Cost Of Cancer Care Research Articles

Disparities in healthcare expenditures according to economic status in cancer patients undergoing end-of-life care

BackgroundsA desire for better outcome influences cancer patients’ willingness to pay. Whilst cancer-related costs are known to have a u-shaped distribution, the actual level of healthcare utilized by patients may vary depending on income and ability to pay. This study examined patterns of healthcare expenditures in the last year of life in patients with gastric, colorectal, lung, and liver cancer and analyzed whether differences exist in the level of end-of-life costs for cancer care according to economic status.MethodsThis study is a retrospective cohort study which used data from the Korean National Elderly Sampled Cohort, 2002 to 2015. End-of-life was defined as 1 year before death. Economic status was classified into three categorical variables according to the level of insurance premium (quantiles). The relationship between the dependent and independent variables were analyzed using multiple gamma regression based on the generalized estimated equation (GEE) model.ResultsThis study included 3083 cancer patients, in which total healthcare expenditure was highest in the high-income group. End-of-life costs increased the most in the last 3 months of life. Compared to individuals in the ‘middle’ economic status group, those in the ‘high’ economic status group (RR 1.095, 95% CI 1.044–1.149) were likely to spend higher amounts. The percentage of individuals visiting a general hospital was highest in the ‘high’ economic status group, followed by the ‘middle’ and ‘low’ economic status groups.ConclusionHealthcare costs for cancer care increased at end-of-life in Korea. Patients of higher economic status tended to spender higher amounts of end-of-life costs for cancer care. Further in-depth studies are needed considering that end-of-life medical costs constitute a large proportion of overall expenditures. This study offers insight by showing that expenditures for cancer care tend to increase noticeably in the last 3 months of life and that differences exist in the amount spent according economic status.

Financial Toxicity Among Older Mexican Adults With Cancer and Their Families: A Mixed-Methods Study.

PURPOSEThe financial toxicity (FT) of cancer is common among older adults in high-income countries, but little is known about the financial hardships faced by older patients with cancer living in developing countries. The aim of this study was to explore the financial burden of cancer among older Mexican adults and their relatives, as well as factors that might mitigate such burden.METHODSThis mixed-methods study included patients age 65 years and older with the 10 most common malignancies in Mexico and 3-24 months from diagnosis at two cancer centers in Mexico City and their relatives. For the quantitative component, patients and relatives answered the Spanish version of the Consumer Financial Protection Bureau Financial Well-Being Scale. Patients completed the Comprehensive Score for Financial Toxicity-Functional Assessment of Chronic Illness Therapy (COST-FACIT) scale and a 3-month, self-reported cost diary. For the qualitative component, focused interviews were used to explore the individual experiences of patients and their relatives.RESULTSNinety-six patients and their relatives were included, of whom 45% had stage IV disease. On the COST-FACIT scale, 9% reported no FT, 52% mild FT, 39% moderate FT, and 0% severe FT. The mean Consumer Financial Protection Bureau Financial Well-Being Scale score was 45.2, with 78% reporting poor financial well-being (score ≤ 50). On cost diaries, most expenses were associated with purchasing medications, including chemotherapy. Focused interviews showed that most patients and relatives had to acquire debt to face costs of cancer care.CONCLUSIONA high proportion of Mexican older adults with cancer reported FT and poor financial well-being. Understanding experiences associated with FT and strategies to mitigate it represents an essential first step to design public policies aimed at protecting older adults with cancer and their families from catastrophic spending.

Abstract P4-11-25: Burden of financial toxicity in an underserved population of breast cancer survivors

Abstract Background: The impact of financial toxicity (FT) on cancer patients is significant in terms of lost productivity and poor quality of life (QoL). Past studies have reported negative influence of high FT on patients actively undergoing treatment for breast cancer. However, existing data largely comes from quaternary referral centers, and the populations surveyed may not be generalizable in terms of income and insurance status across the United States. There is also limited understanding regarding the relationship between FT measured throughout the continuum of cancer care, demographics, disease factors, and QoL indicators in breast cancer survivors, particularly those from underserved communities. Methods: Breast cancer survivors who received treatment between 2015 and 2019 at Loma Linda University Cancer Center located in San Bernardino County, CA were invited to complete an anonymous online survey assessing demographics, disease history, FT, and QoL. A modified version of the Comprehensive Score for Financial Toxicity (COST) survey was used to assess FT at baseline and after treatment. The patient-reported outcomes measurement information system (PROMIS) survey was used to assess QoL. Demographic data were summarized using descriptive statistics. Associations between disease factors and FT measured at baseline and after treatment were analyzed using multivariable linear regression. Positive COST score coefficients indicate lower FT, while negative COST score coefficients indicate higher FT. Correlations between FT and QoL were evaluated using the Pearson correlation. Results: A total of 407 surveys were sent to breast cancer survivors who met study criteria, of whom 16% responded. Amongst 65 patients included in this analysis, the median age was 64 (IQR 56, 70), 68% were white (n = 44), 18% were unemployed, 13% had a high school or lower level of education, and 16% had an annual income < $30,000. Mean COST score at baseline and after treatment were 21.6 ± 9.6 and 12.9 ± 7.8, respectively. During treatment, 21% of patients turned down or skipped treatment, 23% quit their job, and 15% reported family members quit their job. At baseline, lower FT was significantly associated with age > 80 (6.2 95% CI: 4.1 to 8.3), presence of a college (4.5 95% CI: 1.4 to 10.4) or graduate degree (5.2 95% CI: 4.7 to 6.2), current employment (2.7 95% CI: 2.0 to 3.4), retiree status (6.7 95% CI: 0.4 to 13.0), and household income > $30,000 (5.9 95% CI: 2.7 to 9.1) (p < 0.05), while higher FT was significantly associated with Hispanic ethnicity (-4.1 95% CI: -6.7 to -1.5), Medicare (-1.6 95% CI: -5.2 to -2.0), and Medicaid insurance (-6.9 95% CI: -12.5 to -1.2) (p < 0.05). After treatment, higher FT was significantly associated with receiving 3 or more combined modality treatments (-5.6 95% CI: -9.7 to -1.5) and having 5 or more treatment-related side effects (-6.0 95% CI: -10.4 to -1.6) (p < 0.05). Finally, FT after treatment overall correlated positively with physical and mental health (Pearson coefficient 0.63 and 0.60 respectively, p < 0.01). Conclusions: These findings suggest a significant association between FT, baseline demographics, treatment modalities, side effects, and quality of life in an underserved population of breast cancer survivors. In the future, FT should be assessed at baseline and throughout the continuum of breast cancer care to provide individualized assistance to patients facing financial strain, as it affects compliance to treatment which in turn can adversely affect cancer-related outcomes and QoL. Additional policies are needed to address the increasing cost of breast cancer care. Citation Format: Akhil Mehta, Jukes Namm, Ellen D'Errico, Eric Lau, Sharon Lum, Gayathri Nagaraj. Burden of financial toxicity in an underserved population of breast cancer survivors [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P4-11-25.

Impact of venous thromboembolism in hospitalized patients with pancreatic cancer: A nationwide inpatient sample (NIS) study.

535 Background: Pancreatic cancer (PC) has a strong association with venous thromboembolism (VTE) but the impact of it on mortality and morbidity is unknown. Inpatient costs contribute significantly to the overall cancer care costs even though there is a modest improvement in survival of pancreatic cancer patients. This study aims to determine the mortality trends and associated health care utilization in PC patients with and without VTE and to analyze its impact on hospitalized patients. Methods: We used National Inpatient Sample (NIS) to extract data for all patients above 18years of age hospitalized with a primary diagnosis of Pancreatic cancer from 2002-2018 using ICD-9 and ICD-10 codes. Unadjusted odds ratio for dichotomous outcomes were calculated, and independent t test analysis was done for continuous outcomes. Results: The odds of all-cause mortality (OR 1.35, 95% CI 1.33-1.37, p<0.001) and stroke (OR 1.82, 95% CI, 1.76-1.87, p<0.001) were significantly higher in pancreatic cancer patients with VTE compared to without VTE. PC patients with VTE were found to have significantly higher average cost of hospitalization (US $56101 vs US $46325, p<0.001) and longer length of stay(LOS) (8.20 vs 6.83, p<0.001) when compared to patients without VTE. Conclusions: Hospitalized PC patients with VTE have higher odds of mortality and stroke when compared to PC patients without VTE. Similarly, VTE in PC patients is shown to increase the hospitalization costs and overall length of stay.[Table: see text]

An Analysis of Hospital Costs for Childhood Cancer Care.

This study used a linked dataset consisting of all childhood cancers recorded over the course of 10 years in New South Wales (NSW), Australia, to evaluate the hospital and emergency department costs (from a payer perspective) and resources used by patients with childhood cancer. We also analyzed determinants responsible for high-frequency hospital admissions, hospital length of stay (LoS), and hospital costs. We analyzed linked data at the individual patient level for a retrospective cohort of 2,966 patients with cancer aged <18 years with a diagnosis date between 2001 and 2012 from the NSW Central Cancer Registry, Australia. We reported costs and use of hospitalization and emergency department presentation 1 year before the date of diagnosis, 1 year after diagnosis, and 2 to 5 years after diagnosis. We also examined the association between cancer types and hospital admission and hospital costs from the payer perspective. Patient characteristics associated with the frequency of hospital admissions, hospital LoS, and hospital costs were also determined using a generalized linear model. Most hospital admission costs occurred in the first year after diagnosis, accounting for >70% of hospital costs within 5 years after diagnosis. The estimated median annual cost of hospitalization in the first year after diagnosis was A$88,964 (interquartile range [IQR], A$34,399-A$163,968) for patients diagnosed at age 0 to 14 years and A$23,384 (IQR, A$5,585-A$91,565) for those diagnosed at age 15 to 17 years. Higher frequency of hospital admissions, hospital LoS, and hospital costs were significantly associated with younger age at cancer diagnosis, cancer metastases, and living in remote/disadvantaged socioeconomic areas. Our study represents one of the first in Australia to include detailed hospitalization cost information for all childhood cancer cases. This study highlights the high hospital use by pediatric patients and the importance of early diagnosis. Our findings also demonstrate the health inequities experienced by patients from remote areas and the lowest socioeconomic areas.

Prioritising systemic cancer therapies applying ESMO’s tools and other resources to assist in improving cancer care globally: the Kazakh experience

BackgroundIn Kazakhstan, cancer is the second leading cause of death with a major public health and economic burden. In the last decade, cancer care and cancer medicine costs have significantly increased. To improve the efficiency and efficacy of cancer care expenditure and planning, the Kazakhstan Ministry of Health requested assistance from the World Health Organization (WHO) and the European Society for Medical Oncology (ESMO) to review its systemic cancer treatment protocols and essential medicines list and identify high-impact, effective regimens.Materials and methodsESMO developed a four-phase approach to review Kazakhstan cancer treatment protocols: (i) perform a systematic analysis of the country’s cancer medicines and treatment protocols; (ii) cross-reference the country’s cancer protocols with the WHO Model List of Essential Medicines, the ESMO-Magnitude of Clinical Benefit Scale and the European Medicines Agency’s medicine availability and indications database; (iii) extract treatment recommendations from the ESMO Clinical Practice Guidelines; (iv) expert review for all cancer medicines not on the WHO Model List of Essential Medicines and the country treatment protocols.ResultsThis ESMO four-phase approach led to the update of the Kazakhstan national essential cancer medicines list and the list of cancer treatment protocols. This review has led to the withdrawal of several low-value or non-evidence-based medicines and a budget increase for cancer care to include all essential and highly effective medicines and treatment options.ConclusionWhen applied effectively, this four-phase approach can improve access to medicines, efficiency of expenditure and sustainability of cancer systems. The WHO–ESMO collaboration illustrated how, by sharing best practices, tools and resources, we can address access to cancer medicines and positively impact patient care.

The cost of cancer care: how far would you go for a trial?

BackgroundClinical trials are often considered the gold standard in cancer care. However, patients face barriers in trial participation including distances to cancer centres and personal costs including changing employment status, cost of medications, inpatient admissions, and parking tariffs.AimOur aim was to compare the distances patients travelled for clinical trials compared to those receiving standard systemic anticancer therapy (SACT). We also investigated the additional costs associated with this.MethodsThis was a retrospective review of electronic patient medical records. The distance from the patients’ home address to Beaumont was calculated as a one-way journey in kilometres. Patients attending for clinical trials were compared to those receiving standard of care SACT.ResultsA total of 271 patients receiving standard SACT over a 5-day period and 111 patients enrolled on 24 clinical trials were included. The median one-way distance travelled by patients enrolled in clinical trials was 41.4 km, compared to 14 km in those patients’ receiving standard of care SACT. The median estimated cost was €13 vs €4.20 for those enrolled on clinical trials compared to those receiving standard of care treatment, respectively.ConclusionPatients enrolled on clinical trials often travel more than twice as far to receive their anti-cancer treatment compared to those receiving standard of care SACT and incur an increased cost of travel expenses.

Journeys: understanding access, affordability and disruptions to cancer care in India.

BackgroundMuch of the global cancer burden is in low- and middle-income countries (LMICs). Along with the high incidence of cancer, most LMICs have unevenly distributed health care resources. This study is a qualitative exploration of the journey of patients accessing cancer care in India and their caregivers.MethodsThe study followed a cross-sectional qualitative design. Participants were recruited by stratified purposive sampling, and all common cancers in India as reported by the GLOBOCAN database were included in the study. Consenting patients and their caregivers were interviewed using in-depth interview techniques. The data was analysed using principles of qualitative content analysis.ResultsCancer patients (n = 100) and their caregivers (n = 48) were interviewed for the study. The six themes that emerged were related to a) the journey of patients to access care, b) the psychological journey of patients, c) stigma of cancer patients, d) decision-making and adherence to treatment, e) economic costs of cancer care and its impact and f) modifiers to accessing cancer care.ConclusionsPlanning and policymaking in the future of cancer care delivery need to consider the views expressed by the cancer patients and their caregivers as regards to access, adherence and disruptions to cancer care in India. Future policies will hopefully address some of the difficulties faced by patients.

Role of financial toxicity in perpetuating health disparities

Rising costs of cancer care drive patient financial toxicity (FT) that perpetuates known health disparities in access and quality cancer treatment. This Review discusses how FT is a barrier to cancer research and treatment, and discusses potential solutions to improve affordability and reduce healthcare disparities for our patients.

Think Globally, Start Locally: Value-Based Breast Cancer Care for Newly Diagnosed Patients in A Safety-Net Medical Center

Introduction We assessed the efficacy of a multidisciplinary, patient-focused approach emphasizing appropriate use of medical resources among a population of breast cancer patients at our safety-net hospital. Methods A multidisciplinary program coordinated and provided value-based care. Surgery, oncology, and navigation were physically co-located. Real time decisions were made by medical and surgical oncologists. Focused institution-specific protocols initiated in 2018, advised against four specific cancer resources that our team had determined as lower-value: imaging tests for indications not recommended in NCCN guidelines, inappropriate Oncotype Dx testing, radiation for patients ≥65 years with stage I hormone-positive disease, and administration of pertuzumab and neratinib as adjuvant therapy in HER2+ breast cancer patients. Time to treatment and rates of use of these resources were monitored. Results Newly diagnosed breast cancer patients from 2015-2019 were compared to the pre-protocol era (2015-2017). Time from first breast clinic visit to oncology appointment decreased 39 days (60% decrease, median of 63.0 vs 22.5 days, p&lt;0.001), no patients ≥65 years with stage I hormone-positive breast cancer in 2018-2019 received radiation therapy, and rates of ordering of CT, PET, and bone scans for asymptomatic patients decreased by 80%. Overall survival did not differ by cohort protocol category/treatment choices (p=0.69) Compared to the pre-protocol cohort, the post-protocol cohort did not have a significantly lower risk of death (Hazard Ratio 0.66, 95% Confidence Interval 0.08-5.38, p=0.69). Overall breast cancer care cost decreased by $3,675,374 between 2018 and 2019 versus 2015 to 2017. Conclusions After initiating a breast cancer program focused on reducing rates of use of four commonly excessively ordered breast cancer resources our team identified as lower-value, care at our safety-net hospital achieved high compliance with NCCN maging guidelines and also reduced use of a low-value diagnostic test, and low-value radiation and chemotherapy.

The out-of-pocket cost of breast cancer care at a public tertiary care hospital in Nigeria: an exploratory analysis.

Introductionin Nigeria, the incidence of breast cancer has increased by over 80% in the last four decades. This study quantifies the out-of-pocket (OOP) cost of breast cancer management and the associated rate of catastrophic healthcare expenditure (CHE) at a public tertiary care facility in Ile-Ife, Nigeria.Methodspatients treated between December 2017 - August 2018 were identified from a prospective breast cancer database. A questionnaire was developed to capture the total cost of care, including direct and indirect expenses. Three commonly used thresholds for a CHE were used in this analysis. The cost of radiotherapy and targeted therapy were captured separately.Resultsdata was collected from 22 eligible patients. Sixty-eight percent had no form of health insurance. The mean cost of diagnosis and treatment was $2,049 (SD $1,854). At a threshold of 10% and 25% of annual income, 95% and 86% of households experienced a CHE. Based on a household´s capacity-to-pay, 90% experienced a CHE. The mean cost of radiotherapy was $462 (SD $223) and the mean cost of trastuzumab was $6,568 (SD $2,766). Cost precluded surgery in 14% of patients with resectable disease. As a result of accessing treatment, 72% of households had to borrow money and 9% of households interrupted a child´s education.Conclusionthe out-of-pocket cost of breast cancer care in Nigeria is significant. This results in a CHE for 68-95% of households, which has significant health and economic sequelae. Greater financial protection is essential as the burden of breast cancer increases in Nigeria.

Analysis of the Direct Cost of Medical and Surgical Care for Testicular Cancer in Early and Advanced Stages in a Third Level Medical Facility of the Mexican Social Security Institute.

The testicular cancer prevails in the third decade of life, the care cost increases with higher staging of the disease. Compare the direct costs of medical and surgical attention for testicular cancer in early and advanced stages in a Third Level Medical Facility. Process study, direct costs of medical attention are evaluated. Number of laboratory studies, imaging studies, and medical and surgical treatment were analyzed. The patients were divided into 2 groups: group 1 early stages and group 2 advanced stages. Mann Whitney U test was used for the difference between groups. There were 10 patients in each group, Group 1: 8 (80%) seminomas and 2 (20%) non-seminoma, Group 2: 4 (40%) seminomas and 6 (60%) non-seminomas. The average cost of care in Group 2 is higher than in Group 1, $288,827.90 and $145,911.70 Mexican pesos respectively (p=0.00578). The direct cost of medical attention is higher in the advanced stages compared to the early stages.

Abstract PO-087: Diagnosis in young adulthood as a risk factor for unmet social needs among African American cancer survivors

Abstract Background: Increasing attention is being paid to understanding and addressing the financial consequences of cancer and cancer treatment; however, in addition to the direct and indirect costs of cancer care, survivors with few financial resources also face social needs such as food insecurity and housing instability. On average, young adults have fewer financial resources than older adults, placing them at risk for adverse financial outcomes due to cancer, including unmet social needs. The purpose of this study is to estimate associations between young adult age at diagnosis and prevalence of social needs among African American cancer survivors. Methods: We utilized data from 3,241 participants in the Detroit Research on Cancer Survivors (ROCS) cohort. African American adults were invited to participate if they were between the ages of 20-79 at diagnosis with breast, colorectal, lung, or prostate cancer since January 1, 2013; or diagnosed with endometrial cancer (ages 20-79) or any other cancer (ages 20-49) since January 1, 2016. Cases were identified through the Metropolitan Detroit Cancer Surveillance System, a population-based cancer registry. Participants self-reported several forms of unmet social needs, including food insecurity, recent utility shut-offs, housing instability, inability to get medical care due to lack of transportation, and whether they generally felt safe in their neighborhood. Modified Poisson models estimated prevalence ratios (PR) and 95% confidence intervals (CI) for social needs by age at diagnosis (20-39 vs. 65+) and tests for trend by 4-level age (20-39, 40-54, 55-64, 65+), controlling for demographic, socioeconomic, and cancer-related factors. Results: Overall, 32% of ROCS participants reported experiencing social needs, and prevalence was inversely associated with age at diagnosis such that 48% of survivors diagnosed as young adults reported any social needs compared with 22% of those diagnosed as older adults (PRadjusted: 2.3, 95% CI: 1.8-2.9; ptrend&amp;lt;0.001). Associations between young adult age at diagnosis and social needs were particularly high for utility shutoffs (PRadjusted: 4.7, 95% CI: 2.8-7.8) and food insecurity (PRadjusted: 3.4, 95% CI: 2.3-4.9) compared with those diagnosed as older adults. Young adults also reported substantially higher prevalence of not feeling safe in their neighborhood (PRadjusted: 2.8, 95% CI: 1.7, 4.6), housing instability (PRadjusted: 2.7, 95% CI: 1.7-4.5), and going without medical care due to lack of transportation (PRadjusted: 2.0, 95% CI: 1.2-3.3). There was an inverse association with age and all social needs examined (all ptrend&amp;lt;0.001). Conclusions: Each unmet social need considered was at least twice as common among African American cancer survivors diagnosed as young adults compared with those diagnosed when they were 65 or older. Young adults often have fewer financial resources compared older adults and should be prioritized in the development of interventions aimed at improving financial outcomes among cancer survivors. Citation Format: Theresa A. Hastert, Julie J Ruterbusch, Jean A. McDougall, Jamaica R.M. Robinson, Shaila M. Strayhorn, Andrew Abdallah, Gowri Chandrashekar, Ann G. Schwartz. Diagnosis in young adulthood as a risk factor for unmet social needs among African American cancer survivors [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-087.

Out-of-Pocket Costs Among Patients With a New Cancer Diagnosis Enrolled in High-Deductible Health Plans vs Traditional Insurance

The financial burden of a cancer diagnosis is increasing rapidly with advances in cancer care. Simultaneously, more individuals are enrolling in high-deductible health plans (HDHPs) vs traditional insurance than ever before. To characterize the out-of-pocket costs (OOPCs) of cancer care for individuals in HDHPs vs traditional insurance plans. This retrospective cohort study used the administrative claims data of a single national insurer in the US for 134 826 patients aged 18 to 63 years with a new diagnosis of breast, colorectal, lung, or other cancer from 2008 to 2018 with 24 months or more of continuous enrollment. Propensity score matching was performed to create comparator groups based on the presence or absence of an incident cancer diagnosis. A new cancer diagnosis and enrollment in an HDHP vs a traditional health insurance plan. The primary outcome was OOPCs among individuals with breast, colon, lung, or all other types of cancer combined compared with those with no cancer diagnosis. A triple difference-in-differences analysis was performed to identify incremental OOPCs based on cancer diagnosis and enrollment in HDHPs vs traditional plans. After propensity score matching, 134 826 patients remained in each of the cancer (73 572 women [55%]; median age, 53 years [IQR, 46-58 years]; 110 071 non-Hispanic White individuals [82%]) and noncancer (66 619 women [49%]; median age, 53 years [IQR, 46-59 years]; 105 023 non-Hispanic White individuals [78%]) cohorts. Compared with baseline costs of medical care among individuals without cancer, a breast cancer diagnosis was associated with the highest incremental OOPC ($714.68; 95% CI, $664.91-$764.45), followed by lung ($475.51; 95% CI, $340.16-$610.86), colorectal ($361.41; 95% CI, $294.34-$428.48), and all other types of cancer combined ($90.51; 95% CI, $74.22-$106.79). Based on the triple difference-in-differences analysis, compared with patients without cancer enrolled in HDHPs, those with breast cancer paid $1683.36 in additional yearly OOPCs (95% CI, $1576.66-$1790.07), those with colorectal cancer paid $1420.06 more (95% CI, $1232.31-$1607.80), those with lung cancer paid $467.25 more (95% CI, $130.13-$804.37), and those with other types of cancer paid $550.87 more (95% CI, $514.75-$586.99). Patients with cancer and private insurance experienced sharp increases in OOPCs compared with those without cancer, which was amplified among those with HDHPs. These findings illustrate the degree to which HDHPs offer poorer protection than traditional insurance against unexpected health care expenses. Coupled with the increasing cost of cancer care, higher cost sharing in the form of increasing enrollment in HDHPs requires further research on the potential clinical consequences through delayed or foregone care.

Risk factors for financial toxicity in patients with gynecologic cancer

The cost of cancer care is high and rising. Evidence of increased patient cost burden is prevalent in the medical literature and has been defined as "financial toxicity," the financial hardship and financial concerns experienced by patients because of a disease and its related treatments. With targeted therapies and growing out-of-pocket costs, patient financial toxicity is a growing concern among patients with gynecologic cancer. This study aimed to determine the prevalence of financial toxicity and identify its risk factors in patients with gynecologic cancer treated at a large cancer center using objective data. Using institutional databases, we identified patients with gynecologic cancer treated from January 2016 to December 2018. Patients with a preinvasive disease were excluded. Financial toxicity was defined according to institutionally derived metrics as the presence of ≥1 of the following: ≥2 bills sent to collections, application or granting of a payment plan, settlement, bankruptcy, financial assistance program enrollment, or a finance-related social work visit. Clinical characteristics were gathered using a 2-year look-back from the time of the first financial toxicity event or a randomly selected treatment date for those not experiencing toxicity. Risk factors were assessed using chi-squared tests. All significant variables on univariate analysis were included in the logistic regression model. Of the 4655 patients included in the analysis, 1155 (25%) experienced financial toxicity. In the univariate analysis, cervical cancer (35%), stage 3 or 4 disease (24% and 30%, respectively), younger age (35% for age <30 years), nonpartnered marital status (31%), Black (45%) or Hispanic (37%) race and ethnicity, self-pay (48%) or commercial insurance (30%), clinical trial participation (31%), more imaging studies (39% for ≥9), ≥1 emergency department visit (36%), longer inpatient stays (36% for ≥20 days), and more outpatient clinician visits (41% for ≥20 visits) were significantly associated with financial toxicity (P<.01). In multivariate analysis, younger age, nonpartnered marital status, Black and Hispanic race and ethnicity, commercial insurance, more imaging studies, and more outpatient physician visits were significantly associated with financial toxicity. Financial toxicity is an increasing problem for patients with gynecologic cancer. Our analysis, using objective measures of financial toxicity, has suggested that demographic factors and healthcare utilization metrics may be used to proactively identify at-risk patients for financial toxicity.

Cancer care for displaced children in Lebanon.

Lebanon is a small country on the Mediterranean Sea that has been plagued for decades by civil war and internal strife, which result from regional wars and power struggles. Most of the Lebanese population has access to national governmental health-care plans, but these are inadequate to cover the costs of cancer care; therefore, non-governmental organisations (NGOs) are needed to alleviate financial barriers to care. In 2002, the Children's Cancer Institute was established at the American University of Beirut Medical Center (AUBMC; Beirut, Lebanon), as a collaboration between AUBMC, St Jude Children's Research Hospital (SJCRH; Memphis, TN, USA), the Children's Cancer Center of Lebanon Foundation (CCCL; Beirut, Lebanon), and the American Lebanese Syrian Associated Charities (ALSAC; Memphis, TN, USA). This collaboration supports programmatic growth (ie, specific projects aimed at developing medical programmes and services to optimise cancer care and delivery) at the Children's Cancer Institute, and the CCCL and ALSAC ensure that no family pays out-of-pocket expenses for cancer-directed care. Between 2002 and 2012, the Children's Cancer Institute grew to provide care for 35–40% of children with cancer in Lebanon, and consultations or specialised procedures for an additional 20–25%. Networks of paediatric oncologists across the country were established, using funded disease-specific programmes, in which enrolled patients could access centralised diagnosis, specialised surgeries, radiotherapy, and unified treatment plans in coordination with their referring oncologist. Educational attainment in displaced children with cancerSupporting the health of displaced people is a challenge shared by the health system in the location to which they are displaced, non-governmental organisations, and the international community. This challenge is magnified when the host country is struggling with violence, poverty, and an unstable government. The COVID-19 pandemic has added further strain to an already difficult situation, restricting movement both within and between countries. Since 2014, the UN High Commissioner for Refugees has rolled out capacity-building projects in countries hosting displaced people, with the aim of providing access to health care for non-communicable diseases. Full-Text PDF

The dynamic relationship between cancer and employment-related financial toxicity: an in-depth qualitative study of 21 Australian cancer survivor experiences and preferences for support.

People with a cancer diagnosis experience physical and emotional impacts that may affect employment. Alongside cancer care costs, reduced ability to generate an income is a key contributor to financial toxicity which is associated with poor emotional wellbeing, quality of life, treatment adherence and survival. This study aimed to explore people's experiences of changes to employment and their suggestions for how cancer survivors can be better supported. Semi-structured telephone interviews were conducted with a purposive sample of 21 cancer survivors identified as part of a larger study of emotional distress. Purposive sampling was used to include a diverse group of people across age, gender, tumour type, self-reported financial difficulties and employment status. Interviews were inductively and iteratively coded by two independent coders and analysed using thematic analysis. There is a dynamic relationship between a person's cancer treatment and their employment. For some, employment was disrupted due to physical or emotional impacts of cancer, or workplace stigma and discrimination. Others continued to work at the detriment of their health. Participants wished they had been made aware earlier how cancer might impact their capacity to work, their finances and their health. There was a lack of knowledge on the financial supports that may be available to them. Healthcare professionals may have a role in minimising the financial impact of a cancer diagnosis through early assessment, communication of patients' potential work capacity and appropriate referrals to occupational therapy to aid return to work or financial planning. A robust government social support system specifically for households experiencing cancer is urgently required.

Financial toxicity in cancer care: origins, impact, and solutions.

Financial toxicity describes the financial burden and distress that can arise for patients, and their family members, as a result of cancer treatment. It includes direct out-of-pocket costs for treatment and indirect costs such as travel, time, and changes to employment that can increase the burden of cancer. While high costs of cancer care have threatened the sustainability of access to care for decades, it is only in the past 10 years that the term "financial toxicity" has been popularized to recognize that the financial burdens of care can be just as important as the physical toxicities traditionally associated with cancer therapy. The past decade has seen a rapid growth in research identifying the prevalence and impact of financial toxicity. Research is now beginning to focus on innovations in screening and care delivery that can mitigate this risk. There is a need to determine the optimal strategy for clinicians and cancer centers to address costs of care in order to minimize financial toxicity, promote access to high value care, and reduce health disparities. We review the evolution of concerns over costs of cancer care, the impact of financial burdens on patients, methods to screen for financial toxicity, proposed solutions, and priorities for future research to identify and address costs that threaten the health and quality of life for many patients with cancer.

Health system costs and days in hospital for colorectal cancer patients in New South Wales, Australia.

Colorectal cancer (CRC) care costs the Australian healthcare system more than any other cancer. We estimated costs and days in hospital for CRC cases, stratified by site (colon/rectal cancer) and disease stage, to inform detailed analyses of CRC-related healthcare. Incident CRC patients were identified using the Australian 45 and Up Study cohort linked with cancer registry records. We analysed linked hospital admission records, emergency department records, and reimbursement records for government-subsidised medical services and prescription medicines. Cases' health system costs (2020 Australian dollars) and hospital days were compared with those for cancer-free controls (matched by age, sex, geography, smoking) to estimate excess resources by phase of care, analysed by sociodemographic, health, and disease characteristics. 1200 colon and 546 rectal cancer cases were diagnosed 2006-2013, and followed up to June 2016. Eighty-nine percent of cases had surgery, chemotherapy or radiotherapy, and excess costs were predominantly for hospitalisations. Initial phase (12 months post-diagnosis) mean excess health system costs were $50,434 for colon and $60,877 for rectal cancer cases, with means of 16 and 18.5 excess hospital days, respectively. The annual continuing mean excess costs were $6,779 (colon) and $8,336 (rectal), with a mean of 2 excess hospital days each. Resources utilised (costs and days) in these phases increased with more advanced disease, comorbidities, and younger age. Mean excess costs in the year before death were $74,952 (colon) and $67,733 (rectal), with means of 34 and 30 excess hospital days, respectively-resources utilised were similar across all characteristics, apart from lower costs for cases aged ≥75 at diagnosis. Health system costs and hospital utilisation for CRC care are greater for people with more advanced disease. These findings provide a benchmark, and will help inform future cost-effectiveness analyses of potential approaches to CRC screening and treatment.

Machine Learning Applied to Electronic Health Records: Identification of Chemotherapy Patients at High Risk for Preventable Emergency Department Visits and Hospital Admissions.

PURPOSEAcute care use (ACU) is a major driver of oncologic costs and is penalized by a Centers for Medicare & Medicaid Services quality measure, OP-35. Targeted interventions reduce preventable ACU; however, identifying which patients might benefit remains challenging. Prior predictive models have made use of a limited subset of the data in the electronic health record (EHR). We aimed to predict risk of preventable ACU after starting chemotherapy using machine learning (ML) algorithms trained on comprehensive EHR data.METHODSChemotherapy patients treated at an academic institution and affiliated community care sites between January 2013 and July 2019 who met inclusion criteria for OP-35 were identified. Preventable ACU was defined using OP-35 criteria. Structured EHR data generated before chemotherapy treatment were obtained. ML models were trained to predict risk for ACU after starting chemotherapy using 80% of the cohort. The remaining 20% were used to test model performance by the area under the receiver operator curve.RESULTSEight thousand four hundred thirty-nine patients were included, of whom 35% had preventable ACU within 180 days of starting chemotherapy. Our primary model classified patients at risk for preventable ACU with an area under the receiver operator curve of 0.783 (95% CI, 0.761 to 0.806). Performance was better for identifying admissions than emergency department visits. Key variables included prior hospitalizations, cancer stage, race, laboratory values, and a diagnosis of depression. Analyses showed limited benefit from including patient-reported outcome data and indicated inequities in outcomes and risk modeling for Black and Medicaid patients.CONCLUSIONDense EHR data can identify patients at risk for ACU using ML with promising accuracy. These models have potential to improve cancer care outcomes, patient experience, and costs by allowing for targeted, preventative interventions.