Lessening the Impact of Financial Toxicity (LIFT): a protocol for a multi-site, single-arm trial examining the effect of financial navigation on financial toxicity in adult patients with cancer in rural and non-rural settings

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.

An intersectional analysis of behavioral financial hardship and healthcare utilization among lesbian, gay, bisexual, transgender, queer, plus cancer survivors

BACKGROUND

Lesbian, gay, bisexual, transgender, queer, or another nonheterosexual or cisgender identity (LGBTQ+) cancer survivors experience high financial hardship. However, structural drivers of inequities do not impact all LGBTQ+ individuals equally. Using All of Us data, we conducted an intersectional analysis of behavioral financial hardship among LGBTQ+ cancer survivors.

METHODS

LGBTQ+ inequities in behavioral financial hardship (ie, cost-related foregone care, delayed care, and medication alterations) and non-cost-related delayed care were estimated using All of Us data. Multivariable logit models were used to generate predicted probabilities, average marginal effects, and 95% confidence intervals. Models were then used to estimate inequities when disaggregating LGBTQ+ status and combing LGBTQ+ status with age, race, ethnicity, and treatment status.

RESULTS

This analysis included N = 36 217 cancer survivors (6.6%, n = 2399 LGBTQ+). In multivariable models, LGBTQ+ identity was associated with higher probabilities of and significant average marginal effects for all types of behavioral financial hardship (foregone care 31.1% vs 19.4%; delayed care 22.6% vs 15.6%; medication alterations 19.2% vs 11.9%) and non-cost delayed care (14.3% vs 7.2%). Within the disaggregated analysis, cisgender bisexual and another/multiple orientation women and gender minority survivors had the highest predicted probabilities of all outcomes. In intersectional analyses, survivors who were aged 18-39 and LGBTQ+, Black and LGBTQ+, or Hispanic/Latine and LGBTQ+ had the highest predicted probabilities of all outcomes.

CONCLUSIONS

LGBTQ+ cancer survivors experience significantly more behavioral financial hardship and non-cost-related delayed care than non-LGBTQ+ cancer survivors. Interventions at the individual, system, and policy level are needed to address LGBTQ+ inequities in financial hardship.

Catastrophic health expenditures for colorectal cancer care: A retrospective analysis of the first private comprehensive cancer center in Lagos, Nigeria

BACKGROUND

Nearly a billion people worldwide risk Financial Catastrophe (FC) due to Out-of-Pocket (OOP) health expenditures. With Low-and-Middle-Income Countries (LMICs) disproportionately impacted, and the global burden of colorectal cancer (CRC) expected to increase 60 ​% by 2030, Nigeria is of interest. This study aims to evaluate the cost of treating CRC at Nigeria's first private cancer center.

METHODS

The center's cancer registry was queried for CRC diagnosed between 2013 and 2023. Two research assistants in Lagos abstracted treatment costs (adjusted to 2023 USD), demographics and clinical characteristics. FC was defined as OOP >20 ​% of Nigeria's 2023 per-capita GDP ($467).

RESULTS

92 patients (colon (n ​= ​70), rectum (n ​= ​22), 66 ​% stage 4) were included. Average chemotherapy cost $7,678, procedure cost $1157. Average total cost for multi-therapy, $34,983. All treated patients risked FC. The greatest cost-contributors were chemotherapy (30 ​%) and other drugs (21 ​%). Procedures cost 3 ​%.

CONCLUSION

CRC treatment increases the risk of FC for nearly all patients. Risk-protection through insurance or financial navigation may be of benefit, and future studies should investigate the impact of these interventions on FC risk.

From Diagnosis to Survivorship: The Role of Social Determinants in Cancer Care

Social determinants of health (SDOH) profoundly influence cancer outcomes. Disparities in these areas contribute to delayed diagnoses, limited access to advanced treatments, and poorer survival rates, disproportionately affecting marginalized populations. While advancements in cancer care have improved survival, these benefits remain unevenly distributed. This review examines the impact of SDOH on cancer care across multiple domains. It highlights the ways in which structural barriers exacerbate disparities in prevention, diagnosis, and treatment. Evidence-based interventions, including Medicaid expansion, culturally tailored patient navigation programs, increased diversity in clinical trials, telemedicine expansion, and the integration of SDOH screening into oncology workflows-offer promising strategies for addressing these inequities. By integrating these strategies into clinical practice and health policy, the healthcare system can foster a more just and inclusive future for cancer treatment and survivorship.

Screening and Referral for Health-Related Social Needs and Financial Distress: Current Processes Among National Cancer Institute Community Oncology Research Program Practices

PURPOSE

Health-related social needs (HRSNs) are associated with adverse cancer health outcomes. We assessed the processes for screening and responding to both HRSNs and financial distress and described the methods used across National Cancer Institute Community Oncology Research Program (NCORP) practices.

METHODS

The NCORP 2022 Landscape Assessment survey focused on services to screen for and respond to HRSNs and financial distress within a national network of community oncology practices. We calculated the proportions of oncology practices that screened for and responded to HRSNs and financial distress, separately, and described the staff, tools, and methods used for each process. Multivariable logistic regression models estimated the associations between oncology practice characteristics and screening for HRSNs and financial distress.

RESULTS

The majority of community oncology practices reported screening for HRSNs (79%), and of those, most inquired about transportation (96%), family and social support (93%), housing (80%), and food security (80%). Most oncology practices reported screening for financial distress (78%). Social worker evaluation was the most common method used to screen for both HRSNs (77%) and financial distress (65%). Most oncology practices reported social work referral as the method for responding to HRSNs (89%) and financial distress (96%). Oncology practice characteristics such as having a survivorship clinic and geographic region were associated with screening for HRSNs and financial distress.

CONCLUSION

Research is needed to understand the impact of different HRSN screening and referral approaches on care delivery, clinic costs, care quality, and health outcomes of patients with cancer. These efforts are critical to generate evidence to inform best practices, clinical guidelines, and novel interventions aimed to improve cancer health equity.

Material, Psychological, and Behavioral Financial Hardship Among Lesbian, Gay, and Bisexual Cancer Survivors in the United States

PURPOSE

Driven by anti-LGBTQ+ stigma, emerging literature suggests that lesbian, gay, and bisexual (LGB) cancer survivors experience financial hardship (FH) more frequently than heterosexual survivors. However, few studies have used nationally representative samples to estimate this inequity.

METHODS

National Health Interview Survey data from 2019 to 2022 were pooled and weighted. Outcomes included material, psychological, and behavioral FH. The behavioral domain was further broken down into subdomains including medical care, prescription medications, and mental health care. Multivariable logit models controlling for a variety of factors were used to generate LGB and heterosexual predicted probabilities and differential effects for each FH outcome. Stratified estimates were generated by sex and age groups.

RESULTS

A total of N = 374 LGB and N = 12,757 heterosexual cancer survivors were included in this analysis. In adjusted analyses, LGB cancer survivors had significantly higher material (19%, 95% CI, 15 to 24 v 12%, 95% CI, 11 to 13; P = .004), psychological (44%, 95% CI, 38 to 51 v 37%, 95% CI, 36 to 38; P = .035), and behavioral (23%, 95% CI, 18 to 28 v 13%, 95% CI, 13 to 14; P < .0001) FH than heterosexual survivors. LGB cancer survivors also had higher medical behavioral (11%, 95% CI, 7 to 15 v 7%, 95% CI, 6 to 7; P = .030), prescription medication behavioral (14%, 95% CI, 10 to 19 v 10%, 95% CI, 9 to 10; P = .032), and mental health behavioral (9%, 95% CI, 6 to 13 v 3%, 95% CI, 3 to 4; P < .0001) FH than heterosexual survivors. Stratified estimates revealed young LGB cancer survivors had the highest probability of each outcome (material: 31%, 95% CI, 23 to 40; psychological: 58%, 95% CI, 50 to 66; behavioral: 45%, 95% CI, 36 to 53).

CONCLUSION

In this nationally representative analysis, LGB cancer survivors experience substantial inequities in all FH outcomes. It is crucial that future FH interventional work should prioritize populations at the highest risk of FH, such as LGB cancer survivors.

Financial Toxicity Among Women with Breast Cancer Varies by Age and Race

INTRODUCTION

Financial toxicity negatively affects clinical outcomes in breast cancer. Underrepresented demographics may be at higher risk for financial toxicity. We characterized disparities on the basis of age and other factors.

PATIENTS AND METHODS

Surveys completed by women with stage 0-IV breast cancer treated at Memorial Sloan Kettering Cancer Center between 06/2022 and 05/2023 were analyzed. The comprehensive score for financial toxicity (COST) scale was used to assess financial toxicity. Descriptive statistics were calculated for differences in financial toxicity/related factors, and outcomes by age and race. Associations between variables of interest and COST scores were analyzed using linear regression.

RESULTS

Of 8512 respondents (75% white, 9.3% Asian, 8.4% Black), most (68%) had clinical stage 0/I disease. Stratified by age, young Black women had higher financial toxicity than young white or Asian women (p < 0.001). On multivariable analysis, women age < 45 years experienced higher financial toxicity than older women (coefficient - 2.0, 95% CI - 2.8 to - 1.1, p < 0.001). Compared with white women, financial toxicity was greater among Black (coefficient - 6.8, 95% CI - 7.8 to - 5.8) and Asian women (coefficient - 3.5, 95% CI - 4.4 to - 2.5). Cost-related medication non-adherence was more frequent among Black and Asian women (p < 0.001). Asian women more often paid for treatment with savings than white and Black women (p < 0.001). Young women reported using savings for treatment-related costs more than older (45% vs. 32%); p < 0.001).

CONCLUSIONS

Racial minorities and young patients are disproportionately affected by financial toxicity. Further studies are planned to determine how financial toxicity evolves over time and whether referral to financial services effectively reduces toxicity.

Screening for Health-Related Social Needs and Financial Toxicity Among Patients With Cancer Treated With Radiation Therapy: Findings From a Quality Improvement Project

INTRODUCTION

Financial toxicity is common among patients with cancer, as are co-occurring health-related social risks (HRSRs). There is limited evidence to support best practices in screening for HRSRs and financial toxicity in the cancer context. This analysis sought to understand variations of identified needs based on treatment course using data from a large screening program.

METHODS

This 2022 to 2023 screening quality improvement program included four services (breast, gastrointestinal, gynecologic, thoracic) at an urban comprehensive cancer center. The Comprehensive Score for Financial Toxicity measured financial toxicity. Patients completed an HRSR checklist documenting food, housing, medication, or transportation insecurity and financial borrowing practices. Differences were evaluated by treatment course (radiation therapy [RT] versus other treatment and RT plus chemotherapy versus other treatment).

RESULTS

Screening surveys were sent to 70,983 unique patients; 38,249 completed a screening survey (54% response rate). Of responders, 4% (n = 1,686) underwent RT in the 120 days before their survey, and 3% (n = 1,033) received RT in combination with chemotherapy. Overall, patients receiving RT had lower unadjusted Comprehensive Score for Financial Toxicity scores, indicating worse financial toxicity. The proportion of patients receiving RT reporting unmet transportation (15% versus 12%, P < .001) and food (13% versus 11%, P = .02) needs was significantly higher than for patients not receiving RT. More patients receiving RT borrowed money than did patients not receiving RT (17% versus 15%, P = .02). In multivariable models, RT (alone or in combination) was associated with worse financial toxicity and transportation difficulties.

CONCLUSIONS

Screening for financial toxicity and HRSR is possible at a large cancer center. Patients receiving RT have higher transportation insecurity and worse financial toxicity compared with those receiving other treatments. Tailored intervention throughout the treatment trajectory is essential.

Influence of age on financial toxicity in cancer patients

Objective

The aim of this study was to assess the level of financial toxicity (FT) experienced by the following three age groups of cancer patients in China: young working-aged patients (age < 40 years), middle-aged patients (40-64 years), and older patients (≥ 65 years).

Methods

The data used for this study were collected via a cross-sectional survey conducted in China. FT was assessed using the Comprehensive Score for Financial Toxicity (COST). ANOVA was used to examine the differences in FT status between age groups. Multivariate linear regression models were employed to assess the association between age and FT, adjusted by socioeconomic and other clinical characteristics.

Results

A total of 556 cancer patients completed the survey. Approximately 54.3% of the participants were male and 45.7% were female. The majority (61.5%) were aged 40-64 years, while 27.7% were aged 65 or older. The mean FT scores for young patients (< 40 years), middle-aged patients (40-64 years), and older patients (≥ 65 years) were 16.7, 12.8, and 12.4, respectively. The results of the regression analysis revealed that, without adjusting for background characteristics, young patients had significantly higher mean COST scores. This suggests they experienced lower levels of FT compared to patients in other age groups. Stratified analysis revealed that, for older patients, only educational level and type of insurance scheme were significant factors in predicting the COST score.

Conclusions

This study provides empirical evidence for developing targeted interventions and policies to reduce the FT for patients in different age groups. Given that FT is complicated, a longitudinal study should be conducted to explore the long-term impact of FT on cancer patients' quality of life and well-being.

Financial burden among metastatic breast cancer patients: a qualitative inquiry of costs, financial assistance, health insurance, and financial coping behaviors

PURPOSE

Metastatic breast cancer (MBC) patients often face substantial financial burden due to prolonged and expensive therapy. However, in-depth experiences of financial burden among MBC patients are not well understood.

METHODS

Qualitative interviews were conducted to describe the experiences of financial burden for MBC patients, focusing on the drivers of financial burden, their experience using their health insurance, accessing financial assistance, and any resulting cost-coping behaviors. Interviews were transcribed and qualitatively analyzed using a descriptive phenomenological approach to thematic analysis.

RESULTS

A total of n = 11 MBC patients or caregiver representatives participated in the study. MBC patients were on average 50.2 years of age (range: 28-65) and 72.7% non-Hispanic White. MBC patients were diagnosed as metastatic an average of 3.1 years (range: 1-9) before participating in the study. Qualitative analysis resulted in four themes including (1) causes of financial burden, (2) financial assistance mechanisms, (3) health insurance and financial burden, and (4) cost-coping behaviors. Both medical and non-medical costs drove financial burden among participants. All participants reported challenges navigating their health insurance and applying for financial assistance. Regardless of gaining access to assistance, financial burden persisted for nearly all patients and resulted in cost-coping behaviors.

CONCLUSION

Our findings suggest that current systems for health insurance and financial assistance are complex and difficult to meet patient needs. Even when MBC patients accessed assistance, excess financial burden persisted necessitating use of financial coping-behaviors such as altering medication use, maintaining employment, and taking on debt.

An Environmental Scan and Qualitative Inquiry of Cancer Patient Navigation Services in North Carolina

Background and Objectives

Patient navigation services reduce barriers to accessing cancer care and lead to improved outcomes for patients. North Carolina (NC) has thousands of cancer patients seeking cancer care services each year. We sought to complete a digital environmental scan and qualitative inquiry of cancer patient navigation services throughout the state to better inform patients, hospitals administrators, and state officials about the current state of patient navigation programs for cancer patients throughout NC.

Methods

For seven cancer hospitals in NC, two steps were used: an environmental scan of publicly available information on the hospitals' websites about navigation services, and key informant interviews with navigation staff at each site.

Results

The website scans revealed information about navigation services was incomplete. Each hospital had a page dedicated to cancer navigation, but many did not outline the specific services available to patients. Interviews revealed that navigation services are available to cancer patients across diagnoses, although only a subset of patients receive services. Cancer navigators reported that their work includes care coordination, patient advocacy, emotional support, and addressing non-medical barriers to health care access (transportation, finances, childcare, etc.). Each navigation service had a unique configuration and referral pattern.

Conclusions

Cancer hospitals throughout NC are working to address barriers to care commonly faced by patients, with some programs offering more robust services compared to others. Hospitals would benefit from updating their websites at regular intervals to fully report the services available to patients through their programs, including direct and clear patient navigation contact methods.

Oncology Nurse Navigation in Underserved Communities: Opportunities and Future Directions

OBJECTIVES

Provide an overview of navigation in three disparate populations: rural, Native American/Alaska Native, and low- to middle-income countries. Discuss gaps in care and opportunities to improve cancer care.

METHODS

A literature search was conducted in PubMed and on Google Scholar using search terms, nurse navigation, cancer, disparit*, low- to middle-income countries, Native American, American Indian, and rural. Peer-reviewed research studies, review articles, databases and websites of professional organizations, and historical books were reviewed to provide an overview of oncology nurse navigation in underserved communities. Experiences in working with these populations over the past 30 years were also provided to support current literature.

RESULTS

Forty references were included in this overview of nurse navigation in underserved communities. Nurse navigation in these disparate areas is in its infancy. While some programs exist and outcomes have been positive, their dissemination is sparse. A need exists to expand nurse navigation into these areas to provide care for these underserved communities.

CONCLUSION

Oncology nursing navigation for each of these underserved communities requires a culturally sensitive approach. Many of these approaches are universal to cultural competency and can be applied to most disparate populations.

IMPLICATIONS FOR NURSING PRACTICE

Nurses comprise the largest workforce around the globe and are well-equipped to develop navigation programs in some of the most disparate communities around the world. To do so, it is important to use a foundation of building trust, embracing individual differences, providing culturally sensitive education and resources for growth, and good communication.

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.

Job lock among survivors of childhood cancer and their spouses post Affordable Care Act implementation: A Childhood Cancer Survivor Study brief report

It is unknown how common job lock (i.e., staying at job to maintain health insurance) remains among childhood cancer survivors after Affordable Care Act (ACA) implementation in 2010. We examined prevalence of and factors associated with job lock using a cross-sectional survey from the Childhood Cancer Survivor Study (3503 survivors; 942 siblings). Survivor, spousal, and any survivor/spouse job lock were more frequently reported by survivors than siblings. Survivor job lock/any job lock was associated with older age, low income, severe chronic conditions, and debt/inability to pay debt. Job lock remains more common among survivors than siblings after ACA implementation.

Factors Associated with Delaying and Forgoing Care Due to Cost among Long-term, Appalachian Cancer Survivors in Rural North Carolina

Background

Little research exists on delayed and forgone health and mental health care due to cost among rural cancer survivors.

Methods

We surveyed survivors in 7 primarily rural, Appalachian counties February to May 2020. Univariable analyses examined the distribution and prevalence of delayed/forgone care due to cost in the past year by independent variables. Chi-square or Fisher's tests examined bivariable differences. Logistic regressions assessed the odds of delayed/forgone care due to cost.

Results

Respondents (n=428), aged 68.6 years on average (SD: 12.0), were 96.3% non-Hispanic white and 49.8% female; 25.0% reported delayed/forgone care due to cost. The response rate was 18.5%. The proportion of delayed/forgone care for those aged 18-64 years was 46.7% and 15.0% for those aged 65+ years (P<0.0001). Females aged 65+ years (OR: 2.00; CI: 1.02-3.93) had double the odds of delayed/forgone care due to cost compared to males aged 65+ years.

Conclusion

About one in four rural cancer survivors reported delayed/forgone care due to cost, with rates approaching 50% in survivors aged <65 years.

Impact

Clinical implications indicate the need to: 1) ask about the impact of care costs, and 2) provide supportive services to mitigate effects of treatment costs, particularly for younger and female survivors.

Financial burden and recommended multilevel solutions among caregivers of pediatric hematopoietic stem cell transplant recipients

BACKGROUND

The healthcare costs of patients who receive hematopoietic stem cell transplantation (HSCT) are substantial. At the same time, the increasing use of pediatric HSCT leaves more caregivers of pediatric HSCT recipients at risk for financial burden-an understudied area of research.

METHODS

Financial burden experienced by caregivers of recipients who received autologous or allogeneic transplants was assessed using an explanatory mixed-methods design including a one-time survey and semi-structured interviews. Financial burden was assessed through an adapted COmprehensive Score for financial Toxicity (COST) as well as questions about the types of out-of-pocket costs and cost-coping behaviors. Chi-squared or Fisher's exact tests were used to assess differences in costs incurred and coping behaviors by financial toxicity and financial toxicity by demographic factors. Interviews were audio recorded, transcribed, and analyzed using directed content analysis.

RESULTS

Of 99 survey participants, 64% experienced high financial toxicity (COST ≤ $ \le \;$ 22). Caregivers with high financial toxicity were more likely to report costs related to transportation and diet. High financial toxicity was associated with nearly all cost-coping behaviors (e.g., borrowed money). High financial toxicity was also associated with increased use of hospital financial support and transportation assistance. Qualitative analysis resulted in four categories that were integrated with quantitative findings: (1) care-related out-of-pocket costs incurred, (2) cost-coping behaviors, (3) financial support resources used, and (4) multilevel recommendations for reducing financial burden.

CONCLUSIONS

Considering the substantial, long-term financial burden among pediatric HSCT patients and their caregivers, this population would benefit from adapted and tailored financial burden interventions.

Financial hardship differences by LGBTQ+ status among assigned female at birth adolescent and young adult cancer survivors: a mixed methods analysis

BACKGROUND

Adolescent and young adult (AYA) cancer survivors are at an elevated risk of financial hardship. However, financial hardship among LGBTQ+ AYAs has not been widely explored. Thus, we used qualitative and quantitative survey data from the Horizon Study cohort to assess financial hardship of AYAs by LGBTQ+ status.

METHODS

Multivariable logit models, predicted probabilities, average marginal effects or differences in predicted probabilities (AME) and 95% confidence intervals (CI) were used to assess the association of LGBTQ+ status and two components of financial hardship: material and psychological. Qualitative content analysis of an open-ended survey question about financial sacrifices was used to describe the third component of financial hardship, behavioral.

RESULTS

Among 1,635 participants, 4.3% self-identified as LGBTQ+. Multivariable logit models controlling for demographic factors revealed that LGBTQ+ AYAs had an 18-percentage point higher probability of experiencing material financial hardship (95%CI 6-30%) and a 14-percentage point higher probability of experiencing psychological financial hardship (95%CI 2-26%) than non-LGBTQ+ AYAs. Controlling for economic factors attenuated the association of LGBTQ+ status with psychological financial hardship (AME = 11%; 95%CI - 1-23%), while the material financial hardship association remained statistically significant (AME = 14%; 95%CI 3-25%). In the qualitative analysis, LGBTQ+ AYAs frequently reported educational changes and costs (e.g., quitting school), unpaid bills and debt (e.g., medical debt, taking on credit card debt), as well as changes in housing and poor housing conditions (e.g., moving into less expensive house).

CONCLUSIONS

LGBTQ + targeted and tailored interventions are needed to move toward equity for LGBTQ+ AYAs-an overlooked minority population.

Assessing the pre-implementation context for financial navigation in rural and non-rural oncology clinics

Background

Financial navigation (FN) is an evidence-based intervention designed to address financial toxicity for cancer patients. FN's success depends on organizations' readiness to implement and other factors that may hinder or support implementation. Tailored implementation strategies can support practice change but must be matched to the implementation context. We assessed perceptions of readiness and perceived barriers and facilitators to successful implementation among staff at nine cancer care organizations (5 rural, 4 non-rural) recruited to participate in the scale-up of a FN intervention. To understand differences in the pre-implementation context and inform modifications to implementation strategies, we compared findings between rural and non-rural organizations.

Methods

We conducted surveys (n = 78) and in-depth interviews (n = 73) with staff at each organization. We assessed perceptions of readiness using the Organizational Readiness for Implementing Change (ORIC) scale. In-depth interviews elicited perceived barriers and facilitators to implementing FN in each context. We used descriptive statistics to analyze ORIC results and deductive thematic analysis, employing a codebook guided by the Consolidated Framework for Implementation Research (CFIR), to synthesize themes in barriers and facilitators across sites, and by rurality.

Results

Results from the ORIC scale indicated strong perceptions of organizational readiness across all sites. Staff from rural areas reported greater confidence in their ability to manage the politics of change (87% rural, 76% non-rural) and in their organization's ability to support staff adjusting to the change (96% rural, 75% non-rural). Staff at both rural and non-rural sites highlighted factors reflective of the Intervention Characteristics (relative advantage) and Implementation Climate (compatibility and tension for change) domains as facilitators. Although few barriers to implementation were reported, differences arose between rural and non-rural sites in these perceived barriers, with non-rural staff more often raising concerns about resistance to change and compatibility with existing work processes and rural staff more often raising concerns about competing time demands and limited resources.

Conclusions

Staff across both rural and non-rural settings identified few, but different, barriers to implementing a novel FN intervention that they perceived as important and responsive to patients' needs. These findings can inform how strategies are tailored to support FN in diverse oncology practices.

Expanding research on the impact of financial hardship on emotional well-being: guidance of diverse stakeholders to the Emotional Well-Being and Economic Burden of Disease (EMOT-ECON) Research Network

The Emotional Well-Being and Economic Burden (EMOT-ECON) Research Network is one of six research networks funded by the National Institutes of Health (NIH) to advance research about emotional well-being (EWB), and the only one that focuses on addressing how economic burden due to disease or illness affects EWB. The network convened researchers, patients, patient advocates, health care providers and other stakeholders from across the US to discuss the significance of addressing the impact of the economic burden of disease on EWB, the complexity of this prevalent problem for patients and families, and the research gaps that still need to be studied to ultimately develop strategies to reduce the impact of economic burden of disease on EWB and health. Participants identified some important future areas of research as those investigating: (i) prevalent and relevant emotions for patients experiencing economic burden of disease and financial hardship, and how their broader outlook on life is impacted; (ii) constructs and contexts that influence whether the economic burden is stressful; (iii) strategies to deal and cope and their positive or negative effects on EWB and health; and (iv) multi-level and multi-stakeholder interventions to address economic factors (e.g., costs, ability to pay), administrative burdens, education and training, and especially patients' emotional as well as financial status.

Financial toxicity in patients with leukemia undergoing hematopoietic stem cell transplantation: A systematic review

Financial toxicity (FT) is a term used to describe the objective financial burden of cancer care including the associated coping behaviors used by patients and their caregivers. FT has been shown to result in both direct financial burdens and in clinically relevant outcomes, such as non-adherence with care, diminished quality of life, and even decreased overall survival. Much of the data has been described in solid tumors, with limited investigations in the malignant hematology population. Patients with hematologic malignancies undergoing hematopoietic stem cell transplantation (HSCT) face a unique financial burden driven by lengthy hospitalizations and acute and chronic morbidity that have downstream implications on their income and costs. In this review, we discuss the prevalence of FT in patients with leukemia who are eligible for HSCT. We review the impact of FT on financial and clinical outcomes and the role of various interventions that have been studied within this population.

Implementation of Systematic Financial Screening in an Outpatient Breast Oncology Setting

PURPOSE

Implementation of routine financial screening is a critical step toward mitigating financial toxicity. We evaluated the feasibility, sustainability, and acceptability of systematic financial screening in the outpatient breast oncology clinic at a large, urban cancer center.

METHODS

We developed and implemented a stakeholder-informed process to systematically screen for financial hardship and worry. A 2-item assessment in English or Spanish was administered to patients through the electronic medical record portal or using paper forms. We evaluated completion rates and mode of completion. Through feedback from patients, clinicians, and staff, we identified strategies to improve completion rates and acceptability.

RESULTS

From March, 2021, to February, 2022, 3,500 patients were seen in the breast oncology clinic. Of them, 39% (n = 1,349) responded to the screening items, either by paper or portal, 12% (n = 437) preferred not to answer, and the remaining 49% (n = 1,714) did not have data in their electronic health record, meaning they were not offered screening or did not complete the paper forms. Young adults (18-39 years) were more likely to respond compared with patients 70 years or older (61% v 30%, P < .01). English-preferring patients were more likely to complete the screening compared with those who preferred Spanish (46% v 28%, P < .01). Non-Hispanic White patients were more likely to respond compared with Non-Hispanic Black patients and with Hispanic patients (46% v 39% v 32%, P < .01). Strategies to improve completion rates included partnering with staff to facilitate paper form administration, optimizing patient engagement with the portal, and clearly communicating the purpose of the screening.

CONCLUSION

Systematic financial screening is feasible, and electronic data capture facilitates successful implementation. However, inclusive procedures that address language and technology preferences are needed to optimize screening.