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

The development and preliminary evaluation of a financial navigation program among patients with breast cancer in China

Objective

This study aims to develop a financial navigation program among patients with breast cancer in China and assess its feasibility, acceptability, and preliminary effects on cost-related health literacy and financial toxicity (FT).

Methods

The Medical Research Council (MRC) framework were adopted to guide the development of the financial navigation program, providing a structured approach to complex intervention development and evaluation. It consisted of three phases: evidence identification via a scoping review, intervention content modeling through qualitative study analysis, and outcome mapping based on social stress theory. The feasibility, acceptability and primary effectiveness were examined in a single-center, assessor-blinded pilot randomized controlled trial with 26 recruited patients.

Results

The financial navigation program consists of needs assessment, cost-related health education, resource/service referral and personalized counseling. The consent rate and a 1-month attrition rate for the feasibility study of the intervention were 55.9% and 7.7%, respectively. Most (91.7%) participants were satisfied with the program and perceived benefits. The intervention significantly improved cost-related health literacy, although no statistically significant between-group difference in FT was observed.

Conclusions

The MRC framework serves as a useful scientific basis for developing financial navigation program with a culturally sensitive approach. The financial navigation program was feasible, acceptable, effective in improving cost-related health literacy and has the potential to enhance FT among patients with breast cancer in China.

Trial registration

ClinicalTrials.gov Identifier NCT06355440.

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.

A Scoping Review of Interventions to Address Financial Toxicity in Pediatric and Adult Patients and Survivors of Cancer

BACKGROUND

Financial toxicity (FT) is a common and significant challenge for people with cancer, impacting immediate clinical outcomes such as treatment adherence, as well as long-term outcomes such as quality of life and mortality. Multiple studies have tested interventions to address FT and develop recommendations for their implementation.

METHODS

In this scoping review, we analyzed thirty-six studies across 35,405 participants examining institution-based interventions for FT in both pediatric and adult patients and survivors of cancer in the U.S.

RESULTS

Common interventions included: financial navigation (n = 15), direct financial/medical assistance (n = 8), financial counseling or coaching (n = 5), and cost conversations prompters or encounter decision aids for treatment and cost (n = 5). Outcome measures varied widely, including the COmprehensive Score for financial Toxicity (COST), the Medical Expenditure Panel Survey (MEPS), total out-of-pocket costs or savings, and mental/psychological quality-of-life measured by the Patient-Reported Outcomes Measurement Information System (PROMIS). Many interventions showed promising results on improving FT, including financial assistance (e.g., free medication, copay assistance), treatment and insurance decision aids, and financial counseling. These strategies improved FT-related metrics, including patient out-of-pocket costs, care-related financial burden, health insurance knowledge, quality of life, and even overall survival. There was no dominant intervention method, with both low- and high-resource options proving effective.

DISCUSSION

Future research should seek to understand causal relationships between interventions and FT through robust study designs, such as randomized controlled trials with longitudinal follow-up, and evaluate interventions' implementation potential. There is also a need for standardized metrics for evaluating and reporting FT to better compare different interventions' success.

Implementation strategies of financial navigation and its effects on alleviating financial toxicity among cancer survivors: a systematic review

PURPOSE

This systematic review aims to identify the implementation strategies of financial navigation and systematically synthesise its effects on mitigating financial toxicity among cancer survivors, based on the theoretical framework of implementation science.

METHODS

Medline, Web of Science Core Collection, ScienceDirect and ProQuest Health & Medical Collection databases were searched for studies published before 22 August 2023. We sought original research on financial navigation interventions among adult cancer survivors with financial toxicity in healthcare settings. The Revised Cochrane risk-of-bias tool for randomised trials, 2.0 and the Risk Of Bias In Non-randomised Studies of Interventions-I were used to assess the risk of bias in included studies. In addition, the implementation strategies of the included studies were categorised and collated based on Expert Recommendations for Implementing Change, and the Consolidated Framework for Implementation Research was adopted to explain barriers and facilities for implementation.

RESULTS

In total, 6855 records were screened, yielding 14 full-text articles, which were included (3 randomised clinical trials and 11 non-randomised studies). 'Train and educate stakeholders' (n=13 (92.9%)) and 'use evaluative and iterative strategies' (n=12 (85.7%)) were the most common implementation strategies in financial navigation. The feasibility of financial navigation is relatively high, but generally hindered by the health condition of cancer survivors, low willingness to participate and insufficient number of navigators to cover all participants. After the intervention, three of seven studies reported statistically significant mitigations in patient-reported financial toxicity. In studies reporting statistically significant outcomes, 'adapt and tailor to the context' and 'change infrastructure' were proposed as key corresponding recommendations.

CONCLUSIONS

Financial navigation is a potentially beneficial intervention for lessening the financial toxicity of cancer survivors, but more high-level evidence is needed for further validation. Financial navigation combined with the theoretical framework of implementation science provides a foundation for the future realisation of the leap from knowledge to practice.

PROSPERO REGISTRATION NUMBER

CRD42023469114.

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

PURPOSE

As oncology practices implement routine screening for financial hardship (FH) and health-related social needs, interventions that address these needs must be implemented. A growing body of literature has reported on FH interventions.

METHODS

We conducted a scoping review of the literature using PubMed, EMBASE, PsychInfo, and CINAHL to identify key studies (2000-2024) reporting on interventions to address cancer-related FH. Full-length manuscripts were included in the review if they detailed a research, quality improvement, or community-based intervention to address at least one element of FH and drew association with an outcome of interest. Studies were categorized by intervention type and qualitatively analyzed to identify critical components, outcomes, and limitations.

RESULTS

Forty-four publications reporting on 43 interventions were included in the final analysis and were categorized as research interventions (n = 20) and real-world programs (n = 20). Studies reporting on financial navigation programs (n = 17) and specialty pharmacy assistance programs (n = 11) were most common; enrolled patients received concrete assistance with direct medical costs and cost-of-living expenses (eg, transportation and food). In addition, several of these programs improved overall patient-reported financial toxicity, decreased appointment no-shows, and improved enrollment in clinical trials.

CONCLUSION

Interventions to address FH are feasible and can address all domains of FH-material, behavioral, and psychosocial. Future research should address the uptake and implementation of these interventions across diverse cancer care delivery settings. Such programs will be an essential part of cancer care delivery until broad social and policy changes can address the underlying factors that contribute to FH in Americans with cancer.

Development and Validation of a Simplified Financial Toxicity Screening Tool for Use in Clinical Practice

PURPOSE

Cancer-related financial toxicity occurs frequently and is a key driver of inequities in access to care and disparities in treatment outcomes. Current practices to screen for financial toxicity are inconsistent because of the lack of a validated and clinically integrated screening tool. This analysis aimed to create and assess an abbreviated version of the validated Comprehensive Score for Financial Toxicity (COST) tool, a measure of financial toxicity used for research purposes, which could easily be added into often-lengthy clinical screening workflows.

METHODS

At an urban comprehensive cancer center with suburban satellite locations, a financial toxicity screening quality improvement project was conducted from June 2022 to August 2023 as part of routine clinical care: 57,526 longitudinal COST surveys were completed by 38,249 patients with cancer. An iterative algorithm selected the items with highest correlation with the total score. Using a separate validation data set, positive and negative predictive values (PPV and NPV, respectively) of the abbreviated tool (two-item) were assessed against the full COST score, with varying risk thresholds.

RESULTS

Inclusion of two COST questions (Q3: "I worry about the financial problems I will have in the future as a result of my illness or treatment"; Q6: "I am satisfied with my current financial situation") yielded a score that had a correlation of 0.922 with the full instrument score. For the two-item scale, PPV ranged from 74% to 91%, and NPV ranged from 91% to 98% when compared with the full COST tool.

CONCLUSION

This analysis of a large data set finds that a simplified COST tool has high predictive value when compared with the full validated measure. An abbreviated COST measure of two questions is suitable for implementation into clinical screening workflows.

The Financial Toxicity Experience of Patients with Colorectal Cancer During Chemotherapy: A Qualitative Study

BACKGROUND

This study aimed to explore the experience of financial toxicity in patients with colorectal cancer during chemotherapy and to inform the development of targeted interventions.

METHODS

A descriptive qualitative research method was used to conduct semi-structured interviews with a purposive sample of 15 patients with colorectal cancer undergoing chemotherapy who attended the Department of Medical Oncology of the First Affiliated Hospital of Anhui Medical University from March to June 2024, and the data were organized and analyzed using the Nvivo 11.0 qualitative data analysis software and the thematic analysis method.

RESULTS

Four themes were extracted: patients with chemotherapy-stage colorectal cancer bear direct and indirect multifaceted economic pressures, are affected by multidimensional risk factors, which cause multiple adverse outcomes, and cope with financial toxicity in various ways.

CONCLUSIONS

The experience of financial toxicity in colorectal cancer patients undergoing chemotherapy is presented in a multidimensional format, with multiple causes influencing their financial toxicity. In the future, healthcare professionals should identify patients at high risk for financial toxicity, provide financial toxicity interventions and support, and mitigate their exposure to financial toxicity.

A Costly Cure: Understanding and Addressing Financial Toxicity in Cardiovascular Disease Health Care Within the Domain of Social Determinants of Health

Cardiovascular disease (CVD) represents a significant financial burden on patients and families, compounded by both direct and indirect healthcare costs. The increasing prevalence of CVD, coupled with the rising costs of treatment, exacerbates financial toxicity-defined as the economic strain and associated physical, emotional, and behavioral consequences on patients. This review explores the scope of financial toxicity in CVD care, detailing its prevalence, associated risk factors, and the complex interplay with social determinants of health such as income, insurance status, and comorbidities. Drawing from models in oncology, we highlight key interventions aimed at mitigating financial toxicity, including patient counseling, financial navigation, and enhanced patient-physician cost discussions. By adopting these approaches, healthcare providers can better support patients with CVD in managing both their health and financial well-being, potentially improving clinical outcomes. Future research is needed to develop standardized assessment tools for financial toxicity in CVD and implement system-wide mitigation strategies.

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.

Association between financial hardship and psychological burden and the role of social and mental health support: An observational study

We aimed to assess the association between medical financial hardship and psychological burden and the moderating role of social and mental health support. 2021 United States National Health Interview Survey was used. Financial hardship was defined as having financial worry, material hardship, or cost-related care nonadherence. Psychological burden was measured using perceived general health status, satisfaction with life, and serious psychological distress (SPD). Of 29,370 included adults, 49% experienced financial hardship in the last 12 months. Financial hardship was associated with a higher psychological burden (odds ratio [OR], 3.58; 95% confidence interval [CI], 2.43-5.47 for SPD). Eleven percent received counseling/therapy from mental health professionals, and 90% had experienced frequent social support. Frequent social support was associated with lower financial hardship (OR, 0.71; 95% CI, 0.63-0.80) and psychological burden (OR, 0.28; 95% CI, 0.19-0.42 for SPD). Previous mental health support was associated with higher financial hardship (OR,1.40; 95% CI, 1.28-1.54) and psychological burden (OR, 9.75; 95% CI, 6.97-13.94 for SPD). Those experiencing financial hardship had lower odds of SPD if they received mental health support in the last 12 months (OR, 0.57; 95% CI, 0.39-0.85). Future interventions should also focus on improving social support and mental health for patients as a way of mitigating medical financial hardship.

Financial Toxicity in Radiation Oncology: Impact for Our Patients and for Practicing Radiation Oncologists

With rising costs of diagnosis, treatment, and survivorship, financial burdens on patients with cancer and negative effects from high costs, called financial toxicity (FT), are growing. Research suggests that FT may be experienced by more than half of working-age cancer survivors and a similar proportion may incur debt or avoid recommended prescription medications due to treatment costs. As FT can lead to worse physical, psychological, financial, and survival outcomes, there is a discrete need to identify research gaps around this issue that constrain the development and implementation of effective screening and innovative care delivery interventions. Prior research, including within a radiation oncology-specific context, has sought to identify the scope of FT among patients with cancer, develop assessment tools to evaluate patient risk, quantify financial sacrifices, and qualify care compromises that occur when cancer care is unaffordable. FT is a multifactorial problem and potential solutions should be pursued at all levels of the health care system (patient-provider, institutional, and systemic) with specific regard for patients' individual/local contexts. Solutions may include selecting alternative treatment schedules, discussing financial concerns with patients, providing financial navigation services, low-cost transportation options, and system-wide health policy shifts. This review summarizes existing FT research, describes tools developed to measure FT, and suggests areas for intervention and study to help improve FT and outcomes for radiation oncology patients.

Interventions to Mitigate Financial Toxicity in Adult Patients with Cancer in the United States: A Scoping Review

Financial toxicity adversely affects quality of life and treatment outcomes for patients with cancer. This scoping review examined interventions aimed at mitigating financial toxicity in adult patients with cancer and their effectiveness. We utilized five bibliographical databases to identify studies that met our inclusion criteria. The review included studies conducted among adult patients with cancer in the United States and published in English between January 2011 to March 2023. The review identified eight studies that met the inclusion criteria. Each of the studies discussed the implementation of interventions at the patient/provider and/or health system level. Collectively, the findings from this scoping review highlight both the limited number of published studies that are aimed at mitigating financial toxicity and the need to create and assess interventions that directly impact financial toxicity in demographically diverse populations of adult patients with cancer.

Impact of Virtual Navigation on the Education and Access of Patients with Cancer: A National Mixed Methods Investigation

Introduction

Despite growing evidence of efficacy, oncology patient navigation is not ubiquitously offered. Navigation may reduce barriers to cancer care, yet geographic location may limit patient access. To overcome geographical barriers and increase patient education in oncology, our medical center developed a virtual navigation program.

Objective

To examine the efficacy of the Virtual Navigation Program designed to increase patient access and education across local and national contexts.

Methods

In this mixed-methods study, a total of 105 individuals completed an online survey administered nationally to oncology patients who used the navigation program. Clinical and demographic data were collected. Nonparametric tests were used for group comparisons (Wilcoxon Signed-Ranks test).

Results

Virtual navigation increased access as the majority of patients utilized the Virtual Navigation Program beyond the local area; 42% of patients were local; 58% were patients located across the US. 55 (52%) were female; 25% were non-White. Pancreatic cancer was the largest tumor type: 51 (49%). Patients agreed the virtual cancer education helped them make critical health choices (mean 4.89 SD = 84); understand their diagnosis (mean 4.44 SD = .77); were able to make informed decisions (mean 4.43 SD = .83), and empowered to manage their cancer care (mean 4.58 SD = .82). Post navigation, the user experience survey revealed significant increases in a subset of patients' cancer knowledge (P < 0.001), access to quality cancer education (P = 0.045), decision-making in cancer care (P < 0.05), and coordinated cancer care (P = 0.03).

Conclusion

This study explores a unique role that virtual navigation may play in helping accommodate healthcare for many cancer patients in underserved areas. The use of innovative aspects of research and education in virtual navigation may be successful in promoting patient empowerment in the cancer continuum. Internet-strategies are needed to inform sustainable patient navigation in low-resource contexts.

Interventions for financial toxicity among cancer survivors: A scoping review

INTRODUCTION

Financial toxicity impairs cancer survivors' material condition, psychological wellbeing and quality of life. This scoping review aimed to identify interventions for reducing cancer-related financial toxicity (FT), and to summarize their main findings.

METHODS

A systematic search was performed in PubMed, Web of Science, EMBASE, CINAHL, Clinical Trials, China National Knowledge Internet, Wanfang and SinoMed from January 2010 to September 2022 following the PRISMA-ScR checklist.

RESULTS

From 2842 identified articles, a total of 15 were included in this review. Existing interventions can be classified into four types: financial navigation, financial counseling, insurance education and others. Previous interventions preliminarily affirmed the feasibility, satisfaction, and improvement in financial worries and knowledge. However, the effectiveness on FT was controversial.

CONCLUSIONS

Previous interventions affirmed the feasibility and primary effect of these interventions. Studies with more rigorous design are needed to evaluate the effectiveness and generalizability of interventions on FT across diverse healthcare systems.

Patient perceptions of copay card utilization and policies

BACKGROUND

Copay cards are intended to mitigate patient out-of-pocket (OOP) expenses. This qualitative, exploratory focus group study aimed to capture patient perceptions of copay cards and copay adjustment programs (CAPs; insurers' accumulator and maximizer policies), which redirect the copay card utilization benefits intended for patients' OOP expenses.

METHODS

Patients with chronic conditions were recruited through Janssen's Patient Engagement Research Council program. They completed a survey and attended a live virtual session to provide feedback on copay cards.

RESULTS

Among 33 participants (median age, 49 years [range, 24-78]), the most frequent conditions were cardiovascular-metabolic disease and inflammatory bowel disease. Patients associated copay cards with lessening financial burden, improving general and mental health, and enabling medication adherence. An impact on medication adherence was identified by 10 (63%) White and nine (100%) Black respondents. Some patients were unaware of CAPs despite having encountered them; they recommended greater copay card education and transparency about CAPs.

CONCLUSION

Patients relied on copay cards to help afford their prescribed medication OOP expenses and maintain medication adherence. Use of CAPs may increase patient OOP expenses. Patients would benefit from awareness programs and industry - healthcare provider partnerships that facilitate and ensure access to copay cards.

Defining the Role of the Modern Oncology Provider in Mitigating Financial Toxicity

Financial toxicity, the cumulative financial hardships resulting from cancer diagnosis and treatment, is a growing problem in the United States. With the proliferation of costly novel therapeutics and improved cancer survival, financial toxicity will remain a major issue in cancer care delivery. Frontline oncology providers serve as gatekeepers in the medical system and, as such, could play essential roles in recognizing and addressing financial toxicity. Providers and health systems could help mitigate financial toxicity through routine financial toxicity screening, financial navigation, and advocacy. Specific strategies include developing and implementing financial screening instruments that can be integrated in electronic medical records and establishing team-based financial navigation programs to help patients with out-of-pocket medical costs, nonmedical spending, and insurance optimization. Finally, providers should continue to advocate for policies and legislation that decrease cost and promote value-based care. In this review, we examine opportunities for provider engagement in these areas and highlight gaps for future research.