IssueMay 22Opinion

Financial Toxicity

Impact on older adults with advanced cancer. An insight by Dr Arpan Ashok Patel,School  f Medicine and Dentistry, University of Rochester, Rochester, NY, USA

Receiving a cancer diagnosis is a devastating blow. Although patients should be focusing on their treatment, their thoughts often turn to finances, especially if they are without insurance or are not eligible for government support. In 2011, the Centers for Disease Control and Prevention found that nearly one-third of families in the
US reported having financial burdens related to healthcare costs. Moreover, around 10 per cent had medical bills that they were unable to pay.


Cancer is one of the most expensive diseases to treat. Treatment costs are much more likely to be patient-
funded than for other chronic diseases. After receiving a diagnosis, out of pocket medical expenses can increase
exponentially up to tens of thousands of dollars. Even those with Medicare, an American government healthcare plan for the elderly, are likely to experience high out of pocket expenses for cancer treatment, especially if they do not have any supplementary insurance. A recent study revealed that one in every ten cancer patients with
Medicare pays expenses that equate to 60 per cent of their household income.

Patients with private insurance may also experience additional costs due to being under insured or exceeding the cover threshold.

The intensive and lengthy nature of treatments such as chemotherapy may lead to cancer patients losing
their employment. Without a regular income, patients may have to resort to withdrawing retirement funds, selling their homes or even filing for bankruptcy. Sometimes, patients question if they will be able to afford to continue treatment. This adds extreme emotional stress on top of the physical stresses endured throughout their treatment journey.

What is Financial Toxicity?
Financial toxicity refers to the monetary burden of paying for cancer care costs and the negative impact of this on
patient financial stability. Although the impact of financial toxicity upon cancer survivors has not been widely researched, in 2014, a large-scale study reported that almost half of cancer patients taking part were having difficulties living on  their household income. Furthermore, those with a high financial burden were likely to be
experiencing a poorer quality of life.

We should not overlook the impact of the financial strain upon cancer patients. I have witnessed first-hand the relationships between patient distress, financial toxicities and quality of life when treating complex illnesses. Recently, I was involved in research focusing on the impact of financial toxicity upon older adults with advanced cancer.

Older and more advanced patients

Older adults are likely to face a different set of pressures than those younger patients. The main source of income is typically either from the government or from private retirement savings (which may be in the form of a pension). In the US, all over 65s are entitled to Medicare. However, this government financial assistance does not cover all healthcare expenditures, meaning patients have to make up potential shortfalls out of their own pockets. Cancer is also more prevalent in this age group, and the rate of prevalence in older adults is growing.

Indeed, the worldwide cancer diagnosis amongst over 65s is predicted to double by 2035. Previous research has identified two key and important themes concerning financial toxicity amongst older adults. The first is that patients who report financial toxicity are more likely to have a lower health-related quality of life. The second is that patients often wish to discuss treatment expenses with their oncologists but these conversations rarely take place due to healthcare providers’ discomfort. The research was focussed on the experiences of older and more at-risk cancer patients. It was aimed to assess the prevalence of financial toxicity in older advanced cancer patients and to examine the relationship between financial toxicity and health-related quality of life. In addition, we wanted to understand the financial conversations between these patients and their oncologists.

Ascertaining the prevalence of financial toxicity

Questions about the financial hardship were asked to ascertain whether patients met the criteria for financial
toxicity. The main questions asked were about treatment delays due to financial issues and levels of income for food and housing, as well as for clothing, medicine, repairs to the house and transport. The researchers found that almost 20 per cent of patients over the age of 70 with advanced cancer had experienced financial toxicity. The data also suggested this was more likely to be experienced by those who were female, Black/African American, single, had a lower average household income, had a lower level of education, were not employed and whose health costs were covered by Medicare alone. Healthcare providers must use screening tools to assess if patients are at risk of financial toxicity. If validated, even the simple financial hardship questions used in this study could be an effective way of identifying the mostat-risk patients.

Assessing health-related quality of life

As part of the study, patients also undertook various assessments to measure their health-related quality of life. These assessments examined how a person’s physical, mental, emotional and social functioning affected
their health, comfort and ability to participate in or enjoy life events. It was found that patients with financialtoxicity were likely to report higher levels of mental health issues such as depression, anxiety and distress. In line with previous research, it was also found that in this high-risk group, those with financial toxicity were more likely to have a poorer health-related quality of life.

The importance of cost conversations
A unique part of the study was that at least one clinic visit between the oncologist and the patient was audio recorded. These recordings revealed that only 50 per cent of patients experiencing financial toxicity had a
conversation about costs or finances. Previous research has suggested that around 80 per cent of patients wish to have this kind of conversation, indicatinga gap between what the patient desires and practices. Why might this disparity exist? Both parties may be reluctant to bring up the subject of cost. For patients, there is the potential  embarrassment of acknowledging they cannot afford treatment while oncologists may not feel comfortable discussing this topic.

When the researchers examined the content of these conversations, four  main themes emerged. The first was
the cost of care, which was mainly initiated by the patient or caregiver. The second was about the patients’ ability
to continue to work or provide for their household with these costs. The third was typically initiated by the oncologist and focussed on the patient’s ability to afford care. The final theme was about costs that were not treatment-related.

Shockingly, almost 12 per cent of oncologists dismissed cost conversations when patients or caregivers raised
them. However, in the majority of cases, oncologists did offer interventions or signposts to other resources that would be able to help the patient. Dr Patel and his colleagues are keen to emphasise that direct discussions around cost can help prevent financial toxicity. These discussions can allow oncologists to share knowledge about externalresources that can provide support, such as social workers, financial  advisors,support groups,  charities and co-pay assistance.

Addressing financial toxicity at the policy level
The findings shine an important light on the extent to which older and more advanced cancer patients are experiencing financial toxicity and the negative impact this can have. Importantly, it has been identified that there is a clear need for proper screening tools that can identify patients who are at high risk of financial toxicity. Furthermore, it can be noted that there is currently no routine training for healthcare providers and no standardised approach between organisations. The policy change is needed to ensure interventions relating
to financial toxicity occur at a national level.  Critically, the lack of adequate assessment, particularly in older  people with advanced cancer, means that they cannot receive appropriate referrals to support.

REFERENCE: This article originally appeared in Scientia

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