Strategies to Combat Financial Toxicity Improve Overall Survival Rates in Patients With Hematologic Malignancies

Aggressive screening for financial toxicity and a multidisciplinary intervention for patients with a high financial burden led to improved overall survival (OS) and quality-of-life outcomes for patients with hematologic malignancies, according to findings published in JCO Oncology Practice.¹

The estimated 6-month OS rates were estimated to be 81.4% (95% CI, 68.9%-89.2%) in the interventional cohort (n = 59) and 73.9% (95% CI, 58.7%-84.3%) in the standard care cohort (n = 46). The 12-month estimated OS rates were 73.0% (95% CI, 59.0%-82.9%) and 46.4% (28.9%-63.8%), respectively. In a univariate analysis, the intervention was significantly associated with survival (HR, 0.44; 95% CI, 0.22-0.86; P = .017). After adjusting for race, stem cell transplant history, as well as treatment with oral chemotherapy or immunotherapy, the HR was 0.44 (95% CI, 0.21-0.94; P = .034).

“This study helps to define and characterize [financial toxicity] in treatments of hematologic malignancies,” Thomas Knight, MD, a medical oncologist specializing in hematology at Atrium Health Carolinas, and coinvestigators wrote in the study. “More importantly, these data suggest that screening and intervention is feasible in this population and is associated with improvement in survival and quality of life.”

Financial toxicity is gradually becoming more recognized as a key barrier to cancer care across all tumor types. The term refers to financial issues related to disease burden, much as physical toxicities relate to treatment. Although there is a growing body of research describing the problem, a key focus for investigators should be identifying screening tools and interventions that can be applied in a busy and diverse clinical setting, according to investigators.

This analysis was conducted at Levine Cancer Institute’s leukemia clinic between May 26, 2019, and March 10, 2020. Patients were screened for inclusion via 2 standardized previsit question surveys, the Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 measure and the Comprehensive Score for financial Toxicity (COST). Patients who scored 5 or under were identified as experiencing financial toxicity and flagged for inclusion.

First, investigators identified the degree of financial toxicity. Key stakeholders were identified to assist at several levels of the process, highlighting the need for interdisciplinary team support. Nurse navigators undertook this effort, analyzing demographic data including education level, work history, income, marital status, and family size. Patients were asked questions about delays in care, reasons for delays, and missed medical interventions because of cost.

Pharmacists worked to identify opportunities for cost savings. All medications and co-pays were evaluated by a clinical pharmacist and pharmacy technician. The pharmacy team worked with the prescribing clinician to identify available internal and external grant fundings. They also explored opportunities for more cost-effective treatment strategies if they were unable to decrease medications costs to a manageable level. Cost was calculated into patient-specific dosing decisions.

Social workers evaluated patients to see if they were eligible for any grant funding to assist with co-pays, transportation, or household expenses. If patients qualified, the social worker facilitated the application process and connected them with the funder. Social workers also looked at patient’s insurance status to see if they could help patient obtain appropriate insurance coverage when needed.

Lastly, a financial counselor was used. These were volunteer certified financial planners who worked in the local community and chose to become involved with the project. They were recruited via an email from the Foundation of Financial Planning and given a specific training course on financial planning for patients with cancer. For the purpose of this study, patients met with a counselor for at least 3 visits, however, they were encouraged to pursue a longitudinal relationship and continue to meet as long as needed.

Ultimately, 107 patients were both screened and went through the financial toxicity workflow. Most of these patients had Medicare (40.2%) or private insurance (36.5%), but there were a significant number of patients who had Medicaid (16.8%), self-pay (3.7%), and Veterans Affairs Insurance (2.8%). Most patients (80%) earned less than $60,000 annually. In terms of treatment, 55% (n = 59) had received or were receiving intravenous chemotherapy, 60% (n = 64) had history of oral chemotherapy, 33% (n = 35) immunotherapy, and approximately one-third of patients (n = 41) had undergone hematopoietic stem-cell transplant prior to intervention.

Investigators determined that patients with detectable financial toxicity also had increased rates of medication nonadherence—both with prescription (16.8%) and over-the-counter medications (15.9%). Notably, 17% of patients (n = 18) shared that they missed prescription medications because they could not afford it. Unfortunately, nearly half of patients experiencing financial toxicity reported various coping strategies such as reducing food spending (n = 52) or using savings (n = 55) to cover out-of-pocket expenses. Because of the costs associated with certain cancer therapies, 11% of patients with financial toxicity (n = 5) took a reduced dose of their prescribed medication in an attempt to stretch out their prescriptions.

Primary outcomes were measured by improvements in mental and physical quality of life in all patients as well as improvements in overall survival. Patients who received the financial toxicity intervention not only had improved OS, but also experienced improved quality of life compared with the nonintervention cohort. When measured via the PROMIS analysis changes in physical health scores from baseline were 12.5 ± 2.2 in the interventional cohort vs 13.7 ± 1.8 in the standard care cohort, and the changes in mental health scores from baseline were 11.4 ± 2.2 vs 12.4 ± 2.2, respectively (P < .001).

According to study authors, the Levine Cancer Clinic is fortunate to be a well-established institution with support systems including nurse navigators, clinical pharmacists, and financial counselors to help patients navigate financial options. Unfortunately, these findings suggest that even more specific screenings and interventions may be required at other institutions, where the lack of support systems could make the effects of financial toxicity more profound.

“Although this is not a randomized control trial and causation cannot be reliably ascertained, there appears to be an associated benefit in both quality of life and mortality with this multimodal approach,” study authors concluded. “The quality-of-life improvement was seen in both the mental and physical domains of the PROMIS Global-10 measure, which may indicate both reduction in the stress that financial strain so often brings but also the improved care that comes with the ability to be compliant.”

They added that the improvement in survival may be liked to increased treatment adherence in the intervention cohort, and that these findings reinforce the need for regressive surveillance and intervention on financial toxicity in this patient population.

Reference

Knight TG, Aguiar M, Robinson M, et al. Financial toxicity intervention improves outcomes in patients with hematologic malignancy. JCO Oncol Pract. 2022;18(9):e1494-e1504. doi:10.1200/OP.22.00056