness
• Survivors
• Surveys and Questionnaires

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Grants

• U24 CA055727 NCI NIH HHS

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Affiliation(s)

Paul C. Nathan The Hospital for Sick Children, Division of Hematology/Oncology, The University of Toronto, Toronto, Ontario, Canada
I-Chan Huang St Jude Children's Research Hospital, Department of Epidemiology & Cancer Control, Memphis, TN
Yan Chen University of Alberta, Edmonton, School of Public Health Alberta, Edmonton, Alberta, Canada
Tara O. Henderson University of Chicago Comer Children's Hospital, Section of Pediatric Hematology, Oncology and Stem Cell Transplantation, Chicago, IL
Elyse R. Park Massachusetts General Hospital Cancer Center, Boston, MA
Anne C. Kirchhoff Huntsman Cancer Institute, Cancer Control and Population Sciences, University of Utah, Salt Lake City, UT
Leslie L. Robison St Jude Children's Research Hospital, Department of Epidemiology & Cancer Control, Memphis, TN
Kevin Krull St Jude Children's Research Hospital, Department of Epidemiology & Cancer Control, Memphis, TN
Wendy Leisenring Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA
Gregory T. Armstrong St Jude Children's Research Hospital, Department of Epidemiology & Cancer Control, Memphis, TN
Rena M. Conti Department of Markets, Public Policy and Law, Questrom School of Business, Boston University, Boston, MA
Yutaka Yasui St Jude Children's Research Hospital, Department of Epidemiology & Cancer Control, Memphis, TN
K. Robin Yabroff Surveillance and Health Equity Science Department, American Cancer Society, Atlanta, GA

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Out-of-Pocket Expenditures for Imaging Examinations: Perspectives From National Patient Surveys Over Two Decades

PURPOSE

Using national surveys, we longitudinally studied imaging costs-and specifically those paid out-of-pocket (OOP) by patients-over two decades.

METHODS

Using 2000 to 2019 Medical Expenditure Panel Survey data, we identified all imaging-focused encounters (mammography, radiography, ultrasonography, and CT and MR [surveyed together in Medical Expenditure Panel Survey]) and calculated mean overall and OOP encounter costs. Effects of sociodemographic, personal, and clinical factors were measured using logistic regression and generalized linear modeling.

RESULTS

We identified 102,717 patients (mean 45.6 years; 64.8% female; 58.8% White) undergoing 229,010 imaging-focused encounters. Between 2000 and 2019, mean costs of mammography, radiography, and ultrasonography increased 14.5%, 24.5%, and 40% and total mean cost of CT or MR decreased by 15.1%. OOP costs were incurred by 51%. Overall mean OOP costs increased 89.8% from 2000 to 2019. Mean OOP costs for mammography decreased by 32.9%; mean OOP costs for radiography, ultrasonography, and CT or MR increased 81%, 123.2%, and 61%, respectively. Patients were less likely to incur OOP costs when older, of racial and ethnic minorities, female, or recipients of public only (versus private) insurance. Among those with OOP costs, the presence of comorbidities, lack of insurance, younger age, and history of cancer significantly increased OOP costs.

CONCLUSION

Mean overall patient OOP costs for imaging examinations increased significantly and substantially over the last two decades. Lack of insurance, younger age, history of cancer, and other comorbidities were associated with higher OOP costs. As diagnostic imaging utilization increases, patient financial hardship considerations merit further attention.

The Validation of the COmprehensive Score for Financial Toxicity (COST) Scale in Greek Language

The aim of this study was to investigate the psychometric properties of the Greek version of FACIT-COST, as well as to assess the levels of financial distress of patients suffering from lung cancer in relation to their quality of life and lung cancer symptom burden. This was a cross-sectional quantitative study. A self-assessment instrument was used to gather the data. The study involved 120 lung cancer patients who were treated using chemotherapy in a day clinic of a General Hospital in Athens. Data were collected with the COST-FACIT-v2 (used to assess the patients' financial toxicity), The 12-item Health Survey (SF-12), and functional Assessment of Cancer Therapy-Lung Symptom Index Questionnaire-7 items-version 4 (FACIT-FACT-LCS). Descriptive statistics as well as exploratory factor analysis performed all the statistical analyses, which were conducted using IBM SPSS Statistics 25 and had p-values with a significance level of 0.05. The majority of the participants were male (68.3%), married or cohabitated (81.3%), and had been diagnosed with microcell cancer (90%). The factor analysis resulted in one factor that interpreted 35% of the total variance. FACT-L (r = 0.365, p < 0.001), physical component SF-12 (r = 0.184, p = 0.045), and mental health component SF-12 (r = 0.268, p = 0.003) were positively correlated to FACIT-OST, as expected. The Greek validated COST-FACIT-v2 is a reliable tool in providing rapid assessment of cancer patients' level of financial distress.

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

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

Policies and Practices to Address Cancer's Long-Term Adverse Consequences

As cancer detection and treatment improve, the number of long-term survivors will continue to grow, as will the need to improve their survivorship experience and health outcomes. We need to better understand cancer and its treatment's short- and long-term adverse consequences and to prevent, detect, and treat these consequences effectively. Delivering care through a collaborative care model; standardizing information offered to and collected from patients; standardizing approaches to documenting, treating, and reducing adverse effects; and creating a data infrastructure to make population-based information widely available are all actions that can improve survivors' outcomes. National policies that address gaps in insurance coverage, the cost and value of treatment and survivorship care, and worker benefits such as paid sick leave can also concurrently reduce cancer burden. The National Cancer Policy Forum and the Forum on Aging, Disability, and Independence at the National Academies of Sciences, Engineering, and Medicine sponsored a virtual workshop on "Addressing the Adverse Consequences of Cancer Treatment," November 9-10, 2020, to examine long-term adverse consequences of cancer treatment and to identify practices and policies to reduce treatment's negative impact on survivors. This commentary discusses high-priority issues raised during the workshop and offers a path forward.

Financial toxicity impact on younger versus older adults with cancer in the setting of care delivery

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.

Patient-reported benefit from proposed interventions to reduce financial toxicity during cancer treatment

INTRODUCTION

Financial toxicity is common and pervasive among cancer patients. Research suggests that gynecologic cancer patients experiencing financial toxicity are at increased risk for engaging in harmful cost-coping strategies, including delaying/skipping treatment because of costs, or forsaking basic needs to pay medical bills. However, little is known about patients' preferences for interventions to address financial toxicity.

METHODS

Cross-sectional surveys to assess financial toxicity [Comprehensive Score for Financial Toxicity (COST)], cost-coping strategies, and preferences for intervention were conducted in a gynecologic cancer clinic waiting room. Associations with cost-coping were determined using multivariate modeling. Unadjusted odds ratios (ORs) explored associations between financial toxicity and intervention preferences.

RESULTS

Among 89 respondents, median COST score was 31.9 (IQR: 21-38); 35% (N = 30) scored < 26, indicating they were experiencing financial toxicity. Financial toxicity was significantly associated with cost-coping (adjusted OR = 3.32 95% CI: 1.08, 14.34). Intervention preferences included access to transportation vouchers (38%), understanding treatment costs up-front (35%), minimizing wait times (33%), access to free food at appointments (25%), and assistance with minimizing/eliminating insurance deductibles (23%). In unadjusted analyses, respondents experiencing financial toxicity were more likely to select transportation assistance (OR = 2.67, 95% CI: 1.04, 6.90), assistance with co-pays (OR = 9.17, 95% CI: 2.60, 32.26), and assistance with deductibles (OR = 12.20, 95% CI: 3.47, 43.48), than respondents not experiencing financial toxicity.

CONCLUSIONS

Our findings confirm the presence of financial toxicity in gynecologic cancer patients, describe how patients attempt to cope with financial hardship, and provide insight into patients' needs for targeted interventions to mitigate the harm of financial toxicity.

Role of financial toxicity in perpetuating health disparities

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.

Strategies to Mitigate Chemotherapy and Radiation Toxicities That Affect Eating

Background: Cancer and its therapy is commonly associated with a variety of side effects that impact eating behaviors that reduce nutritional intake. This review will outline potential causes of chemotherapy and radiation damage as well as approaches for the amelioration of the side effects of cancer during therapy. Methods: Information for clinicians, patients, and their caregivers about toxicity mitigation including nausea reduction, damage to epithelial structures such as skin and mucosa, organ toxicity, and education is reviewed. Results: How to anticipate, reduce, and prevent some toxicities encountered during chemotherapy and radiation is detailed with the goal to improve eating behaviors. Strategies for health care professionals, caregivers, and patients to consider include (a) the reduction in nausea and vomiting, (b) decreasing damage to the mucosa, (c) avoiding a catabolic state and muscle wasting (sarcopenia), and (d) developing therapeutic alliances with patients, caregivers, and oncologists. Conclusions: Although the reduction of side effects involves anticipatory guidance and proactive team effort (e.g., forward observation, electronic interactions, patient reported outcomes), toxicity reduction can be satisfying for not only the patient, but everyone involved in cancer care.

Medical Financial Hardship in Survivors of Adolescent and Young Adult Cancer in the United States

BACKGROUND

Cancer and its treatment can result in lifelong medical financial hardship, which we aimed to describe among adult survivors of adolescent and young adult (AYA) cancers in the United States.

METHODS

We identified adult (aged ≥18 years) survivors of AYA cancers (diagnosed ages 15-39 years) and adults without a cancer history from the 2010-2018 National Health Interview Surveys. Proportions of respondents reporting measures in different hardship domains (material [eg, problems paying bills], psychological [eg, distress], and behavioral [eg, forgoing care due to cost]) were compared between groups using multivariable logistic regression models and hardship intensity (cooccurrence of hardship domains) using ordinal logistic regression. Cost-related changes in prescription medication use were assessed separately.

RESULTS

A total of 2588 AYA cancer survivors (median = 31 [interquartile range = 26-35] years at diagnosis; 75.0% more than 6 years and 50.0% more than 16 years since diagnosis) and 256 964 adults without a cancer history were identified. Survivors were more likely to report at least 1 hardship measure in material (36.7% vs 27.7%, P < .001) and behavioral (28.4% vs 21.2%, P < .001) domains, hardship in all 3 domains (13.1% vs 8.7%, P < .001), and at least 1 cost-related prescription medication nonadherence (13.7% vs 10.3%, P = .001) behavior.

CONCLUSIONS

Adult survivors of AYA cancers are more likely to experience medical financial hardship across multiple domains compared with adults without a cancer history. Health-care providers must recognize this inequity and its impact on survivors' health, and multifaceted interventions are necessary to address underlying causes.