Financial Toxicity and Patient Care

Kate Yeager, PhD, RN

Kate Yeager, PhD, RN

Nurses are experts at assessing and helping manage the adverse effects (AEs) and toxicities of cancer treatment. We know how to assess pain and nausea and offer multiple treatment options. But what about financial toxicity? What is it, how does it affect our patients, and what can nurses do to help?

DISTRESS FROM WORRY OVER FINANCES CAN AFFECT WELL-BEING

New cancer treatments offer hope but often come with a hefty price tag. Cancer treatment costs are rising, insurance co-pays are increasing, and patients are managing higher out-of-pocket (OOP) expenses. One in three American families have healthcare bills they cannot afford and about half of elderly Americans with cancer pay at least 10% of their income on OOP treatment- related expenses.¹ These factors contribute to financial toxicity. Financial toxicity is the distress caused by financial concerns and affects patients’ well-being and quality of care.

In addition to the OOP cost for cancer treatment, cancer patients may face additional costs related to travel, childcare, and lost wages. Travel costs, including gas, parking, lodging, and food, can accumulate if a patient and family members need to travel distances to their treatment center and stay for extended periods. Furthermore, the effect of cancer treatment on employment for both patients and caregivers should be considered when evaluating the cost associated with cancer treatment.

HOW DO PATIENTS COPE?

The strain of financial distress adds to the suffering associated with the cancer experience and may interfere with the patient’s ability to cope effectively with cancer’s physical symptoms and the complexities of treatment.² When income streams are limited, patients may downscale their standard of living and accumulate debt. Individuals may feel it necessary to spend retirement savings, borrow money, or carry a high credit card balance to pay for treatments.

The impact of the high OOP costs of cancer care is illustrated in a study that found 42% of participants reported a significant or catastrophic financial burden, 68% cut back on leisure activities, 46% reduced spending on food and clothing, and 46% used savings to defray expenses. Individuals with a high financial burden compared with those with a low burden were more likely to skip a recommended test, procedure, or an appointment.³

To save money, 20% took less than the prescribed amount of medication, 19% partially filled prescriptions, and 24% avoided filling prescriptions altogether. The impact of financial toxicity has far reaching consequences.

WE NEED TO EDUCATE OURSELVES AND OUR PATIENTS ABOUT THE COST OF CARE

If we identify financial distress as a toxicity of cancer care, we need to consider a patient’s financial health as a routine part of clinical assessment. We must identify patients at greatest risk for high financial burden and offer support. Unfortunately, built-in support systems to assist with financial strain are not standard in oncology settings. Although some settings employ financial counselors or financial navigators, more work is needed to find the best way to meet our patients’ needs.

All healthcare team members need to collaborate to meet the needs of their patients, including assessing and addressing financial distress experienced by the patient.1 We can start by educating ourselves and then educating our patients about the cost of care.

Nurses can work to:

• promote cost transparency
• identify resources for financial assistance
• encourage patient engagement, and
• advocate for improved patient-physician communication about the cost of cancer care

We must recognize how difficult it is for patients with cancer to raise the topic.¹ Some worry about the perception the oncologist has of them if they bring up money; others fear that a discussion of cost will result in inferior treatments. Yet most do want to have this conversation.

Nurses and other providers can allow patients a voice by simply asking “Do you have concerns about the cost of your treatment?” Some questions patients may ask include:²

• I’m worried about how much cancer treatment is going to cost me. Can we talk about it?
• Will my health insurance pay for this treatment? How much will I have to pay myself?
• Does my health insurance company need to preapprove or precertify any part of the treatment before I start?
• If I can’t afford this treatment are there others that might cost less but work as well?
• Is there a way I can get help to pay for this treatment?

Resources are being developed to assist nurses in having the discussion about the value of cancer care. One helpful resource is ChoosingWisely.org, which focuses on promoting conversations between clinicians and patients by helping patients choose care that is supported by evidence, not duplicative of other tests or procedures already received, free from harm, and truly necessary.

The burden of financial toxicity is great and our patients need our help. In addition, the larger topic of the cost of healthcare is also important to address. All stakeholders including the pharmaceutical industry, payers, providers, and patients must continue the discussion of cancer treatment cost to ensure the delivery of high value care. Fortunately for now, nurses are in a great place to help with the latest AE of cancer treatment—financial toxicity.

Kate Yeager, PhD, RN is an assistant professor at the Nell Hodgson Woodruff School of Nursing at Emory University in Atlanta, Georgia.

REFERENCES

• Carrera PM, Kantarjian HM, Blinder VS. The financial burden and distress of patients with cancer: Understanding and stepping-up action on the financial toxicity of
• cancer treatment. CA Cancer J Clin. 2018;68(2):153-165. doi: 10.3322/caac.21443.
• Zafar SY, Newcomer LN, McCarthy J, Fuld Nasso S, Saltz LB. How should we intervene on the financial toxicity of cancer care? One shot, four perspectives.
• Am Soc Clin Oncol Educ Book. 2017;37:35-39. doi: 10.14694/EDBK_174893.
• Zafar SY, Peppercorn JM, Schrag D, et al. The financial toxicity of cancer treatment: A pilot study assessing out-of-pocket expenses and the insured
• cancer patient’s experience. Oncologist. 2013;18(4):381-390. doi: 10.1634/theoncologist.2012-0279.