In the JournalsPerspective

‘Simply not acceptable’ to ignore financial toxicity of cancer treatment

A substantial proportion of patients with breast cancer did not feel clinicians adequately addressed their concerns about financial toxicity, study data showed.

“We found that even though many doctors reported that they routinely make services available to their patients to help with financial concerns, many patients still reported unmet needs,” Reshma Jagsi, MD, DPhil, professor, deputy chair and residency program director in the department of radiation oncology at University of Michigan, said in a press release. “Efforts must now turn to confront the financial devastation that many patients face, particularly as they progress into survivorship.”

Jagsi and colleagues conducted a survey of surgeons (n = 370), medical oncologists (n = 306), radiation oncologists (n = 160) and patients (n = 2,502) identified through population-based sampling of two different SEER regions.

Questionnaires included questions for clinicians about how often a representative from the participant’s practice discussed financial burdens with patients, how aware clinicians were of financial burdens of treatment and how important it was for clinicians that their patients save money. For patients, the questionnaires asked about lost income due to cancer diagnosis, out-of-pocket medical expenses and out-of-pocket nonmedical expenses.

Slightly more than half (50.9%) of medical oncologists reported that someone from their practice discussed financial burden with patients, compared with fewer than half (43.2%) of radiation oncologists and just 15.6% of surgeons.

Forty percent of medical oncologists believed they were quite or very aware of out-of-pocket costs of the tests and treatments they recommend, as did 27.3% of surgeons and 34.3% of radiation oncologists.

More than half of medical oncologists (57%) and radiation oncologists (55.8%) said it was quite or extremely important to save their patients money, compared with 35.3% of surgeons.

Financial toxicity appeared common among patients, although prevalence varied by race (P < .01).

Debt from treatment occurred among 27.1% of white patients, 58.9% of black patients, 33.5% of Latina patients and 28.8% of Asian patients.

Seventeen percent of patients reported spending at least 10% of their household income on out-of-pocket medical expenses.

Also, 21.5% white patients reported having to cut down on their spending for food, as did 22.5% of Asian patients, 35.8% of Latina patients and 45.2% of black patients.

Patients frequently reported wanting to talk to clinicians about financial burden across races (15.2% of white patients, 31.1% of black patients, 30.3% of Latina patients; 25.4% of Asian patients).

However, of the 945 women who reported worrying about their finances, most (n = 679; 72.8%) responded that they did not receive help from clinicians or their staff.

Further, although 523 women reported wanting to talk to their clinicians about financial burden, 55.4% (n = 283) reported having no relevant discussion.

“To cure a patient’s disease at the cost of financial ruin falls short of our duty as physicians to serve,” Jagsi said in a press release from University of Michigan. “It’s simply not acceptable to ignore patients’ financial distress any longer.” – by Andy Polhamus

Disclosures: Jagsi reports a consultant role with Amgen, as well as grants from Blue Cross Blue Shield of Michigan, the Doris Duke Charitable Foundation and NCI, all outside of the submitted work. Please see the study for all other authors’ relevant financial disclosures.

A substantial proportion of patients with breast cancer did not feel clinicians adequately addressed their concerns about financial toxicity, study data showed.

“We found that even though many doctors reported that they routinely make services available to their patients to help with financial concerns, many patients still reported unmet needs,” Reshma Jagsi, MD, DPhil, professor, deputy chair and residency program director in the department of radiation oncology at University of Michigan, said in a press release. “Efforts must now turn to confront the financial devastation that many patients face, particularly as they progress into survivorship.”

Jagsi and colleagues conducted a survey of surgeons (n = 370), medical oncologists (n = 306), radiation oncologists (n = 160) and patients (n = 2,502) identified through population-based sampling of two different SEER regions.

Questionnaires included questions for clinicians about how often a representative from the participant’s practice discussed financial burdens with patients, how aware clinicians were of financial burdens of treatment and how important it was for clinicians that their patients save money. For patients, the questionnaires asked about lost income due to cancer diagnosis, out-of-pocket medical expenses and out-of-pocket nonmedical expenses.

Slightly more than half (50.9%) of medical oncologists reported that someone from their practice discussed financial burden with patients, compared with fewer than half (43.2%) of radiation oncologists and just 15.6% of surgeons.

Forty percent of medical oncologists believed they were quite or very aware of out-of-pocket costs of the tests and treatments they recommend, as did 27.3% of surgeons and 34.3% of radiation oncologists.

More than half of medical oncologists (57%) and radiation oncologists (55.8%) said it was quite or extremely important to save their patients money, compared with 35.3% of surgeons.

Financial toxicity appeared common among patients, although prevalence varied by race (P < .01).

Debt from treatment occurred among 27.1% of white patients, 58.9% of black patients, 33.5% of Latina patients and 28.8% of Asian patients.

Seventeen percent of patients reported spending at least 10% of their household income on out-of-pocket medical expenses.

Also, 21.5% white patients reported having to cut down on their spending for food, as did 22.5% of Asian patients, 35.8% of Latina patients and 45.2% of black patients.

Patients frequently reported wanting to talk to clinicians about financial burden across races (15.2% of white patients, 31.1% of black patients, 30.3% of Latina patients; 25.4% of Asian patients).

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However, of the 945 women who reported worrying about their finances, most (n = 679; 72.8%) responded that they did not receive help from clinicians or their staff.

Further, although 523 women reported wanting to talk to their clinicians about financial burden, 55.4% (n = 283) reported having no relevant discussion.

“To cure a patient’s disease at the cost of financial ruin falls short of our duty as physicians to serve,” Jagsi said in a press release from University of Michigan. “It’s simply not acceptable to ignore patients’ financial distress any longer.” – by Andy Polhamus

Disclosures: Jagsi reports a consultant role with Amgen, as well as grants from Blue Cross Blue Shield of Michigan, the Doris Duke Charitable Foundation and NCI, all outside of the submitted work. Please see the study for all other authors’ relevant financial disclosures.

    Perspective

    Photo of Mark J. Ratain 2018

    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.

    References:

    Camber R, et al. Cancer patient kills himself day after he is told NHS Trust would not fund £25,000 drug. Daily Mail. June 25, 2008. Available at: www.dailymail.co.uk/news/article-1029038/Cancer-patient-kills-day-told-NHS-Trust-fund-25-000-drug.html. Accessed on Sept. 25, 2018.

    Ismael G, et al. Lancet Oncol. 2012;doi:10.1016/S1470-2045(12)70329-7.

    Lichter AS. J Clin Oncol. 2018;doi:10.1200/JCO.2018.78.4264.

    Motzer RJ, et al. J Clin Oncol. 2015;doi:10.1200/JCO.2014.59.0703.

    Pollack A. “For Profit, Industry Seeks Cancer Drugs.” The New York Times. Sept.1, 2009. Page A1.

    Ratain MJ, et al. J Clin Oncol. 2018;doi:10.1200/JCO.18.00045.

    Ratain MJ, et al. Sales revenues at the potential expense of patient safety: The example of you&i TM. The Cancer Letter. April 13, 2018. Available at: cancerletter.com/articles/20180413_5/. Accessed on Sept. 25, 2018.

    Szmulewitz RZ, et al. J Clin Oncol. 2018;doi:10.1200/JCO.2017.76.4381.

    Yoo SH, et al. ESMO Open. 2018;doi:10.1136/esmoopen-2018-000332.

    Mark J. Ratain, MD

    The University of Chicago Medicine

    Disclosure: Ratain reports serving as an expert witness and patent litigation consultant on behalf of multiple generic pharmaceutical companies. He also reports research funding from AbbVie and Genentech, consultant roles with Aptevo and Cyclacel, and nonpaid roles as director and treasurer of The Value in Cancer Care Consortium.