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

Effectiveness of out-of-pocket cost COMmunication and financial navigation (CostCOM) in cancer patients: Study protocol for ECOG-ACRIN EAQ222CD

BACKGROUND

High out-of-pocket costs (OOPC) of cancer treatment and lost income result in financial hardship. There is compelling evidence that OOPC communication complemented by financial navigation and counseling will decrease financial hardship by enabling cancer patients to anticipate and accommodate treatment costs and proactively seek financial assistance.

METHODS

This is a two-arm randomized controlled trial enrolling 720 patients with newly diagnosed solid tumors (stratified by non-metastatic vs. metastatic) who plan to receive anticancer systemic therapy at one of the participating NCI Community Oncology Research Practices (NCORP). Participants are randomized to receive four up to 1-h remote counseling sessions which include systemic therapy OOP cost communication, financial navigation and counseling (CostCOM intervention) vs. enhanced usual care with provision of an informational brochure for Patient Advocate Foundation (PAF), a national non-profit financial navigation organization (EUC). Patients will complete surveys at baseline, 3, 6, and 12 months after enrollment. Our goals are to compare the effectiveness of CostCOM vs. EUC at 12 months on (1) patient-reported cost-related cancer care nonadherence, defined as any self-reported incident of delay, forgo, stop or change in cancer care due to cost concerns and (2) patient-reported material financial hardship, financial worry, and quality of life; and to (3) conduct a process evaluation to examine practice providers' and CostCOM arm patients' satisfaction with the intervention and their perceptions of barriers and facilitators to CostCOM. A successful CostCOM is a scalable and financially sustainable program that can improve cancer care delivery, patients' experience, and health outcomes.

TRIAL REGISTRATION

NCT06295367.

Financial Toxicity in Dementia Caregiving: Sociodemographic Predictors in a U.S. Nationally Representative Survey

BACKGROUND AND OBJECTIVES

"Financial toxicity" describes the negative effects of medical expenses on financial security and health-related quality of life. Beyond dementia, financial toxicity is used to address the financial and health consequences of illness. Here, we utilize the COmprehensive Score for financial Toxicity (COST) to examine the experience of financial toxicity in dementia caregiving.

RESEARCH DESIGN AND METHODS

We conducted a nationally representative survey of 317 dementia caregivers. Financial toxicity was defined as COST<26 and categorized as mild (COST ≥14 and <26), moderate (COST >0 and <14), or severe (COST = 0). Nested multivariable regression examined potential predictors of financial toxicity. Mediation analyses were performed to assess whether the influence of basic caregiver demographic predictors was mediated by care recipient clinical characteristics, caregiver socioeconomic demographics, or relational characteristics.

RESULTS

52.7% of dementia caregivers in the United States experience financial toxicity. Of those, 73.1% endure mild, 25.7% moderate, and 1.2% severe toxicity. 69.5% of Black, 54.1% of Hispanic, and 42.3% of White caregivers report financial toxicity, with prevalence significantly higher in Black caregivers compared to White caregivers (p = .017). Older caregiver age was associated with less financial toxicity (p = .024). Caregiver employment status mediated this effect, with retirement associated with less financial toxicity (p < .001) and unemployment associated with greater financial toxicity (p < .001).

DISCUSSION AND IMPLICATIONS

Most dementia caregivers in the United States experience financial toxicity, with Black caregivers bearing the highest risk. Older caregiver age protects against financial toxicity, reflecting the relationship between age and employment status.

Financial Distress Screening and Navigation in Pediatric Oncology Within the National Cancer Institute Community Oncology Research Program

PURPOSE

Cancer-related financial hardship is associated with poor quality of life, risk of household material hardship, and psychological distress for families affected by pediatric cancer. Current processes on financial distress screening and financial navigation across the pediatric National Cancer Institute Community Oncology Research Program (NCORP) network remain unknown.

METHODS

Financial distress screening and financial navigation services among NCORP practices were assessed using two survey items from the 2022 NCORP Landscape Assessment Survey. Practices answering yes to providing oncology care for pediatric patients were included. Univariable models were used to test associations between practice characteristics and financial screening and financial navigation.

RESULTS

Of the 53 NCORP practices serving pediatric patients with cancer that responded to the survey, 44 (83%) reported routinely conducting financial distress screening. Most of the practices reported that financial screening is completed by social workers (n = 40/44, 91%). One third of practices reported financial screening using a survey completed by patients/caregivers (n = 14/44, 32%). Almost all practices (n = 51/53, 96%) reported responding to financial needs through a social worker. One third of the practices reported having a cancer-specific financial navigator (n = 17/53, 32%) or a nondedicated (not cancer-specific) financial navigator (n = 19/53, 36%). Practices that served a proportion of new patients with cancer at or above the national average of Hispanic individuals in the United States were as likely to screen for financial distress as practices below the national average (odds ratio, 2.42 [95% CI, 0.45 to 13.03]; P = .30).

CONCLUSION

Most pediatric NCORP practices report screening for financial distress. Fewer groups offer dedicated cancer-specific financial navigation, and practices vary. Further research is needed to explore the development and implementation of standardized financial distress measures and financial navigation interventions within pediatric cancer care.

Prevalence of Health-Related Social Needs and Associated Missed Imaging Appointments Among Patients With Cancer

PURPOSE

Health-related social needs (HRSNs) lead to health disparities and impact cancer care, but their link with missed imaging appointments in patients with cancer is unclear. We assessed screen rate and prevalance of HRSNs and their association with missed imaging appointments among patients with cancer.

METHODS

Patients aged ≥18 years with cancer who completed an oncology wellness form as part of usual care between January 1, 2022, and September 30, 2023, who had an imaging examination scheduled at the same health system within 3 months after form completion were included. The form assessed HRSNs (financial, transportation, and housing) and patients' preference for written or verbal information about HRSNs services. Multivariable regression models evaluated the association between HRSNs and missed imaging appointments.

RESULTS

In all, 3,495 (16.6%) of patients had a completed oncology wellness form during 3,964 (4.3%) encounters; of those, 2,890 had imaging scheduled in the next 3 months and were included (mean age: 61.6 ± 15.9 years; 50.2% female; 20.1% Asian, 2.8% Black, 57% White, 20.6% Hispanic). HRSNs were reported during 22.9% of encounters, with 82.9%, 40.2%, and 37.5% of reported HRSNs being due to financial hardship, transportation, and housing issues. Only 6.5% and 4.4% of encounters positive for HRSNs reported a desire for written information or to speak with someone about their HRSNs, respectively. At least one imaging encounter was missed by 70% in the subsequent 3 months. Adjusting for sociodemographic factors, patients reporting HRSNs were more likely to miss their imaging appointment (odds ratio, 1.29; 95% confidence interval, 1.03-1.61).

CONCLUSION

Patients with cancer with self-reported HRSNs tend to have higher missed imaging appointments.

Strategies for recruitment and retention of diverse and underserved cancer survivor and caregiver dyads in clinical trials

Background

Cancer survivor-caregiver dyads from underrepresented racial and ethnic groups and those with lower socioeconomic status are less likely to participate in clinical research. Sociocultural and socioeconomic barriers perpetuate health inequity and increase disparities in cancer care.

Purpose

We describe our systematic approach to recruiting and retaining diverse survivor-caregiver dyads in supportive cancer care studies.

Methods

Matsuda's research recruitment guidelines of evaluate, engage, reflect, and carefully match ("EERC") were adapted and applied through a framework of six guiding principles.

Results

A systematic approach to recruitment of underrepresented dyads in cancer support research includes 1) Developing a bilingual, bicultural study team with shared language and culture of the study population, 2) Ensuring team members share a passion for cancer health equity and are trained with a community-centric approach, 3) Designing accessible interventions, study materials, and shared data collection tools across similar studies with community and stakeholder input, 4) Engaging local and regional stakeholders with expertise of health disparities among the catchment area, 5) Partnering with Community Health Workers (CHWs) and gatekeepers to enhance community presence, and 6) Ensuring careful application of matching study team members and participants beyond race and ethnicity to prioritize the cultural values and social factors that impact cancer survivors and caregivers.

Conclusion

Applying a systematic approach to recruiting and retaining underrepresented dyads in cancer research can potentially reduce sociocultural and socioeconomic barriers to cancer health equity.

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.

Development of A Caregiver-Reported Scale for Pediatric Cancer Financial Toxicity (CRS-PCFT)

BACKGROUND

Financial toxicity is common among families of pediatric patients with cancer. However, the availability of survey and/or screening instruments specific to pediatric family financial toxicity is limited.

METHODS

A two-round cross-sectional survey was conducted in Shandong Province, China. We combined classical test theory (CTT) and item response theory (IRT) to validate items of the caregiver-reported scale for pediatric cancer financial toxicity (CRS-PCFT) after Delphi. The scale structure, reliability, and validity were determined and validated by exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). The threshold was discussed based on the correlations between CRS-PCFT and socio-factors.

FINDINGS

A 16-item initial scale was determined after Delphi. The data from 206 pilot survey samples was used to select and validate items, and a 10-item CRS-PCFT was developed. The scale showed satisfactory reliability and validity based on data from 398 formal survey samples. When the CRS-PCFT scores were into high and low toxicity groups by the median, they were significantly correlated with education (r = -0.284, p < 0.0001), household income (r = -0.253, p < 0.0001), work status (r = -0.173, p = 0.001), and cancer stages (r = 0.147, p = 0.003).

INTERPRETATION

CRS-PCFT demonstrates robust reliability and validity and makes it more accurate to obtain the pediatric cancer financial toxicity conditions. Additional research should be done to validate CRS-PCFT.

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.

Adaptation, Feasibility, and Acceptability of a Health Insurance Literacy Intervention for Caregivers of Pediatric Cancer Patients (CHAT-C)

We adapted CHAT, a four-session virtual program to help individuals affected by cancer manage insurance and medical costs for caregivers of pediatric cancer patients (called CHAT-C); we then pilot-tested CHAT-C. Eligible caregivers were ages 18+ and the primary caregiver to a pediatric cancer patient (≤25 years old) diagnosed in the past five years and treated at Primary Children's Hospital. We conducted engagement studios to adapt the program. Feedback was evaluated using a rapid qualitative analysis framework and included content preferences, navigator preferences, logistics/structure, timing of delivery, and feasibility/acceptability. A small pilot test of CHAT-C was conducted; feasibility, acceptability, and preliminary efficacy were evaluated based on enrollment rates, qualitative feedback, and baseline/follow-up surveys. Participants in the pilot (n = 14) were primarily white (93%), married (93%), female (86%), ages 40-49 (50%), and college-educated (57%). Most participants (64%) completed all four sessions of CHAT-C. Those who did not complete the sessions cited a lack of time, a child's disease progression, and a perceived lack of benefit. Health insurance literacy (measured by nine items) improved by 10.8 points on average (SD = 6.0, range: 9-36) after CHAT-C. Caregivers of childhood cancer patients are willing to participate in a health insurance program, but some caregivers need less time-intensive options.

Chronic illness and financial burden in Switzerland (FINK): a protocol for a mixed methods research project

INTRODUCTION

People with cancer and other chronic illnesses, their families and caregivers report financial burden as a problem that affects multiple aspects of daily life. While cancer research has coined the term 'financial toxicity' to describe the financial consequences, the understanding, development and operationalisation of the concept of financial burden are still incomplete, particularly regarding subjective financial burden and its relationship with well-being. The overall aim is to investigate financial burden and its implications for the well-being of people living with chronic illness, their families, and caregivers in Switzerland.

METHODS AND ANALYSIS

Transdisciplinary discussion groups and a participatory action design element frame: (1) a conceptualisation using a hybrid concept analysis approach and (2) an assessment of financial burden of chronic illness in relation to well-being. The hybrid concept analysis combines the results of a scoping review with a secondary analysis of existing interviews using computational linguistics and qualitative analysis. The assessment phase will investigate the extent and nature of financial burden through a nationwide survey. Results from mobile diaries/interviews will contribute to both-the conceptualisation and assessment phases.

ETHICS AND DISSEMINATION

The Ethics Committee of the Canton Zurich, Switzerland, did not consider the research project to fall under the Swiss Law on Human Subjects research and issued a waiver (Req-2O23-01496). The project respects all the rules and regulations in the Swiss Federal Act on Data Protection and those by the Swiss Federal Official Responsible for Data Protection and Transparency. Results will be disseminated through presentations at conferences and publications in peer-reviewed journals and through the established multi-stakeholder network.

Impact of Patient Personality on Adherence to Oral Anticancer Medications: An Opportunity?

Adherence to prescribed oral anticancer therapy is an important determinant of patient outcomes, including progression-free and overall survival. While many factors (eg, medication side effects and out-of-pocket costs, problems with insurance authorization, and timely medication refills) can affect adherence, one that is relatively unexplored is the impact of a patient's attitude and personality. Patient personality influences medication adherence and persistence in nonmalignant chronic conditions such as cardiovascular disease and diabetes. In breast cancer and chronic myeloid leukemia, studies suggest that personality also affects adherence to oral chemotherapy which can be targeted to improve adherence. In this viewpoint, we highlight the opportunity of incorporating patient personality as interventions to oral cancer therapy adherence and discuss current barriers to implementation.

A Systematic Review of Interventions Targeting Cancer-Related Financial Hardship: Current Evidence and Implications

BACKGROUND

Despite an increasing emphasis on alleviating financial hardship in cancer care delivery, limited knowledge of evidence-based and effective interventions is available.

OBJECTIVE

This systematic review aimed to identify gaps in the literature and provide insights for future evidence-based interventions targeting financial hardship from both micro and macro perspectives.

METHODS

We comprehensively searched the PubMed, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, and PsycINFO databases from inception to October 2022. Studies examining the effect of an intervention on mitigating cancer-related financial hardship were included.

RESULTS

A total of 24 studies were included. Findings indicate that the most significant positive changes were in the material conditions domain from the micro perspective of financial hardship. From the macro perspective, positive effects were shown for improving access to care, affordability of care, healthcare utilization, and healthcare equity of interventions at the provider or care team level, the community healthcare environment level, and the healthcare system and policy level. Notably, significant heterogeneity was observed among interventions and outcome measurements.

CONCLUSIONS

This is the first comprehensive systematic review of interventions targeting cancer-related financial hardship from both micro and macro perspectives. No consistently positive effect of the interventions on all domains was reported. Multidisciplinary approaches and higher-level hierarchical and evidence-based interventions are needed to address financial hardship.

IMPLICATIONS FOR PRACTICE

Health practitioners should screen and manage financial hardship using a standard and comprehensive measurement at the dyadic level of cancer survivors and caregivers.

Feasibility of Screening for Financial Hardship and Health-Related Social Needs at Radiology Encounters

OBJECTIVE

To evaluate the prevalence of financial hardship and health-related social needs (HRSNs) among outpatients undergoing advanced imaging services and assess the feasibility of screening for financial and social needs during radiology encounters.

METHODS

Adult patients receiving CT, MRI, or PET/CT at outpatient imaging centers of an academic tertiary center were asked to complete a 15-minute survey with adapted validated questions inquiring about their experience of financial hardship related to imaging and HRSNs, and the appropriateness of screening for financial and social needs at radiology encounters. Logistic regression analyses were performed to assess factors associated with perceived appropriateness of screening and level of interest in meeting with financial counselors.

RESULTS

A total of 430 patients responded (10.0% response rate; mean age: 57.1 years; 57.4% female; 54.5% White; 22.1% Hispanic; 19.1% Asian; 1% Black). A total of 35% reported experiencing financial hardship with imaging; 47.5% reported material hardship, 15.3% reported cost-related care nonadherence, and 5.3% reported cost-related imaging nonadherence. Overall, 35.9% had at least one HRSN, with food insecurity being the most common (28.3%). The majority (79.7%) felt that being screened for HRSNs at radiology encounters is appropriate, with those experiencing imaging hardship being more likely to feel that screening is appropriate (odds ratio [OR]: 2.93; 95% confidence interval [CI], 1.31-6.56). Overall, 29.5% were interested in meeting with a financial counselor, with those with imaging hardship (OR: 3.70; 95% CI, 1.96-6.97) and HRSNs (OR: 2.87; 95% CI, 1.32-6.24) and who felt uncomfortable with screening (OR: 2.83; 95% CI, 1.14-7.03) being more likely to be interested.

DISCUSSION

Financial hardship and HRSNs are common among outpatients undergoing advanced imaging, with the majority reporting that getting screened at radiology encounters is appropriate.

Prevalence of financial hardship and health-related social needs among patients with missed radiology appointments

PURPOSE

We aimed to evaluate the prevalence of financial hardship and Health-Related Social Needs (HRSN) among patients who missed their radiology appointment.

METHODS

English-speaking adult patients, with a missed outpatient imaging appointment at any of a tertiary care imaging centers between 11/2022 and 05/2023 were eligible. We measured self-reported general financial worry using Comprehensive Score for Financial Toxicity (COST), imaging hardship (worry that the current imaging is a financial hardship to patient and their family), material hardship (e.g., medical debt), cost-related care nonadherence, and HRSNs including housing instability, food insecurity, transportation problems, and utility help needs.

RESULTS

282 patients were included (mean age 54.7 ± 15.0 years; 70.7 % female). Majority were non-Hispanic White (52.4 %), followed by Asian (23.0 %) and Hispanic (16.0 %) racial/ethnic background. Most missed appointments were patient-initiated (74.8 %); 13.5 % due to cost or insurance coverage and 6.4 % due to transportation and parking. Mean COST score was 26.8 with 44.4 % and 28.8 % reporting their illness and imaging as a source of financial hardship. 18.3 % and 35.2 % endorsed cost-related care nonadherence and material hardship. 32.7 % had at least one HRSNs with food insecurity the most common (25.4 %). Only 12.5 % were previously screened for financial hardship or HRSNs. Having comorbidity and living in more disadvantaged neighborhoods was associated with higher report of financial hardship and HRSNs.

CONCLUSION

Financial hardship and HRSNs are common among those who miss radiology appointments. There needs to be more rigorous screening for financial hardship and HRSNs at every health encounter and interventions should be implemented to address these.

Top Ten Tips Palliative Care Clinicians Should Know About Caring for Family Caregivers

Family and friend caregivers play critical roles in ensuring that persons with serious illness receive high-quality care, and their responsibilities often increase as patients transition from receiving solely curative-focused care to primarily palliative-focused care. Integrating family caregivers into the health care team and supporting them in their role has significant benefits for family caregivers, patients, health care systems, communities, and society. Palliative care clinicians across all disciplines are uniquely suited to provide necessary training and support to family caregivers as they navigate the demands of their role. Here, we contend that providing comprehensive palliative care includes addressing the needs of family caregivers and provide ten tips and practical guidance to assist palliative care clinicians to support family caregivers. Engaging family caregivers as partners in care will ultimately allow palliative care clinicians to deliver the highest quality patient care and ensure the best possible outcomes for families facing serious illnesses.

Financial Toxicity Among Patients With Metastatic Prostate Cancer: A Mixed Methods Approach to Identify Effective Interventions

INTRODUCTION

Financial toxicity associated with treatments for metastatic prostate cancer remains poorly defined. We sought to understand aspects of financial toxicity not captured in a commonly employed financial toxicity questionnaire and identify potential interventions to help alleviate financial toxicity through a convergent mixed methods approach.

METHODS

Patients seen at our institution's advanced prostate cancer clinic were approached for completion of the Comprehensive Score for Financial Toxicity (COST-FACIT) questionnaire (quantitative analysis). A maximal variation purposive sample was chosen to participate in focus group discussions (qualitative analysis). Conventional content analysis was performed using an inductive approach. COST-FACIT scores were compared between patients experiencing high and low financial toxicity using Wilcoxon rank sum test.

RESULTS

Three themes were identified through qualitative analysis: (1) workload, (2) coping strategies, and (3) communication. We found alignment with the existing theory of financial capacity across our findings. Two unique aspects of financial toxicity emerged that were not assessed quantitatively and deemed to be significant. Specifically, cost transparency (including health care teams knowledgeable about and willing to discuss costs) and inclusion of informal caregivers in financial toxicity screening and decision-making may guide future interventions aimed at limiting financial toxicity in this population.

CONCLUSIONS

Prolonged treatment courses involving multiple lines of treatment with varying costs result in distinct financial toxicity components for patients with metastatic prostate cancer that are not assessed with COST-FACIT. Improving cost transparency, health care team knowledge and engagement, and providing resources to support informal caregivers may have a significant impact on the financial toxicity experienced by these patients.

Assessment of Financial Toxicity and Coping Strategies Associated With Cancer Treatment Among Caregivers of Patients With Cancer From a Lower-Middle-Income Country

PURPOSE

The rising cost of cancer treatment causes out-of-pocket spending among patients or caregivers in lower-middle-income countries, resulting in acute misery and insolvency. This study aimed to assess the financial toxicity associated with cancer treatment and the coping strategies for cancer treatment adopted among the caregivers of patients with cancer in a tertiary cancer care center.

MATERIALS AND METHODS

This prospective cross-sectional study was conducted among the primary caregivers of patients with cancer undergoing curative treatment from March to June 2023. The estimated sample size was 403 caregivers. The financial toxicity was assessed using a modified Comprehensive Score for Financial Toxicity-Functional Assessment of Chronic Illness Therapy tool, and coping strategies were explored using a validated questionnaire of 20 questions. Univariate and multivariate analyses investigated the associations and factors influencing financial toxicity.

RESULTS

The caregivers recruited in the study were 403; 83.8% were younger than 50 years, and 66.5% were male. The common cancer types included were breast cancer (27.3%), GI cancer (17.9%), head and neck cancer (12.4%), and gynecological cancer (11.6%). The mean financial toxicity score was 22.32 (standard deviation, 9.55), with 64% experiencing moderate to severe financial toxicity. The most common coping strategies used were spending a portion or all of the savings, borrowing money from others, restructuring their spending habits, seeking financial assistance from the cancer center, and resorting to gold loans.

CONCLUSION

Screening patients and their primary caregivers using a modified COST tool can help identify families experiencing severe financial toxicity and provide necessary intervention.

Dyadic effects of financial toxicity and social support on the fear of cancer recurrence in breast cancer patients and caregivers: an actor-partner interdependence mediation model

PURPOSE

In this study, the actor-partner interdependence mediation model (APIMeM) was applied to breast cancer patients and their caregivers to assess the factors that affect the fear of cancer recurrence. In particular, the purpose of this study was to evaluate the mediating effect of social support on financial toxicity and the fear of cancer recurrence, providing an effective basis for developing plans to reduce the level of fear of cancer recurrence.

METHODS

This study employed a cross-sectional design, and 405 dyads of breast cancer patients and their caregivers were enrolled. Financial toxicity, social support, and fear of cancer recurrence were assessed by computing comprehensive scores for financial toxicity based on patient-reported outcome measures, the Social Support Rating Scale, and the Fear of Cancer Recurrence Inventory Short Form, respectively. The data were analysed using SPSS 24.0 and AMOS 23.0.

RESULTS

The results showed that the fear of cancer recurrence of breast cancer patients and their caregivers was significantly related to dyadic financial toxicity and social support. In addition, the financial toxicity of breast cancer patients and their caregivers had significant actor effects and partner effects on the fear of cancer recurrence through dyadic social support.

CONCLUSIONS

The financial toxicity of breast cancer patients and their caregivers could produce actor and partner effects on the fear of cancer recurrence through the mediation of social support, which provided empirical support for improving reducing the level of fear of cancer recurrence among patients and caregivers at the dyadic level.

Cancer patient and caregiver communication about economic concerns and the effect on patient and caregiver partners' perceptions of family functioning

PURPOSE

Financial strain and stressful life events can constrain open communication within families. A cancer diagnosis can bring heightened emotional stress and financial strain for most cancer patients and their families. We evaluated how level of comfort and willingness to discuss important but sensitive economic topics affected longitudinal assessments of family relationships, exploring both within-person and between partner effects over 2 years after a cancer diagnosis.

METHODS

A case series of hematological cancer patient-caregiver dyads (n = 171) were recruited from oncology clinics in Virginia and Pennsylvania and followed for 2 years. Multi-level models were developed to examine the associations between comfort discussing economic aspects of cancer care and family functioning.

RESULTS

Broadly, caregivers and patients who were comfortable discussing economic topics reported higher family cohesion and lower family conflict. Dyads' assessments of family functioning were influenced both by their own and their partners level of communication comfort. Overtime, caregiver but not patients perceived a significant decrease in family cohesion.

CONCLUSIONS

Efforts to address financial toxicity in cancer care should include examination of how patients and families communicate as unaddressed difficulties can have detrimental effects on family functioning in the long term. Future studies should also examine whether the prominence of specific economic topics, such as employment status, varies depending on where the patient is in their cancer journey.

IMPLICATIONS FOR CANCER SURVIVORS

In this sample, cancer patients did not perceive the decline in family cohesion that was reported by their family caregiver. This is an important finding for future work that aims to identify the timing and nature to best intervene with caregiver supports to mitigate caregiver burden that may negatively impact long-term patient care and QoL.

Evaluation of a Conference on Cancer-Related Financial and Legal Issues: A Potential Resource to Counter Financial Toxicity

This study describes the conception, development, and growth of the Triage Cancer Conference hosted by Triage Cancer, a national nonprofit organization providing free legal and financial education to the cancer community. We conducted a retrospective analysis of post-conference participant surveys. Descriptive statistics were calculated for participant demographics, and acceptability, feasibility, and appropriateness were evaluated. From 2016-2021, 1239 participants attended the conference and completed post-conference surveys. Participants included social workers (33%), nurses (30%), and cancer patients/survivors (21%), with representation from over 48 states. Among those who reported race, 16% were Black, and 7% were Hispanic. For acceptability, more than 90% of participants felt that the conference content, instructors, and format were suitable and useful. For feasibility, more than 90% of participants felt that the material was useful, with 93-96% reporting that they were likely to share the information and 98% reporting that they would attend another triage cancer event. Appropriateness was also high, with >80-90% reporting that the sessions met the pre-defined objectives. Triage Cancer fills an important gap in mitigating financial toxicity, and formal evaluation of these programs allows us to build evidence of the role and impact of these existing resources. Future research should focus on adding validated patient-reported outcomes, longer-term follow-up, and ensuring inclusion and evaluation of outcome metrics among vulnerable populations.

Using Cost Conversations to Address Financial Toxicity in Pediatric Asthma Care: Findings From a Survey of Caregivers

INTRODUCTION

Asthma care teams are well-positioned to help caregivers address financial toxicity in pediatric asthma care, although discussing cost can be challenging. We sought to characterize cost conversations in pediatric asthma specialty care.

METHOD

We surveyed 45 caregivers of children aged 4-17 with asthma. Eligible caregivers reported costs concerns and had accompanied their child to a multisite asthma specialty practice in North Carolina.

RESULTS

About one-third of caregivers reported a cost conversation (36%). Cost conversations were less common among caregivers whose child had public versus private health insurance (16% vs. 56%), who attended a telehealth versus in-person visit (6% vs. 52%), or who did not versus did want a conversation (19% vs. 77%, all p < .05). Common cost conversation topics were medications and equipment like spacers.

DISCUSSION

Our findings suggest cost conversations may be relatively uncommon in pediatric asthma care, particularly for publicly insured patients and telehealth visits.

Caregiver costs and financial burden in caregivers of African American cancer survivors

PURPOSE

People with cancer commonly rely on loved ones as informal caregivers during and after treatment. Costs related to caregiving and their association with caregiver financial burden are not well understood.

METHODS

Results include data from 964 caregivers of African American cancer survivors in the Detroit Research on Cancer Survivors (ROCS) cohort. Caregiving costs include those related to medications, logistics (e.g., transportation), and medical bills. Financial burden measures included caregiver financial resources, strain, and difficulty paying caregiving costs. Prevalence ratios (PR) and 95% confidence intervals (CI) of associations between costs and high financial burden were calculated using modified Poisson models controlling for caregiver characteristics.

RESULTS

Caregivers included spouses (36%), non-married partners (8%), family members (48%), and friends (9%). Nearly two-thirds (64%) of caregivers reported costs related to caregiving. Logistical costs were the most common (58%), followed by medication costs (35%) and medical bills (17%). High financial hardship was reported by 38% of caregivers. Prevalence of high financial hardship was 52% (95% CI: 24%, 86%) higher among caregivers who reported any versus no caregiver costs. Associations between caregiver costs and high financial burden were evident for costs related to medications (PR: 1.33, 95% CI: 1.12, 1.58), logistics (PR: 1.57, 95% CI: 1.29, 1.92), and medical bills (PR: 1.57, 95% CI: 1.28, 1.92).

CONCLUSIONS

Most caregivers experienced costs related to caregiving, and these costs were associated with higher prevalence of high caregiver financial burden.

IMPLICATIONS FOR CANCER SURVIVORS

Informal caregivers experience financial hardship related to cancer along with cancer survivors.

Financial toxicity of informal caregivers of colorectal cancer patients: A cross-sectional study

PURPOSE

To assess the level of financial toxicity of informal caregivers of colorectal cancer patients and explore the related key influencing factors.

METHOD

A descriptive survey design was used in this study. Data were collected from 236 informal caregivers of colorectal cancer patients between March 2023 and July 2023 from a major hospital in central China (Henan province). Potential influence factors of financial toxicity, including basic information, perceived stress, and social support were analyzed using multivariate linear regression.

RESULTS

The financial toxicity score of 236 caregivers of colorectal cancer patients was 19.42 ± 9.72. One hundred and fourteen caregivers (accounting for 48.31%) of colorectal cancer patients had high levels of financial toxicity. Financial toxicity scores of caregivers were negatively correlated with perceived stress (r = -0.421, P < 0.001) and positively correlated with social support (r = 0.416, P < 0.001). Our multivariate regression analysis identified some factors that directly affected caregivers' financial toxicity, including caregiver age (t = 2.105, P = 0.036), medical insurance (t = 2.462, P = 0.015), average household income (t = 2.995, P = 0.003), place of residence (t = 2.872, P = 0.004), perceived stress (t = -4.945, P < 0.001), and social support (t = 4.513, P < 0.001).

CONCLUSIONS

Caregivers of colorectal cancer patients generally experience a higher level of financial toxicity, which could be eased by lower perceived stress and higher social support. In clinical practice, it is necessary to comprehensively assess the level of financial toxicity of particular caregivers and enact targeted interventions such as increasing communication and actively providing information to address the high medical costs, reducing the detrimental effects of financial toxicity, and improving the quality of colorectal cancer care.

Supportive care needs and associated factors among caregivers of patients with colorectal cancer: a cross-sectional study

To assess the level of supportive care needs of caregivers of colorectal cancer patients and explore the related key influencing factors. Totaling 283 caregivers of patients with colorectal cancer were investigated in this study. Firstly, caregivers were invited to complete a set of questionnaires, including the general information questionnaire, the Supportive Care Needs Survey-Partners and the Caregivers of cancer patients, the Caregiver Preparedness Scale, the Benefit Finding Scale, and the Comprehensive Score for Financial Toxicity. Univariate and multivariate linear regression were performed to investigate the associated factors of supportive care needs. The caregivers of patients with colorectal cancer have a moderate level of needs, scored at 2.71 ± 0.42. Caregiver preparedness, benefit finding, and financial toxicity were significantly negatively associated with the supportive care needs of caregivers (r =  - 0.555, P < 0.001; r =  - 0.534, P < 0.001; and r =  - 0.615, P < 0.001, respectively). Our multivariate regression analysis identified some factors that directly affected the supportive care needs of caregivers, including the duration of illness, tumor stage, the age and educational level of caregivers, caregiver preparedness, benefit finding, and financial toxicity (R2 = 0.574, F = 23.337, P < 0.001). Supportive care needs are common among caregivers of colorectal cancer patients. Higher caregiver preparedness, benefit finding, and financial toxicity tend to ease these needs. Healthcare workers should have an in-depth understanding of the needs of caregivers of colorectal cancer patients and actively provide targeted financial/informational/technical/emotional support to promote nursing skills and reduce caregivers' burdens.

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.

Factors of preparedness for loss from cancer among Taiwanese family caregivers

This cohort study investigated factors associated with 336 Taiwanese family caregivers' emotional and cognitive preparedness for death of a loved one with terminal cancer. Caregivers' death-preparedness states (no-death-preparedness [as reference], cognitive-death-preparedness-only, emotional-death-preparedness-only, and sufficient-death-preparedness states) were previously identified. Associations of factors with these states were determined by a hierarchical generalized linear model. Financial hardship decreased caregivers' likelihood for the emotional-death-preparedness-only and sufficient-death-preparedness states. Physician prognostic disclosure increased membership in the cognitive-death-preparedness-only and sufficient-death-preparedness states. The better the quality of the patient-caregiver relationship, the higher the odds for the emotional-death-preparedness-only and sufficient-death-preparedness states, whereas the greater the tendency for caregivers to communicate end-of-life issues with their loved one, the lower the odds for emotional-death-preparedness-only state membership. Stronger coping capacity increased membership in the emotional-death-preparedness-only state, but perceived social support was not associated with state membership. Providing effective interventions tailored to at-risk family caregivers' specific needs may facilitate their death preparedness.

Patient-Reported Financial Burden of Treatment for Colon or Rectal Cancer

Importance

The longitudinal experience of patients is critical to the development of interventions to identify and reduce financial hardship.

Objective

To evaluate financial hardship over 12 months in patients with newly diagnosed colorectal cancer (CRC) undergoing curative-intent therapy.

Design, Setting, and Participants

This prospective, longitudinal cohort study was conducted between May 2018 and July 2020, with time points over 12 months. Participants included patients at National Cance Institute Community Oncology Research Program sites. Eligibility criteria included age at least 18 years, newly diagnosed stage I to III CRC, not started chemotherapy and/or radiation, treated with curative intent, and able to speak English. Data were analyzed from December 2022 through April 2023.

Main Outcomes and Measures

The primary end point was financial hardship, measured using the Comprehensive Score for Financial Toxicity (COST), which assesses the psychological domain of financial hardship (range, 0-44; higher score indicates better financial well-being). Participants completed 30-minute surveys (online or paper) at baseline and 3, 6, and 12 months.

Results

A total of 450 participants (mean [SD] age, 61.0 [12.0] years; 240 [53.3%] male) completed the baseline survey; 33 participants (7.3%) were Black and 379 participants (84.2%) were White, and 14 participants (3.1%) identified as Hispanic or Latino and 424 participants (94.2%) identified as neither Hispanic nor Latino. There were 192 participants (42.7%) with an annual household income of $60 000 or greater. There was an improvement in financial hardship from diagnosis to 12 months of 0.3 (95% CI, 0.2 to 0.3) points per month (P < .001). Patients with better quality of life and greater self-efficacy had less financial toxicity. Each 1-unit increase in Functional Assessment of Cancer Therapy-General (rapid version) score was associated with an increase of 0.7 (95% CI, 0.5 to 0.9) points in COST score (P < .001); each 1-unit increase in self-efficacy associated with an increase of 0.6 (95% CI, 0.2 to 1.0) points in COST score (P = .006). Patients who lived in areas with lower neighborhood socioeconomic status had greater financial toxicity. Neighborhood deprivation index was associated with a decrease of 0.3 (95% CI, -0.5 to -0.1) points in COST score (P = .009).

Conclusions and Relevance

These findings suggest that interventions for financial toxicity in cancer care should focus on counseling to improve self-efficacy and mitigate financial worry and screening for these interventions should include patients at higher risk of financial burden.

Administrative Burden Associated with Cost-Related Delays in Care in U.S. Cancer Patients

BACKGROUND

U.S. cancer patients engage in administrative tasks to pay for their healthcare. This study investigated the relationship between payment tasks and timely access to cancer care.

METHODS

We analyzed online survey data from 510 U.S. cancer patients and survivors to understand the relationship between administrative payment tasks and cost-related delays and nonadherence. Two-part modelling was used to determine if, and to what extent, there was a relationship between administrative burden and cost-related delays/nonadherence.

RESULTS

Younger patients (≤44 years) reported more payment tasks and cost-related delays/nonadherence than older patients (≥ 55 years); African American patients reported more payment tasks and cost-related delays/nonadherence than white patients. After accounting for age, race/ethnicity, education, and out-of-pocket costs, patients who reported engaging in more tasks had greater log odds of delaying/forgoing care [b = 0.18; 95% confidence interval (CI), 0.12-0.24]. Cost-related delays/nonadherence increased by 32% for every unit increase in administrative payment burden (b = 0.32; 95% CI, 0.18-0.46).

CONCLUSIONS

Administrative payment burden increased the odds of cost-related delays and nonadherence by 49%, taking the form of delayed or skipped doctor appointments, tests and bloodwork, and prescription fulfillment. Younger patients and those identifying as African American were more likely to engage in payment tasks and to delay or forgo care due to cost. Administrative burdens can disrupt access to care and traditionally underserved patient populations are disproportionately exposed to these hardships.

IMPACT

Reducing the complexity of healthcare through universal, human-centered design could reduce burdens and increase access.

Factors associated with quality of life for cystic fibrosis family caregivers

Cystic Fibrosis (CF) is a genetic and chronic disease affecting 32,100 people in the United States as of 2021, with a life expectancy of 56 years for people with CF (PwCF) born between 2018 and 2022. While there is extensive literature about cystic fibrosis, there are few studies examining the complexity and challenges experienced by family caregivers for PwCF. The aim of this study was to examine the Caregiver Quality of Life Cystic Fibrosis (CQOLCF) scale using data (N = 217) from two separate studies that used the scale to determine if its items represent multiple factors relevant to CF family caregiver QoL. Factor analysis was conducted on the Seven distinct factors were found with analysis of the CQOLCF. Factors were Existential Dread (12%), Burden (11%), Strain (7%), Support (7%), Positivity (6%), Finance (5%) and Guilt (3%). Study findings indicated it is important for healthcare providers and researchers who use the CQOLCF to be knowledgeable and aware of the multiple factors associated with quality of life in this population in addition to an overall quality of life score.

Financial Toxicity Monitoring in a Randomized Controlled Trial of Patient-Reported Outcomes During Cancer Treatment (Alliance AFT-39)

PURPOSE

Financial toxicity (FT) affects 20% of cancer survivors and is associated with poor clinical outcomes. No large-scale programs have been implemented to mitigate FT. We evaluated the effect of monthly FT screening as part of a larger patient-reported outcomes (PROs) digital monitoring intervention.

METHODS

PRO-TECT (AFT-39) is a cluster-randomized trial of patients undergoing systemic therapy for metastatic cancer. Practices were randomly assigned 1:1 to digital symptom monitoring (PRO practices) or usual care (control practices). Digital monitoring consisted of between-visit online or automated telephone patient surveys about symptoms, functioning, and FT (single-item screening question from Functional Assessment of Chronic Illness Therapy-COmprehensive Score for financial Toxicity) for up to 1 year, with automated alerts sent to practice nurses for concerning survey scores. Clinical team actions in response to alerts were not mandated. The primary outcome of this planned secondary analysis was development or worsening of financial difficulties, assessed via the European Organisation for Research and Treatment of Cancer QLQ-C30 financial difficulties measure, at any time compared with baseline. A randomly selected subset of patients and nurses were interviewed about their experiences with the intervention.

RESULTS

One thousand one hundred ninety-one patients were enrolled (593 PRO; 598 control) at 52 US community oncology practices. Overall, 30.2% of patients treated at practices that received the FT screening intervention developed, or experienced worsening of, financial difficulties, compared with 39.0% treated at control practices (P = .004). Patients and nurses interviewed stated that FT screening identified patients for financial counseling who otherwise would be reluctant to seek, or unaware of the availability of, assistance.

CONCLUSION

In this report of a secondary outcome from a randomized clinical trial, FT screening as part of routine digital patient monitoring with PROs reduced the development, or worsening, of financial difficulties among patients undergoing systemic cancer therapy.

A burden shared: the financial, psychological, and health-related consequences borne by family members and caregivers of people with cancer in India

In India, approximately 1.4 million new cases of cancer are recorded annually, with 26.7 million people living with cancer in 2021. Providing care for family members with cancer impacts caregivers' health and financial resources. Effects on caregivers' health and financial resources, understood as family and caregiver "financial toxicity" of cancer, are important to explore in the Indian context, where family members often serve as caregivers, in light of cultural attitudes towards family. This is reinforced by other structural issues such as grave disparities in socioeconomic status, barriers in access to care, and limited access to supportive care services for many patients. Effects on family caregivers' financial resources are particularly prevalent in India given the increased dependency on out-of-pocket financing for healthcare, disparate access to insurance coverage, and limitations in public expenditure on healthcare. In this paper, we explore family and caregiver financial toxicity of cancer in the Indian context, highlighting the multiple psychosocial aspects through which these factors may play out. We suggest steps forward, including future directions in (1) health services research, (2) community-level interventions, and (3) policy changes. We underscore that multidisciplinary and multi-sectoral efforts are needed to study and address family and caregiver financial toxicity in India.

Factors associated with increased financial toxicity after the completion of radiation treatment for gynecologic cancer

PURPOSE

We evaluated financial toxicity (FT) in patients with gynecologic cancer treated with radiation and assessed the impact of the COVID-19 pandemic on patients' financial wellbeing.

METHODS

Patients completed a survey 1 month after completing radiation from August 2019-March 2020 and November 2020-June 2021. The survey included the COmprehensive Score for Financial Toxicity (COST) tool, EQ-5D to measure quality of life (QOL) and pandemic-related questions for the second survey period. High FT was COST score ≤ 23.

RESULTS

Of 97 respondents (92% response rate), 49% completed the survey pre-pandemic and 51% after; the majority were white (76%) and had uterine cancer (64%). Sixty percent received external beam radiation with or without brachytherapy; 40% had only brachytherapy. High FT was associated with worse QOL (r = -0.37, P < 0.001), younger age and type of insurance (both p ≤ 0.03). Respondents with high FT were 6.0 (95% CI 1.0-35.9) times more likely to delay/avoid medical care, 13.6 (95% CI 2.9-64.3) times more likely to borrow money, and 6.9 (95% CI 1.7-27.2) times as likely to reduce spending on basic goods. The pandemic cohort had a smaller proportion of respondents with high FT than the pre-pandemic cohort (20% vs. 35%, p = 0.10) and a higher median COST score (32 (IQR 25-35) vs. 27 (IQR 19-34), p = 0.07).

CONCLUSION

Privately insured, younger respondents who received radiation for gynecologic cancer were at risk for FT. High FT was associated with worse QOL and economic cost-coping strategies. We observed less FT in the pandemic cohort, though not statistically different from the pre-pandemic cohort.

Working, Low Income, and Cancer Caregiving: Financial and Mental Health Impacts

PURPOSE

Approximately 6 million people provide caregiving to people diagnosed with cancer. Many must remain employed to support their household and to have access to health insurance. It is unknown if caregiving for a spouse diagnosed with cancer is associated with greater financial and mental stress relative to providing care for a spouse with different conditions.

METHODS

Health and Retirement Study (2002-2020) data were used to compare employed caregivers, younger than age 65 years, caring for a spouse diagnosed with cancer (n = 103) and a matched control group caring for a spouse with other conditions (n = 515). We used logistic regression to examine a decrease in household income, increase in household debt, stopping work, and a new report of a mental health condition over a 4-year period, adjusting for socioeconomic and demographic characteristics, and health insurance status. Subanalyses stratified estimations by median household income.

RESULTS

Around a third of cancer caregivers reported they stopped working (35%) and had an increase in household debt (30%). Cancer caregivers in households below the median household income were more likely to report decreased income (13.4 percentage points [pp]; P < .10), increased household debt (14.5 pp; P < .10), and stopping work (18.8 pp; P < .05) than similar noncancer caregivers. Mixed results were found for a change in mental health domains. The results were robust to multiple sensitivity analyses.

CONCLUSION

Cancer caregivers from low-income households were more likely to increase debt and incur work loss compared with noncancer caregivers in similar households. Policies such as paid sick leave and family leave are needed for this strained and important population who have financial and employment responsibilities in addition to caregiving.

Financial Toxicity and Its Association With Health-Related Quality of Life Among Partners of Colorectal Cancer Survivors

Importance

Partners of colorectal cancer (CRC) survivors play a critical role in diagnosis, treatment, and survivorship. While financial toxicity (FT) is well documented among patients with CRC, little is known about long-term FT and its association with health-related quality of life (HRQoL) among their partners.

Objective

To understand long-term FT and its association with HRQoL among partners of CRC survivors.

Design, Setting, and Participants

This survey study incorporating a mixed-methods design consisted of a mailed dyadic survey with closed- and open-ended responses. In 2019 and 2020, we surveyed survivors who were 1 to 5 years from a stage III CRC diagnosis and included a separate survey for their partners. Patients were recruited from a rural community oncology practice in Montana, an academic cancer center in Michigan, and the Georgia Cancer Registry. Data analysis was performed from February 2022 to January 2023.

Exposures

Three components of FT, including financial burden, debt, and financial worry.

Main Outcomes and Measures

Financial burden was assessed with the Personal Financial Burden scale, whereas debt and financial worry were each assessed with a single survey item. We measured HRQoL using the PROMIS-29+2 Profile, version 2.1. We used multivariable regression analysis to assess associations of FT with individual domains of HRQoL. We used thematic analysis to explore partner perspectives on FT, and we merged quantitative and qualitative findings to explain the association between FT and HRQoL.

Results

Of the 986 patients eligible for this study, 501 (50.8%) returned surveys. A total of 428 patients (85.4%) reported having a partner, and 311 partners (72.6%) returned surveys. Four partner surveys were returned without a corresponding patient survey, resulting in a total of 307 patient-partner dyads for this analysis. Among the 307 partners, 166 (56.1%) were aged younger than 65 years (mean [SD] age, 63.7 [11.1] years), 189 (62.6%) were women, and 263 (85.7%) were White. Most partners (209 [68.1%]) reported adverse financial outcomes. High financial burden was associated with worse HRQoL in the pain interference domain (mean [SE] score, -0.08 [0.04]; P = .03). Debt was associated with worse HRQoL in the sleep disturbance domain (-0.32 [0.15]; P = .03). High financial worry was associated with worse HRQoL in the social functioning (mean [SE] score, -0.37 [0.13]; P = .005), fatigue (-0.33 [0.15]; P = .03), and pain interference (-0.33 [0.14]; P = .02) domains. Qualitative findings revealed that in addition to systems-level factors, individual-level behavioral factors were associated with partner financial outcomes and HRQoL.

Conclusions and Relevance

This survey study found that partners of CRC survivors experienced long-term FT that was associated with worse HRQoL. Multilevel interventions for both patients and partners are needed to address factors at individual and systemic levels and incorporate behavioral approaches.

Financial toxicity among head and neck cancer patients and their caregivers: A cross-sectional pilot study

Objectives

Head and neck cancer (HNC) patients experience greater financial toxicity than other cancer patients. Research on financial toxicity has concentrated on patients despite many informal caregivers sharing finances and reducing work hours to provide patient care. Thus, our pilot study: (1) assessed the feasibility of financial toxicity screening of HNC patients and their caregivers, and (2) described financial toxicity levels of HNC patients and their caregivers.

Methods

We surveyed English-speaking adult HNC patients initiating treatment at a National Cancer Institute-designated Comprehensive Cancer Center and their informal caregivers. This survey assessed demographics and financial toxicity through the Comprehensive Score for Financial Toxicity (COST) measure (0-44 range; lower score indicates higher financial toxicity). Screening feasibility was defined as ≥50% consent rate and ≥60% data completion rate.

Results

Our sample included 27 HNC patients and 9 caregivers. They both had slightly lower consent and completion rates than our goals. Patients reported a median COST score of 27 while caregivers reported a median COST score of 16. Approximately 25.9% of patients and 44.4% of caregivers reported high financial toxicity (COST < 17.5). Caregivers reported high concerns about their future financial health and their ability to control the amount of their financial contributions to the patient's care.

Conclusions

Patients and caregivers may require additional outreach approaches beyond emailed questionnaires to screen for their financial toxicity systematically. Future research is needed to replicate our results to determine whether differences in financial toxicity occur between patients and caregivers and identify areas of focus for interventions.

Level of evidence

IV.

The Association Between Cost-Related Non-Adherence Behaviors and Diabetes Outcomes

BACKGROUND

We examined the impact of various comorbid conditions on diabetes and condition-specific cost-related nonadherence (CRN), and HbA1c in adults with diabetes.

METHODS

This was a cross-sectional analysis of participants with diabetes and poor glycemic control in an ongoing trial (n = 600). We computed prevalence of condition-specific CRN, prevalence of specific types of diabetes-related CRN by comorbid condition, prevalence of specific types of condition-specific CRN within each comorbidity, and the association between condition-specific and diabetes-related CRN and HbA1c for each comorbid condition.

RESULTS

Fifty-eight percent (n = 350) of participants reported diabetes-related CRN. Diabetes-related CRN rates were highest in those with liver problems (63%), anemia (61%), respiratory diseases (60%), and hyperlipidemia (60%). Condition-specific CRN rates were high in those with respiratory diseases (44%), back pain (41%), and depression (40%). Participants with cancer and kidney diseases reported the lowest rates of diabetes-related and condition-specific CRN. Delaying getting diabetes prescriptions filled was the most commonly reported form of diabetes-related CRN across all comorbid conditions and was the highest in those with liver problems (47%), anemia (46%), and respiratory diseases (45%). In adjusted models, those with back pain (beta-coefficient, 0.45; 95%CI 0.02-0.88; P = .04) and hyperlipidemia (beta-coefficient, 0.50; 95%CI 0.11-0.88; P = .01) who reported both diabetes-related and condition-specific CRN had higher HbA1c.

CONCLUSIONS

CRN in patients with diabetes is higher than in other comorbid conditions and is associated with poor diabetes control. These findings may be driven by higher out-of-pocket costs for medications to manage diabetes, lack of symptoms associated with poor diabetes control, or other factors, with implications for both clinicians and health insurance programs.

Quality of Life in Caregivers of Cancer Patients: A Literature Review

(1) Background: Cancer constitutes one of the principal causes of morbi-mortality in the world and generates an important loss of patients' self-sufficiency. People who are their caregivers usually become the main care providers, which impacts their quality of life; (2) Aim: Analyze the different problems (physical, emotional, social, and financial) faced by people who are caregivers of adults with cancer and describe the strategies required to improve their quality of life; (3) Method: A literature review was conducted on the following database: PubMed, Cinahl, PsycINFO, and Scopus. The following eligibility criteria were specified: (a) research studies of quantitative, qualitative, or mixed methods, (b) consistent with objective, and (c) published in the English language or Spanish during the last five years; (4) Results: 36 studies were selected from those found in the literature. Regarding the problems mentioned: eight studies described physical issues, 26 emotional effects, 10 social implications, and seven financial strains. Twenty-eight studies described strategies to improve the quality of life of caregivers; (5) Conclusions: Caregivers are usually women around the age of 50. Problems faced are mostly emotional in nature, followed by social, physical, and financial ones. In order to cope with this burden, there are some strategies that can be developed to help to build skills to manage both the disease and the impact derived from it, therefore improving their quality of life.

Out-of-Pocket Expenditures for Imaging Examinations: Perspectives From National Patient Surveys Over Two Decades

PURPOSE

Using national surveys, we longitudinally studied imaging costs-and specifically those paid out-of-pocket (OOP) by patients-over two decades.

METHODS

Using 2000 to 2019 Medical Expenditure Panel Survey data, we identified all imaging-focused encounters (mammography, radiography, ultrasonography, and CT and MR [surveyed together in Medical Expenditure Panel Survey]) and calculated mean overall and OOP encounter costs. Effects of sociodemographic, personal, and clinical factors were measured using logistic regression and generalized linear modeling.

RESULTS

We identified 102,717 patients (mean 45.6 years; 64.8% female; 58.8% White) undergoing 229,010 imaging-focused encounters. Between 2000 and 2019, mean costs of mammography, radiography, and ultrasonography increased 14.5%, 24.5%, and 40% and total mean cost of CT or MR decreased by 15.1%. OOP costs were incurred by 51%. Overall mean OOP costs increased 89.8% from 2000 to 2019. Mean OOP costs for mammography decreased by 32.9%; mean OOP costs for radiography, ultrasonography, and CT or MR increased 81%, 123.2%, and 61%, respectively. Patients were less likely to incur OOP costs when older, of racial and ethnic minorities, female, or recipients of public only (versus private) insurance. Among those with OOP costs, the presence of comorbidities, lack of insurance, younger age, and history of cancer significantly increased OOP costs.

CONCLUSION

Mean overall patient OOP costs for imaging examinations increased significantly and substantially over the last two decades. Lack of insurance, younger age, history of cancer, and other comorbidities were associated with higher OOP costs. As diagnostic imaging utilization increases, patient financial hardship considerations merit further attention.

A Rectal Cancer Surgical Decision Aid Is Not Enough: A Qualitative Study

BACKGROUND

Rectal cancer patients often face complex surgical treatment decisions, but there are few available tools to aid in decision-making.

OBJECTIVE

We aimed to identify content and delivery preferences of rectal cancer patients and colorectal surgeons to guide future surgical decision aid creation.

DESIGN

Qualitative study: inductive thematic analysis of semi-structured interviews.

SETTING

In-person and phone interviews.

PATIENTS

We purposively sampled 15 rectal cancer survivors based on demographics and surgery type. Five caregivers also participated. We purposively selected 10 surgeons based on practice type and years of experience.

INTERVENTIONS

Semi-structured interviews.

MAIN OUTCOME MEASURES

Major and minor themes for survivors and surgeons with thematic saturation.

RESULTS

Interviews were a median of 61 minutes (41-93) for patients and 35 minutes (25-59) for surgeons. Nine survivors were younger than 65 years; 7 were female. Surgeons had been practicing for a mean of 10 years (SD 7.4), with 7 in academic and 3 in private settings. Participating survivors and surgeons wanted a comprehensive educational tool-not just a surgical decision aid. Survivors wanted more information on rectal cancer basics and lifestyle, care timelines, and resources during treatment. Surgeons thought patients mostly desired information about surgical options and bowel function. Both patients and surgeons wanted a tool that was personalized, simple, understandable, visually appealing, interactive, short, and in multiple formats.

LIMITATIONS

Results may not be generalizable due to selection bias of participants.

CONCLUSION

Rectal cancer survivors, their caregivers, and colorectal surgeons wanted an educational support tool that would address substantial educational needs through the continuum of disease rather than a surgical decision aid focusing on a discrete surgical choice only. See Video Abstract at http://links.lww.com/DCR/C20 .

UNA AYUDA PARA LA DECISIN QUIRRGICA DEL CNCER DE RECTO NO ES SUFICIENTE UN ESTUDIO CUALITATIVO

ANTECEDENTES:Los pacientes con cáncer de recto a menudo enfrentan decisiones de tratamiento quirúrgico complejas, pero hay pocas herramientas disponibles para ayudar en la toma de decisiones.OBJETIVO:Nuestro objetivo fue identificar el contenido y las preferencias de entrega de los pacientes con cáncer de recto y los cirujanos colorrectales para guiar la futura creación de ayuda para la toma de decisiones quirúrgicas.DISEÑO:Estudio cualitativo: análisis temático inductivo de entrevistas semiestructuradas.ESCENARIO:Entrevistas en persona y por teléfono.PACIENTES:Tomamos muestras intencionalmente de 15 sobrevivientes de cáncer de recto, según la demografía y el tipo de cirugía. También participaron cinco cuidadores. Seleccionamos intencionalmente a 10 cirujanos según el tipo de práctica y los años de experiencia.INTERVENCIONES:Entrevistas semiestructuradas.PRINCIPALES MEDIDAS DE RESULTADO:Temas principales y secundarios para sobrevivientes y cirujanos con saturación temática.RESULTADOS:Las entrevistas tuvieron una mediana de 61 minutos (41-93) para pacientes y 35 minutos (25-59) para cirujanos. Nueve sobrevivientes tenían menos de 65 años; siete eran mujeres. Los cirujanos habían estado ejerciendo una media de 10 años (DE 7,4), con siete en entornos académicos y 3 en entornos privados. Los sobrevivientes y cirujanos participantes querían una herramienta educativa comprensible, no solo una ayuda para la decisión quirúrgica. Los sobrevivientes querían más información sobre los conceptos básicos y el estilo de vida del cáncer de recto, los plazos de atención y los recursos durante el tratamiento. Los cirujanos pensaron que los pacientes en su mayoría deseaban información sobre las opciones quirúrgicas y la función intestinal. Tanto los pacientes como los cirujanos querían una herramienta que fuera personalizada, simple, comprensible, visualmente atractiva, interactiva, corta y en múltiples formatos.LIMITACIONES:Los resultados pueden no ser generalizables debido al sesgo de selección de los participantes.CONCLUSIÓN:Los sobrevivientes de cáncer rectal, sus cuidadores y los cirujanos colorrectales querían una herramienta de apoyo educativo que cubriera las necesidades educativas sustanciales a lo largo del tratamiento de la enfermedad en lugar de una ayuda para la decisión quirúrgica que se centre solo en una opción quirúrgica discreta. Consulte Video Resumen en http://links.lww.com/DCR/C20 . (Traducción-Dr. Yolanda Colorado ).

Shared burden: the association between cancer diagnosis, financial toxicity, and healthcare cost-related coping mechanisms by family members of non-elderly patients in the USA

PURPOSE

There has been little research on the healthcare cost-related coping mechanisms of families of patients with cancer. Therefore, we assessed the association between a cancer diagnosis and the healthcare cost-related coping mechanisms of participant family members through their decision to forego or delay seeking medical care, one of the manifestations of financial toxicity.

METHODS

Using data from the National Health Interview Survey (NHIS) between 2000 and 2018, sample weight-adjusted prevalence was calculated and multivariable logistic regressions defined adjusted odds ratios (aORs) for participant family members who needed but did not get medical care or who delayed seeking medical care due to cost in the past 12 months, adjusting for relevant sociodemographic covariates, including participant history of cancer (yes vs. no) and participant age (18-45 vs. 46-64 years old). The analysis of family members foregoing or delaying medical care was repeated using a cancer diagnosis * age interaction term.

RESULTS

Participants with cancer were more likely than those without a history of cancer to report family members delaying (19.63% vs. 16.31%, P < 0.001) or foregoing (14.53% vs. 12.35%, P = 0.001) medical care. Participants with cancer in the 18 to 45 years old age range were more likely to report family members delaying (p_interaction = 0.028) or foregoing (p_interaction < 0.001) medical care. Other factors associated with cost-related coping mechanisms undertaken by the participants' family members included female sex, non-married status, poorer health status, lack of health insurance coverage, and lower household income.

CONCLUSION

A cancer diagnosis may be associated with familial healthcare cost-related coping mechanisms, one of the manifestations of financial toxicity. This is seen through delayed/omitted medical care of family members of people with a history of cancer, an association that may be stronger among young adult cancer survivors. These findings underscore the need to further explore how financial toxicity associated with a cancer diagnosis can affect patients' family members and to design interventions to mitigate healthcare cost-related coping mechanisms.

Treatment out-of-pocket cost communication and remote financial navigation in patients with cancer: a feasibility study

OBJECTIVE

We conducted a pilot study assessing the feasibility of a personalized out-of-pocket cost communication, remote financial navigation, and counseling (CostCOM) intervention in cancer patients.

METHODS

Twenty-three adult, newly diagnosed cancer patients at a single community oncology practice were asked to complete a survey and participate in a CostCOM intervention, including patient-specific out-of-pocket cost communication, remote financial navigation, and counseling. Feasibility was defined as patient participation in CostCOM, and its impact on financial worry measured using the Comprehensive Score for Financial Toxicity (COST) (higher score = less worry) was assessed. Eight patients' and two providers' experience with CostCOM was evaluated using qualitative interviews.

RESULTS

Mean patient age was 61 (78.3% female; 100% white). Of 23 CostCOM patients, 86.9% completed CostCOM, 60% of them completed a financial assistance application, and 25% of those who applied were enrolled in a co-pay assistance program. Patients' financial worry significantly improved following CostCOM (COST score of 10.0 ± 9.6 at enrollment vs. 16.9 ± 8.1 at follow-up; p < 0.001). Mean general satisfaction (out of 5) with CostCOM was 4.1 ± 0.7. In qualitative interviews following OOPC communication, 75% felt a positive impact on their mental health, and all patients reported no change in their treatment plan; 83.3% found financial navigation beneficial. In providers' interviews, buy-in from relevant stakeholders, integration of the CostCOM with existing workflow, and larger studies to assess the effectiveness of CostCOM were identified as factors needed for CostCOM implementation in practice.

CONCLUSION

CostCOM interventions are feasible and acceptable and decrease financial worry in patients with cancer.

Navigating financial toxicity in patients with cancer: A multidisciplinary management approach

Approximately one-half of individuals with cancer face personal economic burdens associated with the disease and its treatment, a problem known as financial toxicity (FT). FT more frequently affects socioeconomically vulnerable individuals and leads to subsequent adverse economic and health outcomes. Whereas multilevel systemic factors at the policy, payer, and provider levels drive FT, there are also accompanying intervenable patient-level factors that exacerbate FT in the setting of clinical care delivery. The primary strategy to intervene on FT at the patient level is financial navigation. Financial navigation uses comprehensive assessment of patients' risk factors for FT, guidance toward support resources, and referrals to assist patient financial needs during cancer care. Social workers or nurse navigators most frequently lead financial navigation. Oncologists and clinical provider teams are multidisciplinary partners who can support optimal FT management in the context of their clinical roles. Oncologists and clinical provider teams can proactively assess patient concerns about the financial hardship and employment effects of disease and treatment. They can respond by streamlining clinical treatment and care delivery planning and incorporating FT concerns into comprehensive goals of care discussions and coordinated symptom and psychosocial care. By understanding how age and life stage, socioeconomic, and cultural factors modify FT trajectory, oncologists and multidisciplinary health care teams can be engaged and informative in patient-centered, tailored FT management. The case presentations in this report provide a practical context to summarize authors' recommendations for patient-level FT management, supported by a review of key supporting evidence and a discussion of challenges to mitigating FT in oncology care. CA Cancer J Clin. 2022;72:437-453.

Associations of financial hardship with suicidal ideation among bereaved cancer caregivers

PURPOSE

To examine associations between financial hardship and suicidal ideation among bereaved informal caregivers of cancer patients.

DESIGN

Longitudinal cohort study.

SAMPLE

173 informal caregivers of advanced cancer patients.

METHODS

Caregivers were interviewed a median 3.1 months before and 6.5 months after the death of the patient they cared for. Logistic regression models estimated associations between caregiver-perceived pre-loss and post-loss financial hardship due to the patient's illness and post-loss suicidal ideation.

FINDINGS

Suicidal ideation was identified in 12% (n = 21) of the sample pre-loss, rising to 20% (n = 34) post-loss (p=.049). Pre-loss financial hardship (OR = 3.4, 95% CI = 1.5-7.4, p=.002) and post-loss financial hardship (OR = 3.7, 95% CI = 1.7-8.2, p=.001) were each bivariately associated with post-loss suicidal ideation. In multivariable models adjusting for pre-loss suicidal ideation, psychiatric diagnosis, and spousal relationship to the patient, post-loss financial hardship remained significantly associated with post-loss suicidal ideation (AOR = 3.6, 95% CI = 1.4-8.8, p=.006).

CONCLUSION

Among a cohort of cancer caregivers followed from active caregiving into bereavement, post-loss financial hardship was associated with suicidal ideation in bereavement.

IMPLICATIONS

Economic policies that financially benefit caregivers may represent promising strategies for preventing suicidal thoughts and behaviors.