Financial Toxicity in Metastatic Cancer Patients Receiving Stereotactic Radiosurgery

Abstract

“Financial toxicity,” or the financial burden a patient has as a result of medical care costs, can adversely impact health-related quality of life. As medical care costs are highest at the end of life and among patients with advanced cancer, we sought to characterize the extent of financial toxicity among metastatic cancer patients presenting for stereotactic radiosurgery (SRS). With IRB approval, we prospectively surveyed consecutive adult patients receiving SRS for metastatic cancer using a questionnaire that assessed demographics, financial distress, and physician-patient communication preferences. Financial distress was scored using the validated Personal Financial Wellness (PFW) scale: extremely low/no distress (9-10), low distress (7-8.9), average distress (5-6.9), high distress (3-4.9), and extremely high/overwhelming distress (1-2.9). Financial toxicity was classified as high to overwhelming distress (PFW <5). Additional patient and treatment data were collected from the electronic medical record. Data were analyzed using descriptive statistics, the Wilcoxon rank sum test, and Fisher’s exact test. Of 74 patients approached, a total of 56 patients completed the survey. Median age was 63 years (interquartile range [IQR] 56-71 years). The most common cancers were of lung (29%), breast (20%), melanoma (9%), and renal cell (9%) primary. Most patients were privately insured (54%) or had Medicare with supplemental insurance (41%). Median PFW score was 7.3 (IQR 5.4-9.6). Overall, 13 (23%) patients reported financial toxicity. Within the year prior to SRS, 68% of patients were working full- or part-time, and 61% of patients provided half or more of the earned income for their families. As a result of their diagnosis, 46% of patients had a change in employment status resulting in being on disability (36%), retirement (32%), or leave of absence (16%). A change in employment status was associated with lower PFW score (higher financial distress). 35% of patients with a change in employment status reported financial toxicity versus 13% of patients without a change in employment status. Since being diagnosed with cancer, 23% of patients had met with a financial counselor. While only 9% of patients had discussed cancer-related finances with their doctors and 13% were interested in doing so, the majority (60%) of patients said they would be interested in discussing finances with their doctor if this would promote shared decision making that considered finances without affecting quality of care. Financial toxicity affects a significant proportion of patients with metastatic cancer, even among a well-insured population. Changes in employment status may be one driver of financial distress in this population. Greater access to financial counseling or improved communication between patients and the healthcare team, with an emphasis on shared decision making and focus on quality of care, may reduce financial toxicity.