The cost of cancer care is acknowledged to be one of the fastest growing components of US healthcare expenditures and is projected to increase to about $158 billion by 2020. Current trends suggest that patients will shoulder a larger and larger proportion of their own healthcare costs in the future. As a result, if these trends continue, the overall financial burden of healthcare for patients with cancer will inevitably increase. A study done at Harvard University indicates that this is the biggest cause of bankruptcy, representing 62% of all personal bankruptcies. One of the interesting caveats of this study was that 78% of bankruptcy filers had some form of health insurance, thus bucking the myth that medical bills affect only the uninsured.
The term financial toxicity, which was coined by researchers at Duke University and entered the medical lexicon in 2013, refers to the financial distress that accompanies cancer treatment. Financial toxicity can be viewed as an additional unforeseen adverse effect of treatment. This reality is increasingly recognized by healthcare providers and patients and, while generalizable to other therapeutic areas, is especially relevant to diagnosis and treatment in oncology.
In the first study to address financial toxicity, a remarkable 42% of patients with health insurance reported a significant or catastrophic financial burden resulting from their cancer. Individuals with the greatest self-reported subjective burden tended to be younger and from larger households; they were also more likely to have applied for copayment assistance and to have communicated with their physicians about costs of care. Among all patients in this study, numerous coping strategies were adopted to defray out-of-pocket expenses and to make ends meet. These strategies included working longer hours (when possible by the patient) or having family members work longer hours, cutting back on expenditures for leisure activities, reducing spending on necessities like food and clothing, using savings or borrowing money, using credit cards, and selling possessions or property. Both applicants and nonapplicants for copayment assistance were equally likely to adopt some of these strategies.
An especially worrisome finding of this study was that a substantial number of patients chose to ration their own care. Some took less than the recommended amount of medication by partially filling prescriptions, not filling them at all, or attempting to substitute with over-the-counter replacements. Others skipped health or chemotherapy appointments, or declined recommended procedures. These cost-saving maneuvers may result in suboptimal treatment/medication compliance, worse clinical outcomes, and the potential for higher downstream healthcare costs.
Financially toxic costs associated with cancer treatment may be indirect or hidden. For example, rather than increasing work hours, some patients may find it necessary to curtail hours on the job, thereby reducing their salary, or possibly jeopardizing future career advancement and earnings. Others may use up all paid leave for medical appointments and procedures. Patients may incur costs associated with using in-network providers they would not otherwise visit or traveling away from home for care, such as the cost of gas, parking, public transportation, lodging, or meals. Among 480 cancer survivor respondents to a 2014 online survey by the Cancer Support Community, 37% reported “serious” or “very serious” concerns about bankrupting their family.
A 2014 study by Yale University oncologists and nurses specifically assessed the impact of financial toxicity on quality of life among more than 2100 cancer survivors. These providers identified additional sources of financial distress beyond those measured previously, including loss of productivity at work, total loss of employment and the resulting loss of work-related benefits, along with the need for home healthcare, child or elder care associated with treatment appointments, domestic help, special medical equipment/devices (eg, wigs for chemotherapy-related hair loss), and special foods or nutritional supplements. Not surprisingly, the degree to which cancer treatment caused financial problems associated with these and other costs was the strongest independent predictor of quality of life.
Healthcare providers can recognize and begin to address this important issue. Oncologists at the University of Chicago recently developed a patient-reported outcome tool to measure a patient’s risk for financial toxicity during and after cancer treatment. The goal of this 11-part tool, the Comprehensive Score for Financial Toxicity (COST), is to open the lines of communication between providers and patients and facilitate discussion of this subject that is often neglected.
Even today when more Americans than ever have health insurance coverage after implementation of the Affordable Care Act, the high cost of insurance deductibles, copays for medications and office visits, and ancillary costs in aggregate can add up all too quickly, resulting in financial toxicity to patients with cancer. This issue should be of great concern to all stakeholders involved in cancer care.
For More Information
- American Cancer Society. Health Insurance and Financial Assistance for the Cancer Patient. www.cancer.org/treatment/findingandpayingfortreatment/managinginsuranceissues/healthinsuranceandfinancialassistanceforthecancerpatient/health-insurance-and-financial-assistance-living-exp-help. Accessed June 29, 2015.
- Cancer Support Community. Insight into Patient Access to Care in Cancer; March 2015.
de Souza JA, Yap BJ, Hlubocky FJ, et al. The development of a financial toxicity patient-reported outcome in cancer: The COST measure. Cancer. 2014 Oct 15;120(20):3245-3253.
- Fenn KM, Evans SB, McCorkle R, et al. Impact of financial burden of cancer on survivors’ quality of life. J Oncol Pract. 2014 Sep;10(5):332-338.
- Schnipper LE, Davidson NE, Wollins DS, et al. American Society of Clinical Oncology Statement: A conceptual framework to assess the value of cancer treatment options. J Clin Oncol. 2015 Jun 22. pii: JCO.2015.61.6706. [Epub ahead of print]
- 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.
About the Connexion Healthcare Oncology Center of Excellence
Connexion Healthcare’s Oncology Center of Excellence offers executive talent with decades of experience in the pharmaceutical industry. Our medical directors have conducted oncology research at leading institutions and major pharmaceutical companies. Our account leads have years of project execution expertise, and our medical editors are versed in the language of oncology. Our design leads are tops in their fields and ensure that your objectives are met effectively and even surpassed in an industry-eloquent and compliant manner. Our team works with you to conceive a strategy and execute communications through your product’s lifespan – from drug discovery through market launch and beyond. With particular expertise in phase 2 through postlaunch, we will engage with you wherever you are in development and whenever you need us.
For further information regarding the Oncology Center of Excellence at Connexion Healthcare and how we can develop oncology communications to differentiate therapies by their unique attributes, contact:
Larry Lunak, Senior Vice President
Valery Sudakin, PhD
Hematology/Oncology Scientific Services