Financial toxicity in patients with lung cancer: a scoping review protocol

Patient Reported Financial Toxicity in Acute Leukemia

Assessment of the prevalence and related factors of financial toxicity in cancer patients based on the COST scale: A systematic review and meta-analysis

To describe financial toxicity (FT) in patients with resected lung cancer and identify risk factors in this population. FT describes the financial burden associated with cancer care and its impact on the quality of survivorship. Few prior studies have examined FT in patients with lung cancer. Patients who underwent lung cancer resection at our institution between January 1, 2016 and December 31, 2021, were surveyed to gather demographic information and evaluate FT using a validated questionnaire. A multivariable model was built to identify risk factors for FT. Of the total, 1477 patients were contacted, of whom 463 responded (31.3%). Most patients were stage I (n = 349, 75.4%) and lobectomy was performed often (n = 290, 62.8%). There were 196 patients (42.3%) who experienced FT. Upon multivariable analyses, divorced marital status [odds ratio (OR) = 3.658, 95% CI: 1.180-11.337], household income <$40,000 (OR = 2.544, 95% CI: 1.003-6.455), credit score below 739 (OR = 2.744, 95% CI: 1.326-5.679), clinical stage >I (OR = 2.053, 95% CI: 1.088-3.877), and change in work hours or work cessation (all P < 0.05) were associated with FT. Coping mechanisms, such as decreased spending on food or clothing and increased use of savings or borrowing money, were more likely to be reported by patients experiencing FT than those who did not ( P < 0.001). Patients undergoing lung cancer resection often experienced significant financial stress with several identifiable risk factors. FT should be considered early in the care of these patients to alleviate detrimental coping mechanisms and enhance their quality of survivorship.

Cancer-related financial toxicity impacts head and neck cancer patients and survivors. With increasing use of proton therapy as a curative treatment for head and neck cancer, the multifaceted financial and economic implications of proton therapy—dimensions of “financial toxicity”—need to be addressed. Herein, we identify knowledge gaps and potential solutions related to the problem of financial toxicity. To date, while cost-effectiveness analysis has been used to assess the value of proton therapy for head and neck cancer, it may not fully incorporate empiric comparisons of patients' and survivors' lost productivity and disability after treatment. A cost-of-illness framework for evaluation could address this gap, thereby more comprehensively identifying the value of proton therapy and distinctly incorporating a measurable aspect of financial toxicity in evaluation. Overall, financial toxicity burdens remain understudied in head and neck cancer patients from a patient-centered perspective. Systematic, validated, and accurate measurement of financial toxicity in patients receiving proton therapy is needed, especially relative to conventional photon-based strategies. This will enrich the evidence base for optimal selection and rationale for payer coverage of available treatment options for head and neck cancer patients. In the setting of cancer care delivery, a combination of conducting proactive screening for financial toxicity in patients selected for proton therapy, initiating early financial navigation in vulnerable patients, engaging stakeholders, improving oncology provider team cost communication, expanding policies to promote price transparency, and expanding insurance coverage for proton therapy are critical practices to mitigate financial toxicity in head and neck cancer patients.

Background: The impact of financial toxicity is extensive and far‐reaching, even affecting the prognosis of patients with lung cancer. While the influence of sociodemographic factors on financial toxicity in patients with lung cancer has been identified, the exploration of the impact of psychosocial factors remains insufficient. Aims: This study aims to explore the influencing factors and their pathways of financial toxicity in patients with lung cancer. Methods: This was a cross‐sectional study that utilized a convenience sampling method to select hospitalized patients with lung cancer as research population from a tertiary hospital in Sichuan Province between May and November 2023. Investigations were conducted using a general information questionnaire, Comprehensive Scores for Financial Toxicity, Social Support Rating Scale, and General Self‐Efficacy Scale. Data analysis was performed using descriptive analysis, Mann–Whitney U test, Kruskal–Wallis H test, Spearman correlation analysis, stepwise linear regression analysis, and path analysis. Results: The influencing factors of financial toxicity in patients with lung cancer include age, family income, commercial insurance coverage, social support, and self‐efficacy. Furthermore, family income and social support have indirect effects on financial toxicity, while self‐efficacy mediates the relationship between social support and financial toxicity. Conclusion: The financial toxicity experienced by patients with lung cancer should be taken seriously. In clinical practice, healthcare professionals should promptly assess the level of financial toxicity in patients with lung cancer and implement personalized and diversified intervention measures to address it.

518 Background: With the rising cost of chemotherapy, the financial toxicity (FT) of systemic therapy can substantially impair patient quality of life. FT is also associated with various socioeconomic factors, one being race. Patients of African American race often bear the worst burden of cancer treatment-related FT, with a 40% increased mortality from breast cancer. The degree to which chemotherapy prior to radiation therapy (RT) impacts FT has yet to be formally quantified. We report early FT findings among African American breast cancer patients prior to receipt of adjuvant RT on the ongoing Navigator-Assisted Hypofractionation (NAVAH) Phase I clinical trial (ClinicalTrials.gov ID: NCT05978232) to assess the impact of chemotherapy on FT. Methods: African-American breast cancer patients undergoing RT were eligible if age 18+ with pathologically confirmed breast cancer following resection. As part of the trial, patients were assisted by a patient navigator during and after treatment. FT was measured using the validated 12-item COmprehensive Score for financial Toxicity-Functional Assessment of Chronic Illness Therapy (COST-FACIT) survey instrument. COST-FACIT scoring was used to find FT in patients before receipt of RT. Values from 26-44 represent Grade 0 FT (none), values from 14-25 represent mild Grade 1 FT (mild), values from 1-13 represent Grade 2 FT (moderate), and values of 0 represent Grade 3 FT (severe). The chi-square test was used to identify statistically significant differences (p &lt;0.05) between patients who received chemotherapy versus no chemotherapy prior to receipt of RT. Results: The first 32 enrolled patients completing the pre-RT COST-FACIT survey were evaluated. 53% of patients underwent chemotherapy before RT. Mild to moderate FT was apparent in 56% of patients. The mean and median COST-FACIT score (range 4.4-39) was 25 (+/- 10.4). 78% of patients who experienced some level of FT underwent chemotherapy and 22% of patients experiencing FT did not receive chemotherapy (p = 0.0015). Of patients who did not experience FT, 21% received chemotherapy and 79% of patients did not. In total, 82% of patients who underwent chemotherapy before RT reported mild to moderate FT. Grade 3 FT was not observed. Conclusions: The NAVAH study is the first to objectively compare FT among patients receiving chemotherapy before RT for early-stage breast cancer. Our findings indicate that more than 80% of patients who underwent chemotherapy experienced FT. Approximately 1 in 5 patients not experiencing FT received chemotherapy. The findings indicate that chemotherapy plays a significant role in patient quality of life, highlighting a subsection of patients who may benefit from proactive financial assistance to reduce the detrimental effect of FT on their livelihood. Clinical trial information: NCT05978232 .

267 Background: Financial toxicity (FT) adversely influences patient quality of life and is a barrier to clinical trial enrollment. Early phase clinical trials (EPTs) primarily recruit patients with advanced malignancies who have received all standard therapy regimens and may thus have high levels of FT. We sought to assess baseline FT and its association with clinicodemographic factors in patients participating in early phase clinical trials. Methods: We conducted a study to assess baseline FT in English-speaking patients (pts) with advanced metastatic solid tumors who were participating in EPTs at the Yale Cancer Center (Yale) and the Tisch Cancer Institute at Mount Sinai (Sinai). Pts were consented after EPT consent and prior to day 1 of study treatment. Pts completed a clinical and demographic questionnaire as well as the 11-item validated Comprehensive Score for Financial Toxicity (COST) FT instrument. Primary endpoints included baseline FT and association with clinicodemographic variables. Statistical analysis was performed using two-sided T-tests and Pearson correlations for numeric data and Fisher’s Exact Test for categorical data. Multivariate analysis was performed using a linear regression model. Results: 138 pts enrolled in this study, of whom 132 completed the COST instrument (Yale, N = 84; Sinai, N = 48). Median age was 62 and 49.2% were male. 71.2% patients self-identified as White and 15.2% as Black; 7.2% identified as Hispanic. 32.6% reported an annual income of &lt; $50,000. Insurance providers included private insurers (50%), Medicare (31.8%), Medicaid (10.6%), and Medicaid with Medicare supplemental (3.8%). 56.8% reported monthly out of pocket medical expenses of $100 or more. Median FT score was 22.5 out of a maximum score of 44 (mean 21.5). FT scores ≥ 22.5 in pts were associated with age &lt; 65 (OR = 2.229, P = 0.04), being the household money manager (OR = 2.98, P = 0.02), and being the primary wage earner (OR = 3.12, P = 0.004). FT scores &lt; 22.5 in pts was associated with retirement (OR = 0.15, P = 3.67e-05). In multivariate analysis, retirement was associated with FT score &lt; 22.5 (OR = 0.18, P = 0.02). There was no statistically significant difference in FT scores between Yale and Sinai pts. However, Sinai pts were more racially diverse (p = 3.05e-05), had lower household income (P = 0.01), out of pocket expenses (P = 0.01), ED visits (P = 0.0075), and dependents (P = 0.004) and were less likely to have private insurance (P = 0.004). Conclusions: Pts with advanced cancers consenting to EPTs report significant baseline FT. Our study encompasses a diverse population from two large urban academic centers. Baseline FT was higher among pts &lt; 65 years of age, primary wage earners, and those who managed household finances independently. Retirement was a protective factor, which may be explained by the life savings often required to retire. Ongoing work will compare baseline and 2 month FT in this patient population.

Cancer patients experience severe financial toxicity, with the mechanisms influencing the relationship between socioeconomic status and financial toxicity in lung cancer patients remaining poorly defined. This study aims to investigate how social support and self-efficacy mediate the association between socioeconomic status and financial toxicity among lung cancer patients in China. A survey of 755 lung cancer patients was conducted at a tertiary oncology hospital in Shandong Province, China, from October to December 2023, utilizing random sampling. Data collection included demographic and socioeconomic details, along with assessments of social support, self-efficacy, and financial toxicity. Regression and Bootstrap analyses were used to explore the sequential mediating effects of socioeconomic status, self-efficacy, social support, and financial toxicity. (1) Significant correlations emerged among socioeconomic status, social support, self-efficacy, and financial toxicity (p < 0.05). (2) Socioeconomic status was significantly associated with financial toxicity (p < 0.05). (3) Self-efficacy mediated the relationship between socioeconomic status and financial toxicity (β = 0.203, p < 0.05), whereas social support did not exhibit a mediating effect in this relationship (β = 0.039, p = 0.194). (4) Social support and self-efficacy had a chain-mediated role in the relationship between socioeconomic status and financial toxicity in patients with multimorbidity (β = 0.072, p < 0.05). This study identifies social support and self-efficacy as chained mediators that link socioeconomic status with financial toxicity among lung cancer patients. It is recommended that targeted interventions be implemented to increase social support for patients with lower socioeconomic status to mitigate financial toxicity.

318 Background: Financial toxicity (FT), a patient-reported outcome measure (PROM) is defined as the detrimental impact of financial burden caused by a cancer diagnosis on a patient’s well-being. FT is common among cancer patients, yet little is known about FT following radical prostatectomy (RP) for prostate cancer in countries with universal health coverage. We aimed to assess de novo FT and its impact on health-related quality of life (HRQOL) in a large prospective cohort of patients undergoing RP with a systematic follow-up of up to 10 yrs. Methods: 2254 consecutive patients who underwent RP at a large tertiary care center were analyzed. PROMs were prospectively assessed preoperatively, postoperatively at 3mo, then annually until a maximum follow-up of 120mo, applying the validated EORTC QLQ-C30- and the prostate cancer-specific QLQ-PR25 questionnaires. FT was assessed by the “financial toxicity subscale” (FTS) of the EORTC QLQ-C30. Based on previous reports, meaningful FT was defined as FTS ≥ 17. Multivariable regression analysis was used to identify predictors for the development of de novo FT. Separate modeling of longitudinal HRQOL was performed for patients with de novo FT (FT-cohort) and without FT (no-FT-cohort). General HRQOL was assessed by the global health status domain (GHS) of the EORTC QLQ-C30. Results: 298 patients reporting FT prior RP were excluded from further analysis. 20.3% (n=397) of the included patients reported de novo FT within 12 months after RP with a mean FTS-score of 47.3 (SD 21.9). Baseline clinicopathological characteristics did not differ between the FT-cohort and the no-FT-cohort (p-range .060-.173). Multivariable logistic regression analysis revealed subsequent therapies following RP (OR 1.981, 95%CI 1.11-3.53, p=.020), low preoperative emotional functioning (OR 0.990, 95%CI 0.92-0.99, p=.031) and low preoperative social functioning (OR 0.990, 95%CI 0.98-0.99, p=.035) to independently predict development of de novo FT after RP. In longitudinal analysis, significantly worse general HRQOL was observed for patients with de novo FT postoperatively and up to 48mo after RP (p-value each &lt; .001). In the longer term, both cohorts reported no significant difference in general HRQOL up to 10yrs post RP (p-range: .90 - .91). Conclusions: The current study provides prospective data from a unique contemporary patient cohort, which reveals independent predictors for de novo FT in prostate cancer patients following RP. Furthermore, it displays the natural course of general HRQOL for patients who develop de novo FT.

Objective: To investigate financial toxicity (FT) and the factors influencing it in patients with chronic kidney disease undergoing peritoneal dialysis (PD). Methods: A cross-sectional design was used. From August 2023 to December 2023, 148 PD patients were selected for investigation. The selection was conducted using the convenience sampling method across Shenzhen Third People’s Hospital, Peking University Shenzhen Hospital, and The First Affiliated Hospital of Guangzhou University of Chinese Medicine. Patients’ financial toxicity was assessed using a general demographic questionnaire, laboratory test results, and the Comprehensive Score for Financial Toxicity-Functional Assessment of Chronic Illness Therapy (COST-FACIT). t tests, ANOVA, Pearson χ2 test, and multiple linear regression analysis were used to evaluate the predictors of FT in patients with PD. Results: Seventy-nine patients (53.38%) had mild FT, and 61 patients (41.21%) had moderate FT. Age, working status, monthly household income per capita, and PD-related complications were significantly associated with FT in PD patients (P &lt; 0.05). Conclusions: There were varying degrees of FT in PD patients. Measuring FT can help medical professionals develop treatment care strategies, reduce the financial burden on patients, and avoid treatment interruption.

Financial toxicity is commonly reported by cancer patients, but few studies have assessed caregiver perceptions. We aimed to validate the modified Comprehensive Score for Financial Toxicity (COST) in cancer caregivers, identify factors associated with financial toxicity in both patients and caregivers, and assess the association of caregiver financial toxicity with patient and caregiver outcomes. Using a convenience sampling method, 100 dyads of adult cancer patients and a primary caregiver visiting outpatient oncology clinics (Jan-Sep 2019) were recruited. We assessed the internal consistency and convergent and divergent validity of the modified COST. Multivariable analyses identified correlates of financial toxicity. Association of financial toxicity with care non-adherence, lifestyle-altering behaviors (e.g., home refinance/sale, retirement/saving account withdrawal), and quality of life (QOL) was investigated. Recruited patient vs. caregiver characteristics were as follows: mean age: 60.6 vs. 56.5; 34% vs. 46.4% female; 79% vs. 81.4% white. The caregiver COST measure demonstrated high internal consistency (Cronbach α = 0.91). In patients, older age (B, 0.3 [95% CI, 0.1-0.4]) and higher annual household income (B, 14.3 [95% CI, 9.3-19.4]) correlated with lower financial toxicity (P < 0.05). In caregivers, lower patient financial toxicity (B, 0.4 [95% CI, 0.2-0.6]) and cancer stages 1-3 (compared to stage 4) (B, 4.6 [95% CI, 0.4-8.8]) correlated with lower financial toxicity (P < 0.05). Increased caregiver financial toxicity correlated with higher care non-adherence in patients, increased lifestyle-altering behaviors, and lower QOL in patients and caregivers (P < 0.05). The COST measure can also be used to assess caregiver financial toxicity. Caregivers' financial toxicity was associated with negative outcomes for both dyad members.

This study aims to investigate the longitudinal trajectories of family functioning and financial toxicity in glioma patients, while examining their predictive interrelationships, to establish evidence-based strategies for alleviating economic burden in neuro-oncology care. This prospective longitudinal cohort study enrolled 266 glioma patients from the Second Affiliated Hospital of Xuzhou Medical University and Xuzhou Central Hospital (January 2022-June 2024). Family functioning and financial toxicity were serially assessed at three timepoints: baseline (T1, initial diagnosis), 3-month follow-up (T2), and 6-month follow-up (T3). Structural equation modeling (SEM) framework incorporated cross-lagged panel analysis and latent growth curve modeling to examine temporal relationships. A total of 242 valid consecutive questionnaires were collected. The cross-lagged panel analysis demonstrated that the average family functioning level significantly and positively predicted subsequent financial toxicity at follow-up time points (β = 0.478, p = 0.01; β = 0.463, p < 0.001), while financial toxicity exhibited no significant longitudinal predictive effect on family functioning across subsequent assessments. The latent growth curve modeling revealed parallel declining trajectories: family functioning (slope [S] = -0.410, p < 0.001) and financial toxicity (slope [S] = -0.102, p < 0.001) both decreased significantly from T1 to T3. At baseline, family functioning showed positive correlation with financial toxicity scores (r = 0.377, p = 0.002). Initial family functioning level demonstrated dual regulatory effects: (1) negative auto-regulation (β = -0.352, p = 0.007) and (2) inverse prediction of financial toxicity's developmental trajectory (β = -0.516, p = 0.002). Crucially, the initial family functioning level exhibited compensatory effects on financial toxicity dynamics, showing negative coupling with its growth rate (β = -0.534, p < 0.001). Family functioning and financial toxicity of glioma patients can predict each other. The initial level of family functioning can positively predict the initial level of financial toxicity, the initial level of family functioning can negatively predict the development speed of itself and financial toxicity, and the development speed of family functioning can positively predict the development speed of financial toxicity.

e24116 Background: Current financial toxicity (FT) screening tools rely on patient-reported risk factors (RF)1. Underrepresented populations may not be forthcoming about FT fears due to cultural concerns of treatment withholding or migratory repercussions, if applicable1–4. Identifying objective RF, such as social determinants of health (SDH) and disease-specific factors (DSF), could reduce FT in cancer patients and healthcare systems. Methods: This was a multi-center retrospective study evaluating SDH and DSF associated with FT (defined as ≥$15,000 owed) related to cancer treatment. Inferential statistics were used to evaluate differences between the FT cohort and those who owed &lt; $15,000. Continuous data were compared with a Student’s t or Mann-Whitney U test, depending on distribution. Categorical outcomes were compared with a chi square test. A logistic regression model was used to evaluate multivariate associations with FT, using p &lt; 0.05 to define significant results. Results: The sample comprised 162 records, 81 in each group. Univariate analyses demonstrated differences in age, lack of PCP, non-US country of origin, lack of insurance, lower education levels, need for an English interpreter, stage 4 at diagnosis, recurrent or metastatic disease, use of immune checkpoint inhibitors (ICI), and use of targeted molecular therapy (TMT) (Table 1). Employment status and marital status were not statistically different. The logistic regression model showed that lack of insurance and stage 4 at diagnosis were significantly associated with FT (p = 0.001 and p = 0.0495, resp.). Conclusions: Objective FT screening can minimize response bias and incidence in those at increased risk. Non-US country of origin and lack of English proficiency suggests that first-generation Hispanics may not be appropriately navigated for FT. These findings identify specific subpopulations at risk for FT and will guide prospective interventions looking to minimize FT. Healthcare systems should analyze objective measures of FT while considering loco-regional and subcultural SDH/DSF in order to overcome response bias. Ref. Witte J et al. Methods for measuring financial toxicity after cancer diagnosis and treatment. Annals of Oncology. 2019;30(7) Strasser-Weippl K et al. Progress and remaining challenges for cancer control in Latin America and the Caribbean. Lancet Oncol. 2015;16(14) Zhu Z et al. Cancer survivors’ experiences with financial toxicity. Psychooncology. 2020;29(6) Chebli P et al. Multilevel determinants of financial toxicity in breast cancer care. Supportive Care in Cancer. 2020;28(7). [Table: see text]

ObjectiveUsing the Comprehensive Score for Financial Toxicity (COST) tool to measure financial toxicity (FT) among differentiated thyroid cancer (DTC) patients in China and investigate the association between FT and psychological distress.MethodsWe carried out a cross-sectional investigation of individuals who had survived DTC in two tertiary medical facilities. The assessment of FT was performed using the Chinese version of the COST tool. The National Comprehensive Cancer Network (NCCN) Distress Thermometer (DT) was used to measure psychological distress. A multivariate logistic regression model was constructed to identify factors related to FT, and the Pearson correlation was used to evaluate the association between COST and DT scores.ResultsOut of the 207 patients who participated in this study, the average COST score was 16.3. Notably, the prevalence of financial toxicity was 47.8% (95% CI: 41% ~ 54.7%) of the patients. Of these, 22.7% (47/207) were mild FT, 23.7% (49/207) were moderate FT, and 1.4% (3/207) were severe FT. Four variables were found to be associated with increased FT in the logistic regression model, younger age (odd ratio [OR], 4.52; p = 0.003), lower educational level [OR], 1.13; p = 0.040, uninsured (odd ratio [OR], 6.53; p = 0.028), had lower household income (odd ratio [OR], 6.34; p = 0.037), and advanced cancer (odd ratio [OR], 2.99; p = 0.034). Furthermore, the Pearson correlation revealed a mild correlation between financial toxicity and psychological distress (r = −0.53, p &amp;lt; 0.001).ConclusionIn this study, the prevalence of FT in DTC patients was 47.8%. FT was associated with younger age, lower educational level, uninsured, had lower household income, and advanced cancer. Clinicians should identify patients by predictors early and conduct psychological interventions.

Predictors of Financial Toxicity in Patients Receiving Concurrent Radiation and Chemotherapy