Even with health insurance, almost 3 out of 4 patients have metastases Colon cancer (mCRC) are experiencing great financial hardship one year after their diagnosis, according to new findings.
At 12 months, 71.5% of patients reported major financial difficulties, with debt being the most common cause, which gradually increased over time.
“Financial hardship, or toxicity, is a recognized complication of cancer diagnosis and treatment today, resulting from the high direct medical costs, non-medical costs, and indirect costs that uniquely affect cancer patients,” said lead author Veena Shankaran, MD, co-director of the Hutchinson Institute for Cancer Outcomes at the Fred Hutchinson Cancer Research Center, Seattle, Washington.
She presented the results of the new study at the ASCO Quality Care Symposium 2020, which took place virtually due to the pandemic.
The phrase “financial toxicity” was there originally coined in 2013 by a team at the Duke Cancer Institute to describe the “adverse event” of self-expense that negatively impacts patient lives.
More recently, the financial hardship has been further broken down into three parts, commented Shankaran. There are essential aspects like debt, default and bankruptcy; psychological aspects such as fear or concern about finances; and the behavioral issues, such as non-compliance with treatment or skipping and delaying treatment for reasons of cost.
“Despite our increasing recognition of the financial burden of cancer, there are gaps in our understanding of this problem,” she commented. “Earlier studies in particular have measured the financial impact largely retrospectively using questionnaires or single financial measures such as debt or bankruptcy.”
She also found that few studies have recorded and measured the financial impact on both patients and caregivers at the same time. That’s what she and her team did by evaluating the time to the first sign of significant financial distress in 368 patients with mCRC who were within 120 days of their initial diagnosis. Patients either had to start therapy within 60 days of study enrollment or should begin treatment within 30 days of study enrollment.
The primary objective was to estimate the cumulative incidence of self-reported serious financial difficulties 12 months after a patient was diagnosed and treated. Serious financial distress has been defined as one or more of the following situations: new debt, home sale or refinancing due to cost issues, income drop by 20% or more, or borrowing and borrowing to pay for cancer treatment. At least one credit report was obtained from over 90% of the patients in order to establish a correlation with the self-reported data.
Secondary objectives included risk factors for major financial distress and the ability to recruit and survey a patient’s primary caregivers.
The median age of the patient population was 60.2 years and most of the patients were male, white, married, and had private or Medicare insurance.
“Also, 73% of these patients were still alive after 12 months, which speaks for the improved metastatic colon cancer survival rate we’ve seen over the past decade,” Shankaran said.
Within the study group, nearly 60% had an annual household income less than or equal to $ 50,000 per year, and 40% had a high school degree or less. Most of the patients stated that they had been employed before their diagnosis.
The results showed that the cumulative incidence of major financial distress reached about 71% after 12 months. The largest component of the great financial distress was debt build-up (56.7%), followed by credit (25.8%) and a drop in income of 20% or more. Overall, 41% of patients reported two or more components of financial distress.
“Selling or refinancing the home because of cancer costs was very unusual for this population,” Shankaran said.
The authors also examined the cumulative incidence of major financial distress that excluded debt, and found that although it decreased to 43% after 12 months, it still accumulated continuously and progressively over time.
A trend towards increased risk of financial hardship has been seen in patients under 65, non-whites, unmarried, and those with household incomes less than $ 50,000 per year.
Conversely, a trend towards less financial hardship has been observed among the unemployed, but Shankaran pointed out that this observation is most likely confused by age and the likelihood that unemployed people are older and have greater financial hardship.
A post-hoc analysis showed that income less than $ 100,000 and total assets less than $ 100,000 were associated with significant financial hardship. “Every increase in these two risk factors, from 0 to 1 and 1 to 2, was associated with a 49% increased risk of major financial distress,” said Shankaran.
One limitation of the study was that only 2% of the cohort were uninsured, so these results are not applicable to the uninsured population. Another limitation was that the endpoint focused on material financial hardship rather than psychological or behavioral issues.
“We believe that clinical and policy interventions are critical and necessary to protect cancer patients and their families from financial harm during and after cancer treatment,” concluded Shankaran.
“Our team is currently doing several analyzes that we will report on at a later date,” she said. This includes analyzing credit report data, the extent to which financial hardship predicts poorer health-related quality of life, the financial experience of caregivers, and developing a predictive model to identify those at greatest risk for greater financial hardship so that interventions and them could be targeted to be helped.
How do we screen?
This study shows “how far we have come in our discussion to better understand the path from cancer diagnosis to financial distress for patients and their families,” said Reginald Tucker-Seeley, MA, ScM, ScD, Assistant Professor of Gerontology of the University of Southern California, Los Angeles, the newspaper’s discussant.
However, there are still many questions about how the next step can be taken to ensure that financial hardship screening is a routine part of cancer care and survival, he said. “For those of us who work in this area, there are still some unanswered questions. And one is whether financial hardship is a patient-level construct or a household-level construct? “
This work “will bring us closer to answering that question,” said Tucker-Seeley. “And while we try to intervene in financial difficulties, do we need to figure out what to do after the screening? Community organizations and patient advocacy organizations? “
The study was funded by grants from the NIH / NCI as well as the Hope Foundation and the ASCO Conquer Cancer Foundation. Shankaran reported on relationships with Proteus Digital Health, Taiho Pharmaceutical, and has received institutional research grants from Amgen, AstraZeneca, Bayer, Bristol-Myers Squibb, and Merck. Tucker-Seeley reported on the leadership at the American Board of Internal Medicine Foundation.
2020 ASCO Quality Care Symposium: Abstract 137. Presented on October 9, 2020.