Financial Toxicity Beginning to Gain Oncologists’ Attention, Finally

VBCC - November 2014, Vol 5, No 9 - ASCO Quality Care Symposium
Phoebe Starr

Boston, MA—The good news for patients with cancer is that oncologists are beginning to recognize financial toxicity as a side effect of cancer treatment. According to S. Yousuf Zafar, MD, MHS, Medical Oncologist, Duke University Medical Center, Durham, NC, financial toxicity should be assessed as a patient-reported outcome as early as possible after a cancer diagnosis so that interventions can be put in place to assist patients in getting expanded coverage for their treatments.

At the 2014 ASCO Quality Care Symposium, Dr Zafar spoke about factors that contribute to financial toxicity and the negative impact it can have on patients’ outcomes if not addressed. Oncologists are often unaware of the exact costs of the treatments they prescribe and typically do not discuss costs of treatment or insurance coverage with their patients.

There is currently no expert consensus on which healthcare professionals should discuss finances with patients, or what the optimal timing of such discussions should be. However, there is agreement that financial toxicity needs to be addressed.

“Financial toxicity is the elephant in the room. You can begin the discussion by asking your patients one simple question about whether their cancer care is covered by a drug plan,” Dr Zafar suggested. He noted that many patients with cancer who have health insurance often have inadequate coverage for cancer treatment.

A confluence of factors contributes to financial toxicity, including high drug costs, the widespread use of expensive biologics in oncology, increasing reliance on oral chemotherapy, increasing insurance premiums, and much higher copays for cancer treatments.

Regarding the cost of drugs, Dr Zafar noted that 1 month of chemotherapy is estimated to cost $10,000, and the cost of cancer drugs continues to rise. Between 2007 and 2014, the price of erlotinib (Tarceva) increased by 91%, the price of dasatinib (Sprycel) increased by 130%, and the price of imatinib (Gleevec) increased by 158%. Spending on oral chemotherapy increased by 37% per quarter at the same time that the use of oral chemotherapy increased by 17% per quarter.

In addition, there has been an exponential increase in health insurance premiums in the past decade or so that can adversely affect patients with cancer. From 1999 to 2013, insurance premiums increased by 182%, and workers’ contributions to their health insurance increased by almost 200%, on average.

The 4-tiered formularies are now being used in many drug plans, and cancer drugs are among the most expensive drugs to be covered; they are typically falling into tiers 3 and 4, which have significantly higher member copays than drugs in the first 2 tiers.

Patients often experience their cancer treatment as a significant financial burden and stint on basic necessities to pay for their cancer drugs. Some exhaust their savings and file for bankruptcy, Dr Zafar continued.

The fallout from financial toxicity impacts patient well-being, according to several recent studies. “There is a growing list of financial adverse events as a result of the care we are providing. These include delaying care, nonadherence, missed appointments, and taking fewer medications,” Dr Zafar said.

Financial Interventions
The glass is not half empty, however. Interventions can be implemented by oncologists and other healthcare providers on the individual, interpersonal, and systemic levels to improve patients’ situations, improve patient adherence to therapy, and avoid the considerable financial hardship on some patients.

On the individual level, patients should be educated about the costs of healthcare so that they can gain healthcare cost literacy. Many patients are unaware of the availability of assistance programs, and that their oncologist can intercede with the payer to request expanded coverage. Providers can help patients get this type of information to help them gain control of the financial burden associated with cancer treatment.

On the interpersonal level, oncologists or other healthcare providers should communicate with patients about the cost of cancer care, and inform patients about programs and other ways to decrease their healthcare costs, including patient assistance programs offered by drug manufacturers and/or by the health insurance plan. Many cancer centers today offer patients some form of financial consultation when requested, but not all patients ask for help. Oncologists should take the initiative to ask patients about their financial situation in relation to their cancer treatment, find out how it may affect their treatment, and offer help when needed.

On a systemic level, identification of patients at high risk for financial toxicity is important before they find themselves deeply in debt. Dr Zafar urged oncologists to make use of existing screening tools to identify patients in financial need, and addressing price transparency with patients. Many oncologists still shy away from discussing costs with patients, which can affect treatment results.

Overall, bringing together resources in health literacy, patient engagement, and healthcare delivery can start to reduce the impact of the ever-rising costs of cancer care and of financial toxicity on patients with cancer.

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Last modified: November 20, 2014
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