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Financial Toxicity in Cancer Care

Laura Cannon, PharmD MPH
Clinical Assistant Professor and Oncology Pharmacist
The University of Texas at Austin College of Pharmacy
and Dell Medical School Livestrong Cancer Institutes
Austin, TX

Chelsea Gustafson, PharmD BCOP
Oncology Pharmacy Specialist
Community Health Network: Community Regional
Cancer Centers
Kokomo, IN

Caroline Quinn, PharmD BCOP
Clinical Pharmacy Specialist
The University of Texas MD Anderson Cancer Center >
Houston, TX

If you spend a day in an oncology clinic, in only a few minutes you will hear discussion about the prevention or treatment of common toxicities. Myelosuppression, neuropathy, diarrhea, and nausea and vomiting are routinely discussed toxicities in the management of cancer care. Financial toxicity, however, may not be the first toxicity that comes to mind, or it may not even be considered at all.

Financial toxicity in cancer care can be viewed through many lenses. In our work on this article, we took the opportunity to interview four individuals who have distinct roles in cancer care: an oncology nurse practitioner, an oncology pharmacist, an oncology clinical social worker, and a pharmacy technician who works as an outpatient medication assistance coordinator. We asked them several questions about financial toxicity. It is our hope that the answers below (which contain our own thoughts and those of the four professionals) will highlight areas for improvement in clinical practice.

How do you define financial toxicity of cancer care?

As pharmacists, we often think of financial toxicity as the cost of cancer treatments. We know that these costs continue to increase, especially for newer treatment options like immunotherapy and oral chemotherapies.1 Medication assistance coordinator Samantha Shaver states that “patients who are newly diagnosed not only worry about life-changing news but also have to worry about the affordability of treatment while maintaining the normal costs of living.” When considering the cost of medication therapy alone, “clinic staff members should be cognizant of how their patients are tolerating the treatment financially,” according to pharmacist Ashish Suthar. “Patients may be just as likely to dose-reduce or stop treatment on their own because of cost, just as we would for a lab abnormality.”

But financial toxicity may extend beyond the cost of medications. Oncology nurse practitioner Anne Courtney defines financial toxicity as “any cost of cancer treatment that alters the way people may make treatment decisions or that impacts their ability to live their baseline life.” This extends beyond medication therapy, because cancer treatment can include surgery, radiation, frequent office visits, and lab tests. The cost of medication therapy alone can be high, but it does not exist in a vacuum and should be viewed in combination with all potential causes of financial toxicity for cancer patients and their loved ones. Oncology clinical social worker Angela Luna adds, “Financial toxicity is what happens when healthcare costs eat up so much of a family’s disposable income that they can’t afford daily necessities, much less save for the future.” Her perspective introduces financial toxicity as not just a concern for the present but something that may extend far beyond the time of the initial diagnosis and treatment.

In your opinion, what are the biggest financial issues for cancer patients right now?

Each of our four respondents (nurse practitioner, clinical social worker, pharmacist, and medication assistance coordinator) identified a different area as the biggest financial concern for cancer patients. They spoke about the cost of medication therapy and the frequency of treatments, the cost of copayments for diagnostic imaging, the cost of hospital and emergency department admissions, worries about being underinsured (having insurance but with either costly copayments for every aspect of care or else high deductibles), and the need for patients and healthcare providers to have better access to information on assistance programs. This list highlights the need for awareness of financial toxicity from all disciplines and perspectives, because the overall costs of cancer care can quickly accumulate.

Clinicians may be aware of costs related to their own areas of practice but fail to view the overall financial situation, which identifies an additional area of need. Luna points out that “financial toxicity is a tricky area because you really need an expert who knows the ins and outs of all the resources and strategies. The irony is that many institutions don’t prioritize that in their funding of positions. This situation means that dealing with these issues is left to people who are trying their best but may not be operating in their area of expertise.” Suthar adds, speaking specifically about medication-related costs, “Depending on the size of the practice, it could take one (or more) full-time staff members to help patients find and enroll in assistance programs.”

The other difficulty in navigating through concerns about financial toxicity is the fact that cancer care costs are not always known upfront, and our responses are often reactive rather than proactive. Healthcare organization and insurance disclosures about upfront costs for procedures, imaging, medications, and office visits could shift this paradigm. In addition, Luna suggests that more detailed education on the selection of insurance plans could offset the problem of patients’ being underinsured.

What strategies do you employ to help patients overcome the financial toxicity of cancer care?

Current strategies to combat financial toxicity include the use of drug manufacturers’ copay cards, patient assistance programs, and disease-based grant funding for medication copay assistance. However, Shaver notes that some of the biggest difficulties she deals with are finding grants and funding related to rare diagnoses and off-label medication uses, in addition to accessing assistance with deductible payments for commercially insured patients. Suthar suggests keeping a list of resources and documents (phone numbers, points of contact, and eligibility and documentation requirements for various assistance programs) and connecting with field reimbursement representatives in drug companies who can help break down barriers to getting patients access to medications. He also recommends using online portals for real-time feedback. Courtney’s strategy is proactive: she ensures that she “provides the best patient education to decrease toxicities and risks that may lead to the patient missing work or being admitted to the hospital.” She highlighted the need to tackle financial toxicity from all angles. Luna points out that sometimes the only course of action is to help patients shift costs based on available resources. For example, you may find resources to assist with transportation so that patients can then apply the money saved toward another cost.

Discussion

We have many opportunities to improve how we manage the financial toxicity of cancer care. Institutions must make this improvement a priority because patients’ inability to receive all aspects of care because of concerns about cost can have a negative impact on overall outcomes and survival. With rising healthcare and medication costs, this problem will only become more serious. Just as we assess for treatment-related toxicity during each visit, we should also assess a patient’s risk for financial toxicity, particularly at high-risk points such as treatment initiations, dose changes, or changes in a patient’s insurance. Although the perspectives shared here do not address all the problems, they show the variety of contributing factors and management strategies and highlight the importance of teamwork and interprofessional collaboration to help reduce the financial burden for cancer patients and their loved ones.

Acknowledgments

We thank oncology nurse practitioner Anne Courtney, DNP ACNP, pharmacy manager Ashish Suthar, PharmD MJ, oncology clinical social worker Angela Luna, LCSW, and medication assistance coordinator Samantha Shaver, CPhT, for the gift of their time and for their thoughtful contributions to this article.

Request for Contributions of Best Practices

If you or your institution has a best practice related to financial toxicity, please contact Laura Cannon, member of HOPA’s Patient Outreach Committee, at This email address is being protected from spambots. You need JavaScript enabled to view it..

Reference

  1. Prasad V, De Jesus K, Mailankody S. The high price of anticancer drugs: origins, implications, barriers, solutions. Nat Rev Clin Oncol. 2017;14:381-390.
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