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The financial implications of cancer are significant and affect a significant percentage of the patient population.
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Financial toxicity can lead to morbidity and potentially mortality, in addition to significant quality-of-life decrements.
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The concept of financial toxicity accounts for monetary and consequential health-related effects associated with health care expenditures.
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Solutions to FT include effective patient screening; transparent pricing; and provider commitment to delivering
Financial Toxicity and Cancer Therapy: A Primer for Radiation Oncologists
Section snippets
Key points
Influence of insurance plans on financial toxicity
In the United States, most of the working population is covered through employer-provided health insurance.4 The years before the implementation of the PPACA saw increasingly widespread adoption of the employer-provided health insurance model. Health care expenditures continued to increase steadily from year to year, from consisting of 4.6% of the Gross Domestic Product in 1950% to 16.8% in 2015.5, 6 These rising costs have triggered increasing concerns, as health insurance premiums have risen
Employment
Patients with cancer also experience the risk of temporary and long-term unemployment. A multinational meta-analysis consisting of nonelderly cancer survivors demonstrated this population has a relative risk of 1.37 for unemployment compared with healthy control subjects.17 A separate multinational meta-analysis characterized employment patterns for cancer survivors and found that only 63.5% of cancer survivors ultimately returned to work, at a mean time of 151 days.18 Within this analysis,
Measures of financial toxicity
A systematic review by Gordon and colleagues20 characterized 25 studies involving FT, and demonstrated that the metrics used to measure FT vary dramatically. One commonly used metric was monetary measures (ie, absolute OOP cost compared with income); large population databases, such as Medicare claims, can provide OOP cost for specific services or medications that may predispose a patient to FT. Functional measures (ie, ability to secure a short-term loan) constitute another important way to
Prevalence of financial toxicity
The incidence of financial distress for patients with cancer has been reported as high as 49% from large meta-analyses.20, 24 Narang and Nicholas13 analyzed health and retirement study data for Medicare beneficiaries enrolled in fee-for-service or HMO coverage and identified 1409 participants who were newly diagnosed with cancer during the study period. Yearly mean OOP expenditure was $3737 and at the 90th percentile of expenditure, annual spending was $8048 with financial burden of 29.6% (OOP
Health effects
The financial burden imposed by a cancer diagnosis may have downstream effects that negatively affect care delivery and HRQoL, especially in a population for whom financial difficulties predate their cancer diagnosis. The lack of financial stability presents another barrier to adequate care or preventative care. It has been shown that a preexisting financial burden, compounded by increasing OOP costs, can lead to delaying or completely forgoing recommended care.34 This can have catastrophic
Starting the conversation
The administrative, financial, and treatment aspects of a cancer diagnosis are complex. Patients face many barriers to financial assistance with medical bills, based on citizenship status, socioeconomic status, availability of financial assistance, and complexity and heterogeneity of financial assistance applications.34 Additionally, limited provider and patient knowledge of availability of assistance programs, combined with low referral rates to these programs, all contribute to the high
Actionable solutions
Based on the increased understanding of risk factors that may predispose a patient to FT, it is imperative to identify the optimal time and method to screen patients for preexisting or potential FT. Unfortunately, the optimal timing of screening has not been established, but patients could potentially benefit at multiple points throughout work-up and treatment.50 Ideally, a financial screening instrument should be brief, integrated into routine clinical workflow, and assess financial risk in
Implications for radiation oncology
Within radiation oncology specifically, the progressive increase in hypofractionation holds the greatest promise for reducing FT. There is robust evidence for short-course treatments in common cancers (ie, breast and prostate), and increased diffusion of these regimens into routine practice should not only limit the time patients are not working but also minimize other unappreciated costs, such as child care and transportation costs.54, 55 A recent analysis compared the cost-effectiveness of
Summary
As cancer care continues to evolve and increase in cost, FT represents a real and growing risk for many patients. For oncologists, evidenced-based practice should guide treatment decisions to maximize value, not just to the health care system, but to patients themselves. Clinician awareness and sensitivity are mandatory to mitigate this risk in susceptible patients, and they must recognize that FT influences not just financial decision-making but also quality-of-life and potentially even
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Cited by (16)
Assessing the Prevalence of Financial Toxicity, its Predictors and Association with Health- Related Quality of Life Among Radiation Oncology Patients in India: A Cross-Sectional Patient Reported Outcome Study
2023, International Journal of Radiation Oncology Biology PhysicsPredictors of Financial Toxicity in Patients Receiving Concurrent Radiation Therapy and Chemotherapy
2023, Advances in Radiation OncologyDeterminants of Commercial Prices for Common Radiation Therapy Procedures
2023, International Journal of Radiation Oncology Biology PhysicsCitation Excerpt :However, higher prices may not assure better access or higher quality, and studies have found that for-profit hospitals tend to have increased readmission rates,35,36 worse risk-adjusted mortality,37 and offer fewer patient support services.38 Although little data exist on RT-specific outcomes at for-profit hospitals, their high relative prices may affect access and total costs of cancer care.39 A critique of the recent price transparency legislation is that it focuses the public's attention on the costs of health care while ignoring potentially important differences in the quality of care provided at different institutions.25
Special Considerations in Patients with Early-Stage Breast Cancer and Survivors
2022, Obstetrics and Gynecology Clinics of North AmericaCitation Excerpt :Patients diagnosed with breast cancer are at significant risk of financial toxicity. The overall cost of treatment includes not only surgery, medication, and sometimes radiation therapy but also transportation, family care, and temporary or long-time unemployment.59 In one meta-analysis, only 63.5% of cancer survivors ultimately returned to work.60
Disclosure Statement: The authors have nothing to disclose.