Financial Toxicity and Cancer Therapy: A Primer for Radiation Oncologists

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Key points

  • The financial implications of cancer are significant and affect a significant percentage of the patient population.

  • Financial toxicity can lead to morbidity and potentially mortality, in addition to significant quality-of-life decrements.

  • The concept of financial toxicity accounts for monetary and consequential health-related effects associated with health care expenditures.

  • Solutions to FT include effective patient screening; transparent pricing; and provider commitment to delivering

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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