1
|
Desai R, Jiang Y, VanWagner LB, Singal AG, Lieber SR. Financial burden in a US cohort of patients with HCC. Hepatol Commun 2024; 8:e0453. [PMID: 38829203 PMCID: PMC11150032 DOI: 10.1097/hc9.0000000000000453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 04/03/2024] [Indexed: 06/05/2024] Open
Abstract
BACKGROUND High financial burden for patients has been reported for multiple types of cancer, but there are limited data in those with HCC. We aimed to describe the financial burden for patients diagnosed with HCC and identify correlates of high financial burden. METHODS We used the IQVIA PharMetrics Plus for Academics database to identify commercially insured patients diagnosed with HCC between 2006 and 2021. Patient financial liability was defined as the difference between allowed and paid amounts from adjudicated insurance claims. We reported total and HCC-related financial liabilities (i.e., cost for HCC-related claims), with high total financial liability defined as ≥$3000 annually and high HCC-related financial liability as ≥$1000 annually. We used multivariable logistic regression modeling to identify factors associated with high total and HCC-related financial liability. RESULTS Among 11,609 patients with HCC, the median total financial liability during the year after HCC diagnosis was $2955 (Q1-Q3: $972-$6293). Nearly half (45%) of patients experienced high total financial liability, with the greatest liability incurred in the 3-month period immediately following HCC diagnosis. Older age, increased comorbidity, and cirrhosis-related complications were associated with higher total patient liability. Patient liability also varied by type of HCC treatment, with systemic therapy and liver transplantation having the highest financial liability in multivariable analysis. However, only 66.7% of the patients experienced HCC-related liability. CONCLUSIONS Patients with HCC experience significant financial liability underscoring a need for price transparency as well as financial counseling in this population.
Collapse
Affiliation(s)
- Ruchi Desai
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Yue Jiang
- Department of Statistical Science, Duke University, Durham, North Carolina, USA
| | - Lisa B. VanWagner
- Division of Gastroenterology and Hepatology,Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Amit G. Singal
- Division of Gastroenterology and Hepatology,Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Sarah R. Lieber
- Division of Gastroenterology and Hepatology,Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| |
Collapse
|
2
|
Olateju OA, Shen C, Thornton JD. The Affordable Care Act and income-based disparities in health care coverage and spending among nonelderly adults with cancer. HEALTH AFFAIRS SCHOLAR 2024; 2:qxae050. [PMID: 38812986 PMCID: PMC11135644 DOI: 10.1093/haschl/qxae050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 04/12/2024] [Accepted: 04/23/2024] [Indexed: 05/31/2024]
Abstract
The Patient Protection and Affordable Care Act (ACA) significantly reduced uninsured individuals and improved financial protection; however, escalating costs of cancer treatment has led to substantial out-of-pocket expenses, causing severe financial and mental health distress for individuals with cancer. Mixed evidence on the ACA's ongoing impact highlights the necessity of assessing health-spending changes across income groups for informed policy interventions. In our nationally representative survey evaluating the early- and long-term effects of the ACA on nonelderly adult patients with cancer, we categorized individuals-based income subgroups defined by the ACA for eligibility. We found that ACA implementation increased insurance coverage, which was particularly evident after 2 years of implementation. Early post-ACA (within two years of implementation), there were declines in out-of-pocket spending for the lowest and low-income groups by 26.52% and 38.31%, respectively, persisting long-term only for the lowest-income group. High-income groups experienced continuously increased out-of-pocket and premium spending by 25.39% and 34.28%, respectively, with a notable 122% increase in the risk of high-burden spending. This study provides robust evidence of income-based disparities in financial burden for cancer care, emphasizing the need for health care policies promoting equitable care and addressing spending disparities across income brackets.
Collapse
Affiliation(s)
- Olajumoke A Olateju
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, Houston, TX 77204-5000, United States
| | - Chan Shen
- Departments of Surgery and Public Health Sciences, Penn State Cancer Institute, Hershey, PA 17033, United States
| | - James Douglas Thornton
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, Houston, TX 77204-5000, United States
| |
Collapse
|
3
|
Wu VS, Shen X, de Moor J, Chino F, Klein J. Financial Toxicity in Radiation Oncology: Impact for Our Patients and for Practicing Radiation Oncologists. Adv Radiat Oncol 2024; 9:101419. [PMID: 38379894 PMCID: PMC10876607 DOI: 10.1016/j.adro.2023.101419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 11/16/2023] [Indexed: 02/22/2024] Open
Abstract
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.
Collapse
Affiliation(s)
- Victoria S. Wu
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Xinglei Shen
- Department of Radiation Oncology, University of Kansas Cancer Medical Center, Kansas City, Kansas
| | - Janet de Moor
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland
| | - Fumiko Chino
- Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jonathan Klein
- Department of Radiation Oncology, Maimonides Medical Center and State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, New York
| |
Collapse
|
4
|
Su CT, Shankaran V. Digital symptom assessment tools: the next frontier in financial toxicity screening. Nat Rev Clin Oncol 2024; 21:85-86. [PMID: 37880408 DOI: 10.1038/s41571-023-00833-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Affiliation(s)
- Christopher T Su
- Division of Hematology and Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA.
- Hutchinson Institute for Cancer Outcome Research, Fred Hutchinson Cancer Center, Seattle, WA, USA.
| | - Veena Shankaran
- Division of Hematology and Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
- Hutchinson Institute for Cancer Outcome Research, Fred Hutchinson Cancer Center, Seattle, WA, USA
| |
Collapse
|
5
|
Abujaradeh H, Mazanec SR, Sereika SM, Connolly MC, Bender CM, Gordon BB, Rosenzweig M. Economic Hardship and Associated Factors of Women With Early-Stage Breast Cancer Prior to Chemotherapy Initiation. Clin Breast Cancer 2024; 24:36-44. [PMID: 37852896 PMCID: PMC10841408 DOI: 10.1016/j.clbc.2023.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 07/07/2023] [Accepted: 09/11/2023] [Indexed: 10/20/2023]
Abstract
INTRODUCTION Economic hardship (EH) can negatively influence cancer outcomes. Little is known about the factors that are associated with higher levels of EH among patients with breast cancer (BC). This paper describes EH in women with early-stage BC prior to or at their first chemotherapy treatment (baseline) and explores whether there are differences by race, area deprivation, stress, symptom distress, and social support. PATIENTS AND METHODS A descriptive comparative/correlational design was employed using baseline data of a multisite, longitudinal, multimethod study comparing the symptom experience and management prior to prescribed chemotherapy for women with early-stage BC. Participants completed measures for EH, perceived stress, symptom distress, and social support. Race was measured by self-report. Area deprivation indices (ADI) measuring neighborhood economic factors were calculated from publicly available websites. RESULTS Participants (N = 248; age = 52.9 ± 12.3 years) were 62% White and 38% Black, 54% partnered, and 98% insured. Compared to White patients, Black patients reported higher (worse) EH (1.2 ± 3.0 vs. -0.7 ± 2.4), lived in areas of greater deprivation (80.1 ± 2.1 vs. 50.5 ± 23.5),and were more likely to report inadequate household income (Black: 30.5%; White: 11.1%). Adjusting for race and age, being Black (P< .001), living in an area of greater deprivation (P = .049), higher perceived stress (P = .008), lower perceived appraisal (P = .040), and less tangible support (P < .001) contributed to greater EH. Worse symptom distress trended toward greater EH (P = .07). CONCLUSIONS This study emphasizes the importance of incorporating baseline holistic assessment to identify patients most likely to experience EH during early-stage BC treatment.
Collapse
Affiliation(s)
- Hiba Abujaradeh
- University of Pittsburgh School of Nursing, Pittsburgh, PA, USA
| | - Susan R Mazanec
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, USA
| | - Susan M Sereika
- University of Pittsburgh School of Nursing, Pittsburgh, PA, USA
| | - Mary C Connolly
- University of Pittsburgh School of Nursing, Pittsburgh, PA, USA
| | | | | | | |
Collapse
|
6
|
Waitman LR, Bailey LC, Becich MJ, Chung-Bridges K, Dusetzina SB, Espino JU, Hogan WR, Kaushal R, McClay JC, Merritt JG, Rothman RL, Shenkman EA, Song X, Nauman E. Avenues for Strengthening PCORnet's Capacity to Advance Patient-Centered Economic Outcomes in Patient-Centered Outcomes Research (PCOR). Med Care 2023; 61:S153-S160. [PMID: 37963035 PMCID: PMC10635342 DOI: 10.1097/mlr.0000000000001929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
PCORnet, the National Patient-Centered Clinical Research Network, provides the ability to conduct prospective and observational pragmatic research by leveraging standardized, curated electronic health records data together with patient and stakeholder engagement. PCORnet is funded by the Patient-Centered Outcomes Research Institute (PCORI) and is composed of 8 Clinical Research Networks that incorporate at total of 79 health system "sites." As the network developed, linkage to commercial health plans, federal insurance claims, disease registries, and other data resources demonstrated the value in extending the networks infrastructure to provide a more complete representation of patient's health and lived experiences. Initially, PCORnet studies avoided direct economic comparative effectiveness as a topic. However, PCORI's authorizing law was amended in 2019 to allow studies to incorporate patient-centered economic outcomes in primary research aims. With PCORI's expanded scope and PCORnet's phase 3 beginning in January 2022, there are opportunities to strengthen the network's ability to support economic patient-centered outcomes research. This commentary will discuss approaches that have been incorporated to date by the network and point to opportunities for the network to incorporate economic variables for analysis, informed by patient and stakeholder perspectives. Topics addressed include: (1) data linkage infrastructure; (2) commercial health plan partnerships; (3) Medicare and Medicaid linkage; (4) health system billing-based benchmarking; (5) area-level measures; (6) individual-level measures; (7) pharmacy benefits and retail pharmacy data; and (8) the importance of transparency and engagement while addressing the biases inherent in linking real-world data sources.
Collapse
Affiliation(s)
- Lemuel R. Waitman
- Department of Biomedical Informatics, Biostatistics, and Medical Epidemiology, University of Missouri School of Medicine, Greater Plains Collaborative, PCORnet Clinical Research Network, Columbia, MO
| | | | | | | | | | | | | | - Rainu Kaushal
- Weill Cornell University School of Medicine, New York, NY
| | | | | | | | | | - Xing Song
- University of Missouri School of Medicine, Columbia, MO
| | | |
Collapse
|
7
|
Grafova IB, Manne SL, Hudson SV, Elliott J, Llanos AAM, Saraiya B, Duberstein PR. Functional impairment is associated with medical debt in male cancer survivors and credit card debt in female cancer survivors. Support Care Cancer 2023; 31:605. [PMID: 37782442 DOI: 10.1007/s00520-023-08070-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 09/23/2023] [Indexed: 10/03/2023]
Abstract
PURPOSE To examine the associations of functional limitations with medical and credit card debt among cancer survivor families and explore sex differences in these associations. METHODS This cross-sectional study used data from the 2019 wave of the Panel Study of Income Dynamics, a nationally representative, population-based survey of individuals and households in the US administered in both English and Spanish and includes all households where either the head of household or spouse/partner reported having been diagnosed with cancer. Participants reported on functional limitations in six instrumental activities of daily living (IADL) and seven activities of daily living (ADL). Functional impairment was categorized as 0, 1-2 and ≥ 3 limitations. Medical debt was defined as self-reported unpaid medical bills. Credit card debt was defined as revolving credit card debt. Multivariable logistic regression analyses were performed. RESULTS Credit card debt was more common than medical debt (39.8% vs. 7.6% of cancer survivor families). Families of male cancer survivors were 7.3 percentage points more likely to have medical debt and 16.0 percentage points less likely to have credit card debt compared to families of female cancer survivors. Whereas male cancer survivors with increasing levels of impairment were 24.7 percentage point (p-value = 0.006) more likely to have medical debt, female survivors with more functional impairment were 13.6 percentage points (p-value = 0.010) more likely to have credit card debt. CONCLUSIONS More research on medical and credit card debt burden among cancer survivors with functional limitations is needed.
Collapse
Affiliation(s)
- Irina B Grafova
- Edward J. Bloustein School of Planning and Public Policy, Rutgers University, 33 Livingston Avenue, New Brunswick, NJ, 08901, USA.
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA.
| | - Sharon L Manne
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Shawna V Hudson
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, Piscataway, NJ, USA
| | - Jennifer Elliott
- Edward J. Bloustein School of Planning and Public Policy, Rutgers University, 33 Livingston Avenue, New Brunswick, NJ, 08901, USA
| | - Adana A M Llanos
- Department of Epidemiology, Mailman School of Public Health and Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY, USA
| | - Biren Saraiya
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, Piscataway, NJ, USA
| | - Paul R Duberstein
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
- Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, Piscataway, NJ, USA
| |
Collapse
|
8
|
Bogdanovski AK, Sturgeon C, James BC. Financial toxicity in thyroid cancer survivors. Curr Opin Endocrinol Diabetes Obes 2023; 30:238-243. [PMID: 37470486 DOI: 10.1097/med.0000000000000826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
PURPOSE OF REVIEW Financial burden and distress are high in patients with thyroid cancer. However, little has been done to evaluate potential interventions to mitigate financial toxicity in survivors. This review will cover current data on the impact of financial toxicity on quality of life and clinical outcomes in patients with thyroid cancer and highlight areas for future study. RECENT FINDINGS Thyroid cancer incidence has nearly tripled in the past decades, and cost of treatment is predicted to rise more than other cancers over the next decade. With mean age of diagnosis at 51 years, most patients begin treatment while still working, do not qualify for Medicare or Social Security, and are susceptible to higher financial burden. Though thyroid cancer has high survival rates, some studies suggest patients have worse quality of life and higher financial burden than more morbid cancers. SUMMARY Thyroid cancer survivors have high rates of financial toxicity, and there remains need for longitudinal studies to evaluate how financial burden may change during the treatment process while also assessing potential tools to mitigate this burden.
Collapse
Affiliation(s)
- Anastasia K Bogdanovski
- Harvard Medical School
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Cord Sturgeon
- Northwestern University Feinberg School of Medicine
- Department of Surgery, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Benjamin C James
- Harvard Medical School
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| |
Collapse
|
9
|
Joyce DD, Dusetzina SB. Financial toxicity of oral therapies in advanced prostate cancer. Urol Oncol 2023; 41:363-368. [PMID: 37029039 DOI: 10.1016/j.urolonc.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 03/02/2023] [Accepted: 03/10/2023] [Indexed: 04/09/2023]
Abstract
The treatment landscape of advanced prostate cancer (CaP) has evolved significantly over the past 20 years. As the number of oral anticancer treatment options continues to increase, so do the costs of these drugs. Furthermore, payment responsibility for these treatments is increasingly shifted from insurers to patients. In this narrative review, we sought to summarize existing assessments of financial toxicity (FT) associated with oral advanced CaP treatments, describe efforts targeted at limiting FT from these agents, and identify areas in need of further investigation. FT is understudied in advanced CaP. Oral treatment options are associated with significantly higher direct costs to patients compared to standard androgen deprivation therapy or chemotherapy. Financial assistance programs, Medicare low-income subsidies, and recent health policy changes help offset these costs for some patients. Physicians are reluctant to discuss treatment costs with patients and further work is needed to better understand best practices for inclusion of FT discussions in shared decision-making. Oral therapies for advanced CaP are associated with significantly higher patient out-of-pocket costs which may contribute to FT. Currently, little is known regarding the extent and severity of these costs on patients' lives. While recent policy changes have helped reduce these costs for some patients, more work is needed to better characterize FT in this population to inform interventions that improve access to care and lessen the harms associated with the cost of novel treatments.
Collapse
Affiliation(s)
| | - Stacie B Dusetzina
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN
| |
Collapse
|
10
|
Fingrut WB, Chinapen S, Flynn J, Katrichis A, Stewart M, Davis E, Shaffer BC, Shah GL, Barker JN. Association between non-European ancestry, low socioeconomic status, and receipt of HLA-disparate allografts in adult BMT recipients. Blood Adv 2023; 7:3834-3837. [PMID: 37083929 PMCID: PMC10393742 DOI: 10.1182/bloodadvances.2023009955] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 04/11/2023] [Accepted: 04/12/2023] [Indexed: 04/22/2023] Open
Affiliation(s)
- Warren B. Fingrut
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Stephanie Chinapen
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jessica Flynn
- Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Angela Katrichis
- Department of Social Work, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Melissa Stewart
- Department of Social Work, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Eric Davis
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Brian C. Shaffer
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Cornell Medicine, New York, NY
| | - Gunjan L. Shah
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Cornell Medicine, New York, NY
| | - Juliet N. Barker
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Cornell Medicine, New York, NY
| |
Collapse
|
11
|
Shi JJ, McGinnis GJ, Peterson SK, Taku N, Chen YS, Yu RK, Wu CF, Mendoza TR, Shete SS, Ma H, Volk RJ, Giordano SH, Shih YCT, Nguyen DK, Kaiser KW, Smith GL. Pilot study of a Spanish language measure of financial toxicity in underserved Hispanic cancer patients with low English proficiency. Front Psychol 2023; 14:1188783. [PMID: 37492449 PMCID: PMC10364629 DOI: 10.3389/fpsyg.2023.1188783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 06/23/2023] [Indexed: 07/27/2023] Open
Abstract
Background Financial toxicity (FT) reflects multi-dimensional personal economic hardships borne by cancer patients. It is unknown whether measures of FT-to date derived largely from English-speakers-adequately capture economic experiences and financial hardships of medically underserved low English proficiency US Hispanic cancer patients. We piloted a Spanish language FT instrument in this population. Methods We piloted a Spanish version of the Economic Strain and Resilience in Cancer (ENRICh) FT measure using qualitative cognitive interviews and surveys in un-/under-insured or medically underserved, low English proficiency, Spanish-speaking Hispanics (UN-Spanish, n = 23) receiving ambulatory oncology care at a public healthcare safety net hospital in the Houston metropolitan area. Exploratory analyses compared ENRICh FT scores amongst the UN-Spanish group to: (1) un-/under-insured English-speaking Hispanics (UN-English, n = 23) from the same public facility and (2) insured English-speaking Hispanics (INS-English, n = 31) from an academic comprehensive cancer center. Multivariable logistic models compared the outcome of severe FT (score > 6). Results UN-Spanish Hispanic participants reported high acceptability of the instrument (only 0% responded that the instrument was "very difficult to answer" and 4% that it was "very difficult to understand the questions"; 8% responded that it was "very difficult to remember resources used" and 8% that it was "very difficult to remember the burdens experienced"; and 4% responded that it was "very uncomfortable to respond"). Internal consistency of the FT measure was high (Cronbach's α = 0.906). In qualitative responses, UN-Spanish Hispanics frequently identified a total lack of credit, savings, or income and food insecurity as aspects contributing to FT. UN-Spanish and UN-English Hispanic patients were younger, had lower education and income, resided in socioeconomically deprived neighborhoods and had more advanced cancer vs. INS-English Hispanics. There was a higher likelihood of severe FT in UN-Spanish (OR = 2.73, 95% CI 0.77-9.70; p = 0.12) and UN-English (OR = 4.13, 95% CI 1.13-15.12; p = 0.03) vs. INS-English Hispanics. A higher likelihood of severely depleted FT coping resources occurred in UN-Spanish (OR = 4.00, 95% CI 1.07-14.92; p = 0.04) and UN-English (OR = 5.73, 95% CI 1.49-22.1; p = 0.01) vs. INS-English. The likelihood of FT did not differ between UN-Spanish and UN-English in both models (p = 0.59 and p = 0.62 respectively). Conclusion In medically underserved, uninsured Hispanic patients with cancer, comprehensive Spanish-language FT assessment in low English proficiency participants was feasible, acceptable, and internally consistent. Future studies employing tailored FT assessment and intervention should encompass the key privations and hardships in this population.
Collapse
Affiliation(s)
- Julia J. Shi
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Gwendolyn J. McGinnis
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Susan K. Peterson
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Nicolette Taku
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Ying-Shiuan Chen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Robert K. Yu
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Chi-Fang Wu
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Tito R. Mendoza
- Department of Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Sanjay S. Shete
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Hilary Ma
- Department of General Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Robert J. Volk
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Sharon H. Giordano
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Ya-Chen T. Shih
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Diem-Khanh Nguyen
- University of California Riverside School of Medicine, Riverside, CA, United States
| | - Kelsey W. Kaiser
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Grace L. Smith
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| |
Collapse
|
12
|
Williams JC, Ford ML, Coopersmith CM. Cancer and sepsis. Clin Sci (Lond) 2023; 137:881-893. [PMID: 37314016 PMCID: PMC10635282 DOI: 10.1042/cs20220713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 05/15/2023] [Accepted: 05/23/2023] [Indexed: 06/15/2023]
Abstract
Sepsis is one of the leading causes of death worldwide. While mortality is high regardless of inciting infection or comorbidities, mortality in patients with cancer and sepsis is significantly higher than mortality in patients with sepsis without cancer. Cancer patients are also significantly more likely to develop sepsis than the general population. The mechanisms underlying increased mortality in cancer and sepsis patients are multifactorial. Cancer treatment alters the host immune response and can increase susceptibility to infection. Preclinical data also suggests that cancer, in and of itself, increases mortality from sepsis with dysregulation of the adaptive immune system playing a key role. Further, preclinical data demonstrate that sepsis can alter subsequent tumor growth while tumoral immunity impacts survival from sepsis. Checkpoint inhibition is a well-accepted treatment for many types of cancer, and there is increasing evidence suggesting this may be a useful strategy in sepsis as well. However, preclinical studies of checkpoint inhibition in cancer and sepsis demonstrate results that could not have been predicted by examining either variable in isolation. As sepsis management transitions from a 'one size fits all' model to a more individualized approach, understanding the mechanistic impact of cancer on outcomes from sepsis represents an important strategy towards delivering on the promise of precision medicine in the intensive care unit.
Collapse
Affiliation(s)
- Jeroson C. Williams
- Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322, U.S.A
- Emory Critical Care Center, Emory University School of Medicine, Atlanta, GA 30322, U.S.A
| | - Mandy L. Ford
- Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322, U.S.A
- Emory Transplant Center, Emory University School of Medicine, Atlanta, GA 30322, U.S.A
| | - Craig M. Coopersmith
- Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322, U.S.A
- Emory Critical Care Center, Emory University School of Medicine, Atlanta, GA 30322, U.S.A
| |
Collapse
|
13
|
Birkenmaier J, Jung E, McMillin S, Qian Z. Are credit scores and financial well-being associated with physical health? SOCIAL WORK IN HEALTH CARE 2023; 62:162-178. [PMID: 37120849 DOI: 10.1080/00981389.2023.2207614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 11/03/2022] [Accepted: 04/21/2023] [Indexed: 05/30/2023]
Abstract
Consumer credit score has been used as an indicator of financial strain that could potentially impact health. Subjective financial well-being, or one's feelings about one's expectations, preferences, and satisfaction with their financial situation, is related to financial strain. This study examined whether subjective financial well-being mediates the association between credit score and self-reported physical health in a national representative sample. Using structural equation modeling (SEM), we test whether a mediating association exists between self-rated credit score and self-rated physical health. Results suggest that, after controlling for sociodemographic variables, those who reported higher credit scores have better health (β = 0.175, p < .001) and higher financial well-being (β = 0.469, p < .001), and those who reported higher financial well-being have better health (β = 0.265, p < .001). The mediation effect of financial well-being on the association between credit and physical health is also positive and statistically significant (β = 0.299, p < .001). Thus, subjective feelings about one's financial situation would enhance the observed positive association between credit and health. Practice and policy implications are included.
Collapse
Affiliation(s)
- Julie Birkenmaier
- School of Social Work, Saint Louis University, St Louis, Missouri, USA
| | - Euijin Jung
- Refugee Behavioral Health Postdoctoral Fellow, Research Program on Children and Adversity, Boston College School of Social Work, Chestnut Hill, Massachusetts, USA
| | - Stephen McMillin
- School of Social Work, Saint Louis University, St Louis, Missouri, USA
| | - Zhengmin Qian
- College for Public Health and Social Justice, Saint Louis University, Saint Louis, Missouri, USA
| |
Collapse
|
14
|
Khan HM, Ramsey S, Shankaran V. Financial Toxicity in Cancer Care: Implications for Clinical Care and Potential Practice Solutions. J Clin Oncol 2023; 41:3051-3058. [PMID: 37071839 DOI: 10.1200/jco.22.01799] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2023] Open
Abstract
Patients with cancer face an array of financial consequences as a result of their diagnosis and treatment, collectively referred to as financial toxicity (FT). In the past 10 years, the body of literature on this subject has grown tremendously, with a recent focus on interventions and mitigation strategies. In this review, we will briefly summarize the FT literature, focusing on the contributing factors and downstream consequences on patient outcomes. In addition, we will put FT into context with our emerging understanding of the role of social determinants of health and provide a framework for understanding FT across the cancer care continuum. We will then discuss the role of the oncology community in addressing FT and outline potential strategies that oncologists and health systems can implement to reduce this undue burden on patients with cancer and their families.
Collapse
Affiliation(s)
- Hiba M Khan
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Center, Seattle, WA
| | - Scott Ramsey
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Center, Seattle, WA
| | - Veena Shankaran
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Center, Seattle, WA
- Division of Medical Oncology, University of Washington School of Medicine, Seattle, WA
| |
Collapse
|
15
|
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.
Collapse
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
| |
Collapse
|
16
|
Chino F, Sadigh G. Introduction to Financial Toxicity and the Growing Affordability Crisis. J Am Coll Radiol 2023; 20:6-7. [PMID: 36513261 DOI: 10.1016/j.jacr.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 12/05/2022] [Indexed: 12/14/2022]
Affiliation(s)
- Fumiko Chino
- Affordability Working Group and the Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York; is a member of the Health Equity, Diversity and Inclusion Counsel, American Society for Radiation Oncology; is on the steering committee of ASCO Quality; and a director of the Costs of Care group.
| | - Gelareh Sadigh
- Department of Radiological Sciences, University of California, Irvine, Irvine, California; is an Associate Editor of the Journal of American College of Radiology; and Director of Health Services and Comparative Effectiveness Outcome Research at the University of California, Irvine, Irvine, California
| |
Collapse
|
17
|
Cartun Z, Kunz WG, Heinzerling L, Tomsitz D, Guertler A, Westphalen CB, Ricke J, Weir W, Unterrainer M, Mehrens D. Cost-effectiveness of Response-Adapted De-escalation of Immunotherapy in Advanced Melanoma. JAMA Dermatol 2022; 158:1387-1393. [PMID: 36260321 PMCID: PMC9582967 DOI: 10.1001/jamadermatol.2022.4556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 08/30/2022] [Indexed: 01/13/2023]
Abstract
Importance Combination immunotherapy with nivolumab and ipilimumab has markedly improved outcomes for patients with advanced melanoma. However, these therapies pose a considerable financial burden to both patients and the health care system. The ADAPT-IT trial demonstrated comparable progression-free and overall survival for patients with response-adapted ipilimumab discontinuation compared with standard of care (SOC). Objective To determine the cost-effectiveness of ipilimumab discontinuation for patients with interim imaging-confirmed tumor response in the treatment of advanced melanoma. Design, Setting, and Participants This cost-effectiveness analysis was performed using data from the ADAPT-IT (follow-up of 33 months) and CheckMate 067 (follow-up of 6.5 years) trials, as well as published literature over the ADAPT-IT trial duration of 33 months. The analysis was performed in a US setting from a US-payer perspective, and the willingness-to-pay (WTP) threshold was set at $100 000/quality-adjusted life-year (QALY). A total of 355 patients with previously untreated melanoma (unresectable stage III or IV metastatic melanoma) were included. Exposure Response-adapted ipilimumab discontinuation compared with SOC therapy. Main Outcomes and Measures The primary outcomes of the CheckMate trial were overall survival and progression-free survival, while that of ADAPT-IT was objective response. This informed a decision model to estimate lifetime costs and QALYs associated with both strategies. Incremental cost, effectiveness, and cost-effectiveness ratio were assessed. Sensitivity and scenario analyses were performed to account for variability in trials and input parameters. Results Of the 355 patients included in the analysis, 41 patients were from the ADAPT-IT trial (median age, 65 years; 28 [68%] male) and 314 patients from the CheckMate 067 trial (median age, 61 years; 206 [66%] male). Response-adapted treatment was the cost-effective option in 94.0% of scenarios based on Monte Carlo simulations, with a dominant incremental cost-effectiveness ratio and an incremental net monetary benefit of $28 849 compared with SOC therapy. Cost savings were estimated at $19 891 per patient compared with SOC. In scenario analyses, current SOC was only considered as a cost-effective option under best survival assumptions and if the willingness-to-pay threshold exceeded $630 000/QALY. Conclusions and Relevance This economic evaluation demonstrated that response-adapted treatment de-escalation in patients with advanced melanoma may lead to considerable savings in health care costs and could represent the most cost-effective strategy across various resource settings. Future trials should aim to provide further evidence on noninferiority.
Collapse
Affiliation(s)
- Zachary Cartun
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
- Department of Radiology, University of Massachusetts Medical School, Worcester
| | - Wolfgang G. Kunz
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Lucie Heinzerling
- Department of Dermatology and Allergology, University Hospital, LMU Munich, Munich, Germany
- Department of Dermatology and Allergology, University Hospital Erlangen, Friedrich Alexander Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Dirk Tomsitz
- Department of Dermatology and Allergology, University Hospital, LMU Munich, Munich, Germany
| | - Anne Guertler
- Department of Dermatology and Allergology, University Hospital, LMU Munich, Munich, Germany
| | - C. Benedikt Westphalen
- Department of Medicine III and Comprehensive Cancer Center, University Hospital, LMU Munich, Munich, Germany
| | - Jens Ricke
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - William Weir
- Department of Radiology, University of Massachusetts Medical School, Worcester
| | - Marcus Unterrainer
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Dirk Mehrens
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| |
Collapse
|
18
|
Mullangi S, Aviki EM, Hershman DL. Reexamining Social Determinants of Health Data Collection in the COVID-19 Era. JAMA Oncol 2022; 8:1736-1738. [PMID: 36301554 DOI: 10.1001/jamaoncol.2022.4543] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This Viewpoint describes the association of various factors, including demographic factors, disease-related factors, and social determinants of health, with cancer treatment delays among a cohort of patients across multiple sites who had all tested positive for SARS-CoV-2.
Collapse
Affiliation(s)
- Samyukta Mullangi
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Emeline M Aviki
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Dawn L Hershman
- Department of Medicine, Columbia University Medical Center, New York, New York
| |
Collapse
|
19
|
Affiliation(s)
- Edward Christopher Dee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
- Affordability Working Group, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| |
Collapse
|
20
|
Eala MAB, Dee EC, Ginsburg O, Chua MLK, Bhoo-Pathy N. Financial toxicities of cancer in low- and middle-income countries: Perspectives from Southeast Asia. Cancer 2022; 128:3013-3015. [PMID: 35713589 DOI: 10.1002/cncr.34353] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/04/2022] [Accepted: 05/25/2022] [Indexed: 12/19/2022]
Affiliation(s)
| | - Edward Christopher Dee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ophira Ginsburg
- Center for Global Health, National Cancer Institute, Rockville, Maryland, USA
| | - Melvin Lee Kiang Chua
- Department of Head and Neck and Thoracic Cancers, Divisions of Radiation Oncology and Medical Sciences, Duke-NUS Medical School, Singapore.,Oncology Academic Programme, Duke-NUS Medical School, Singapore
| | - Nirmala Bhoo-Pathy
- Centre for Epidemiology and Evidence-Based Practice, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| |
Collapse
|