Financial Toxicity Gaining Momentum Among Patients With Cancer

Cancer affects the physical, emotional, functional, and financial well-being of people fighting for their lives. But oftentimes, the financial aspect is pushed to the back burner—waiting to implode.

Many factors play a role in the financial burden: limited or no health insurance, high copays, work limitations due to illness, and type of treatment—chimeric antigen receptor therapies can run as much as $475,000.

The money strain may result in trouble paying for housing, food, treatment, medications, and other household bills. Patients often use their savings to cover their costs of care. And, unfortunately, debt and even bankruptcy (up to 3% of patients) may become a reality.

In the medical field, this economic hardship is called financial toxicity, or the problems a patient encounters related to the cost of medical care. Similar to other toxicities related to cancer treatment, financial toxicity is directly related to patient’s quality of life and treatment outcomes.

On the frontline to potentially help struggling patients are oncology nurses. During a presentation at the Oncology Nursing Society 43rd Annual Congress held in Washington, DC, Teresa Hagan Thomas, PhD, RN, and Margaret Rosenzweig, PhD, CRNP-C, AOCNP, FAAN, both from the University of Pittsburgh School of Nursing, discussed current trends, risk factors, consequences, interventions, and next directions when it comes to cancer care and financial toxicity in the United States.

“Patients who report financial toxicity are more likely to have low health-related quality of life, be non-adherent to medical treatment (eg, skip doses of medicine, not fill prescriptions, or take less medication), and take on debt related to their costs of care,” Hagan Thomas told Oncology Nursing News. “Nationally, as out-of-pocket expenses increase, insurance relies increasingly on cost-sharing, and prescription drug co-payments increase, patients are responsible for a larger percentage of the ever-increasing costs of cancer care.”

During her presentation, she cited three main historical reasons why financial toxicity is a concern: Americans are paying higher health care expenditures, there has been a shift from community hospitals to academic-based practices, and the cost of cancer drugs are increasing.

Risk factors such as advanced or multiple cancers, comorbidities, younger age, lower income, race, and change in employment may play roles in the financial burden put on patients.

“Estimates vary between about 10-64% of all patients with cancer experience financial toxicity,” she said. “This partly represents difficulties in measuring the objective (eg, costs of care relative to financial resources) and subjective (eg, the distress related to financial concerns) aspects of financial toxicity.”

Thomas discussed clinical barriers that affect finances, such as perceptions of clinicians’ time, embarrassment, efficacy expectations, and financial information relative to treatment decisions.

So, are oncology nurses aware of their patients’ financial situations? And, how equipped are they in assessing financial burden?

Per the presenters, financial toxicity interventions are limited. For instance, Rosenzweig said that financial toxicity needs to be measured in a consistent way, so that healthcare providers know what they are talking about and the literature can build upon on each other.

Current measurement tools include out-of-pocket spending reports, collection of indirect and nonmedical directs costs (COIN), economic impact assessment, comprehensive score for financial toxicity (COST), personal financial wellness scale (PFWS), and single-item screen.

“Several practice guidelines recommend screening for psychological distress in cancer care,” Rosenzweig said. “While evidence is mixed as to the impact on routine screening, we do know that patients will identify their needs for financial assistance.”

The researchers discussed how social workers, patient navigators, and financial counselors can help patients identify copayment assistance programs, alternative insurance plans, and local resources. They may also act as a liaison between providers to streamline care.

Specifically, oncology nurses can explain the difference in care and treatment options to help patients make informed decisions. “Nurses are at the frontline, so knowing which resources are available and promptly referring patients is essential,” Thomas said. “Nurses also provide comfort and understanding to patients experiencing the stress related to financial worry.”

Rosenzweig called for larger scale, well-defined interventions. “We can start to think about research, research-based interventions or perhaps clinically-based interventions,” she said. “We can identify our patients and do an ongoing assessment to determine which patients may need financial counseling. That can go a long way.”

Both agree that nurses can be the best advocates for patients on many fronts. “First, nurses can regularly assess patients level of financial toxicity and refer patients who are worried about their costs of care,” Thomas said. “Second, they can assist the healthcare team in identifying ways to mitigate the costs of care and distress related to financial concerns. Finally, nurses can advocate for improved policies that ensure that all patients have access to high value drugs, treatments, and survivorship care that are not compromised by costs.”

Reference

Hagan T, Rosenzweig M. Non-physical distress of cancer treatment: Financial toxicity. Presented at: Presented at: ONS 43rd Annual Congress; May 17-20, 2018; Washington, DC. https://ons.confex.com/ons/2018/meetingapp.cgi/Session/1578