Financial Toxicity From Cancer Is a Patient-Facing Problem, MSK’s Chino States

This morning’s in-depth discussion on toxicity in cancer care at the San Antonio Breast Cancer Symposium, taking place December 6-10, encompassed not only the financial reverberations following diagnosis and treatment, but the emotional repercussions as well. It was delivered by Fumiko Chino, MD, assistant attending radiation oncologist at Memorial Sloan Kettering Cancer Center and co-lead of its Affordability Working Group.

“Although we would never start someone on a chemotherapy regimen without warning them of the risk that they may lose their hair or they may have painful neuropathy,” Chino pointed out, “we’re routinely committing our patients to potentially financially toxic regimens without really giving them significant warning about that. Patients get this; they understand that care is unaffordable, because it’s been unaffordable—for themselves, for their family members, for their coworkers, for their loved ones, for their neighbors.”

She underscored this with a startling fact: Slightly more patients worry about the financial impact of their cancer diagnosis (57%) than they do dying from their disease (54%). In addition, according to data from the American Society of Clinical Oncology’s 2018 National Cancer Opinion Survey, caregivers, too, are affected. Sixty-one percent relayed how they or a loved one had to work extra hours (23%) or a second job (13%), postponed their retirement (14%), or took from their savings (35%) just to pay for their cancer care.

“Cancer is messy,” Chino stated.

Advanced disease, quality of life (QOL), financial distress, and lower perceived quality of care are all factors that are interrelated in the cancer space, she continued. Because of advanced disease, patients have a 25% greater risk of reporting financial distress (odds ratio [OR], 1.25; P = .33) and are 19% less likely to report receipt of high-quality care (OR, 0.81; P = .32), her data show. In addition, financial distress influences QOL and care quality perception, which itself also suffers from patients’ decreased QOL.

Comparing outcomes between patients who have no financial burden or a low financial burden with those who have a high financial burden only drives this point home even more, in that there is an overall decreased satisfaction with care in general (coefficient, –0.29; P = .04), as well as the financial aspects (coefficient, –0.62; P < .01) and technical quality (coefficient, –0.26; P = .03) of that care among the latter. She especially emphasized the technical quality of care aspect, noting there is an erosion of trust stemming from cancer-related issues.

“We can erode people’s trust with their diagnosis or their treatment when their costs are too high,” she stated. “We know that there’s an erosion in the quality of care based on affordability.” For example, even though medication nonadherence can immediately compromise the efficacy of patient treatment regimens, patients have been known to not fill a prescription due to its cost, to skip doses to make their medications last longer, and to skip, take less of, or not even fill their chemotherapy prescriptions, Chino highlighted. On the flip side of this is evidence showing that some patients go into debt just to afford their cancer treatment or burn through their savings just to stay adherent.

These financial struggles only grow over time, she said, and are often accompanied by increased personal and family burdens—for example, having to make at least 1 sacrifice, spending less on such basics as food or clothing, or not being able to pay bills—as well as higher risks of bankruptcy and mortality. She cited research that notes a 2.65 times higher risk of bankruptcy with a cancer diagnosis.

“We know that cancer can harm you both now and later. If you are so lucky to survive your cancer diagnosis, we know you are more than 2.5 times likely to have to declare bankruptcy in the context of your cancer diagnosis. Ultimately, this matters,” she illustrated. “Because if you have the ultimate negative financial hardship related to a cancer diagnosis, you can have the ultimate negative everyday outcome—which is death.” Data from 2016 bear this out, showing a 79% higher risk of death (HR, 1.79; 95% CI, 1.64-1.96) stemming from bankruptcy after a cancer diagnosis.

Another disturbing aspect of financial toxicity, she continued, is how it can drive disparities. In what she termed the “winding road to health,” Chino discussed the barriers that continually arise throughout the care cascade, how lack of social support services (eg, adequate housing, transportation, family care, translation services) can affect all of the following:

• Screening
• Making it to a first appointment
• Making it to follow-up appointments
• Treatment adherence
• Maintaining health
• Having access to healthy foods, such as fruits and vegetables

Unfortunately, these disparities extend even further, with Black women being more likely to report a worsened financial situation following a cancer diagnosis that includes health care–related financial and transportation barriers and loss of health insurance. Compared with White patients, this patient population has also been shown to be more likely to be denied insurance and to be hurt financially, she pointed out. In addition, homelessness has become an insidious issue in the cancer space, even among patients with early-stage disease.

“Our cancer treatments are so financially toxic for our patients, that 1 in 20 Black or Latinx women are actually becoming housing instable related to the cost of their care,” Chino said. “So, although you may survive your cancer diagnosis, you are left financially devastated.”

Additional issues inherent among cancer-related disparities that stem from financial toxicity include unequal access to clinical trials because of out-of-pocket costs, insurance-related barriers preventing enrollment, and lower-income patients being less likely to even participate. Younger patients are also more likely to experience a negative event such a losing a job or having to endure a furlough and not even having enough money to pay rent or a mortgage.

Prevention of financial toxicity should be a top priority, and the approach to this is multifactorial, she emphasized: preventing disease before it has a chance to occur, instituting treatment as soon as possible following a diagnosis, and providing assistance for those with ongoing illness. This could potentially involve the following:

• Patient and provider education, such as financial counseling and streamlining the care process
• Improving medical education (2022 data Chino cited included that 87.8% of recent medical school graduates felt their education on cost affordability was marginal)
• Telemedicine
• Screening for financial toxicity early and often
• Screening for financial sacrifice and social determinants of health
• Having those difficult cost conversations (“We’re not having the cost conversations that are really necessary,” she stated)

“I think we have so many resources, we have so much goodwill, we have so much intelligence, we need to really create solutions,” Chino concluded. “The burden is on all of us to fix this issue. We can make care more efficient and affordable. The first step is always to try.”

Reference

Chino F. Financial toxicity. Presented at: SABCS; December 6-10, 2022; San Antonio, TX.