Pain is often thought of as the fifth vital sign; namely, pain is such a prevalent problem in patients with cancer, that we should strive to measure it at every visit and minimize it as part of patient-centered care. The job of the oncologist is to cure (when possible), prolong survival while maintaining quality of life (when possible), and to minimize pain and suffering, particularly for our patients who are not going to be cured of their malignancy.
Financial instability, economic uncertainty, and personal bankruptcy—each intimately associated with the ever-rising and unsustainable costs of cancer treatment—induce great individual, familial, and societal pain and suffering.
Much has been written lately about financial toxicity among patients with cancer, which represents a very real and growing problem in the United States, affecting large numbers of patients with cancer. Financial toxicity can be caused by the loss of income or personal assets related to patients’ efforts to pay the costs of cancer care; the loss of a job or a house; or what is becoming more common, “medical bankruptcy” after a diagnosis of or the progression of cancer; or any other cancer-related element that lowers a patient’s ability to earn a living.
Financial toxicity, however, is often also something we oncologists impose on our patients through the choices we make in selecting treatment for them, either knowingly or unknowingly.
As oncologists, we must be conscious of financial toxicity: assess it as the sixth vital sign, measure it, and continually strive to minimize it. Financial toxicity is particularly relevant among the increasing number of patients who have high-deductible health insurance policies or large copayments.
When choosing between 2 chemotherapy drugs with equal efficacy and similar side-effect profiles, we should always choose the less expensive drug to minimize financial toxicity to our patients. For example, branded epirubicin costs 20 times as much as generic doxorubicin, and because the 2 drugs were equivalent in efficacy and side-effect profiles, branded epirubicin had markedly greater personal financial toxicity. In a world where we strive to practice patient-centered cancer care, we should logically choose doxorubicin.
The choices we make related to imposing financial toxicity on patients can directly impede our goal of caring for patients. For example, for patients with breast cancer, as copay amounts for adjuvant hormonal therapy increase, adherence drops; even small changes in the patient’s out-of-pocket cost can lead to a decrease in drug adherence, reducing the patient’s chance of being cured of her cancer. Adding financial toxicity to the already full plate of a patient with cancer can result in worse clinical outcomes, thereby reducing our ability to cure the disease, to prolong survival, or to minimize pain and suffering.
Just this week, I saw a patient for a second opinion: a young woman who had a rapidly growing supraclavicular lymph node, with pain in her shoulder and a biopsy that was positive for a high-grade neuroendocrine cancer. Based on her history and physical examination, this was clearly metastatic cancer. Nevertheless, a local academic center had ordered magnetic resonance imaging (MRI) of her neck, as well as a positron emission tomography/computed tomography. She was then hospitalized for 1 week to begin a chemotherapy regimen that could easily and safely be given in an outpatient setting.
Considering that her cancer is metastatic, did a neck MRI add anything to her care, besides financial toxicity? Instead, hospitalization was imposing additional financial toxicity for the inpatient stay from the high copayment related to the hospitalization. This financial toxicity was incremental to the psychologic difficulty of a new diagnosis and of being in the hospital away from her husband and children during Thanksgiving week.
Unnecessary imaging and diagnostic tests that do not improve patient care are not “Veblen goods” that patients should covet; as oncologists, we should strive to minimize financial toxicity to our patients in our treatment decisions and minimize the use of diagnostic imaging.
In general, clinical toxicities are similar across different patient demographics: pain is subjective and varies from patient to patient, but more severe pain is more unpleasant than minor pain, regardless of socioeconomic status. However, financial toxicity is more severe among patients of limited financial resources who have health insurance policies with large copayments or large deductibles.
Financial toxicity is also a key element to consider in caring for medically underserved patient populations. In the United States, race is largely a proxy for socioeconomic status, and the field of racial disparities in cancer is often thought of as a variation in care among persons of lower socioeconomic status.
Patients of lower socioeconomic status are uniquely susceptible to the financial toxicity of cancer and its treatment, often for systemic reasons. This forms the basis to many solutions of healthcare disparities: by minimizing financial toxicity to patients of low socioeconomic status, we can dramatically improve their care and their health.
This perspective is a call to providers to consider the financial toxicity of our patients as the “sixth vital sign”—to strive to understand it better, to be conscious of the decisions we make in the clinic, and to measure it on an ongoing basis. It requires consideration of the patient, the related health insurance policy, and the healthcare system where care is provided.
As caregivers, we should innovate to minimize financial toxicity for our individual patients, as well as around our entire patient population as health service researchers. Solving this problem starts with measuring it: a simple question—“How are your finances holding up in all this?”—can quickly assess the patient’s sixth vital sign and help us better care for our patients.
The principle of primum non nocere is a moral call to minimize unnecessary financial toxicity for our patients with cancer. Our patients depend on us for spiritual and holistic care. Our goal as caregivers is to relieve pain and suffering. We must treat our patients as we would wish to be treated if we had cancer. Being diagnosed with cancer is devastating enough; we should avoid or minimize financial toxicity to our patients whenever possible.