Financial Toxicity in Patients with Gynecologic Cancer Undergoing Brachytherapy

Abstract

<h3>Purpose/Objective(s)</h3> Financial toxicity (FT) affects about 50% of patients with gynecologic cancer. Brachytherapy (BT) is an important component of treatment for many of these patients. We aimed to assess factors that contribute to FT in patients with gynecologic cancer who undergo BT. <h3>Materials/Methods</h3> Gynecologic oncology patients undergoing BT from October 2017-February 2021 completed a survey that included demographics, EQ-5D-3L to measure quality of life, and Comprehensive Score for Financial Toxicity (COST) tool to measure FT. High FT was defined as a COST score ≤23. We stratified patients into 3 groups: vaginal BT (VBT) only, VBT with external beam radiation therapy (EBRT + VBT), or "other" types of BT with external beam radiation therapy (EBRT + other BT). "Other" types of BT included tandem with ovoids/ring and interstitials. Data are presented as percent or median (interquartile range) and compared with Chi-square/Fisher's exact test and Wilcoxon rank-sum test, respectively. We used modified Poisson regression to calculate risk ratios (RR) and 95% confidence intervals (CI). <h3>Results</h3> Among 101 respondents, median COST score was 30 (21-35); 28% had high FT (median COST: 14 (9-19)) and 72% had low FT (median COST: 32 (28-37)). Respondents were white (81%), 9% Black, and 7% Asian. Median age was 63 (57-71), with a younger age in the high FT group [59 (49-62)] compared to the low FT group [67 (61-72), p<0.01]. In the high FT group, 68% of patients had private insurance, whereas 38% had private insurance in the low FT group (p<0.01). Most patients (71%) had uterine cancer, followed by cervical (23%) and vaginal/vulvar (6%) cancer. The majority (69%) had stage I disease; 51% received VBT alone, 29% received EBRT + VBT, and 21% received EBRT + other BT. Treatment group was significantly associated with FT. VBT alone was more common in the low FT group (58%) than the high FT group (32%), and EBRT + VBT was less common in the low FT group (21%) than the high FT group (50%, p=0.01). Patients who had EBRT + VBT were 2.8 times (95% CI 1.2-6.5) more likely to have high FT compared to VBT patients; this association was attenuated when adjusting for age and insurance (RR 2.0; 95% CI 0.84-4.7). Of the assessed cost-coping strategies, borrowing money was reported by 31% of the EBRT + VBT, 24% of the EBRT + other BT, and 2% of the VBT groups (p<0.01), and reduced leisure spending was reported by 31% of the EBRT + VBT, 5% of the EBRT + other BT, and 16% of the VBT groups (p<0.01). <h3>Conclusion</h3> A substantial proportion of patients going through BT have high FT. Younger age and private insurance were associated with higher FT. There is a higher risk of FT associated with undergoing EBRT. Patients who go through only VBT were least likely to have high FT. Patients going through EBRT were more likely to borrow money and reduce leisure spending as cost-coping strategies. Further research is needed to understand specific drivers of high FT for patients receiving EBRT and to evaluate FT over time.