Financial toxicity due to breast cancer treatment in low- and middle-income countries: evidence from Vietnam

Financial Toxicity and Breast Cancer: Why Does It Matter, Who Is at Risk, and How Do We Intervene?

Financial toxicity, or the financial burden patients experience because of medical costs, can lead to negative patient effects including lower quality of life, compromised clinical care, and worse health outcomes. People with cancer and survivors are more likely to have financial toxicity than those without cancer, and patients with breast cancer are uniquely at risk. Patients with breast cancer often require multimodal treatment (surgery, radiation, and/or systemic therapy) and adjuvant hormonal therapy can continue for years after primary treatment. With improved disease outcomes, patients with breast cancer have prolonged survivorship often lasting decades but may carry chronic toxicities from treatment; both ongoing treatment of metastatic disease and long-term surveillance include continued tests, imaging, and medical visits that add to the cumulative burden on patients and their families. Additionally, breast cancer predominately affects women, who are more likely to have dual caregiver responsibilities, and increasingly is diagnosed in younger patients, who may have fertility preservation expenses and are more likely to experience education and/or employment disruption. When faced with high costs, patients may face difficult decisions regarding what sacrifices they are willing to endure to receive care. Interventions designed to reduce financial toxicity are moving out of the pilot phase, and ongoing randomized trials are expected to provide evidence into the effectiveness of financial navigation programs. Further work to address financial toxicity in breast cancer at the patient-provider, institutional, and governmental levels is needed for comprehensively better financial outcomes and quality of life.

Financial toxicity amongst cancer patients and survivors: a comparative study of the United Kingdom and United States

BACKGROUND

The study investigated the experiences of financial toxicity (FT) amongst cancer patients/survivors in the United Kingdom (UK) and the United States (USA/US).

METHODS

Six hundred cancer patients/survivors residing in the UK (n = 319) or USA/US (n = 281) completed an online cross-sectional survey using the COmprehensive Score for financial Toxicity (COST)-a validated measure of FT. Severity of FT was defined as 'no' (COST scores ≥ 26), 'mild' (14-25), and 'moderate/severe' (0-13).

RESULTS

Thirty-four percent of UK participants faced FT which was significantly lower compared to the USA/US at 55% (crude OR = 2.44, 95% CI 1.73-3.42). An ordered logistic regression model showed that in the USA/US, being 65 + years old (adjusted OR = 0.19, 95% CI 0.07-0.48), retired (aOR = 0.26, 95% CI 0.09-0.75), and having a higher household income (aOR ranged 0.03-0.19) decreased the risk of FT, whilst being female increased the risk (aOR = 1.83, 95% CI 1.01-3.32). In the UK, age and sex did not have an effect, but higher income and being retired showed an identical pattern compared to the US.

CONCLUSIONS

FT was less prevalent and less severe in the UK, compared to the USA/US. The high prevalence of FT underscores the need to provide an additional level of protection to the most vulnerable groups than is currently offered in either country.

Financial Toxicity Among Breast Cancer Patients: A Scoping Review of Risk Factors and Outcomes

BACKGROUND

Breast cancer has become the leading cause of global cancer incidence. With the improvement of treatment methods, financial toxicity among breast cancer patients has been widely studied.

OBJECTIVES

The aims of this study were to summarize the risk factors for and outcomes of financial toxicity among breast cancer patients, to identify populations at risk for financial toxicity, to identify the consequent health impacts, and to provide evidence for subsequent intervention programs.

METHODS

We searched the PubMed/MEDLINE, Web of Science, MEDLINE (Ovid), CINAHL (EBSCO), EMBASE (Ovid), ProQuest, and China National Knowledge Infrastructure databases from inception to July 21, 2022. We followed the updated framework for scoping reviews proposed by the Joanna Briggs Institute.

RESULTS

A total of 31 studies were included. Risk factors and outcomes of financial toxicity among breast cancer patients were identified and extracted. The risk factors included socioeconomic, demographic, disease and treatment, and psychological and cognitive factors, whereas financial toxicity affected the physical, behavioral, and psychological domains of breast cancer patients, resulting in material loss, coping behaviors, and impaired health-related quality of life.

CONCLUSION

Financial toxicity among breast cancer patients depends on multiple factors and has profound effects. The findings will be helpful for identifying breast cancer patients at a high risk of financial toxicity and developing intervention programs to reduce financial toxicity and outcomes.

IMPLICATIONS FOR PRACTICE

More high-quality prospective, multicenter studies should be conducted in the future to better understand the trajectory of and risk factors for financial toxicity. Further studies should merge symptom management and psychosocial support into intervention programs.

Changes in employment status and income and workplace organizational support among cancer survivors: A descriptive study in Iran

PURPOSE

Cancer is the second leading cause of mortality in Iran, significantly impacting patients' lives and the public health system. This study aims to investigate changes in employment status and income and workplace organizational support among Iranian cancer survivors following their diagnosis.

METHODS

This study was conducted at the Cancer Institute of Imam Khomeini Hospital complex in Tehran, Iran, in 2019. A total of 250 cancer survivors who were employed prior to their diagnosis and more than a year had passed since their diagnosis were selected from the IROPICAN study and participated in this research. Data collection was performed through telephone interviews using a validated researcher-made questionnaire. Statistical analyses were carried out using SPSS v.18 software.

RESULTS

Cancer diagnosis led to changes in the employment status of 75 % (N = 188) of participants, with nearly half (N = 122) becoming unemployed. Financial necessity was the primary reason survivors continued working after treatment. Additionally, 76 % experienced income changes, with 85 individuals facing a complete loss of income. Only half of the 115 patients requiring organizational support in the workplace received assistance, while the rest primarily benefited from approved leave applications.

CONCLUSION

Iranian cancer patients face significant socioeconomic challenges, including unemployment, reduced income, and inadequate organizational support in the workplace.

Defining and Measuring Financial Toxicity in Low- and Middle-Income Countries

PURPOSE

Financial toxicity (FT) of cancer treatment likely affects more patients in low- and middle-income countries (LMICs); however, most of the research on FT comes from high-income countries, which may not apply to LMICs. The causes and consequences of FT in patients with cancer in LMICs remain understudied.

METHODS

Following PRISMA guidelines, we searched MEDLINE, Web of Science, and CINAHL for FT literature in cancer originating from LMICs from inception until the end of 2023, and documented the different definitions used to define FT in LMICs, and the magnitude of FT documented using those definitions. LMIC was defined using the World Bank Country and Lending Group classification.

RESULTS

Sixty-eight studies met the inclusion criteria. Studies on FT in cancer originating from LMICs have increased in recent years (>75% studies published 2020 onward) and used varying criteria to define FT, broadly categorized into five themes. Majority of the studies defined FT in terms of catastrophic health expenditure (45%) or household impoverishment (10%), while 26% of the studies used the Comprehensive Score for Financial Toxicity tool, developed and validated in US patients, to measure FT in LMIC settings. Twenty-six percent of the studies defined FT in terms of coping mechanisms and 10% in terms of subjective financial burden. The magnitude of FT in patients with cancer was substantial irrespective of the definitions used.

CONCLUSION

This review synthesizes the different definitions of FT for LMICs that have been used in the literature so far. We conclude that the definitions that capture the coping mechanisms or hardships might reflect the magnitude of FT better than absolute dollar values or relative percentages of expenditures. Future studies can use our results to devise locally tailored definitions of FT.

Financial toxicity in cancer palliative care in India: Addressing existence and beyond - Seeking remedies for a balanced financial journey

Financial toxicity (FT) places a significant burden on individuals undergoing cancer care, leading to emotional distress, social isolation and financial burnout. In India, the growing number of cancer cases and the ever-expanding population, combined with insufficient government investment in public healthcare, inadequate insurance coverage, poor financial literacy among medical and non-medical communities and the lack of comprehensive financial planning exacerbate the financial difficulties faced by patients. This article aims to address FT as a source of suffering and explores potential frameworks and solutions for preventing and managing FT in patients undergoing cancer treatment and seeking palliative and hospice care in India. We conducted a literature search to review the burden of FT, across diverse healthcare settings for cancer patients. The prevalence of FT in cancer care ranges from 30% to 90.1% and is influenced by various socio-demographic, disease and healthcare-related factors. The sources of distress financing include consumption of savings, asset sales and borrowing, which add to the financial suffering. This interdisciplinary collaborative research paper highlights the dearth of financial literacy in our population and emphasises the pressing need to enhance financial awareness for healthcare professionals, cancer patients and their families. More than 30% of the Indian population lacks any form of insurance coverage, and many of those who do have it mostly lack 'adequate' coverage. We explore essential financial strategies, such as budgeting, expense analysis, asset consolidation, liquidity management, understanding estate planning tools and banking operations, streamlining paperwork, ensuring smooth transactions, adopting methods like low-interest loans and crowdfunding platforms, advance care planning, early palliative care ntegration and timely transition to hospice care. We also highlight the importance of available community resources, non-profit organisations, cancer foundations, health insurance and government support. Overall, integrating financial planning into cancer palliative care seems essential for reducing FT and enhancing the quality of cancer care in India. Further research on the topic is needed.

Quality of life in long-term breast cancer survivors in Sub-Saharan Africa: the African Breast Cancer-Disparities in Outcomes study

PURPOSE

In Sub-Saharan Africa (SSA), breast cancer survivors' (BCS) quality of life (QoL) remains understudied. We compared QoL in BCS to cancer-free (CF) women across SSA settings with different levels of development, healthcare systems, ethnic compositions, and HIV prevalence.

METHODS

In 2022-2023, all 5 + year BCS from the African Breast Cancer-Disparities in Outcomes study and age-matched CF women from the community setting answered the WHOQOL-BREF questionnaire in Namibia, Nigeria, and Uganda. For each WHOQOL-BREF domain and general item, we estimated BCS-CF adjusted mean differences (AMD) in scores in absolute percentage points (p.p.).

RESULTS

Overall, 862 women (BCS 357 vs. CF 505) (mean age ± SD, 57.5 ± 12.5 vs. 55.1 ± 11.2; tertiary education, 30% vs. 20%) were included. BCS reported higher/better overall QoL (AMD (95% CI) 10.65 p.p. (7.56, 13.74), i.e., ~ 40% of a change in QoL category), general health (5.84 (2.71, 8.98)), psychological (3.46 (1.43, 5.49)), social relationships (3.94 (1.25, 6.63)), and environment scores (4.27 (1.88, 6.67)) than CF women. There was no BCS-CF difference for physical health in all settings (1.52 (- 0.82, 3.87)), psychological health in Namibian Black women (0.58 (- 2.90, 4.06)), and social relationships in Nigeria (- 0.33 (- 5.81, 5.14)). BCS reported both lower energy and sexual life satisfaction than CF women.

CONCLUSIONS

In SSA, long-term BCS have slightly better QoL than CF women except for physical health. Areas for which BCS scored lower or similar than CF women may indicate BCS' QoL issues.

IMPLICATIONS FOR CANCER SURVIVORS

BCS-only studies using cancer-specific QoL questionnaires are needed to better characterize BCS' QoL in SSA.

Financial toxicity in patients with cancer: a cross-sectional study at an oncology hospital in central Vietnam

PURPOSE

Cancer imposes a substantial financial burden on patients because of the high out-of-pocket expenses and the significant hardships. Financial toxicity describes the impact of cancer care costs at the patient level. Although the financial impact of cancer has been recognized, understanding the extent and determinants of financial toxicity in specific contexts is crucial. This study investigated the level of financial toxicity and its associated factors among patients with cancer at an oncology hospital in central Vietnam.

METHODS

This cross-sectional study included 334 patients with cancer. Direct interviews and medical record reviews were used for data collection. Financial toxicity was assessed using the 11-item Comprehensive Score for financial Toxicity (COST). A logistic regression model was used to determine factors associated with financial toxicity.

RESULTS

A notable 87.7% of patients experienced financial toxicity due to cancer cost, with 37.7% experiencing mild financial toxicity and 49.7% suffering from moderate financial toxicity, 0.3% reporting severe financial toxicity. Individuals with low household income exhibited a higher proportion of financial toxicity compared to that of those with higher income (odds ratio (OR) = 5.78, 95% confidence interval (CI): 1.29-25.68). Compared with that of participants in the early stages, a higher burden was found in patients with advanced-stage cancer (OR = 3.88, 95% CI: 1.36-11.11).

CONCLUSION

Our study indicates that patients with cancer in Vietnam facefinancial toxicity. It is thus necessary for interventions to mitigate the financial burden on patients with cancer, focusing on vulnerable individuals and patients in the advanced stages.

A pre-post evaluation of a digital intervention to improve psychosocial outcomes of caregivers of people living with cancer in Vietnam

OBJECTIVES

To evaluate a co-designed intervention using digital resources "Vietnam Cancer Caring Coping" (V-CCC) on the health literacy, depression, and quality of life of caregivers supporting a cancer patient in oncology hospitals in Vietnam.

METHODS

A pre-post quantitative evaluation with adult cancer caregivers across regional Oncology hospitals in Vietnam (Ho Chi Minh City, Da Nang, Can Tho, and Hue). Participants completed baseline and follow-up measures of health literacy (HLS-SF12) depression (PHQ-9) and Health-related Quality of Life (5Q-5D-5L). Participants accessed and reviewed V-CCC for a 2-week period.

RESULTS

Two hundred and thirty-four caregivers completed pre and post-tests. Most participants were female (n = 143, 61%), married (n = 165, 70%), aged 18-44 (n = 155, 66%), lived rurally (n = 157, 67%). All health literacy scores of participants in post-intervention were significantly higher than that in pre-intervention across all domain's healthcare, disease prevention, and health promotion as well as the total score (p < 0.001). A significant reduction in the proportion of caregivers reporting PHQ-9 moderately severe/severe depression post-intervention was demonstrated (10.2 vs. 6.1%, respectively (p ≤ 0.001). No significant differences were observed pre and post-intervention across four 5Q-5D-5L health dimensions: mobility, self-care, usual activities, and pain/discomfort. Regarding anxiety/depression as measured by 5Q-5D-5L the proportion of participants who reported having moderate, severe, and extreme problems in pre- and post-intervention was statistically significant (32 vs. 24%), respectively (p = 0.0028).

CONCLUSION

Co-designed digital resources can reduce health literacy inequities and improve psychological outcomes for cancer caregivers.

Cancer cost-related subjective financial distress among breast cancer: a scoping review

PURPOSE

This article provided a comprehensive scoping review, synthesizing existing literature on the financial distress faced by breast cancer patients. It examined the factors contributing to financial distress, the impact on patients, coping mechanisms employed, and potential alleviation methods. The goal was to organize existing evidence and highlight possible directions for future research.

METHODS

We followed the scoping review framework proposed by the Joanna Briggs Institute (JBI) to synthesize and report evidence. We searched electronic databases, including PubMed, Web of Science, Embase, and Cochrane Library, for relevant literature. We included English articles that met the following criteria: (a) the research topic was financial distress or financial toxicity, (b) the research subjects were adult breast cancer patients, and (c) the article type was quantitative, qualitative, or mixed-methods research. We then extracted and integrated relevant information for reporting.

RESULTS

After removing duplicates, 5459 articles were retrieved, and 43 articles were included based on the inclusion and exclusion criteria. The articles addressed four main themes related to financial distress: factors associated with financial distress, impact on breast cancer patients, coping mechanisms, and potential methods for alleviation. The impact of financial distress on patients was observed in six dimensions: financial expenses, financial resources, social-psychological reactions, support seeking, coping care, and coping lifestyle. While some studies reported potential methods for alleviation, few discussed the feasibility of these solutions.

CONCLUSIONS

Breast cancer patients experience significant financial distress with multidimensional impacts. Comprehensive consideration of possible confounding factors is essential when measuring financial distress. Future research should focus on exploring and validating methods to alleviate or resolve this issue.

Beyond Medical Bills: High Prevalence of Financial Toxicity and Diverse Management Strategies Among Vietnamese Patients With Cancer

OBJECTIVES

This study was conducted to measure financial toxicity (FT) among patients with cancer in Vietnam using the COmprehensive Score for financial Toxicity (COST) and to describe the cost management strategies employed by these patients.

METHODS

This comprehensive cross-sectional study enrolled 634 patients from 2 specialized oncology hospitals in Vietnam. Using COST cut-off scores, FT was classified as none/mild (≥26), moderate (14-25), or severe (≤13). Cost management strategies, or coping mechanisms, were classified into 4 groups: lifestyle changes, financial resource strategies, treatment modifications, and support seeking.

RESULTS

The prevalence of FT was 91.8%, with 51.7% of participants demonstrating severe and 40.1% exhibiting moderate FT. Severe FT was significantly associated with female, low education level, unstable employment, low household economic status, and advanced cancer stage. The most common coping strategies were as follows: among lifestyle changes, reducing spending on basic items and leisure activities (78.7%) and cutting back on essential household expenses (66.4%); among financial resource strategies, borrowing money from relatives or friends (49.1%) and withdrawing funds from retirement or savings accounts (34.1%); within treatment modifications, switching treatment facilities or doctors due to cost concerns (9.3%); and within support seeking, obtaining help from welfare or community organizations (18.8%). All strategies were significantly more likely to be used by patients with severe FT.

CONCLUSIONS

FT was highly prevalent among patients with cancer. Most patients relied on lifestyle adjustments and coping strategies, underscoring the need for improved financial support systems to alleviate the economic burden associated with cancer care.

Validation of the COmprehensive Score for Financial Toxicity (COST) in Vietnamese patients with cancer

INTRODUCTION

The COmprehensive Score for Financial Toxicity (COST) has proven to be a reliable tool for quantifying the impact of financial toxicity (FT) in patients with cancer in clinical and public health settings. However, the COST has not yet been validated in Vietnam. Therefore, we aimed to evaluate its reliability and validity among Vietnamese patients with cancer.

METHODS

A cross-sectional study was conducted in a sample of 300 patients with cancer aged 27-95 years (mean: 58.5±11.2) in a tertiary hospital. The COST was translated into Vietnamese and English and adjusted to suit the local culture. Reliability was evaluated using Cronbach's alpha and McDonald's omega coefficients. The construct and convergent validities were also assessed.

RESULTS

The COST demonstrated good internal consistency and reliability (Cronbach's alpha = 0.913; McDonald's omega = 0.915). The exploratory factor analysis revealed two factors that explained 64.9% of the variance. The adjusted fit indices indicated a good fit of the model (χ2 (39) = 67.78, p = 0.003; standardized root mean squared residual = 0.042; Tucker-Lewis index = 0.971; comparative fit index = 0.979; root mean square error of approximation = 0.061, 90% confidence interval = 0.035-0084). Higher COST scores were significantly correlated with higher health-related quality of life (EQ-5D-5L utility score: r = 0.21, p = 0.002; EQ VAS: r = 0.28, p < 0.001). Multivariate quantile regression analysis revealed that female sex, rural residence, and unstable job/unemployment were associated with lower COST scores. There was no statistically significant difference in other factors, including clinical factors (types of cancer, staging, and treatment modalities).

CONCLUSIONS

The COST is reliable and valid, making it suitable for assessing FT severity in Vietnamese patients with cancer.

Pediatric cancers and family financial toxicity in the Philippines: insights for Southeast Asia and similarly resourced settings

Cancer is a leading cause of death among children in the Philippines, a low-middle-income country of over 110 million people. In this Comment, we describe how financial toxicity affects families of pediatric patients with cancer in the Philippines. We explore direct costs of care, indirect costs such as transportation and lodging, and psychosocial sequelae, in the Filipino medical system and sociocultural contexts. We present examples of successful interventions in the Philippines and in similarly resourced settings, with the goal of galvanizing further research, clinical interventions, and policy-level changes, aimed at mitigating family financial toxicity for pediatric patients with cancer in the Philippines and globally.

Willingness to Pay for a Quality-Adjusted Life Year among Gastrointestinal Cancer Patients at a Tertiary Hospital of Vietnam, 2022

BACKGROUND

Gastrointestinal (GI) cancer burden in Asia is increasing, and Vietnam is no exception. Assessing the affordability of achieving a quality-adjusted life year (QALY) in gastrointestinal cancer patients Vietnam, as well as identifying predictors of willingness to pay (WTP) per QALY, is crucial to decision-making around medical intervention prioritization and performing medical technology assessments for these cancers.

OBJECTIVES

Our study aimed to estimate WTP/QALY gained and associated factors among patients diagnosed with GI cancer at a tertiary hospital in Hue, Vietnam.

METHODS

A cross-sectional descriptive study, using contingent valuation methodology was conducted among 231 patients at tertiary hospital in 2022. A double limited dichotomous choice and the EQ-5D-5L were utilised to estimate WTP and QALY, respectively. Quantile regression was applied to determine predictors of WTP/QALY.

RESULTS

The mean and median maximum WTP/QALY gained among GI patients was $15,165.6 (42,239.6) and $4,365.6 (IQR: 1,586.5-14,552.0), respectively, which was equal to 3.68 times the 2022 gross domestic product (GDP) per capita in Vietnam.  Additionally, cancer severity was found to have a significant impact  on WTP per QALY gained, with a higher amount identified among patients with earlier stages of GI cancer. Furthermore, living in an urban dwelling and patients' treatment modalities were significantly associated with WTP/QALY.

CONCLUSION

Evidence from our study can be used to inform how decision-makers in Vietnam to determine the cost-effectiveness of GI cancer interventions.

Demand analysis of health care services for community-dwelling breast cancer survivors based on the Kano model: A cross-sectional study

Objectives

Providing satisfactory healthcare services for breast cancer survivors can effectively reduce their burden and the pressure on medical resources. The aim of this study was to explore health care service demands for community-dwelling breast cancer survivors using the Kano model.

Methods

A cross-sectional survey was conducted from January to March 2023 among breast cancer survivors discharged from a tertiary cancer hospital. Participants were asked to fill out a self-designed questionnaire involving the Kano model, which helped to categorize and prioritize the attributes of healthcare services. The questionnaire included 30 health care services. Additionally, their social demographic characteristics were collected during the survey.

Results

A total of 296 valid questionnaires were collected, and demand attributes of the 30 health care services were evaluated. The findings revealed that one of 30 services was classified as "must-be attributes" (body image management), 13 as "one-dimensional attributes" (focused on medical security support, health management, and health counseling), 3 as "attractive attributes" (focused on communication needs and telehealth services), and 11 as "indifferent attributes" (mainly in the area of psycho-social services).

Conclusions

Breast cancer survivors in the community have different levels of need for various health care services. It's crucial for healthcare providers to identify these needs and devise effective strategies to deliver the appropriate services. Services with must-be and one-dimensional attributes should be given priority, and efforts should be made to provide services with attractive attributes, hence improving the quality of life of breast cancer survivors.

Financial toxicity among cancer patients, survivors and their families in the United Kingdom: a scoping review

BACKGROUND

The aim of this scoping review was to identify key research gaps and priorities in order to advance policy and practice for people living with cancer in the UK.

METHODS

The review adhered to PRISMA guidelines for scoping review. We searched MEDLINE, EMBASE, Scopus, Web of Science and Google Scholar on 16 July 2022. There were no restrictions in terms of study design and publication time; gray literature was included. The key words, 'financial' or 'economic', were combined with each of the following words 'hardship/stress/burden/distress/strain/toxicity/catastrophe/consequence/impact.'

RESULTS

29/629 studies/reports published during 1982-2022 were eligible to be included in the review. No study conducted a comprehensive inquiry and reported all aspects of financial toxicity (FT) or used a validated measure of FT. The most three commonly reported outcomes related to financial hardship were financial well-being (24/29), benefit/welfare (17/29) and mental health status (16/29).

CONCLUSIONS

It is evident that FT is experienced by UK cancer patients/survivors and that the issue is under-researched. There is an urgent need for further research including rigorous studies which contribute to a comprehensive understanding about the nature and extent of FT, disparities in experience, the impacts of FT on outcomes and potential solutions to alleviate FT and related problems.

Evaluation of financial toxicity and associated factors in female patients with breast cancer: a systematic review and meta-analysis

PURPOSE

These systematic review and meta-analysis were conducted to discuss the financial toxicity (FT) level among breast cancer (BC) patients and the associated demographic and economic factors.

METHODS

A systematic review and meta-analysis of single means were used by following the Joanna Briggs Institute guidelines and PRISMA guidance. Untransformed means (MRAW) were used to estimate the confidence interval for individual studies, while I2 and tau2 statistics were used to examine heterogeneity among pooled studies. Electronic databases were PubMed, CINAHL, Web of Science, Scopus, Cochrane Library, Ovid MEDLINE(R), Science Direct, and Turkish databases were used to find relevant studies published in the last 15 years (between 2008 and 2023).

RESULTS

A total of 50 studies were reviewed in the systematic review, and 11 were included in the overall and subgroup meta-analyses. The majority of reviewed studies were from the USA (38 studies), while there were four studies from China and eight studies from other countries having different types of health systems. The overall estimated FT level based on 11 pooled studies was 23.19, meaning mild level FT in the range of four categories (no FT score > 25, mild FT score 14-25, moderate FT score 1-13, and severe FT score equal to 0), with a 95% CI of 20.66-25.72. The results of subgroup meta-analyses showed that the estimated FT levels were higher among those patients who were single, with lower education levels, stage 3 patients, younger, lower income, unemployed, and living in other countries compared to those who were married, more educated, and stages 1 and 2 patients, more aged, more income, employed, and patients in the USA.

CONCLUSION

The cost-effectiveness of the treatment strategies of BC depends on the continuity of care. However, FT is one of the leading factors causing BC patients to use the required care irregularly, and it has a negative effect on adherence to treatment. So, removing the economic barriers by taking appropriate measures to decrease FT will increase the efficiency of already allocated resources to BC treatments and improve the health outcomes of BC patients.

The impact of adding cost information to a conversation aid to support shared decision making about low-risk prostate cancer treatment: Results of a stepped-wedge cluster randomised trial

BACKGROUND

Decision aids help patients consider the benefits and drawbacks of care options but rarely include cost information. We assessed the impact of a conversation-based decision aid containing information about low-risk prostate cancer management options and their relative costs.

METHODS

We conducted a stepped-wedge cluster randomised trial in outpatient urology practices within a US-based academic medical center. We randomised five clinicians to four intervention sequences and enroled patients newly diagnosed with low-risk prostate cancer. Primary patient-reported outcomes collected postvisit included the frequency of cost conversations and referrals to address costs. Other patient-reported outcomes included: decisional conflict postvisit and at 3 months, decision regret at 3 months, shared decision-making postvisit, financial toxicity postvisit and at 3 months. Clinicians reported their attitudes about shared decision-making pre- and poststudy, and the intervention's feasibility and acceptability. We used hierarchical regression analysis to assess patient outcomes. The clinician was included as a random effect; fixed effects included education, employment, telehealth versus in-person visit, visit date, and enrolment period.

RESULTS

Between April 2020 and March 2022, we screened 513 patients, contacted 217 eligible patients, and enroled 117/217 (54%) (51 in usual care, 66 in the intervention group). In adjusted analyses, the intervention was not associated with cost conversations (β = .82, p = .27), referrals to cost-related resources (β = -0.36, p = .81), shared decision-making (β = -0.79, p = .32), decisional conflict postvisit (β = -0.34, p= .70), or at follow-up (β = -2.19, p = .16), decision regret at follow-up (β = -9.76, p = .11), or financial toxicity postvisit (β = -1.32, p = .63) or at follow-up (β = -2.41, p = .23). Most clinicians and patients had positive attitudes about the intervention and shared decision-making. In exploratory unadjusted analyses, patients in the intervention group experienced more transient indecision (p < .02) suggesting increased deliberation between visit and follow-up.

DISCUSSION

Despite enthusiasm from clinicians, the intervention was not significantly associated with hypothesised outcomes, though we were unable to robustly test outcomes due to recruitment challenges. Recruitment at the start of the COVID-19 pandemic impacted eligibility, sample size/power, study procedures, and increased telehealth visits and financial worry, independent of the intervention. Future work should explore ways to support shared decision-making, cost conversations, and choice deliberation with a larger sample. Such work could involve additional members of the care team, and consider the detail, quality, and timing of addressing these issues.

PATIENT OR PUBLIC CONTRIBUTION

Patients and clinicians were engaged as stakeholder advisors meeting monthly throughout the duration of the project to advise on the study design, measures selected, data interpretation, and dissemination of study findings.

Characteristics and influencing factors of social isolation in patients with breast cancer: a latent profile analysis

PURPOSE

The goal of this study is to investigate the social isolation (SI) subtypes of patients with breast cancer (BC) and to explore its influencing factors.

METHODS

A sample of 303 BC patients participated in the study from September to December, 2021. Latent profile analysis (LPA) was performed to identify SI clusters based on the three sub-scales of the Chinese version of the Social Anxiety Scale, the Chinese version of the Social Avoidance and Distress Scale, and the Chinese version of the Loneliness Scale.

RESULTS

We found that SI can be divided into three categories: high-level (Class 1), middle-level (Class 2), and low-level (Class 3), accounting for 20.46%, 33.00%, and 46.54%, respectively. Compared to Class 3, Class 1, which had the lower average monthly income per family member (RMB) (< 3000: OR = 5.298, P = .021; 3000 ~ 5000: OR = 5.320, P = .018), was more likely to suffer from SI due to occupation (Laborer: OR = 12.023, P = .009). Surgery (OR = 14.138, P < .001; OR = 2.777, P = .020), chemotherapy (OR = 10.224, P = .001; OR = 3.545, P = .001); poorer family functioning (OR = .671, P < .001; OR = .801, P = .002), and lower levels of self-transcendence (OR = .806, P < .001; OR = .911, P < .001) were important influencing factors for SI in Class 1 and Class 2 compared to Class 3.

CONCLUSION

SI is classifiably heterogeneous among patients with BC. Strategies that identify characteristics of SI and give targeted intervention focusing on family functioning and improving self-transcendence levels contribute to the prevention of SI among patients with BC.

Financial toxicity assessment and associated factors analysis of patients with cancer in China

PURPOSE

Cancer-related expenditures present a lasting economic burden on patients and their families and may exert long-term adverse effects on the patients' life and quality of life. In this study, the comprehensive score for financial toxicity (COST) was used to investigate the financial toxicity (FT) levels and related risk factors in Chinese patients with cancer.

METHODS

Quantitative data were collected through a questionnaire covering three aspects: sociodemographic information, economic and behavioral cost-coping strategies, and the COST scale. Univariate and multivariate analyses were performed to identify factors associated with FT.

RESULTS

According to 594 completed questionnaires, the COST score ranged 0-41, with a median of 18 (mean±SD, 17.98±7.978). Over 80% of patients with cancer reported at least moderate FT (COST score <26). A multivariate model showed that urban residents, coverage by other health insurance policies, and higher household income and consumption expenditures were significantly associated with higher COST scores, indicative of lower FT. The middle-aged (45-59 years old), higher out-of-pocket (OOP) medication expenditures and hospitalizations, borrowed money, and forgone treatment were all significantly associated with lower COST scores, indicating higher FT.

CONCLUSION

Severe FT was associated with sociodemographic factors among Chinese patients with cancer, family financial factors, and economic and behavioral cost-coping strategies. Government should identify and manage the patients with high-risk characteristics of FT and work out better health policies for them.

Trajectories and predictors of social avoidance in female patients with breast cancer

Background

Social avoidance plays an important role in influencing quality of life among patients with breast cancer. Social avoidance behaviors change with treatment periods. However, the trajectory patterns and the predictive factors have not been fully studied.

Objective

This study examined the growth trajectory of social avoidance and its predictors in patients with breast cancer.

Materials and methods

A total of 176 patients with breast cancer in a university hospital in Shaanxi Province, China, were followed up four times over 6 months following surgery, and data from the final 144 patients were analyzed. The growth mixed model (GMM) was used to identify the trajectory categories, and the predictive factors of the trajectory types were analyzed by logistic regression.

Results

The best-fit growth mixture modeling revealed three class models: persistent high social avoidance group (Class 1), social avoidance increased first and then decreased group (Class 2), and no social avoidance group (Class 3), accounting for 13.89, 31.94, and 54.17% of patients, respectively. Single-factor analysis showed that family income per capita, residence, and temperament type were related to the social avoidance trajectory. Logistic regression analysis showed that only temperament type was an independent predictor of the social avoidance trajectory, and patients with melancholia were more likely to have persistent high social avoidance.

Conclusion

Our study proved the heterogeneity of social avoidance behaviors and the influencing effect of temperament type on the development of social avoidance behaviors in Chinese patients with breast cancer. Health professionals should pay more attention to patients who are at higher risk of developing a persistent social avoidance pattern and provide target interventions.

Costs of breast cancer treatment incurred by women in Vietnam

BACKGROUND

There is a paucity of research on the cost of breast cancer (BC) treatment from the patient's perspective in Vietnam.

METHODS

Individual-level data about out-of-pocket (OOP) expenditures on use of services were collected from women treated for BC (n = 202) using an online survey and a face-to-face interview at two tertiary hospitals in 2019. Total expenditures on diagnosis and initial BC treatment were presented in terms of the mean, standard deviation, and range for each type of service use. A generalised linear model (GLM) was used to assess the relationship between total cost and socio-demographic characteristics.

RESULTS

19.3% of respondents had stage 0/I BC, 68.8% had stage II, 9.4% had stage III, none had stage IV. The most expensive OOP elements were targeted therapy with mean cost equal to 649.5 million VND ($28,025) and chemotherapy at 36.5 million VND ($1575). Mean total OOP cost related to diagnosis and initial BC treatment (excluding targeted therapy cost) was 61.8 million VND ($2667). The mean OOP costs among patients with stage II and III BC were, respectively, 66 and 148% higher than stage 0/I.

CONCLUSIONS

BC patients in Vietnam incur significant OOP costs. The cost of BC treatment was driven by the use of therapies and presentation stage at diagnosis. It is likely that OOP costs of BC patients would be reduced by earlier detection through raised awareness and screening programmes and by providing a higher insurance reimbursement rate for targeted therapy.