Coping mechanisms for financial toxicity: a qualitative study of cancer patients’ experiences in Germany

Experiences and coping strategies related to financial toxicity among frail older colorectal cancer survivors in China: a qualitative study

PURPOSE

Cancer-related financial toxicity (FT) plays a key role in patients' disease prognosis, well-being, and quality of life. This study aimed to explore the experiences and coping strategies related to FT among frail older colorectal cancer (CRC) survivors in China.

METHODS

This study adopted a descriptive qualitative approach. Individual interviews were performed with 10 frail older CRC patients at a local hospital from March 2024 to August 2024. Relevant data were analyzed using the Colaizzi's phenomenological analysis.

RESULTS

The experiences of FT among frail older CRC patients included (1) insufficient economic income and inadequate medical security; (2) long course of cancer treatment and unaffordability of financial burden; (3) the vulnerability of household economies; and (4) under high psychological pressure and a sense of financial uncertainty. Meanwhile, the coping strategies to mitigate the impacts of FT in this population were as follows: (1) utilizing medical security and insurance policies to reduce FT; (2) financial planning, support, and sharing of responsibilities among family members; and (3) self-psychological adjustment and family members' emotional support.

CONCLUSION

Mitigating FT in frail older CRC survivors is crucial for improving their disease outcomes and quality of life. Understanding the experiences related to FT and identifying relevant coping strategies in this population may contribute to formulating medical and health policies for protecting these patients and their families from the adverse effects of FT. Future studies should be placed on developing effective interventions and providing personalized support for this population to alleviate FT.

The impact of financial burden on quality of life among German head and neck cancer survivors

Head and neck cancer (HNC) survivors experience a significant financial burden (FB) after treatment, even in Germany with a statutory health insurance. The financial toxicity of cancer can cause higher morbidity and mortality rates but may also impair quality of life (QoL). Our investigation aims to elucidate the impact of HNC-related FB on QoL potentially facilitating better understanding of their interplay. Of n = 209 consecutive HNC patients attending our university hospital's cancer aftercare program between August 2022 and March 2023, n = 200 patients completed the EORTC QLQ-Q30 questionnaire, and we analyzed the QoL scale data based on their self-reported FB. Parametric and non-parametric analyses were used to assess the impact of FB and independent predictors on QoL and QoL scales, and causal diagrams were used to visualize their causal relationship. HNC patients reported significant impaired QoL in consequence of FB. Significant detrimental effects of FB were observed on role functioning (RF; p = 0.0011), emotional functioning (EF; p = 0.0039), cognitive functioning (CF; p = 0.0149), and social functioning (SF; p = 0.0011). Advanced stage, advanced T category, and suffering from larynx/hypopharynx cancer demonstrated a significant quantitative interaction with FB increasing the risk for impaired QoL with respect to RF, EF, CF, and SF. HNC survivors suffer from significant impaired QoL and FB after treatment. In general, FB impairs particular QoL scales, and these QoL scales are differentially affected by particular tumor characteristics together with FB jointly impairing QoL of HNC survivors.

Cross-Cultural Validation of the COmprehensive Score for Financial Toxicity (COST) Measure in an Australian Sample

INTRODUCTION

The COmprehensive Score for Financial Toxicity (COST) measure developed in the United States measures the financial impact resulting from cancer and its treatment. This paper reports on an Australian cross-cultural validation of the COST measure.

METHODS

Participant eligibility criteria included individuals aged ≥ 18, undergoing or completed primary treatment for cancer. Immediate family members of patients were also eligible for Phase 1. Face and content validity were assessed through concurrent interviews and a brief survey (Phase 1). The subsequent revised version of COST was field-tested using a prospective sample of participants to examine item importance, internal consistency reliability, and construct validity (Phase 2).

RESULTS

Phase 1: Pretesting included 20 patients and two family members (mean age 61, range: 20-87). 19 or more patients agreed or strongly agreed that the COST items were written in clear language, easy to understand, and relevant to their experiences. Content analysis of interviews led to the inclusion of two family-related items to improve content coverage (hereby referred to as Australian-COST), along with two additional stand-alone items to facilitate clinical actions. Phase 2: One hundred and twenty-two patients completed a field-test survey. Each Australian-COST item was rated as "extremely important" or "important" by most participants (62%-81%). Cronbach's alpha coefficients were > 0.9 for both the COST and the Australian-COST. Exploratory factor analysis revealed two factors, explaining 64% (COST) and 63% (Australian-COST) of the variance. Both measures discriminated between low and high household income groups (< $39,999/year, > $125,000/year), demonstrating known-groups validity (COST: mean 19.51 vs. 28.33, p = 0.002, Australian-COST: mean 23.51 vs. 33.29, p = 0.006).

CONCLUSIONS

The COST is a valid and reliable measure for Australian cancer patients, and the results largely support the construct equivalence across the United States and Australia. The revised version contains new family-related items to enhance content coverage, which may be applicable in other countries where the financial impact of cancer on the family is of significant concern for patients.

Explore Potential Profiles and Influencing Factors for Financial Toxicity in Patients with Colorectal Cancer Undergoing Chemotherapy: A Cross-Sectional Study

OBJECTIVES

To explore the potential financial toxicity (FT) profiles in patients with colorectal cancer (CRC) undergoing chemotherapy and analyze its influencing factors.

METHODS

A cross-sectional study was conducted on 373 CRC patients undergoing chemotherapy in southwest China from January 2024 to May 2024. We utilized the General Information Questionnaire, the FT based on Patient-Reported Outcome Measures (COST-PROM), the Brief Illness Perception Questionnaire (BIPQ), and the Family APGAR Index (APGAR). Latent profile analysis (LPA) by Mplus8.3 was used to identify the latent profiles of the FT. Multinomial logistic regression analysis was used to analyze the relevant factors in the different categories.

RESULTS

The patients with CRC undergoing chemotherapy were divided into four profiles: high FT group (44.5%), moderate FT-low psychological adaptation group (22.8%), moderate FT-high psychological adaptation group (18.0%), and low FT group (14.7%). Age, average monthly household income per capita, employment status, disease duration, round of chemotherapy, illness perception, and family function were the influencing factors for potential profiles of FT in CRC chemotherapy patients (P < 0.05).

CONCLUSIONS

There are four potential profiles of FT in patients with CRC undergoing chemotherapy. Healthcare providers should pay attention to patients with CRC undergoing chemotherapy aged 18 to 59 years old, employed and unemployed, with lower average monthly household income per capita, disease duration of less than 1 year, and more times of chemotherapy. Additionally, reducing patients' negative perceptions of the disease and improving family function can help lower the level of FT.

IMPLICATION FOR NURSING PRACTICE

This research can assist nurses in identifying patients at high risk of FT, enabling early intervention and the implementation of targeted psychological nursing interventions. Nurses can help patients develop positive perceptions of the disease and improve family relationships, thereby mitigating the negative effects of FT.

Self-reported determinants for subjective financial distress: a qualitative interview study with German cancer patients

OBJECTIVES

Patient-reported financial effects of a tumour disease in a universal healthcare setting are a multidimensional phenomenon. Actual and anticipated objective financial burden caused by direct medical and non-medical costs as well as indirect costs such as loss of income can lead to subjective financial distress. To better understand subjective financial distress, the presented study explores self-reported determinants for subjective financial distress in German patients with cancer, aiming to inform a new German-language patient-reported outcome measure for determining the financial effects of a tumour disease.

DESIGN

Semistructured interviews with n=18 patients with cancer were conducted between May 2021 and December 2021. Patients were recruited based on a purposive sampling strategy in outpatient and inpatient settings. The interviews were audiorecorded, transcribed verbatim and analysed using qualitative content analysis.

SETTING

Participants were recruited from two German academic cancer centres, that is, the National Center for Tumor Diseases Heidelberg and Jena University Hospital.

PARTICIPANTS

18 patients who had undergone cancer-related therapy for at least 2 months were interviewed (10 females).

RESULTS

Based on the results of the qualitative content analysis, we developed a multicomponent construct of determinants that could influence subjective financial distress. The self-reported determinants can be classified into material (savings, good salary, shared rent through shared living, employed partner, paid-off house, potential financial support from family and friends, work-related specifics, consumer restrictions, out-of-pocket-costs and anticipated financial changes), social (social support from friends and family), systemic (administrative hurdlers and insurance cover) and inner personal determinants (coping strategies, change of attitude, character traits).

CONCLUSION

Subjective financial distress depends not only on material but also on social, systemic and inner personal determinants. Knowledge of these determinants can inform a new comprehensive German-language instrument for measuring self-reported financial effects of a tumour disease.

TRIAL REGISTRATION NUMBER

NCT05319925.

Strategies for Mitigating Cancer-Related Financial Toxicity in China: A Multiperspective Qualitative Study Based on the Socioecological Framework

PURPOSE

To explore strategies related to cancer-related financial toxicity (FT) from the perspectives of cancer survivors and stakeholders in China and to evaluate their views within the context of the social ecological model (SEM).

METHODS

Between March and July 2022, we conducted a descriptive qualitative study with semistructured interviews of 23 cancer survivors and 14 stakeholders. Qualitative content analysis on the basis of the SEM was used to analyze the data with NVivo 12.

RESULTS

Guided by the SEM, we identified 12 subthemes that described how to mitigate FT. Individual-level strategies included increasing cost-related health literacy, strengthening adherence to standardized treatments, and improving resilience to cancer and financial changes. Interpersonal-level strategies included strengthening family support and social networks. Organizational-level strategies included using evidence-based treatments, effective communication of costs, and providing financial information support. Community-level strategies included improving symptom management throughout survivorship and providing psychosocial support. Policy-level strategies included optimizing health insurance policies and promoting collaboration among medical institutions.

CONCLUSION

Our findings provide a comprehensive understanding of strategies pertaining to FT, offering insights that could support the development of future interventions. This research suggests that interventions that encompass multiple levels-individual, interpersonal, organizational, community, and policy-rather than focusing on only one level might be the most beneficial for managing FT.

Impact of the National Drug Price Negotiation policy on the price, usage, and affordability of anticancer medicines in Shandong Province, China

Objective

In order to reduce the price and increase the accessibility of innovative medicines, China has implemented the National Drug Price Negotiation (NDPN) since 2016. Anticancer drug is the largest category of NDPN and the number continue to increase. This study evaluated the impact of this policy on the price, utilization rate and affordability of anticancer drugs based on the experiences of Shandong province.

Methods

25 anticancer drugs were included in this study involved the NDPN in the year 2018 and 2019. Data on prices and utilization of the policy related drugs from 2017 to 2022 were collected from Shandong Province, using an adaptation of the WHO/HAI methodology. Prices were measured as Median Price Ratio (MPR). Usage was measured as Defined Daily Doses (DDDs). Affordability was measured as days of daily per capita disposable income required for the cost of 1 month's treatment. The Mann-Whitney U test was used to estimate the significance of the difference in the change in the MPRs before and after the negotiation.

Results

The data of this study come from 42 key monitoring medical institutions in Shandong Province, including 31 tertiary medical institutions and 11 secondary medical institutions. There has been a significant reduction in the MPR following NDPN, with a median MPR of 0.57 in 2022, and the prices of anticancer medicines were generally lower than IPR. During the period from 2017 to 2022, the total usage of the 25 negotiated medicines continued to rise. With the implementation of negotiation policy, the average number of days of disposable income per capita required for 1 month of medicine costs changed from 104 days to 36 days and 256 days to 80 days for urban and rural residents, respectively. The affordable proportion of anticancer medicines is still not high.

Conclusion

The NDPN policy has reduced the prices of anticancer drugs and greatly improved their affordability. More attention should be paid to improve the affordability to the rural and the poor patients. It is essential to encourage the research and development of high-quality generic drugs to strengthen reasonable market competition, as well as improve the multi-tiered medical security system.

Measuring financial distress in German cancer patients: development and validation of the Financial Distress of Cancer Assessment Tool (FIAT)

BACKGROUND

Cancer diagnosis and therapy can lead to significant financial distress for those affected, even in universal health care systems. We present the development and validation of a patient-reported outcome measure for financial distress in German cancer patients.

METHODS

Validation of the newly developed instrument followed a two-step approach, including two quantitative paper-pencil surveys (N1 = 111, N2 = 267) with patients of all types of cancer and treatment status at two German university hospitals. Factorial validity, reliability, construct, and criterion validity were assessed using exploratory and confirmatory factor analysis, correlative and linear regression analysis.

RESULTS

The Financial Distress of Cancer Assessment Tool (FIAT) comprises 19 items across three domains of subjective financial distress: (i) financial worries; (ii) dissatisfaction across various life domains, and (iii) challenging experiences with authorities and benefit providers (e.g. employment agency, health insurance). Confirmatory factor analysis confirmed the instrument's factorial structure. Composite reliability (Raykov's rho) ranges from 0.88 to 0.96, and retest reliability ranges from 0.64 to 0.75. Correlational analyses showed significant associations between FIAT scores and related constructs [e.g. correlations with the EORTC-QLQ-C30 financial distress subscale (Q28) ranging from 0.47 to 0.60], supporting its construct validity. Additionally, higher FIAT scores were significantly associated with lower health-related quality of life measured by Q29 and Q30 of the EORTC-QLQ-C30, with correlations ranging from -0.21 to -0.28. They were also positively correlated with depression (PHQ-4), with correlations ranging from 0.33 to 0.45, and anxiety (PHQ-4) with correlations ranging from 0.25 to 0.36, confirming its criterion validity.

CONCLUSIONS

The newly developed patient-reported outcome measure is the first reported measurement tool to assess financial distress in German cancer patients. The instrument can be used for research purposes and to enable the provision of coordinated support services.

Financial Distress in Testicular Cancer Survivors and Its Impact on Cancer Survivors' Quality of Life in the German Healthcare System

INTRODUCTION

Testicular cancer accounts for the largest proportion of solid tumors in young adult men. With an average age of onset under 40 years and a relative 5-year survival of 97%, it is one of the prognostically favorable tumors. Little is known about the relationship between the financial burden and physical and emotional health of testicular cancer survivors. We examined the association between financial problems caused by cancer and the self-reported quality of life in a cohort-based sample of testicular cancer patients.

METHODS

A cross-sectional analysis of testicular cancer patients (n = 87, average age 39 years) was performed. Self-reported data were collected on demographics, income, wealth, cost-coping strategies, out-of-pocket costs, supportive medication compliance, quality of life, and perceived social isolation. A multivariable regression model was used to examine the relationship between the degree to which cancer caused financial burdens and the patients' reported quality of life.

RESULTS

The survey showed that, in addition to illness-related additional expenses, a disease-related loss of income can lead to severe financial disadvantages and impair quality of life. The study data show that concerns about the economic situation can increase the burden on patients which already results from cancer diagnosis and therapy. In this patient cohort, 32% reported financial stress.

CONCLUSION

Financial distress affects testicular cancer survivors in unique ways. To provide support, health professionals should consider survivors' developmental life stage to understand their financial stress, and ultimately, to improve quality of life.

INTRODUCTION

Testicular cancer accounts for the largest proportion of solid tumors in young adult men. With an average age of onset under 40 years and a relative 5-year survival of 97%, it is one of the prognostically favorable tumors. Little is known about the relationship between the financial burden and physical and emotional health of testicular cancer survivors. We examined the association between financial problems caused by cancer and the self-reported quality of life in a cohort-based sample of testicular cancer patients.

METHODS

A cross-sectional analysis of testicular cancer patients (n = 87, average age 39 years) was performed. Self-reported data were collected on demographics, income, wealth, cost-coping strategies, out-of-pocket costs, supportive medication compliance, quality of life, and perceived social isolation. A multivariable regression model was used to examine the relationship between the degree to which cancer caused financial burdens and the patients' reported quality of life.

RESULTS

The survey showed that, in addition to illness-related additional expenses, a disease-related loss of income can lead to severe financial disadvantages and impair quality of life. The study data show that concerns about the economic situation can increase the burden on patients which already results from cancer diagnosis and therapy. In this patient cohort, 32% reported financial stress.

CONCLUSION

Financial distress affects testicular cancer survivors in unique ways. To provide support, health professionals should consider survivors' developmental life stage to understand their financial stress, and ultimately, to improve quality of life.

Experiences of financial toxicity among caregivers of cancer patients: a meta-synthesis of qualitative studies

OBJECTIVES

The purpose of this study was to explore the experience of financial toxicity among caregivers of cancer patients and to provide recommendations for subsequent intervention strategies.

METHODS

Computer searches of PubMed, EmBase, The Cochrane Library, Web of Science, CINAHL (EBSCO), CNKI, Wanfang database, and SinoMed for qualitative studies experience of financial toxicity among caregivers cancer patients. The search time frame was from the establishment of the database to May 2023. The quality of included studies was assessed using the Qualitative Research Checklist from the Joanna Briggs Institute (JBI) Reviewer's Manual. The meta-synthesis was integrated following the meta-aggregation method proposed by the Joanna Briggs Institute (JBI) and reported following the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) guidelines.

RESULTS

A total of nine studies were included, distilling 25 qualitative findings into nine new categories and synthesizing three synthesized findings: caregivers have strong negative experiences that affect their family relationships, daily work and life; caregivers use different strategies to cope with financial toxicity; needs and expectations of caregivers coping with financial toxicity.

CONCLUSIONS

Financial toxicity among caregivers of cancer patients affects their daily lives. Receiving timely recognition of this financial burden and providing assistance to enhance their coping skills are crucial in mitigating its impact. Healthcare professionals should focus on the financial toxicity experienced by caregivers of people with cancer, address their supportive needs, and develop a comprehensive support system to improve caregivers' coping abilities and quality of life.

Perspectives, risk factors, and coping mechanisms in patients with self-reported financial burden following lung cancer surgery

OBJECTIVE

We evaluated self-reported financial burden (FB) after lung cancer surgery and sought to assess patient perspectives, risk factors, and coping mechanisms within this population.

METHODS

Patients with lung cancer resected at our institution between January 1, 2016, and December 31, 2021, were surveyed. Descriptive and multivariable analyses were performed to evaluate the association between clinical and financial characteristics with patient-reported major ("significant" or "catastrophic") FB.

RESULTS

Of 1477 patients contacted, 31.3% (n = 463) completed the survey. Major FB was reported by 62 (13.4%) patients. multivariable analyses demonstrated increasing age (odds ratio [OR], 0.92; 95% CI, 0.88-0.96), credit score >740 (OR, 0.29; 95% CI, 0.14-0.60), and employer-based insurance (OR, 0.24; 95% CI, 0.07-0.80) were protective factors. In contrast, an out of pocket cost greater than expected (OR, 3.63; 95% CI, 1.67-7.88), decrease in work hours (OR, 4.42; 95% CI, 1.59-12.25), or cessation of work (OR, 5.13; 95% CI, 2.06-12.78), chronic obstructive pulmonary disease diagnosis (OR, 5.39, 95% CI, 1.87-15.50), and hospital readmission (OR, 4.87; 95% CI, 1.11-21.42) were risk factors for FB. To pay for care, some patients reported "often" or "always" decreasing food (n = 102 [23.4%]) or leisure spending (n = 179 [40.7%]). Additionally, use of savings (n = 246 [62.9%]), borrowing funds (n = 72 [16.6%]), and skipping clinic visits (n = 36 [8.3%]) at least once were also reported. Coping mechanisms occurred more often in patients with major FB compared with those without (P < .001).

CONCLUSIONS

Patients with resected lung cancer may experience major FB related to treatment with several identifiable risk factors. Targeted interventions are needed to limit the adoption of detrimental coping mechanisms and potentially affect survivorship.

Cancer-associated financial burden in German head and neck cancer patients

Background

The financial toxicity of cancer causes higher morbidity and mortality. As the financial burden due to head and neck cancer (HNC) in European healthcare systems with legally established compulsory health insurance is still poorly understood, we set up an investigation to assess the financial impact of HNC.

Methods

Between August 2022 and March 2023, HNC consecutive patients (n = 209) attending the cancer aftercare program of a university hospital in an outpatient setting were surveyed utilizing self-administered questionnaires about their socioeconomic situation, income loss, and out-of-pocket payments (OOPPs).

Results

The majority of HNC patients (n = 119, 59.5%) reported significant financial burden as a consequence of OOPP (n = 100, 50.0%) and/or income loss (n = 51, 25.5%). HNC patients reporting financial burden due to OOPP had on average 1,716 € per year costs related to their disease, whereas patients reporting an income loss had a mean monthly income loss of 620.53 €. Advanced UICC (7th edition, 2017) stage, T3 or T4 category, and larynx/hypopharynx cancer are significant predictors of financial burden.

Conclusion

HNC survivors suffer from significant financial burden after HNC treatment, even in Germany with a healthcare system with statutory health insurance. The findings from this study offer valuable insights for healthcare professionals and policymakers, helping them acknowledge the economic impact of HNC.

Experience of financial toxicity and coping strategies in young and middle-aged patients with stroke: a qualitative study

BACKGROUND

While financial toxicity (FT) is prevalent in patients with cancer, young and middle-aged patients with stroke are also affected by FT, which can exacerbate their physical and psychological challenges. Understanding the patient's experience and response measures can further understand the impact of FT on patients with stroke, to help alleviate FT. However, little is known concerning the experience of patients with stroke with FT or their coping strategies. Therefore, this study aimed to describe the experiences of FT in young and middle-aged patients with stroke and their coping strategies.

METHODS

A phenomenological method was utilized. Semi-structured interviews were conducted with 21 young and middle-aged stroke patients (aged 18-59) between October 2022 and March 2023. The participants were recruited from a tertiary hospital in Shanghai, China. The research team used NVivo 12.0 software. Giorgi's phenomenological analysis method was used to analyse the interview data.

RESULTS

The interview results were divided into two categories in terms of patients' experiences of FT and their coping strategies. Nine subthemes were constructed. The experience category included four subthemes: (1) taking on multifaceted economic pressure, (2) dual choice of treatment, (3) decline in material living standards, and (4) suffering from negative emotions such as anxiety and depression. The coping strategy category included five subthemes: (1) reducing expenses, (2) improving living habits, (3) proactive participation in medical decision-making, (4) making a job position choice, and (5) seeking social support.

CONCLUSIONS

FT in young and middle-aged patients with stroke, which affected their physical and mental health, led them to implement strategies for dealing with FT. The Chinese government needs to broaden the reach of health insurance coverage and advance the fairness of healthcare policies. Healthcare professionals must pay active attention to FT in such patients in terms of strengthening their health education and considering their needs and preferences. Patients need to improve their sense of self-efficacy, actively reintegrate into society, and adhere to rehabilitation and treatment. Individuals at a high risk of stroke are recommended to purchase health insurance. Multifaceted efforts are needed to reduce the impact of FT in young and middle-aged patients with stroke.

Suffering and adjustment: a grounded theory of the process of coping with financial toxicity among young women with breast cancer

PURPOSE

To explore the process of coping with financial toxicity among young women with breast cancer and formulate a grounded theory that serves as a foundation for creating intervention strategies aimed at supporting cancer survivors.

METHODS

A qualitative study using the Corbin and Strauss variant of grounded theory. A series of in-depth interviews were carried out with young women with breast cancer (n = 29) using the theoretical sampling method. We analyzed data by coding core categories in the patients' coping processes and developing theory around these categories. Data collection and analysis were performed simultaneously.

RESULTS

A substantial theory of the process of coping with financial toxicity among young female breast cancer survivors was constructed. Two core concepts, suffering and adjustment, were identified. Young women with breast cancer suffered from financial toxicity, which was related to risk factors, coping resources, and unmet needs. To overcome financial toxicity, young women with breast cancer adjusted by reshaping consumption concept, re-dividing of family functions, re-planning of occupation career, and rebuilding life confidence.

CONCLUSION

This qualitative study constructed a theory delineating the coping strategies employed by young women with breast cancer in response to financial toxicity, offering profound insights into the intricacies of cancer-related financial toxicity. Identifying risk factors, enhancing coping resources, and meeting unmet needs would be helpful to patients' adjustment to financial stress.

Financial Toxicity Experiences of Patients With Cancer in Indonesia: An Interpretive Phenomenological Analysis

OBJECTIVES

Financial toxicity (FT) is an important adverse effect of cancer. Recent systematic reviews have shown that FT may lead to treatment nonadherence and impaired health-related quality of life, both of which may adversely influence the survival rates of patients. However, less is known about how patients endure FT, particularly in low- and middle-income countries. The purpose of this study was to explore how patients with cancer experience and cope with FT in Indonesia.

METHODS

Semistructured in-depth interviews were conducted to explore the experiences of Indonesian patients with cancer. Qualitative data were analyzed using interpretive phenomenological analysis approach. We purposefully recruited 8 patients undergoing active treatment (aged 27-69 years) who had been diagnosed of cancer over 5 years before and possessed health insurance at the time of diagnosis.

RESULTS

We identified 2 main themes: (1) the experienced financial burden, with subthemes underinsurance, out-of-pocket nonhealthcare cancer-related costs, and negative income effect from employment disruption, and (2) the financial coping strategies, with subthemes reallocating household budget, seeking family support, rationalizing treatment decisions, and topping up insurance for family members.

CONCLUSIONS

This is the first interpretive phenomenological study on FT in the literature and the first qualitative FT study in Indonesia. Our findings provide insight into the occurrence of FT and coping strategies used by Indonesian patients with cancer. The subjective experiences of patients may be considered to further improve oncology care, support the need for measurement of FT, and provide mitigation programs for patients.

Financial Toxicity in Patients With Resected Lung Cancer

OBJECTIVES

To describe financial toxicity (FT) in patients with resected lung cancer and identify risk factors in this population.

BACKGROUND

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.

METHODS

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.

RESULTS

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).

CONCLUSIONS

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.

Challenges and solutions to cancer-related financial toxicity according to Australian health professionals: qualitative results from a national survey

PURPOSE

To qualitatively explore Australian healthcare professionals' perspectives on how to improve the care and management of cancer-related financial toxicity, including relevant practices, services, and unmet needs.

METHODS

We invited healthcare professionals (HCP) who currently provide care to people with cancer within their role to complete an online survey, which was distributed via the networks of Australian clinical oncology professional associations/organisations. The survey was developed by the Clinical Oncology Society of Australia's Financial Toxicity Working Group and contained 12 open-ended items which we analysed using descriptive content analysis and NVivo software.

RESULTS

HCPs (n = 277) believed that identifying and addressing financial concerns within routine cancer care was important and most believed this to be the responsibility of all HCP involved in the patient's care. However, financial toxicity was viewed as a "blind spot" within a medical model of healthcare, with a lack of services, resources, and training identified as barriers to care. Social workers reported assessment and advocacy were part of their role, but many reported lacking formal training and understanding of financial complexities/laws. HCPs reported positive attitudes towards transparent discussions of costs and actioning cost-reduction strategies within their control, but feelings of helplessness when they perceived no solution was available.

CONCLUSION

Identifying financial needs and providing transparent information about cancer-related costs was viewed as a cross-disciplinary responsibility, however, a lack of training and services limited the provision of support. Increased cancer-specific financial counselling and advocacy, via dedicated roles or developing HCPs' skills, is urgently needed within the healthcare system.

Facing financial barriers to healthcare: patient-informed adaptation of a conceptual framework for adults with a history of cancer

Background

Cancer-related financial hardship is associated with negative clinical outcomes, which may be partially explained by cost-related delayed or forgone care in response to financial barriers. We sought to understand patient experiences facing financial barriers to medical care following a cancer diagnosis.

Methods

We conducted virtual, semi-structured interviews in Fall 2022 with 20 adults with a history of cancer who had experienced cancer-related financial hardship in the prior year. We used template analysis within a pragmatic paradigm, combining constructivist and critical realist theoretical perspectives, to analyze interview transcripts and adapt an existing conceptual framework of financial barriers to care.

Results

The majority of interviewees identified as women (70%), non-Hispanic white (60%), and reported an annual household income of <$48,000 (60%). As interviewees sought to overcome financial barriers, they described substantial frustration at the limitations and complexities of United States health and social care systems, resulting in a reliance on a fragmented, uncertain resource landscape. The administrative burden resulting from bureaucratic systems and the advocacy responsibilities required to navigate them ultimately fell on interviewees and their caregivers. Thus, participants described their ability to overcome financial barriers as being influenced by individual and interpersonal factors, such as social support, comfort asking for help, time, prior experience navigating resources, and physical and mental health. However, participants noted health system organizational factors, such as whether all new patients proactively met with a social worker or financial navigator, as having the potential to lessen the administrative and financial burden experienced.

Conclusion

We present an adapted conceptual framework outlining multi-level factors influencing patient experiences coping with financial barriers to medical care. In addition to influencing whether a patient ultimately delays or forgoes care due to cost, financial barriers also have the potential to independently affect patient mental, physical, and financial health.

"My Cancer Is Worth Only Fifteen Weeks"? A Critical Analysis of the Lived Experiences of Financial Toxicity and Cancer in Canada

BACKGROUND

Cancer patients experience financial hardship due to rising expenses related to cancer treatment and declining income levels associated with reduced employability. Employment Insurance Sick Benefits (EI-SB) is a social income support program which provides temporary income replacement to Canadians when they fall ill. Although EI-SB is designed to maintain continuity of income during an illness, little is known about the perspectives of cancer patients who receive EI-SB. This knowledge can inform the development of public policies which are responsive to the needs and priorities of cancer patients.

METHODS

We conducted a theory-informed thematic analysis of data collected from twenty semi-structured interviews with participants who were receiving care in a cancer centre in Cape Breton, Nova Scotia and had received EI-SB. A coding framework was developed using Taplin and colleagues' intermediate outcomes of patient care across the cancer care continuum. Interpretation of findings was guided by the synergies of oppression theoretical lens.

RESULTS

Three overarching themes describe the experiences of cancer patients receiving social income support: Economic exclusion, in which the structure of the labour market and social welfare system determine access to workplace benefits and continuity of reasonable income; financial toxicity, a vicious cycle of financial burden and increasing financial distress; and constrained choices, where cancer influences employability and lowered income influences the need to be employed.

CONCLUSION

Cancer patients need income support programs that are tailored to match their healthcare priorities. In addition, policies which strengthen working conditions and facilitate a reintegration to work when possible will be important in addressing the structural drivers of income insecurity experienced by cancer patients.

Financial toxicity in female patients with breast cancer: a national cross-sectional study in China

PURPOSE

To quantify financial toxicity of female patients with breast cancer in China and investigate its factors and patients' coping strategies.

METHODS

The Comprehensive Score for Financial Toxicity (COST) is defined by using a structured questionnaire containing 12 items measuring perceived affordability of healthcare services, with the range of scoring of which being from 0 to 44 (higher score indicates lower financial toxicity). From January to March 2021, a total of 664 female patients diagnosed with stage 0-IV breast cancer were recruited from 33 public tertiary cancer hospitals located in 31 provinces of China. Multivariate linear regression models were used.

RESULTS

The median age of patients was 48 years (range: 26-84 years), and 62.04% lived in urban areas. The median COST score was 21.00 (interquartile range: 15-26). Older age, higher household income, and better self-reported health status were associated with lower financial toxicity, while a bigger household size, being retired or unemployed, stage IV cancer, and a history of targeted therapy were associated with higher financial toxicity (all P < 0.05). Nearly half of the patients reported using at least one coping strategy, including considering quitting treatment, delaying treatment, and failing to take medicine or attend medical visits as instructed. The people with increased financial toxicity seem to adopt more coping strategies.

CONCLUSIONS

Financial toxicity and coping strategies are common among Chinese women with breast cancer. An understanding of the factors regarding financial toxicity may help oncologists and policy-makers identify at-risk patients and develop targeted interventions.

Disadvantaged Subgroups Within the Global Head and Neck Cancer Population: How Can We Optimize Care?

Within the global head and neck cancer population, there are subgroups of patients with poorer cancer outcomes independent from tumor characteristics. In this article, we review three such groups. The first group comprises patients with nasopharyngeal cancer in low- and middle-income countries where access to high-volume, well-resourced radiotherapy centers is limited. We discuss a recent study that is aiming to improve outcomes through the instigation of a comprehensive radiotherapy quality assurance program. The second group comprises patients with low socioeconomic status in a high-income country who experience substantial financial toxicity, defined as financial hardship for patients due to health care costs. We review causes and consequences of financial toxicity and discuss how it can be mitigated. The third group comprises older patients who may poorly tolerate and not benefit from intensive standard-of-care treatment. We discuss the role of geriatric assessment, particularly in relation to the use of chemotherapy. Through better recognition and understanding of disadvantaged groups within the global head and neck cancer population, we will be better placed to instigate the necessary changes to improve outcomes and quality of life for patients with head and neck cancer.

An exploration of financial toxicity among low-income patients with cancer in Central Texas: A mixed methods analysis

OBJECTIVE

Financial toxicity is of increasing concern in the United States. The Comprehensive Score for Financial Toxicity (COST) is a validated measure; however, it has not been widely utilized among low-income patients and may not fully capture financial toxicity in this population. Furthermore, the relationships between financial toxicity, quality of life (QOL), and patient well-being are poorly understood. We describe the experience of financial toxicity among low-income adults receiving cancer care. We hypothesized that higher financial toxicity would be associated with less income and lower quality of life. Qualitative interviews focused on the financial impact of cancer treatment.

METHOD

This study was conducted at a cancer clinic in Central Texas. Quantitative and qualitative data were collected in Fall and Spring 2018, respectively. The quantitative sample (N = 115) was dichotomized by annual income (<$15,000 vs. >$15,000). Outcomes included financial toxicity (COST), quality of life (FACT-G), and patient well-being (PROMIS measures: Anxiety, Depression, Fatigue, Pain Interference, and Physical Function). Associations between quality of life, patient well-being, and financial toxicity were evaluated using linear regression. Sequential qualitative interviews were conducted with a subsample of 12 participants.

RESULTS

Patients with <$15k had significantly lower levels of QOL and patient well-being such as depression and anxiety compared to patients with >$15k across multiple measures. A multivariate linear regression found QOL (Β = 0.17, 95% CI = 0.05, 0.29, p = 0.008) and insurance status (Β = -3.79, 95% CI = -7.42, -0.16, p = 0.04), but not income, were significantly associated with financial toxicity. Three qualitative themes regarding patient's access to cancer care were identified: obtaining healthcare coverage, maintaining financial stability, and receiving social support.

SIGNIFICANCE OF RESULTS

Low-income patients with cancer face unique access barriers and are at risk for forgoing treatment or increased symptom burdens. Comprehensive assessment and financial navigation may improve access to care, symptom management, and reduce strain on social support systems.

Patient-Reported Financial Distress in Cancer: A Systematic Review of Risk Factors in Universal Healthcare Systems

Simple Summary

A comprehensive understanding of risk factors associated with experiencing subjective financial distress is needed to inform the development of valid instruments and effective interventions to tackle financial toxicity. Several studies from the US indicate a strong correlation of the US-healthcare system’s systematic organisation and its particular socioeconomic risk factors for cancer patients experiencing financial toxicity. It is assumed that risk factors differ in other high-income countries due to the different structure of universal healthcare coverage. As an exhaustive analysis for other countries is lacking, this review aims to identify risk factors for subjective financial distress in universal healthcare systems.

Abstract

Financial toxicity is a side effect of cancer that results from the perceived financial distress an individual may experience in the course of the disease. The purpose of this paper is to analyse underlying factors related to subjective financial distress in high-income countries with universal healthcare coverage. A systematic literature review was conducted to identify qualitative and quantitative studies of cancer patient-reported subjective financial distress by performing a search in the databases of PubMed, PsycINFO and CINAHL up to December 2020. A qualitative synthesis was performed linking the time-dependent occurrence of risk factors to derived categories of risk factors. Out of 4321 identified records, 30 quantitative and 16 qualitative studies were eligible. Classification of risk factors resulted in eight categories with a total of 34 subcategories. Subjective financial distress is primarily determined by pre-diagnosis sociodemographic- factors as well as financial and work factors that might change during the course of the disease. The design of healthcare and social security systems shapes the country-specific degree of subjective financial distress. Further research should focus on evolving multidisciplinary intervention schemes and multidimensional instruments for subjective financial distress to account for identified risk factors in universal healthcare systems more precisely.

Unequal distribution of financial toxicity among people with cancer and its impact on access to care: a rapid review

PURPOSE OF REVIEW

Research demonstrates that patients and their families often carry a good portion of the economic burden during and following cancer treatment, frequently resulting in implications for access to care. This rapid review summarizes how this knowledge has evolved in recent years.

RECENT FINDINGS

The number of articles on patient financial burden is increasing, suggesting awareness about the growing impact of economic burden on patients. This is particularly evident when discussing out-of-pocket costs, and lost work for patients/caregivers. However, there is an increasing focus on 'foregone care' and 'financial distress'. Additionally, emerging literature is examining policies and approaches to screen and/or mitigate these patient financial risks, thereby improving access to care. There is also increasing focus on populations that shoulder a disproportionate financial burden, including ethnic minorities (blacks, Asians, Latinos) as well as those with lower socioeconomic status. Additionally, there is evidence that this burden also affects the middle class.

SUMMARY

As healthcare budgets become stretched, especially during a pandemic, supportive programs benefiting the less fortunate often shrink, which impacts access to care. The emerging research on strategies with government or institutions to mitigate these burdens and access issues are both welcome and needed.

Correlates of financial toxicity in adult cancer patients and their informal caregivers

BACKGROUND

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.

METHODS

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.

RESULTS

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).

CONCLUSION

The COST measure can also be used to assess caregiver financial toxicity. Caregivers' financial toxicity was associated with negative outcomes for both dyad members.

Association of significant financial burden with survival for head and neck cancer patients treated with radiation therapy

OBJECTIVE

To assess the association between financial toxicity and survival in patients with head and neck cancer (HNC).

MATERIALS AND METHODS

Using a single-institution database, we retrospectively reviewed HNC patients treated at Roswell Park Comprehensive Cancer Center treated with definitive or postoperative radiation therapy between 2013 and 2017. Kaplan-Meier method and log-rank tests were used to analyze survival outcomes. Propensity score matching on all clinically relevant baseline characteristics was performed to address selection bias. All statistical tests were two-sided and those less than 0.05 were considered statistically significant.

RESULTS

Of a total of 284 HNC patients (age: median 61 years, IQR 55-67; 220 [77.5%] men), 204 patients (71.8%) received definitive radiation and 80 patients (28.2%) received adjuvant radiation. There were 41 patients (14.4%) who reported high baseline financial toxicity. Chemotherapy was used in 237 patients (83.5%). On multivariable analysis, those with high financial toxicity exhibited worse overall survival (hazards ratio [HR] 1.75, 95% confidence interval [CI] 1.05-2.94, p = 0.03) and cancer specific survival (HR 2.28, 95% CI 1.31-3.96, p = 0.003). On matched pair analysis of 66 patients, high financial toxicity remained associated with worse OS (HR 2.72, 95% CI 1.04-7.09, p = 0.04) and CSS (HR 3.75, 95% CI 1.22-11.5, p = 0.02).

CONCLUSION

HNC patient reported baseline financial toxicity was significantly correlated with both decreased overall and cancer specific survival. These significant correlations held after match pairing. Further research is warranted to investigate the impact of financial toxicity in HNC and mitigate its risk.

Translation and validation of the Traditional Chinese version of the COmprehensive Score for financial Toxicity-Functional Assessment of Chronic Illness Therapy (Version 2)

Background

Cancer patients often experience severe financial distress due to the high cost of their treatment, and strategies are needed to objectively measure this financial distress. The COmprehensive Score for financial Toxicity-Functional Assessment of Chronic Illness Therapy (COST-FACIT) is one instrument used to measure such financial distress. This study aimed to translate the COST-FACIT (Version 2) [COST-FACIT-v2] instrument into traditional Chinese (COST-FACIT-v2 [TC]) and evaluate its psychometric properties.

Methods

The Functional Assessment of Chronic Illness Therapy (FACIT) translation method was adopted. The translated version was reviewed by an expert panel and by 20 cancer patients for content validity and face validity, respectively, and 640 cancer patients, recruited from three oncology departments, completed the translated scale. Its reliability was evaluated in terms of internal consistency and test–retest reliability. Confirmatory factor analysis has been used to evaluate the one- and two-factor structures of the instrument reported in the literature. The convergent validity was examined by the correlation with health-related quality of life (HRQoL) and psychological distress. Known-group validity was examined by the difference in the COST-FACIT-v2 (TC) total mean score between groups with different income levels and frequency of health care service use.

Results

The COST-FACIT-v2 (TC) showed good content and face validity and demonstrated high internal consistency (Cronbach’s alpha, 0.86) and acceptable test–retest reliability (intraclass correlation coefficient, 0.71). Confirmatory factor analysis showed that the one- and two-factor structures of the instrument that have been reported in the literature could not be satisfactorily fitted to the data. Psychological distress correlated significantly with the COST-FACIT-v2 (TC) score (r = 0.47; p < 0.001). HRQOL showed a weak to moderate negative correlation with the COST-FACIT-v2 (TC) score (r = − 0.23 to − 0.46; p < 0.001). Significant differences were seen among the COST-FACIT-v2 (TC) scores obtained in groups of different income level and frequency of health care service use.

Conclusions

The COST-FACIT-v2 (TC) showed some desirable psychometric properties to support its validity and reliability for assessing cancer patients’ level of financial toxicity.

Translation and Cultural Adaptation of the Patient Self-Administered Financial Effects (P-SAFE) Questionnaire to Assess the Financial Burden of Cancer in French-Speaking Patients

People living with and beyond cancer (PLC) experience financial hardship associated with the disease and its treatment. Research demonstrates that the "economic toxicity" of cancer can cause distress and impair well-being, health-related quality of life and, ultimately, survival. The Patient Self-Administered Financial Effects (P-SAFE) questionnaire was created in Canada and tested in English. The objective of this study is to describe the processes of translation and cultural adaptation of the P-SAFE for use with French speaking PLC in Canada. The Canadian P-SAFE questionnaire was translated from English to French in collaboration with the developer of the initial version, according to the 12-step process recommended by the Patient-Reported Outcome (PRO) Consortium. These steps include forward and backward translation, a multidisciplinary expert committee, and cross-cultural validation using think-aloud, probing techniques, and clarity scoring during cognitive interviewing. Translation and validation of the P-SAFE questionnaire were performed without major difficulties. Minor changes were made to better fit with the vocabulary used in the public healthcare system in Quebec. The mean score for clarity of questions was 6.4 out of a possible 7 (totally clear) Cognitive interviewing revealed that lengthy questionnaire instructions could be confusing. Our team produced a Canadian-French version of the P-SAFE. After minor rewording in the instructions, the P-SAFE questionnaire appears culturally appropriate for use with French-speaking PLC in Canada. Further testing of the French version will require evaluation of psychometric properties of validity and reliability.