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So far, a lot of the articles we have been discussing here on Oncobites have been revolving around bench research regarding cancer biology and therapeutics. On the public health side of cancer care, there are a lot of emerging fields: one of which investigates the economic burden of cancer care. The cost of cancer care is beginning to be studied in many different aspects, including its effect on individual families, the healthcare system as a whole, and the greater economy. In this post, I will be focusing on the “financial toxicity” of patients with cancer.
The term financial toxicity refers to two things: 1.) the objective expenses related to cancer treatment and related treatments and 2.) the financial distress and hardships encountered by the patient and their family due to these expenses. A review article written by Drs. Carrera, Kantarjian, and Blinder discusses the research concerning financial toxicity for cancer care in the United States. Review articles summarize all the existing research regarding a topic and condense the currently known data into a single article. This specific review discusses strategies for coping with this financial toxicity and the impact of being unable to properly cope with the costs and distress related to cancer care.
The objective financial burden includes the cost of doctor visits, getting the treatment, follow-up care, and hospitalizations due to the cancer. This is a dollar amount that should more or less stay consistent irrespective of wealth and income. The financial distress, however, refers to how these objective costs manifests in the life of a patient with cancer and their family. This distress will be much greater among cancer patients with lower wealth and income. These patients are less likely to have financial reserves that can cushion the financial burden of treatment than wealthier patients. These lower income patients are also the patients who are at higher risk of losing their jobs due to a cancer diagnosis. A study by Blinder and colleagues reported that patients whose annual household income was less than 200% of federal poverty line were four times more likely to lose their job after a breast cancer diagnosis. This may be because lower income workers in the US are more likely to have work environments with less support and accommodations such as no or reduced sick leave available. This leads to a cycle of financial hardship by having the patients who need their jobs the most be at highest risk of losing it.
Zafar and colleagues found that patients engaged in lifestyle-changing strategies once they began cancer treatment. For example, they reduced spending on food and clothing, borrowed money/used credit to pay for their medications, and even altered the way they obtained their medications, shopping around across various pharmacies and asking for samples from their physicians. There is also an emotional burden of being diagnosed with cancer. Once that is coupled with the financial obligations of cost, driving patients into debt and erosion of wealth, it hinders the ability to cope with cancer, adversely affecting health outcomes of these patients. Studies measuring physical and mental health, pain, and other questions asking about patient symptoms have found that those who do not have good financial reserves reported poorer quality of life during their cancer care. According to Lathan and colleagues, patients who reported less financial reserves had a 4-fold decrease in the likelihood of having a good quality of life. Ramsey and colleagues saw that in the state of Washington, patients with cancer had a 2.65 times greater risk of declaring personal bankruptcy than those without cancer. These numbers were much greater depending on the cancer. Lung cancer patients, for example had 3.8 times the risk of declaring personal bankruptcy.
The prices of cancer drugs have been rising dramatically in the last 25 years. Perhaps surprisingly, just because a drug is being marketed as more expensive than another doesn’t mean that it is more effective. A 2015 analysis showed this when examining the survival benefit of 58 different anticancer drugs approved by the FDA between 1995 and 2013. The authors, Howard and colleagues, also showed that launch prices increased by about $8500 on average every year after adjusting for inflation. And doctors are noticing. In 2017, the American Society of Clinical Oncology released a statement raising concern about the increasing prices of oncology specialty drugs coupled with unaffordable co-pays with insurance companies and high out of pocket (OOP) expenses.
Because this topic is being studied more heavily now, there is more knowledge from which we can begin developing solutions. Physicians are uniquely placed in a position of advocating for their patients while also being the demographic advertised to by drug companies. When physicians begin taking note, changes start happening to the drug market, albeit slowly. For example, there were two drugs that Memorial Sloan Kettering Cancer Center in New York was using to treat patients who had advanced stage colorectal cancer. After studies demonstrated that the two drugs were equally effective (ziv-aflibercept or becavizumab) but one was twice as expensive (ziv-aflibercept), the cancer center decided to no longer stock the more expensive drug. They drew public attention to that action and consequently saw the use of that drug drop in half. Some physicians have also began switching patients from oral therapies with high co-pays to IV therapies infused into the blood which had greatly reduced or no co-pays. Another suggestion for alleviating this financial toxicity is by screening for individuals at increased risk and providing information about resources offered through social work to provide supportive care in the management of financial toxicity. While much of this toxicity stems out of systemic imbalances that will take decades more to correct, there are many steps physicians are taking to begin to address this challenge and patients can also raise awareness about it and learn to ask questions about the financial burden of their treatments. The American Cancer Society suggests patients ask:
- Will my health insurance pay for this treatment? How much will I have to pay myself?
- I know this will be expensive. Where can I get an idea of the total cost of the treatment we’ve talked about?
- If I can’t afford this treatment, are there others that might cost less but will work as well?
- Is there any way I can get help to pay for this treatment? Does my health insurance company need to pre-approve or pre-certify any part of the treatment before I start?
Talking about finances is hard. It is especially hard when it feels as if your life is on the line. You cannot put a dollar amount on the value of someone’s life and so to ask questions about costs when your doctor suggests a certain cancer therapy feels not only taboo, but irresponsible. However, as Memorial Sloan Kettering saw with treating the advanced colorectal patients, there are treatment options that are equally effective with different costs. Teasing out these differences could translate to huge financial burden differences, and all involved parties have a right to question these costs to search for the most cost-effective treatment options available for their care.
Primary work discussed:
Carrera PM, Kantarjian HM, Blinder VS. The financial burden and distress of patients with cancer: understanding and stepping-up action on the financial toxicity of cancer treatment. CA Cancer J Clin. 2018;68:153-165.
Other works discussed:
Howard DH, Bach PB, Berndt ER, Conti RM. Pricing in the market for anticancer drugs. NBER Working Paper No. 20867. Cambridge, MA: National Bureau of Economic Research, NBER Program; 2015.
Blinder V, Eberle C, Patil S, Gany F, Bradley CJ. Women with breast cancer who work for accommodating employers more likely than others to retain jobs after treatment. Health Aff (Milwood). 2017;36:274-281.
Zafar SY, Peppercorn JM, Schrag D, et al. The financial toxicity of cancer treatment: a pilot study assessing out-of-pocket expenses and the insured cancer patient’s experience. Oncologist. 2013;18:381-390.
Lathan CS, Cronin A, Tucker-Seeley R, Zafar SY, Ayanian JZ, Schrag D. Association of financial strain with symptom burden and quality of life for patients with lung or colorectal cancer. J Clin Oncol. 2016;34:1732-1740.
Ramsey S, Blough D, Kirchhoff A, et al. Washington state cancer patients found to be at greater risk for bankruptcy than people without a cancer diagnosis. Health Aff (Millwood). 2013;32:1143-1152.
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