The high cost of cancer treatment can lead to significant financial and emotional strain for patients and their families. The problem appears to be getting worse, as over the past 2 decades the median price of one month of chemotherapy has sharply increased, far exceeding the rate of inflation.1

Measuring Financial Toxicity in Acute Leukemia

According to a study published in Blood, patients with acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL) are particularly vulnerable to financial toxicity (FT), or difficulties related to the cost of cancer treatment.2

Over a 6-month period, all patients aged ≥18 years diagnosed with AML or ALL and receiving treatment at a hospital-based leukemia practice were surveyed about FT. The patients were asked whether they agreed or disagreed with a pair of statements: “I know that I have enough money in savings, retirement, or assets to cover the costs of my treatment” and “I am satisfied with my current financial situation.” Reponses were recorded on a 10-point scale, with 1 indicating maximum disagreement and 10 indicating maximum agreement. FT was defined as a rating of ≤4.

Of 106 patients surveyed, 58 (54%) met the definition of FT. The researchers concluded that “patients with acute leukemia represent an extremely vulnerable population for financial toxicity with rates of distress even higher than other reported malignancies.”

Risk Factors

The investigators identified 3 risk factors for FT: age, race, and insurance. Patients aged <65 were 2.7 times more likely to experience FT than patients ≥65; African American patients were 4.3 times more likely to experience FT than white patients; and patients with Medicaid insurance were 14.2 times more likely to experience FT than patients with commercial insurance. Gender, proximity to the hospital, type of acute leukemia, history of blood or marrow transplant, and history of relapsed disease were not found to be significant factors.

These findings largely align with the National Cancer Institute’s (NCI) risk factors for all cancers. NCI lists age, race, and health insurance among its causes of financial distress.3

The Role of the Clinician

In 2017, the American Society of Clinical Oncology (ASCO) Educational Book offered methods to manage FT from the perspectives of the pharmaceutical industry, payer, oncologist, and patient advocate.1 The oncologist’s perspective was authored by Leonard Saltz, MD, an oncologist at Memorial Sloan Kettering Cancer Center in New York City.

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Saltz asserted that the first step toward lower-cost, higher-value medicines for patients is “physician acceptance, practice, and promotion of transparency in price.” He emphasized the importance of oncologists knowing the prices of the drugs they prescribe, factoring prices into decision-making, and discussing prices as openly as risks, toxicities, and benefits. “Doctors do not have the ability to unilaterally lower the prices of drugs,” he said, but they “do have the ability to be aware of the prices of the drugs, tests, treatments, and recommendations we offer.”

However, in an article for Oncology Nurse Advisor, Dan Sherman, MA, LPC, president at the NaVectis Group and speaker at the 2018 Oncology Nurse Advisor Navigation Summit, wrote that “most oncologists fall short in providing adequate guidance to patients and their families about financial issues.” He noted that, while most oncologists feel that it’s important to discuss how treatment may affect their patients’ financial well-being, nearly 1 in 3 feel uncomfortable doing so.

Sherman argues that, to address financial toxicity, improving cost communication between patients and oncologists is insufficient on its own. “Clinics must either collaborate with outside organizations that have expertise in financial counseling and medical costs or invest in internal financial navigation resources to provide consistent and proactive financial support to all patients beginning at diagnosis.”

References

  1. Zafar SY, Newcomer LN, McCarthy J, Nasso FS, Saltz LB. How should we intervene on the financial toxicity of cancer care? One shot, four perspectivesAm Soc Clin Oncol Educ Book. 2017;37:35-39.
  2. Knight TG, Robinson M, Grunwald MR, et al. Patient reported financial toxicity in acute leukemiaBlood. 2018;132:4796.
  3. Financial toxicity and cancer treatment (PDQ®)-health professional versionNational Cancer Institute. Updated April 15, 2019. Accessed May 8, 2019.