Patient-reported Financial Toxicity Research Articles

Interventions to Address Cancer-Related Financial Hardship: A Scoping Review and Call to Action.

As oncology practices implement routine screening for financial hardship (FH) and health-related social needs, interventions that address these needs must be implemented. A growing body of literature has reported on FH interventions. We conducted a scoping review of the literature using PubMed, EMBASE, PsychInfo, and CINAHL to identify key studies (2000-2024) reporting on interventions to address cancer-related FH. Full-length manuscripts were included in the review if they detailed a research, quality improvement, or community-based intervention to address at least one element of FH and drew association with an outcome of interest. Studies were categorized by intervention type and qualitatively analyzed to identify critical components, outcomes, and limitations. Forty-four publications reporting on 43 interventions were included in the final analysis and were categorized as research interventions (n = 20) and real-world programs (n = 20). Studies reporting on financial navigation programs (n = 17) and specialty pharmacy assistance programs (n = 11) were most common; enrolled patients received concrete assistance with direct medical costs and cost-of-living expenses (eg, transportation and food). In addition, several of these programs improved overall patient-reported financial toxicity, decreased appointment no-shows, and improved enrollment in clinical trials. Interventions to address FH are feasible and can address all domains of FH-material, behavioral, and psychosocial. Future research should address the uptake and implementation of these interventions across diverse cancer care delivery settings. Such programs will be an essential part of cancer care delivery until broad social and policy changes can address the underlying factors that contribute to FH in Americans with cancer.

Pre- and Post-Treatment Patient-Reported Financial Toxicity in Head and Neck Cancer: Identifying Influential Factors and Clinical Significance

Head and neck cancer patients are at high-risk for financial stress due to the often complex, time-consuming, and expensive treatments that can impact physical function and quality of life. It is important to identify factors that affect financial toxicity early on in treatment and to help mitigate their effects. The goals of this study are to assess patient-reported financial toxicity prior to and after completion of radiation therapy (RT) and to uncover any interactions with socioeconomic factors, quality of life, treatment satisfaction, and treatment adherence. A total of 80 patients who were evaluated for RT to the head and neck region between July 2021 and December 2022 and had completed surveys prior to the initiation of RT were included. Surveys included the FACIT-COST and FACIT-TS-G. Patient clinical information and demographics were collected. Linear regression was used to evaluate categorical variables and Pearson correlation was used to evaluate continuous variables and their associations with COST. The median pre-RT COST was 29.5 (range 4-44) with lower scores indicating worse financial toxicity. The majority of patients were white (69%), non-Hispanic (75%), and English-speaking (75%). 65% had Medicare, 14% had Medicaid, and 21% had other insurance. 60 of 80 (75%) patients ultimately underwent RT at our institution. 34 (57%) missed at least one day of scheduled RT fractions and 11 (14%) patients had G-tubes placed. Lower COST was associated with decreased age, thyroid primary disease, advanced stage, metastatic disease, Medicaid insurance, Hispanic ethnicity, unemployment, and G-tube placement. Higher COST was associated with cutaneous primary disease and ability to speak English, while Medicare insurance trended toward significance. 18 of 80 patients (23%) completed follow-up surveys post-RT and 9 reported a decrease in COST. At baseline, the standard deviation of the COST was 10.6. Effect size was defined as the number of standard deviation change. Mean decrease in COST was 9.4 (effect size of 89%). Mean FACT-TS-G was lower, indicating decreased treatment satisfaction, for these patients as compared to those that had the same or increased COST compared to baseline, (17.4 vs. 22.7, p < 0.01). There were more missed RT days, 4 vs. 1, and G-tube placements, 2 vs. 0, in those with decreased COST as well. Worse baseline financial toxicity was associated with younger age, advanced stage, metastatic disease, Medicaid insurance, unemployment, and G-tube placement. Those that reported worsened financial toxicity after RT reported worse treatment satisfaction and had more missed RT days and G-tube placements. These findings support work to better understand financial toxicity as it may predict those at higher risk of missing treatments, particularly crucial considering prolonged RT duration is linked to poorer outcomes. Future efforts will focus on automating early referrals to case managers and social work services for these patients.

Impact of a Comprehensive Financial Resource on Financial Toxicity in a National, Multiethnic Sample of Adult, Adolescent/Young Adult, and Pediatric Patients With Cancer.

Financial toxicity is a well-recognized problem for patients with cancer. However, a crucial gap remains in describing and implementing mitigation strategies. We conducted a national survey of a multiethnic adolescent/pediatric and adult patient population served by Family Reach, a nonprofit organization focused on removing financial barriers to cancer care, to evaluate the impact of a comprehensive financial resource on patient-reported financial toxicity. An electronic survey was administered to characterize patients' current financial health and the impact of Family Reach's resources on financial toxicity. The survey was e-mailed to all patients or caregivers who received resources from Family Reach between January 1, 2020, and June 30, 2020. Factors associated with higher financial stress and higher potential impact of resources on financial burden were evaluated through separate multivariate regression models. Qualitative responses were analyzed using manual coding and thematic analysis. Three hundred thirty socioeconomically and racially diverse respondents (overall response rate 40%; 46% non-Hispanic White; 48% with incomes below the federal poverty line) completed the survey and were included in the analysis. More than half of respondents reported high financial stress in the previous week. Hispanic ethnicity, Black race, and low annual household income were associated with higher financial toxicity. A greater amount of financial assistance was associated with a higher confidence rating that resources provided would decrease financial stress. In open-ended comments, respondents highlighted the impact of the COVID-19 pandemic and resulting job loss on financial toxicity, the importance of financial navigation, the benefits of financial assistance, and anxiety about long-term financial health. A comprehensive financial resource, particularly financial assistance, alleviated financial toxicity in a multiethnic national sample of patients with cancer. Ongoing work is critical to address sustainable funding sources and financial navigation to support patients during treatment and survivorship.

Patient-Reported Financial Toxicity in a Population-Based Cohort of Oropharynx Cancer Survivors after Primary Radiotherapy or Surgery

<h3>Purpose/Objective(s)</h3> Patients with oropharynx cancer are at risk for financial toxicity due to the intensive treatment and impact on critical normal functions such as eating and speaking. The nature, extent, and predictors of financial toxicity experienced after primary radiotherapy (RT) or surgery are not well-described in this population. Since the treatment strategy for oropharynx cancer is likely sensitive to patient preferences, the effects on financial toxicity may inform decision-making and facilitate interventions. <h3>Materials/Methods</h3> We identified a population-based sample of oropharynx cancer patients from the Texas Cancer Registry aged ≥18, diagnosed 2006-2016, stage I-III, and treated with primary RT or primary surgery +/- post-operative RT (PORT). Out of 1,668 eligible patients, 1,600 were mailed an invitation, survey, and $10 gift card in 2020-21. The survey included demographic and treatment questions, the MD Anderson Symptom Inventory Head and Neck (MDASI-HN), Neck Dissection Impairment Index (NDII), Effectiveness of Auditory Rehabilitation (EAR) scale, and an 8-question financial toxicity instrument adapted from the iCanCare study. Multivariable (MVA) logistic regression identified predictors of self-reported long-term financial decline attributable to cancer and treatment with p<0.05 considered significant. <h3>Results</h3> In total, 400 patients responded (25% response rate), of whom 271 (68%) received primary RT and 129 (32%) primary surgery. Of primary surgery patients, 105 (83%) received PORT while 22 (17%) did not. Median time from diagnosis to survey was 7 years. Overall, due to oropharynx cancer, 45% used personal savings, 19% could not make bill payments, 28% cut down on food spending, 2% had utilities turned off, 6% could no longer afford their housing, and 54% experienced some form of financial toxicity. Patients who received primary surgery without PORT used less personal savings (p=0.04) with less short-term financial toxicity overall (p=0.04). At the time of survey, 45% of patients worried about financial problems because of their cancer and treatment. On MVA, factors associated with worse long-term financial status included younger age (≤57 years), primary RT (only in >57 years), female sex, Black non-Hispanic race, unmarried status, lower income, tonsil subsite, more recent diagnosis, and worse scores on the MDASI-HN, NDII, and EAR. <h3>Conclusion</h3> In this population-based cohort, oropharynx cancer survivors reported high rates of short- and long-term financial toxicity, with nearly half worrying about financial problems due to their cancer at a median 7 years after diagnosis. Higher chronic symptom burden was associated with worse long-term financial status while the effect of primary RT vs surgery was significantly modified by age. The subset of primary surgery without PORT reported less short-term financial toxicity. Identifying patients with risk factors for financial toxicity presented here may allow for appropriate intervention and counseling.

Discordance between patient with cancer and caregiving partner self-reported financial toxicity.

182 Background: While financial toxicity (FT) is a well-documented problem facing cancer patients, few studies have simultaneously investigated the financial experiences of patients and their caregiving partners. Here, we report concordance and discordance in experiences of FT between cancer patients and their caregiving partners. Methods: Patients aged ≥18 with stage II-IV breast, lung, or colorectal cancer who had received treatment within the past two years and were married or in a committed, cohabitating relationship were enrolled along with their partners. Patient and caregiver responses to the FACIT-COST (lower scores indicating higher FT; score ≤ 26 meeting FT threshold) were calculated, and dyads were categorized as concordant or discordant in their experience of FT. Logistic regression models were used to explore patient and caregiver predictors of FT. Results: A total of 327 dyads (median patient age 53, 45% stage IV, 36% breast, 44% colorectal, 19% lung) were included in the analysis. Numeric COST scores were lower in patients (27, IQR: 19, 25) than in caregivers (30, IQR: 23,37) and more patients than caregivers met the threshold for FT (45% vs. 34%, p = 0.002). Both members of the dyad had similar FT experiences in 74% of cases (26% and 48% reported FT and no FT respectively) while 26% diverged in their experience of FT (8% of partners reported FT while the patient did not; 18% of patients reported FT while the caregiver did not.) Higher patient age was associated with a reduced odds of patient-reported FT (OR for each year: 0.92, 95% CI 0.86-0.98) while higher odds of FT was seen with increased patient comorbidities (OR: 1.56, 95% CI: 1.26-1.96 for each comorbidity) and patient race (Black OR: 1.41 - &gt; 10 compared to White). Similarly, caregiver comorbidity, caregiver race, and female sex increased the odds of caregiver-reported FT. In addition, the odds of caregiver-reported FT were higher with lower annual household income ($60,000-$120,000: OR: 0.26, 95% CI: 0.09-0.73, &gt; $120,000: OR 0.15, 95% CI 0.04-0.51 compared to less than $60,000), and the presence of children in the home (OR: 4.15, 95% CI: 1.88-9.67). Conclusions: More than a quarter of patients and caregivers had discordant experiences of FT. Assessing both members of a patient-caregiver dyad for FT is therefore critical to understanding the household financial impact of cancer diagnosis and treatment.

A randomized controlled trial of routine financial toxicity screening via electronic patient-reported outcomes (AFT-39).

180 Background: Financial toxicity affects 20% of cancer survivors and is associated with decreased treatment adherence and poor clinical outcomes. No large-scale programs have been implemented to mitigate financial toxicity among patients undergoing cancer treatment. We evaluated the effect of monthly patient-reported financial toxicity screening as part of a larger digital monitoring intervention. Methods: PRO-TECT (AFT-39) is a cluster-randomized trial of patients undergoing systemic therapy for metastatic cancer. Practices were randomized 1:1 to digital symptom monitoring with patient-reported outcomes (“PRO practices”) or usual care (“control practices”). Digital monitoring consisted of between-visit online or automated telephone patient surveys containing symptom, functioning, and financial toxicity screening questions for up to one year, with automated alerts sent to practice nurses for concerning survey scores. Clinical team actions in response to alerts were not mandated. The primary outcome of this analysis was development or worsening of financial difficulties, assessed via the EORTC QLQ-C30 (“Has your physical condition or medical treatment caused you financial difficulties?”), at any time compared to baseline. A randomly selected subset of patients and nurses were interviewed about their experiences with the intervention. Results: 1,191 patients were enrolled (593 PRO; 598 control) at 52 US community oncology practices. Overall, 30.2% of patients treated at practices that received the intervention developed, or experienced worsening of, financial difficulties, compared to 39.0% of patients treated at control practices (p = 0.01). Patients and nurses interviewed stated that financial toxicity screening identified patients for financial counseling who otherwise would be reluctant to seek, or unaware of the availability of, assistance. Conclusions: Screening for financial toxicity as part of routine digital patient monitoring with PROs reduces the development, or worsening, of financial difficulties among patients undergoing systemic cancer therapy. Clinical trial information: NCT03249090.

Patient-reported financial toxicity within the Italian public healthcare system: a single center cross-sectional analysis in patients with cancer

PROFFIT (Patient Reported Outcome for Fighting FInancial Toxicity of cancer) questionnaire has been developed in Italy, within a universal healthcare system, for measuring financial toxicity (FT) in patients with cancer and understanding its determinants. Our aim was to describe the amount of FT in patients with cancer, by using the PROFFIT questionnaire in subjects … Continued

Patient-Reported Financial Toxicity Following Definitive Radiation Therapy for Localized Prostate Cancer

<h3>Purpose/Objective(s)</h3> Financial toxicity is increasingly recognized but poorly characterized in the context of prostate cancer. The purpose of this study was to evaluate the magnitude of financial toxicity experienced by men with localized prostate cancer treated with definitive radiation therapy (RT) at a comprehensive cancer center. <h3>Materials/Methods</h3> Between 5/2020 and 10/2020, 1233 prostate cancer patients at our institution completed a one-time survey, which included the COmprehensive Score for financial Toxicity (COST) instrument, estimates of out-of-pocket (OOP) expenditures, and beliefs regarding costs of treatment. For this study, we analyzed the 373 men who received definitive RT within the prior 4-26 months. The COST scores (ranging from 0-44 with lower scores corresponding to higher financial toxicity) and other survey responses were stratified by RT modality (SBRT, moderate hypofractionation, brachytherapy alone, or combination EBRT with brachytherapy). <h3>Results</h3> Patients were primarily white (85%), English-speaking (99%), married (79%), employed/retired (94%), insured (100%), and reported annual household incomes > $50k (86%). Median (quartile) COST score for all patients was 33 (26, 38) with 5.3% qualifying their prostate cancer associated financial hardship as ‘quite a bit' or ‘very much'. Fifty-six (15%) respondents report an estimated OOP cost > $5,000 and 33 respondents (9.5%) reported spending above 20% of annual income. Results by RT modality are presented in Table 1. Patients undergoing SBRT had higher COST scores (i.e., lower financial toxicity) than the other RT types. There is some evidence of differences in COST score by RT type, however this did not meet conventional levels of significance (Kruskal-Wallis <i>P</i>-value 0.088). Most patients (82%) reported giving little or no consideration to potential costs prior to making a treatment decision, yet the majority (79%) felt that potential OOP costs should be communicated to a patient. <h3>Conclusion</h3> Although the overall degree of financial toxicity in this cohort of patients with above average income and insurance coverage was low, most patients would want to discuss potential costs before treatment and 5-10% reported high levels of distress. Further analyses are planned to identify independent predictors for severe toxicity in order to inform strategies aimed to mitigate risk.

Development of a Financial Toxicity Screening Tool for Radiation Oncology: A Secondary Analysis of a Pilot Prospective Patient-Reported Outcomes Study

PurposeFinancial toxicity is highly prevalent in oncology. Early identification of at-risk patients is essential because financial toxicity is associated with inferior outcomes. Validated general oncology screening tools are cumbersome and not specific to challenges related to radiation therapy, such as daily treatments. In the population of radiation oncology patients, no standardized, validated, rapid screening tool exists. We sought to develop a rapid, no-cost, and reliable financial-toxicity screening tool for clinical radiation oncology. Methods and MaterialsWe retrospectively analyzed data from a prospective survey study conducted at a large referral center with a heterogeneous population. Before treatment, a 25-item modified comprehensive survey for financial toxicity incorporating subjective and objective patient-reported measures was administered to identify factors linked to the risk of developing financial toxicity, which was defined as radiation therapy resulting in any of the following: loss of income, job, or spouse or difficulty paying for meals, housing, or transportation. We applied a logistic regression model with a stepwise, backward model selection procedure. Estimated probabilities of experiencing financial toxicity were computed using the inverse-logit transformation of the sum of patient-specific predictor values multiplied by the coefficients of the selected logistic regression model. The Youden index was used to determine a reasonable risk threshold. ResultsA total of 157 patients completed the questionnaire, and 34 (22%) were assessed as experiencing financial toxicity. The model retained 3 factors: age, money owed, and copayment-related worries. It resulted in a concordance statistic of 0.85, developed with a risk threshold of 18% (Youden index, 0.59). This model conferred a sensitivity of 89%, specificity of 70%, positive predictive value of 44%, and negative predictive value of 96%. ConclusionsOur proposed financial-toxicity screen is rapid, free, sensitive, and specific, and in this study, it identified early-onset, patient-reported financial toxicity after radiation therapy with just 3 simple variables: age, money owed, and copayment-related concerns. Future research steps should include a validation cohort and identification of interventions to mitigate financial toxicity.

Patient-reported financial toxicity following management of localized prostate cancer.

e17053 Background: Cancer patients’ potential for severe financial toxicity (FT) is well-established, however there is limited data on the magnitude of this challenge associated with treatment of localized prostate cancer (PC). The extent to which men consider potential financial implications prior to selection of a treatment strategy remains poorly understood. Methods: Between 5/2020-10/2020, 1233 insured PC patients treated at a comprehensive cancer center completed a one-time FT survey which included the COmprehensive Score for financial Toxicity (COST) instrument, impressions of PC costs and financial coping strategies. Inclusion criteria was localized disease and treatment with either radical prostatectomy (RP) or definitive radiotherapy (RT) in the previous 4-26 months (mo) or at least 6mo of active surveillance (AS) prior to survey. To assess possible temporal differences in FT, responses were grouped into 6, 12, 18 and 24 months after treatment start, and we plotted COST against time, using generalized additive models to allow for non-linearity. Results: Overall, 988 men were eligible for analysis: 347 (35%) underwent RP, 384 (39%) underwent RT, and 257 (26%) were on AS. The median age at survey completion was 67 years (quartiles 62, 72). Men were predominantly white (89%), English-speakers (99%) and married (84%). The median (quartiles) COST score for all patients was 33 (26, 38) with possible range of 0-44 with lower scores indicating greater FT; median values were identical with similar quartiles (+/- 1 point) when stratified by treatment type. There were no significant changes in median COST between men surveyed at the four time points for any treatment subgroup. In total, 66 men (7.1%) reported spending &gt; 20% of annual income on treatment and 10% felt that PC has created at least somewhat of a financial hardship for their family. Top drivers of burdensome cost included medical bills (37%) and transportation costs (21%). Most (83%) reported giving little or no consideration to possible costs prior to making a PC treatment decision, yet the majority (77%) felt that out of pocket costs should be communicated to a patient prior to decision making. Most believed patients should definitely (46%) or possibly (33%) have the opportunity to discuss financial concerns with the radiation oncologist or urologist. Conclusions: Our study is the first reported use of the COST instrument to assess subjective financial distress in localized PC patients. Our results demonstrate that the overall degree of FT in this cohort of insured patients treated at a specialized cancer center is low. While potential financial burden does not strongly influence treatment decision making in this cohort, most want this information and an opportunity to discuss financial concerns with their oncologist. Next steps include identification of predictors for high FT risk and extension of our survey to hospital systems with differing demographic profiles.

Financial toxicity, symptom burden, illness perceptions, and communication confidence in cancer clinical trial participants.

6526 Background: Cancer clinical trial (CCT) participants are at high risk for experiencing adverse effects from financial toxicity, yet this remains understudied in the CCT population. We sought to describe associations among patient-reported financial toxicity (financial burden [FB] and trial cost concerns), physical and psychological symptoms, illness perceptions, and communication confidence in CCT participants. Methods: From 7/2015-7/2017, we prospectively enrolled CCT participants who expressed interest in financial assistance and a group of patients matched by age, sex, cancer type, specific trial, and trial phase. We assessed FB (burdened by costs of cancer care), trial cost concerns (worried about affording medical costs of a CCT), physical (Edmonton Symptom Assessment Scale [ESAS]) and psychological (Patient Health Questionnaire-4 [PHQ-4]) symptoms, illness perceptions (Brief Illness Perception Questionnaire [BIPQ]), and communication confidence (Perceived Efficacy in Patient-Physician Interactions [PEPPI]). We used regression models to explore sociodemographic associations with FB and trial cost concerns, and to examine associations of FB and trial cost concerns with patients’ symptom burden, illness perceptions, and communication confidence, adjusting for age, sex, race, performance status, marital status, and metastatic status. Results: Of 198 patients enrolled, 112 (56.6%) reported FB and 82 (41.4%) had trial cost concerns. Patients with FB were younger (OR 0.96, 95% CI 0.94-0.98) and had lower incomes ( &lt; $100,000, OR 4.61, 95% CI 2.35-9.01). Patients reporting trial cost concerns also had lower incomes ( &lt; $100,000, OR 2.78, 95% CI 1.45-5.29). On adjusted analyses, patients with FB had higher ESAS total (OR 1.03, 95% CI 1.02-1.05), ESAS physical (OR 1.04, 95% CI 1.02-1.07), PHQ-4 depression (OR 1.54, 95% CI 1.22-1.94), and PHQ-4 anxiety (OR 1.30, 95% CI 1.08-1.55) scores, as well as more negative illness perceptions (OR 1.04, 95% CI 1.01-1.07), but no significant difference in communication confidence (OR 0.98, 95% CI 0.93-1.05). Patients reporting trial cost concerns had higher ESAS total (OR 1.03, 95% CI 1.01-1.05), ESAS physical (OR 1.04, 95% CI 1.01-1.06), PHQ-4 depression (OR 1.35, 95% CI 1.10-1.65), and PHQ-4 anxiety (OR 1.27, 95% CI 1.07-1.51) scores, as well as more negative illness perceptions (OR 1.06, 95% CI 1.03-1.10), and lower communication confidence (OR 0.93, 95% CI 0.87-0.99). Conclusions: In this study of CCT participants, younger patients with lower incomes were most vulnerable to financial toxicity. Financial toxicity was associated with greater symptom burden, more negative illness perceptions, and lower communication confidence, which underscores the importance of addressing these issues when seeking to alleviate the adverse effects of financial toxicity in CCT participants.

Assessing the financial toxicity in Tunisian cancer patients using the Comprehensive Score for Financial Toxicity (COST).

Cancer care-related out-of-pocket expenses and financial toxicity (FT) are a rising burden for patients. We aimed to evaluate patient-reported FT and to identify relevant correlates within a Tunisian population. We conducted a survey using the 11-item Comprehensive Score for Financial Toxicity (COST) that could range from 0 = high to 44 = low. FT was grade 0 if ≥ 26, grade 1 = (14-25), grade 2 = (1-13), and grade 3 = 0. Scores were collected along with data regarding patient medical/social features and out-of-pocket expenses. Univariate and multivariate analyses were performed to identify factors associated with higher financial burden. Among the 179 participants, median COST score was 20.8 (Q1 17-Q3 24), with 80.4% of patients experiencing financial toxicity: grade 0 = 20%, grade 1 = 68.4%, grade 2 = 11.7%, grade 3 = 0%. Most patients (66.5%) used to work before cancer and 44.7% reported ceasing work because of cancer. The time to go to the hospital was > 30min in 66.5% of cases. Unemployment, time to hospital > 30min, ceasing work because of cancer, and expenses on non-chemotherapy drugs exceeding 70 dinars (25 US dollars) were mostly associated with higher FT on univariate analysis. Distance to hospital and ceasing work because of cancer were the single most significant factors in multivariate analysis. Losing work due to cancer and unequal distribution of health care particularly in cities with long travel times to the nearest hospital are the main sources of financial distress.

Patient-Reported Financial Toxicity Associated with Contemporary Treatment for Localized Prostate Cancer.

Contemporary treatment modalities for localized prostate cancer provide comparable overall and cancer-specific survival. However, the degree of financial burden imposed by treatment, the factors contributing to that burden, and how different treatments compare with regard to financial toxicity remain poorly understood. The Comparative Effectiveness Analysis of Surgery and Radiation (CEASAR) study enrolled men with localized prostate cancer from 2011 to 2012. Questionnaires were collected at 6, 12, 36, and 60 months after enrollment. Differences in patient-reported financial burden were compared between active surveillance, radical prostatectomy, and external beam radiotherapy using multivariable logistic regression. Among 2,121 patients meeting inclusion criteria, 15% reported large or very large burden of treatment costs within 6 months, declining to 3% by year 5. When controlling for age, education, income and other covariates, external beam radiotherapy was associated with greater financial burden than active surveillance and radical prostatectomy at 1 year (OR 2.2, 95% CI 1.2-4.1 and OR 1.5, 95% CI 1.0-2.3, respectively) and 3 years (OR 3.1 95% CI 1.1-8.8 and OR 2.1, 95% CI 1.2-3.7, respectively). Radical prostatectomy and active surveillance had similar rates of financial burden at all time points. Age, race, education, and D'Amico risk group were associated with financial burden. External beam radiotherapy was associated with the highest financial burden, even when controlling for age, education and income. Prospective studies that directly measure out-of-pocket and indirect costs and account more thoroughly for baseline socioeconomic differences are warranted in order to identify those most at risk.

Patient-reported financial toxicity in multiple sclerosis: Predictors and association with care non-adherence

Background: Multiple sclerosis (MS) results in considerable financial burdens due to expensive treatment and high rates of disability, which could both impact care non-adherence. Objective: To measure financial toxicity in MS patients, identify its predictors and association with care non-adherence. Methods: Adult MS patients visiting neurology clinic (June 2018 to February 2019) were consented to complete a survey. Financial toxicity was measured using Comprehensive Score for Financial Toxicity (COST) (range: 0–44, the lower the score, the worse the financial toxicity). Independent predictors of financial toxicity were identified using linear regression. Associations of COST score with patient outcomes were assessed. Results: The mean COST score in 243 recruited patients was 17.4 ± 10.2. In response to financial burdens, 66.7% and 34.7% reported life-style altering behaviors or care non-adherence, respectively. Higher financial self-efficacy was associated with less financial toxicity (coefficient, 1.33 (95% confidence interval (CI), 1.02–1.64); p < 0.001). At least one relapse in the last 3 months was associated with greater financial toxicity (coefficient, −3.34 (95% CI, −6.66 to −0.01); p = 0.049). Greater financial toxicity correlated with life-style-altering coping strategy use (p < 0.001), care non-adherence (p = 0.001), and worse health-related quality of life (HRQOL) (p = 0.03). Conclusion: MS patients with lower financial self-efficacy and prior relapse history are at higher risk for financial toxicity, with associated care non-adherence and lower HRQOL.

Financial toxicity and contralateral prophylactic mastectomy: an analysis using propensity score methods.

Contralateral prophylactic mastectomy (CPM) is increasingly performed in average-risk patients despite the lack of survival benefit. In an era of heightened awareness of healthcare costs, we sought to determine the impact of CPM on financial toxicity in breast cancer. A single-institution propensity-matched analysis of female patients who underwent unilateral mastectomy (UM) with or without CPM for breast cancer over an 18-month period. Patients with a history of genetic predisposition or bilateral cancer were excluded. The validated Comprehensive Score for financial Toxicity (COST) evaluated financial toxicity among participants. Multivariable regression analysis evaluated the relationship between CPM and financial toxicity. Relevant domains of the Breast Q and SF12 instruments were examined as secondary outcomes. Sensitivity analysis was performed using propensity-weighting to examine robustness of results and increase our sample size. Overall, 104 patients were identified, equally distributed across UM and CPM. CPM was not associated with financial toxicity, as evidenced by comparable COST scores (adjusted difference, 1.53 [- 3.24 to 6.29]). Minor complications were significantly lower in UM patients (UM, 8%; CPM, 31%). CPM was associated with significantly higher Breast Q psychosocial well-being score (adjusted difference, 10.58 [1.34 to 19.83]). BREAST Q surgeon satisfaction, SF12 mental and physical component scores were comparable. Similar results were noted onsensitivityanalysis involving 194 patients. Choice for CPM was associated with higher minor complications, but led to improved psychosocial well-being without a higher degree of patient-reported financial toxicity. Prospective studies are needed to discern the influence of CPM on the incidence and trajectory of financial toxicity.

Financial toxicity in patients with multiple myeloma participating in clinical trials: A U.S. Food and Drug Administration pooled analysis.

e19370 Background: Financial toxicity (FT) is a major concern for patients receiving standard cancer treatment, and FT can lead to worse cancer outcomes. However, little is known about the FT of patients enrolled in clinical trials (CT). While investigational treatment may be provided by sponsors free of charge, patients are subject to increased clinic visits (ie, missed workdays, travel costs) and still bear the cost of usual care. This analysis evaluates patient-reported FT in multiple myeloma (MM) trials submitted to US FDA and explores the relationship between baseline FT and overall response rate (ORR). Methods: We pooled data from 9 MM registration CTs submitted to the FDA that included the EORTC Quality of Life questionnaire (QLQ-C30). The QLQ-C30 includes an item asking patients “Has your physical condition or medical treatment caused you financial difficulties?”. We looked at proportion of patients at baseline reporting any FT and their ORR. We also report prevalence, incidence and change from baseline FT at 3 and 6 months. Results: 5,667 patients answered the FT item. Mean age of patients was 65 years, 55% were male, 85% were white and 6% were enrolled in the US. Approximately a third of patients reported experiencing any FT at baseline, 3 and 6 months. When compared to their baseline, 69% of patients had unchanged FT and 14% had worse FT at both 3 and 6 months. The incidence of new cases of FT at 3 months was 17% and at 6 months 7%. The ORR in patients who reported any FT at baseline was 69% compared to 72% in patients with no baseline FT, and was similar regardless of the degree of FT. Conclusions: Few studies have investigated FT in a large sample of CT participants. In this pooled analysis of patients enrolled in MM CTs, approximately a third of patients reported FT associated with their physical condition or medical treatment at baseline and throughout the trial. A small percentage of patients experienced worsening FT during the trial and a small percentage went from no FT to reporting any FT. The impact of baseline FT on ORR was small. Limitations of this preliminary analysis include missing patient level or group level insurance status, socio-economic status and other important determinants of health.

Patient-reported financial toxicity, quality of life, and health behaviors in insured US cancer survivors.

Fighting cancer is a costly battle, and understanding the relationship between patient-reported financial toxicity (FT) and health outcomes can help inform interventions for post-treatment cancer survivors. Stages I-III solid tumor, insured US cancer survivors (N = 103) completed a survey addressing FT (as measured by the standardized COST measure) and clinically relevant health outcomes (including health-related quality of life [HRQOL] and adherence to recommended survivorship health behaviors). Univariate and multivariate analyses were used to assess demographic and disease-specific correlates of FT, and to assess the predictive value of FT on HRQOL and adherence to survivorship health behaviors. Approximately 18% of respondents noted FT levels associated with significant financial burden. In univariate analyses, after correcting for multiple comparisons, greater FT was associated with unpartnered status, non-retirement, and lower level of educational attainment. Greater FT was also significantly associated with HRQOL components of anxiety, fatigue, pain, physical functioning, and social functioning. FT was not significantly associated with any measured survivorship health behaviors. In multivariate analyses, FT was found to be a meaningful predictor of patient-reported anxiety, fatigue, physical functioning, and social functioning above and beyond theoretically and statistically relevant demographic characteristics. Although overall levels of FT were lower among cancer survivors in this sample, as compared with active treatment patients assessed in previous studies, financial burden continued to be a concern for a significant minority of cancer survivors and was associated with components of reduced HRQOL. Further research is needed to understand FT among underinsured survivors and those treated in community oncology settings. Incorporation of FT assessment into survivorship care planning could enhance clinical assessment of survivors' FT vulnerability, help address the dynamic and persistent challenges of survivorship, and help identify those most in need of intervention across the cancer care continuum.

Patient-reported financial toxicity and adverse medical consequences in head and neck cancer.

Financial toxicity (FT) is a significant barrier to high-quality cancer care, and patients with head and neck cancer (HNCA) are particularly vulnerable given their need for intensive support, daily radiotherapy (RT), and management of long-term physical, functional, and psychosocial morbidities following treatment. We aim to identify predictors of FT and adverse consequences in HNCA following RT. We performed a prospective survey study of patients with HNCA seen in follow-up at an academic comprehensive cancer center (CCC) or Veterans Affairs hospital between 05/2016 and 06/2018. Surveys included validated patient-reported functional outcomes and the COST measure, a validated instrument for measuring FT. The response rate was 86% (n=63). Younger age and lower median household income by county were associated with lower COST scores (i.e., worse FT) on multivariable analysis (p=.045 and p=.016, respectively). Patients with worse FT were more likely to skip clinic visits (RR (95% CI) 2.13 (1.23-3.67), p=.007), be noncompliant with recommended supplements or medications (1.24 (1.03-1.48), p=.02), and require supportive infusions (1.10 (1.02-1.20), p=.02). At the CCC, patients with worse FT were more likely to require feeding tubes (1.62 (1.14-2.31), p=.007). Overall, 36% reported that costs were higher than expected, 48% were worried about paying for treatment, and 33% reported at least a moderate financial burden from treatment. HNCA patients experience substantial FT from their diagnosis and/or therapy, with potential implications for medical compliance, QOL, and survivorship care.

Financial toxicity of cancer treatment at a diverse county hospital.

76 Background: The rising costs of cancer care increasingly results in financial distress for patients and their families. Low-income patients face a greater burden of financial toxicity, but few studies have characterized what factors contribute to this, and what interventions can relieve toxicity. Methods: From October 2017 to December 2017, we used a validated COST survey tool to understand the extent of financial burden that patients with cancer experience. We surveyed patients who receive their oncology care in a medical system that serves predominantly minority and low-income patients in Santa Clara County. We collected demographic information including sex, education level, ethnicity, income, insurance status, monthly out of pocket costs (OOPC) and employment status prior to diagnosis. We used a multivariable linear regression to study the association between the patient factors and financial burden as demonstrated by the COST score. All data were analyzed using Stata 14. Results: Demographic information is presented in Table 1. A total of 152 patients completed all 11 items of the COST survey. In the multivariate model, there was no significant difference in COST score by sex, education level, or ethnicity. However, income ≤$25,000 was associated with higher COST scores (p = 0.019), as was higher monthly OOPC (p = 0.003). Medicare patients and patients who were employed prior to diagnosis tended to have higher COST scores although not quite statistically significant (p = 0.057, p = 0.083). Conclusions: Patient-reported financial toxicity is an unmet concern among patients in this single institution study with a high proportion of underinsured patients. Higher OOPC and low income was associated with a higher financial burden. These findings suggest that patients would benefit from targeted interventions to mediate out of pocket costs of cancer care.[Table: see text]

Financial Toxicity Concerns are Associated With Overall Levels of Patient Reported Distress During Radiation Therapy

We examined the association between patient reported financial toxicity (PRFT), Overall Survival (OS), and overall PRD in radiotherapy patients. 518 consecutive patients who underwent radiotherapy (RT) at an academic medical center between March 2012 and May 2016 were included in this retrospective study. Only patients were included. Information was collected regarding age at the start of RT, gender, type of RT (curative or palliative), cancer primary site, RT dose, metastatic disease, chemotherapy, surgery, and survival. Patient reported distress level was also assessed and ranges from 0 (the lowest) to 10 (the highest). Levels of concern regarding out of pocket costs and regarding finances were the primary measures of this study, and both of these measures were scored as either “not at all”, “a little bit”, “somewhat”, “quite a bit”, or “very much”. Baseline patient characteristics of these concerns were compared using Fisher’s exact test or a Kruskal-Wallis rank sum test. Associations between baseline patient characteristics and survival after the start of RT were evaluated using single variable (i.e. unadjusted) Cox proportional hazards regression models. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated. Associations of level of concern regarding out of pocket costs and level of concern regarding finances with survival after RT were evaluated using single variable and multivariable Cox proportional hazards regression models. Overall PRD level and concern regarding out of pocket costs were positively correlated (P<0.001). Additionally, there was a significant association between cancer primary site and level of concern regarding out of pocket costs (P=0.008), with level of concern highest for breast cancer, head and neck cancer, and musculoskeletal cancer. There were no other statistically significant associations between baseline characteristics and level of concern regarding out of pocket costs. Overall PRD level was significantly higher for patients expressing a greater level of concern regarding finances (P<0.001) as well as for younger patients (P=0.03). There was not a significant between either measures of financial distress in survival in single-variable analysis or in multivariable analysis adjusting for potential confounding variables. For curative RT patients, there was a significantly higher overall distress level as level of concern regarding out of pocket costs increased (P<0.001) and finances (P<0.001), but not for palliative RT patients for either measure. Correlations between concern for out of pocket costs and distress highlight the existence of sources of distress external to therapeutic treatments. The significance of younger patients reporting greater PRD scores also points to concern regarding early onset financial insecurity.