In addition to affecting patient well-being and quality of life, financial toxicity has been shown to worsen survival outcomes because of nonadherence to drug therapy. Although policy interventions, improvements in benefit designs, and adjustments to reimbursement may help reduce costs for patients in the long-term, immediate changes are needed to alleviate financial burden, said Yousuf Zafar, MD, MHS, of the Duke Cancer Institute, Durham, NC, at ASCO 2016.
“We should think of financial toxicity as a symptom, because it frames the issue in terms of effective treatment and is much more manageable to handle than a systemwide, health economic crisis. Until changes happen at the policy level, it’s important for providers to think about what [they] can do to prevent, assess, and reduce their patients’ financial toxicity in the clinic,” Dr Zafar said, suggesting strategies oncologists can follow.
Prevention: Low- versus High-Value Treatment
To prevent the financial burden of cancer treatment, providers must consider the value of the treatment they prescribe. “We need to focus on high-value interventions,” he said. The Choosing Wisely initiative has compiled the following list of low-value interventions for oncologists to avoid:
- Do not use cancer-directed therapy for patients with a solid tumor and low performance status (3 or 4); those who receive no benefit from previous evidence-based interventions; those not eligible for a clinical trial; or when there is no strong evidence supporting the clinical value of further anticancer treatment
- Do not use growth factors in patients who are receiving low-risk treatment
- Avoid using positron-emission tomography scanning in asymptomatic patients who are in surveillance.
These are reasonable interventions to avoid, even if the patient has insurance, said Dr Zafar, but having insurance does not prevent financial burden of low-value interventions.
“Somewhere in the range of 15% to 20% of patients we see have coinsurance, which means they’re paying up to 30% of the cost of everything that I prescribe. As oncologists, we need to do a better job of having goals of care discussions with our patients, frankly, and in a timely fashion.”
“With patient-reported outcomes moving from research into standard of care, we’re regularly and longitudinally assessing patients for their nausea and fatigue, but what we’re not assessing patients for is their financial toxicity,” said Dr Zafar.
Although studies underway are evaluating the financial impact of treatment longitudinally on patients, tools are available for practicing providers. For example, the Comprehensive Score for Financial Toxicity (COST) developed by Jonas A. de Souza, MD, and colleagues at the University of Chicago. COST is an 11-item questionnaire that measures a patient’s risk for financial toxicity after cancer diagnosis and treatment.
You Can Help Reduce Patient Burden
Dr Zafar believes that oncologists can help reduce financial toxicity by their direct actions.
“It comes down to shared decision-making, goals of care, and ultimately communication. We can decrease patients’ cost of care not by changing treatment but by referring them to financial assistance in a timely fashion, and by talking to their insurance company and appealing on their behalf,” Dr Zafar said.
In some cases, oncologists may switch to less expensive medications or change the frequency of interventions. The critical point, however, is the lack of price transparency, which can only be resolved by better patient–physician communication. Even if such discussion does not lead to a direct cost reduction, it still aligns oncologists with the interests of their patients, he said.
“Patients know that we’re aware of what they’re going through in terms of their financial burden, and just like with any other physical symptom, that is the first step in reducing that symptom,” Dr Zafar concluded.