Chicago, IL—With healthcare premiums on the rise and out-of-pocket costs skyrocketing, almost every person diagnosed with cancer is at risk for being underinsured, but this threat extends beyond a patient's bank balance. Recent research has shown that when patients face extreme financial distress, they have a greater risk for worse outcomes, including mortality. At ASCO 2018, Yousuf Zafar, MD, MHS, Director, Center for Applied Cancer Health Policy, Duke Cancer Institute, Durham, NC, discussed the need to prevent financial toxicity at the patient level by focusing on high-value interventions.
"Treating financial toxicity at the patient level is similar to treating a symptom like fatigue," said Dr Zafar. "You can try to prevent it, but to some degree, patients are going to experience it, and when they do, you need a plan."
Cost Still a Taboo Subject
As part of their study involving insured patients with cancer undergoing cancer treatment, Dr Zafar and colleagues asked the patients, "Do you want to talk to your oncologist about your out-of-pocket costs?" Approximately 50% of the patients said that they wanted to have a discussion about costs, but only 19% actually had such a discussion.
"We have noticed a disparity between the desire to talk and actually having the discussion," said Dr Zafar, who noted that this disparity may stem from concern over not receiving the best possible care.
"In my mind, patients are worried that if they ask about more affordable care, they are also asking about lower-quality care. They see this link between cost and quality," he added.
However, the consequences of financial toxicity can be severe, leading to bankruptcy, skipping medications, working longer hours, buying less food or other items, as well as delaying treatment and medication nonadherence, which directly affect cancer outcomes.
According to Dr Zafar, a small percentage of patients are also embarrassed to talk about costs.
"As a GI [gastrointestinal] oncologist, I talk to patients about their rectums day in and day out, and they have no problems with that. But for some reason, cost is still embarrassing for a handful of patients," he said.
When asked why they did not discuss cost issues with their providers, patients listed the following reasons:
- 43% had no financial difficulties
- 28% wanted the best care possible
- 18% said this is not their doctor's job
- 18% said their doctor could not help
- 9% talked to someone else
- 9% were embarrassed to discuss costs.
When a patient complains about fatigue, for example, the oncologist will address the issue to reduce or prevent fatigue, he said. Similarly, to prevent financial toxicity, providers need to assess it and try to reduce or prevent it through intervention.
Intervention Can Lower Patient Costs
Among the small proportion of patients in the study who did talk to their oncologists about costs, 57% reported lower out-of-pocket costs after that discussion. Given the small sample size, Dr Zafar acknowledged that these outcomes are more hypothesis-generating than conclusive, but he found it noteworthy that these discussions resulted in decreased costs 78% of the time without patients changing their treatment.
A separate analysis of nearly 700 recorded conversations between oncologists and patients with breast cancer showed that when costs were discussed, cost-reduction strategies were mentioned only 38% of the time.
"I might not have any idea how much a certain treatment costs, but I know that if a patient is having trouble, I can at least point them to someone who can provide financial assistance or appeal to the insurance company," said Dr Zafar. "Although effective cost discussions are taking place in many cases, we need to have them more frequently and more methodically."
Dr Zafar emphasizes that oncologists should focus on "high-value" intervention.
When to Avoid Treatment
According to Choosing Wisely, an initiative of the ABIM Foundation, one of the first things providers can do to prevent financial toxicity is to avoid cancer-directed therapy in patients who are too sick to benefit from the treatment. That includes:
- Patients with low (3 or 4) performance status
- Those with no benefit from previous evidence-based interventions
- Those not eligible for a clinical trial
- No strong evidence supporting the clinical value of further anticancer treatment.
"Basically, if my patient is too sick, I shouldn't subject them to chemotherapy," Dr Zafar explained. "Oncologists have a really hard time with this, but this comes down to delivering high-value care."
Facilitating Cost Discussions
Finally, although physicians may be reluctant to take time away from treatment to discuss financial toxicity, research has shown that the vast majority of these conversations last less than 1 minute, Dr Zafar said.
"These conversations don't have to take a long time to be effective," Dr Zafar added.
To help facilitate that discussion and intervene at the patient level, Dr Zafar and colleagues developed a patient-facing app called "Pathlight."
Using videos, online tools, and informational materials, Pathlight empowers patients to better understand and reduce treatment-related expenses through a 3-step process:
- Pathlight guides patients through important topics related to insurance and affordable healthcare
- Pathlight connects those in need to financial assistance resources specific to their treatment and financial situation
- Pathlight can coach patients through the process of talking to their healthcare team about costs.
Ultimately, Dr Zafar said, the app will prepare a personalized plan to help manage cancer costs and reduce the burden of financial toxicity so that patients can focus on what is most important—their health.
"Now, it's part of my practice to make sure that either I or my pharmacist or somebody on my team has that discussion with our patients to ensure that we don't just continue to study this important problem, but actually intervene on it at the level of the patient," Dr Zafar concluded.