The first publication of the term “financial toxicity” was in the Sept. 1, 2009 issue of The New York Times in an article written by Andrew Pollack, based in part on an interview he conducted with me at the 2009 ASCO Annual Meeting. In fact, I had been using the phrase for more than a year, in the context of the suicide of a British bus driver with metastatic renal cancer who was unable to obtain coverage by his local primary care trust for the drug sunitinib (Sutent, Pfizer). In this context, I coined the phrase “grade 5 financial toxicity,” even submitting a paper on the topic to Journal of Clinical Oncology, albeit without acceptance for publication.
The paper by Jagsi and colleagues concludes that there is inadequate clinician engagement regarding “management of financial toxicity,” which included concerns regarding both lost income and increased expenses. The optimal management of financial concerns needs to consider a number of factors, most importantly the patient’s overall prognosis and impact of therapy. For patients who can be cured, the concerns regarding temporary loss of income may be more palatable, whereas financial concerns of patients with incurable cancers are more problematic.
Reduction of the prescribing cost of modern oncology drugs is a major opportunity for physicians, payers, health systems and patients. Many modern oncology drugs appear to be labeled at average daily doses that are at least double the maximally effective dose.
One randomized study has been completed to date, demonstrating comparability of 250 mg of abiraterone acetate (Zytiga, Janssen) taken with food to the standard 1,000 mg dose taken fasting, conferring a 75% savings. A study of ibrutinib (Imbruvica; Pharmacyclics, Janssen) is in development, which has the potential to reduce prescribing costs as much as 83%, because 140 mg every other day may be comparable to 420 mg daily for the treatment of chronic lymphocytic leukemia.
The opportunity to reduce prescribing costs is not limited to oral small molecules, as there is abundant evidence that the nivolumab (Opdivo, Bristol-Myers Squibb) dosage recommended by the manufacturer is much higher than necessary to achieve benefit. Similarly, the trastuzumab dosage and/or frequency can be reduced by 50% or more and still maintain a target trough concentration of 10 μg/mL to 20 μg/mL.
Physicians, payers, health systems and patients need to be engaged to organize, fund and participate in value-based clinical trials. The Value in Cancer Care Consortium (www.vi3c.org) was recently organized to catalyze this effort.
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