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Blachut B, Woodard TJ, Morris D, Vanderlan JR, Tippey A, Hagemann AR, Kuroki LM. Inequities in health insurance influence psychosocial outcomes and coping among patients seeking gynecologic oncology care. Am J Obstet Gynecol 2024; 230:e6-e11. [PMID: 38836343 DOI: 10.1016/j.ajog.2023.10.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 10/24/2023] [Indexed: 06/06/2024]
Affiliation(s)
- Barbara Blachut
- Department of Obstetrics and Gynecology, Washington University, St. Louis, MO
| | - Tyler J Woodard
- Division of Gynecologic Oncology, Washington University School of Medicine, St. Louis, MO
| | - David Morris
- Department of Psychiatry, Alvin J. Siteman Cancer Center, St. Louis, MO
| | | | - Amaris Tippey
- Department of Psychiatry, Alvin J. Siteman Cancer Center, St. Louis, MO
| | - Andrea R Hagemann
- Division of Gynecologic Oncology, Washington University School of Medicine, 660 South Euclid Ave, Mail Stop 8064-34-905, St. Louis, MO 63110
| | - Lindsay M Kuroki
- Division of Gynecologic Oncology, Washington University School of Medicine, 660 South Euclid Ave, Mail Stop 8064-34-905, St. Louis, MO 63110.
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Liang MI, Harrison R, Aviki EM, Esselen KM, Nitecki R, Meyer L. Financial toxicity: A practical review for gynecologic oncology teams to understand and address patient-level financial burdens. Gynecol Oncol 2023; 170:317-327. [PMID: 36758422 DOI: 10.1016/j.ygyno.2023.01.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/19/2023] [Accepted: 01/29/2023] [Indexed: 02/10/2023]
Abstract
Financial toxicity describes the adverse impact patients experience from the monetary and time costs of cancer care. The financial burden patients experience comes from substantially increased out-of-pocket spending that often occurs concurrent with reduced income due to sick leave from work. Financial toxicity is common affecting approximately half of patients with a gynecological cancer depending on the validated instrument used for measurement. Financial toxicity is experienced by patients in three domains: economic hardship affecting patients' material conditions (i.e., medical debt), psychological response (i.e., distress), and health-related coping behaviors that patients adopt (i.e., foregoing care due to costs). Higher financial toxicity among cancer patients has been associated with decreased quality of life, impaired adherence to recommended care, and worse overall survival. In this review, we describe the current literature on financial toxicity, including how it can be assessed with validated tools, the downstream impact on patients, risk factors, and employment concerns of survivors. Whenever possible, we highlight data from research featuring patients with gynecologic cancer specifically. We also review studies with interventions aimed to mitigate financial toxicity and offer the reader real world examples of interventions currently being used. Lastly, we provide an overview of health policy developments relevant to financial toxicity and advocate for innovation in the development and implementation of strategies to decrease the financial toxicity patients experience following a diagnosis of gynecologic cancer.
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Affiliation(s)
- Margaret I Liang
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Ross Harrison
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, Oregon Health and Science University, Portland, OR, USA
| | - Emeline M Aviki
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Katharine M Esselen
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Roni Nitecki
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Larissa Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Wall JA, Lipking K, Smith HJ, Huh WK, Salter T, Liang MI. Moderate to severe distress in half of ovarian cancer patients undergoing treatment highlights a need for more proactive symptom and psychosocial management. Gynecol Oncol 2022; 166:503-507. [PMID: 35778291 PMCID: PMC9678245 DOI: 10.1016/j.ygyno.2022.06.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 06/17/2022] [Accepted: 06/19/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Distress screening and management is a recommended component of oncology care. Our objective was to evaluate distress rate, sources, and compliance with psychosocial follow-up among ovarian cancer patients receiving chemotherapy. METHODS We reviewed patient distress surveys completed by ovarian cancer patients receiving chemotherapy from 10/2017-6/2019. Lay or nurse navigators conducted screening with the NCCN Distress Thermometer from 0 (none) to 10 (highest distress). A distress score ≥ 4 (moderate/severe) was considered a positive screen. A recommendation for psychosocial follow-up was automatically generated in the treatment care plan based upon a yes response to any depression-related concern, independent of distress score. Documentation of referral to a mental health professional or social worker for counseling was considered compliant with psychosocial follow-up. We performed descriptive statistics and bivariate analyses. RESULTS 97/211 (46%) ovarian cancer patients screened positive for distress. Average score was 6.1 for those who screened positive and 3.3 for the entire cohort (range 0-10). Unmarried status (p < 0.01) was associated with positive screen, whereas non-white race (p = 0.26) and recurrent disease (p = 0.21) were not. Median age was older for patients with a positive distress screen (p < 0.01). Among screened patients, the most frequent sources of distress were: cognitive/physical (87%), psychosocial (62%), practical (84%), and family concerns (40%). Of 50 patients recommended to have psychosocial referral, 4 (8%) patients had documented psychiatric follow-up and 19 (38%) patients had documented psychosocial counseling by a social worker. CONCLUSIONS Nearly half of ovarian cancer patients screened positive for moderate/severe distress. Cancer/treatment-related cognitive/physical symptoms were the most frequent sources. Improved methods of symptom monitoring and management during treatment and resources to address psychosocial concerns are needed to improve distress management of ovarian cancer patients.
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Affiliation(s)
- Jaclyn A Wall
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, United States of America.
| | - Kelsey Lipking
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Haller J Smith
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, United States of America; O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Warner K Huh
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, United States of America; O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Terri Salter
- O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Margaret I Liang
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, United States of America; O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, United States of America
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Albright BB, Nitecki R, Chino F, Chino JP, Havrilesky LJ, Aviki EM, Moss HA. Catastrophic health expenditures, insurance churn, and nonemployment among gynecologic cancer patients in the United States. Am J Obstet Gynecol 2022; 226:384.e1-384.e13. [PMID: 34597606 PMCID: PMC10016333 DOI: 10.1016/j.ajog.2021.09.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 09/23/2021] [Accepted: 09/23/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND In recent years, there has been growing recognition of the financial burden of severe illness, including associations with higher rates of nonemployment, uninsurance, and catastrophic out-of-pocket health spending. Patients with gynecologic cancer often require expensive and prolonged treatments, potentially disrupting employment and insurance coverage access, and putting patients and their families at risk for catastrophic health expenditures. OBJECTIVE This study aimed to describe the prevalence of insurance churn, nonemployment, and catastrophic health expenditures among nonelderly patients with gynecologic cancer in the United States, to compare within subgroups and to other populations and assess for changes associated with the Affordable Care Act. STUDY DESIGN We identified respondents aged 18 to 64 years from the Medical Expenditure Panel Survey, 2006 to 2017, who reported care related to gynecologic cancer in a given year, and a propensity-matched cohort of patients without cancer and patients with cancers of other sites, as comparison groups. We applied survey weights to extrapolate to the US population, and we described patterns of insurance churn (any uninsurance or insurance loss or change), catastrophic health expenditures (>10% annual family income), and nonemployment. Characteristics and outcomes between groups were compared with the adjusted Wald test. RESULTS We identified 683 respondents reporting care related to a gynecologic cancer diagnosis from 2006 to 2017, representing an estimated annual population of 532,400 patients (95% confidence interval, 462,000-502,700). More than 64% of patients reported at least 1 of 3 primary negative outcomes of any uninsurance, part-year nonemployment, and catastrophic health expenditures, with 22.4% reporting at least 2 of 3 outcomes. Catastrophic health spending was uncommon without nonemployment or uninsurance reported during that year (1.2% of the population). Compared with patients with other cancers, patients with gynecologic cancer were younger and more likely with low education and low family income (≤250% federal poverty level). They reported higher annual risks of insurance loss (8.8% vs 4.8%; P=.03), any uninsurance (22.6% vs 14.0%; P=.002), and part-year nonemployment (55.3% vs 44.6%; P=.005) but similar risks of catastrophic spending (12.6% vs 12.2%; P=.84). Patients with gynecologic cancer from low-income families faced a higher risk of catastrophic expenditures than those of higher icomes (24.4% vs 2.9%; P<.001). Among the patients from low-income families, Medicaid coverage was associated with a lower risk of catastrophic spending than private insurance. After the Affordable Care Act implementation, we observed reductions in the risk of uninsurance, but there was no significant change in the risk of catastrophic spending among patients with gynecologic cancer. CONCLUSION Patients with gynecologic cancer faced high risks of uninsurance, nonemployment, and catastrophic health expenditures, particularly among patients from low-income families. Catastrophic spending was uncommon in the absence of either nonemployment or uninsurance in a given year.
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Affiliation(s)
- Benjamin B Albright
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC.
| | - Roni Nitecki
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Junzo P Chino
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC
| | - Laura J Havrilesky
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| | - Emeline M Aviki
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Haley A Moss
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
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Yang ZY, Lai CH, Ho CL, Wang CC. Epidemiological Study of Return to Work and Mortality in Lung Cancer Survivors. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 19:309. [PMID: 35010569 PMCID: PMC8744858 DOI: 10.3390/ijerph19010309] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 12/24/2021] [Accepted: 12/26/2021] [Indexed: 06/14/2023]
Abstract
Lung cancer is the second most common cancer and the leading cause of cancer-related deaths worldwide. Return to work (RTW) plays an important role for lung cancer survivors. Few studies focus solely on the relationship among possible variables and the RTW of lung cancer patients. The aim of our study was to examine sociodemographic, disease-related and work-related factors associated with RTW among lung cancer survivors in Taiwan. A total of 2206 employees who had been diagnosed with lung cancer at the Labor Insurance Database (LID), Taiwan Cancer Registry (TCR) and the National Health Insurance Research Database (NHIRD) during the period 2004-2015, were included in the study. We used the Cox proportional hazards model to investigate the associations between sociodemographic, disease-related and work-related factors on one hand and RTW on the other hand. The Kaplan-Meier method was used for analyzing the survival probability. Patients with an early cancer stage and those who underwent surgery had a higher likelihood of RTW. Factors including older age, male, higher monthly income and receipt of radiotherapy were inversely correlated with RTW. For lung cancer patients, RTW was a predictor of a lower risk of all-cause mortality in both the unadjusted and fully adjusted model. A better survival rate was found in stage III and IV lung cancer patients who had RTW. Sociodemographic and clinical-related variables had an impact on RTW among employees with lung cancer. RTW was correlated with a lower risk of all-cause mortality and better lung cancer survival. Our study showed the influence of RTW and independent confounding factors in lung cancer survivorship.
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Affiliation(s)
- Zhe-Yu Yang
- Division of Family Medicine, Department of Family and Community Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan;
| | - Ching-Huang Lai
- School of Public Health, National Defense Medical Center, Taipei 114, Taiwan;
| | - Ching-Liang Ho
- Division of Hematology/Oncology, Department of Medicine, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei 114, Taiwan;
| | - Chung-Ching Wang
- Division of Family Medicine, Department of Family and Community Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan;
- Division of Occupational Medicine, Department of Family & Community Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan
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Sun YS, Chen WL, Wu WT, Wang CC. The Fact of Return to Work in Cervical Cancer Survivors and the Impact of Survival Rate: An 11-Year Follow-Up Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182010703. [PMID: 34682449 PMCID: PMC8535606 DOI: 10.3390/ijerph182010703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 10/08/2021] [Accepted: 10/09/2021] [Indexed: 01/22/2023]
Abstract
The aim of the current cohort study was to explore the relationship between return to work (RTW) after cervical cancer treatment and different medical and occupational covariates. We also investigated the effect of RTW on all-cause mortality and survival outcomes of cervical cancer survivors. Data were collected between 2004 and 2015 from the database of the Taiwan Cancer Registry, Labor Insurance Database, and National Health Insurance Research Database. The associations between independent variables and RTW were analyzed by Cox proportional hazard models. A total of 4945 workers (82.3%) who returned to work within 5 years after being diagnosed with cervical cancer. Patients who underwent surgical treatment were more likely to RTW by the 5th year compared to other groups, with a hazard ratio (HR) of 1.21 (95% CI: 1.01~1.44). Small company size and a monthly income greater than NT 38,200 were inversely associated with RTW (HR = 0.91, 95% CI: 0.84~0.98 and HR = 0.48, 95% CI: 0.44~0.53). Furthermore, RTW showed a statistically significant decrease in the risk of all-cause mortality in the fully adjusted HR, (HR = 0.42, p < 0.001). Some medical and occupational factors are associated with RTW in cervical cancer survivors. Returning to work may have a beneficial effect on the survival of patients with cervical cancer.
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Affiliation(s)
- Yu-Shan Sun
- Division of Family Medicine, Department of Family and Community Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan; (Y.-S.S.); (W.-L.C.)
- Division of Environmental Health & Occupational Medicine, Department of Family and Community Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan
| | - Wei-Liang Chen
- Division of Family Medicine, Department of Family and Community Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan; (Y.-S.S.); (W.-L.C.)
- Division of Environmental Health & Occupational Medicine, Department of Family and Community Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei 114, Taiwan
| | - Wei-Te Wu
- National Institute of Environmental Health Sciences, National Health Research Institutes, Miaoli 350, Taiwan;
| | - Chung-Ching Wang
- Division of Family Medicine, Department of Family and Community Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan; (Y.-S.S.); (W.-L.C.)
- Division of Environmental Health & Occupational Medicine, Department of Family and Community Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei 114, Taiwan
- Correspondence: ; Tel.: +886-287-923-311
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