Factors associated with increased financial toxicity after the completion of radiation treatment for gynecologic cancer

Abstract

<h3>Objectives:</h3> Financial toxicity is estimated to impact up to 50% of patients with gynecologic malignancies, but little is known about the factors that may predispose patients receiving radiation treatment for gynecologic cancer to increased financial distress. <h3>Methods:</h3> Patients from an urban academic gynecologic radiation oncology practice completed a financial toxicity survey at their 1-month follow-up visit after completion of radiation treatment from August 2019-March 2020. The survey was modified from our prior study and included basic demographic questions, the Comprehensive Score for Financial Toxicity (COST) tool and the EQ-5D to measure quality of life. Consistent with our prior work, high financial toxicity was defined as COST score ≤23. We assessed correlation of COST scores with QOL. Demographic and disease characteristics between high and low financial toxicity groups were compared using Chi-square or Fisher's exact test for categorical variables and Wilcoxon rank sum test for continuous variables. We used log-binomial regression to examine associations between high financial toxicity and cost-coping strategies. <h3>Results:</h3> The response rate was 88%. Of the 49 patients surveyed, 71% were White, 14% Black and 10% Asian. The majority of patients had uterine cancer (65%), followed by cervical (23%) and vaginal (8%) cancer. Two-thirds (63%) received external beam radiation with or without brachytherapy; the remaining (37%) received brachytherapy alone. Median COST score was 13 (IQR 5-19) in the high financial toxicity group (n=18) and 32 (IQR 27-36) in the low toxicity group (n=31). Greater financial toxicity was significantly correlated with worse QOL (R=-0.36, P=0.02). No demographic, disease or treatment characteristics were associated with high financial toxicity aside from employment status (p=0.03), though income was borderline significant (p=0.053). Compared with the low financial toxicity group, patients with high financial toxicity were more likely to move from full-time to part-time employment since diagnosis (22% vs 0%, p=0.01) and reported that difficulty paying for transportation or parking was a consideration in making medical decisions (33.3 vs 3.2%, p=0.01). Patients with high financial toxicity were more likely to report delaying or avoiding medical care (22% vs 0%, P=0.01), 13.8 (95% CI 1.9-101.4, P<0.001) times more likely to borrow money, and 10.3 (95% CI 1.3-79.1, p=0.01) times more likely to report reduced spending on basic goods. <h3>Conclusions:</h3> Financial toxicity correlated with worse quality of life in patients who received radiation for their gynecologic cancer diagnosis and was associated with delays or avoidance of medical care and use of economic cost-coping strategies. A larger survey cohort may improve our ability to meaningfully detect other associations with high financial toxicity. Moreover, transportation and parking costs should be considered in the design of any future intervention study in this population.