Severity of Financial Toxicity for Patients Receiving Palliative Radiation Therapy

Abstract

Patients receiving palliative radiotherapy (RT) are often at their most vulnerable state, but the impact of financial toxicity on their health and quality of life (QOL) is not well-described. We set out to determine the degree of financial toxicity in a population undergoing palliative RT. A review of patients referred for palliative RT at our site was conducted. Financial toxicity was determined with COST-FACIT, and previously suggested grading cutoffs were used. Additional patient-reported outcome (PRO) instruments included the EORTC overall health and quality of life questions and the FACIT-TS-G (treatment satisfaction). Multiple imputations by chained equations using predictive mean matching were used for incomplete responses. Spearman's rank correlation coefficient, Kruskal-Wallis testing, and linear regressions were used to measure associations. A total of 53 patients were identified who had completed PRO surveys between May 2021 and December 2022. Median COST was 25 (range 0-44), with lower scores indicating greater financial toxicity. 49% reported grade 0 financial toxicity (COST ≥26), 32% had grade 1 financial toxicity (COST 14-25), 19% had grade 2 financial toxicity (COST 1-13), and 6% had grade 3 financial toxicity (COST = 0). Overall, cancer caused financial hardship among 45%. Higher COST was moderately associated with higher overall health (rho = 0.36, p = 0.02) and weakly associated with higher QOL (rho = 0.28, p = 0.07). From a demographic standpoint, median area family income from census tract data was $98,598 (range $32,303-$190,833), and higher income was associated with higher COST (rho = 0.47, p<0.001). Having Medicare (beta = 13.8, p = 0.003) or private (beta = 13.5, p = 0.001) coverage (rather than Medicaid) were associated with less financial toxicity, whereas having an underrepresented minority background (beta = -13.2, p<0.001), or having a non-English language preference (rho = 0.40, p = 0.003) were associated with greater financial toxicity. Median time from diagnosis was 12.9 mo, and 40% of patients had ≥2 prior systemic therapies. The median RT dose was 25 Gy (range 4-45 Gy). The most common irradiated sites included spine (24%), non-spine bones (21%), brain (18%), and lung/mediastinum (18%). COST was not associated with number of prior systemic therapies (p = 0.31), RT dose (p = 0.83), RT technique (p = 0.86), or treatment satisfaction (p = 0.34). Median follow up was 8.0 months, and median 6-month survival was 83% (95% CI 73%-95%). Inferior OS was associated with more prior systemic therapies (HR 3.43, p = 0.03), but not with COST (HR 1.01, p = 0.67). Financial toxicity was seen in approximately half of patients receiving palliative RT. Patient-reported overall health, Medicaid coverage, and area income correlated well with financial toxicity, but the investigated clinical characteristics did not. This supports the hypothesis that financial toxicity is common and a unique factor that should be measured in cancer patients.