The financial burden and distress of patients with cancer: Understanding and stepping-up action on the financial toxicity of cancer treatment

Abstract

"Financial toxicity" has now become a familiar term used in the discussion of cancer drugs, and it is gaining traction in the literature given the high price of newer classes of therapies. However, as a phenomenon in the contemporary treatment and care of people with cancer, financial toxicity is not fully understood, with the discussion on mitigation mainly geared toward interventions at the health system level. Although important, health policy prescriptions take time before their intended results manifest, if they are implemented at all. They require corresponding strategies at the individual patient level. In this review, the authors discuss the nature of financial toxicity, defined as the objective financial burden and subjective financial distress of patients with cancer, as a result of treatments using innovative drugs and concomitant health services. They discuss coping with financial toxicity by patients and how maladaptive coping leads to poor health and nonhealth outcomes. They cover management strategies for oncologists, including having the difficult and urgent conversation about the cost and value of cancer treatment, availability of and access to resources, and assessment of financial toxicity as part of supportive care in the provision of comprehensive cancer care. CA Cancer J Clin 2018;68:153-165. © 2018 American Cancer Society.

Keywords: antineoplastic agents; costs and cost analysis; decision making; health financing; oncologists; precision medicine; referral and consultation; supportive care.

FIGURE 1.

Conceptual Framework of Financial Toxicity in the Treatment of Patients With Cancer. Financial toxicity results from both objective financial burden and subjective financial distress. The objective financial burden is due to the direct costs of cancer treatment, which increase over time from diagnosis. This financial burden is relative to the income and assets of the household of the patient with cancer, which decreases over time. Subjective financial distress ensues with mounting cancer-related expenditures and reduction in wealth combined with the anxiety and discomfort by the patient over their cancer experience. Adapted from: Carrera PM. The financial hazard of personalized medicine and supportive care. Paper presented at: Multi-national Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO) 2017 Annual Meeting; June 22–24, 2017; Washington, DC; Carrera PM, Zafar Y. Financial toxicity. In: The MASCC Textbook of Cancer Supportive Care and Survivorship. 2nd ed. New York: Springer; In press.

FIGURE 2.

Flowchart of Economic Consequences of Cancer Treatment on the Patient and Patient Coping. After signs and symptoms of disease, the decision to seek medical treatment is influenced by an individual’s health insurance coverage. Patients with health care plans that require significant cost sharing face barriers in access to timely and comprehensive cancer care given the insufficient financial protection from medical expenditures. As the patient with cancer undergoes treatment, he or she faces an accumulation of direct medical and surgical costs concurrent with income constraints. Lifestyle-changing, and potentially maladaptive, coping mechanisms may be used with implications for quality-of-life and health outcomes. Adapted from: Carrera PM. The financial hazard of personalized medicine and supportive care. Paper presented at: Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO) 2017 Annual Meeting; June 22–24, 2017; Washington, DC; Keese M. Who feels constrained by high debt burdens? Subjective versus objective measures of household debt. J Econ Psych. 2012;33:125–141³⁶; Jaspers L, Colpani V, Chaker L, et al The global impact of noncommunicable diseases on households and impoverishment: a systematic review. Eur J Epidemiol. 2015;30:163–188.

FIGURE 3.

Action Points for Mitigating Financial Toxicity in Patient-Centered Cancer Care. There are various action points toward mitigating the financial toxicity of cancer treatment. In the context of patient-centered cancer care, medical oncologists not only play a pivotal role in the delivery of high-quality treatment, but they also serve as a focal point in helping contain the financial burden on and financial distress of their respective patients, in the short term and for all patients with cancer in the long term. NCI indicates National Cancer Institute. Adapted from: Tefferi A, Kantarjian H, Rajkumar SV, et al In support of a patient-driven initiative and petition to lower the high price of cancer drugs. Mayo Clin Proc. 2015;90:996–1000; American Society of Clinical Oncology (ASCO). ASCO Position Statement on Addressing the Affordability of Cancer Drugs. asco.org/advocacy-policy/asco-in-action/asco-offers-path-addressing-affordability-cancer-drugs-new-position. Accessed July 13, 2017; Carrera PM. The financial hazard of personalized medicine and supportive care. Paper presented at: Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO) 2017 Annual Meeting; June 22–24, 2017; Washington, DC.