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

Modifiable risk factors for cancer among people with lynch syndrome: an international, cross-sectional survey

BACKGROUND

Lynch syndrome is the most common cause of hereditary colorectal and endometrial cancer. Lifestyle modification may provide an opportunity for adjunctive cancer prevention. In this study, we aimed to characterise modifiable risk factors in people with Lynch syndrome and compare this with international guidelines for cancer prevention.

METHODS

A cross-sectional study was carried out utilizing survey methodology. Following public and patient involvement, the survey was disseminated through patient advocacy groups and by social media. Self-reported demographic and health behaviours were collected in April 2023. Guidelines from the World Cancer Research Fund (WCRF) were used to compare percentage adherence to 9 lifestyle recommendations, including diet, physical activity, weight, and alcohol intake. Median adherence scores, as a surrogate for lifestyle risk, were calculated and compared between groups.

RESULTS

156 individuals with Lynch syndrome participated from 13 countries. The median age was 51, and 54% were cancer survivors. The mean BMI was 26.7 and the mean weekly duration of moderate to vigorous physical activity was 90 min. Median weekly consumption of ethanol was 60 g, and 3% reported current smoking. Adherence to WCRF recommendations for cancer prevention ranged from 9 to 73%, with all but one recommendation having < 50% adherence. The median adherence score was 2.5 out of 7. There was no significant association between median adherence scores and age (p = 0.27), sex (p = 0.31), or cancer history (p = 0.75).

CONCLUSIONS

We have characterised the modifiable risk profile of people living with Lynch syndrome, outlining targets for intervention based on lifestyle guidelines for the general population. As evidence supporting the relevance of modifiable factors in Lynch syndrome emerges, behavioural modification may prove an impactful means of cancer prevention.

Cost-of-care discussions for individuals with advanced non-small cell lung cancer and melanoma: Findings from a large, population-based pilot study

BACKGROUND

Costs of cancer care can result in patient financial hardship; many professional organizations recommend provider discussions about treatment costs as part of high-quality care. In this pilot study, the authors examined patient-provider cost discussions documented in the medical records of individuals who were diagnosed with advanced non-small cell lung cancer (NSCLC) and melanoma-cancers with recently approved, high-cost treatment options.

METHODS

Individuals who were newly diagnosed in 2017-2018 with stage III/IV NSCLC (n = 1767) and in 2018 with stage III/IV melanoma (n = 689) from 12 Surveillance, Epidemiology, and End Results regions were randomly selected for the National Cancer Institute Patterns of Care Study. Documentation of cost discussions was abstracted from the medical record. The authors examined patient, treatment, and hospital factors associated with cost discussions in multivariable logistic regression analyses.

RESULTS

Cost discussions were documented in the medical records of 20.3% of patients with NSCLC and in 24.0% of those with melanoma. In adjusted analyses, privately insured (vs. publicly insured) patients were less likely to have documented cost discussions (odds ratio [OR], 0.54; 95% confidence interval [CI], 0.37-0.80). Patients who did not receive systemic therapy or did not receive any cancer-directed treatment were less likely to have documented cost discussions than those who did receive systemic therapy (OR, 0.39 [95% CI, 0.19-0.81] and 0.46 [95% CI, 0.30-0.70], respectively), as were patients who were treated at hospitals without residency programs (OR, 0.64; 95% CI, 0.42-0.98).

CONCLUSIONS

Cost discussions were infrequently documented in the medical records of patients who were diagnosed with advanced NSCLC and melanoma, which may hinder identifying patient needs and tracking outcomes of associated referrals. Efforts to increase cost-of-care discussions and relevant referrals, as well as their documentation, are warranted.

Measures of financial toxicity in cancer survivors: a systematic review

PURPOSE

Comprehensive cancer-related financial toxicity (FT) measures as a multidimensional construct are lacking. The aims of this systematic review were to (1) identify full measures designed explicitly for assessing FT and evaluate their psychometric properties (content validity, structural validity, reliability, and other measurement properties) using Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN), and (2) provide an analysis of the domains of FT covered in these measures.

METHODS

MEDLINE, CINAHL, Web of Science, and Cochrane CENTRAL were searched for quantitative studies published from January 2000 to July 2023 that reported psychometric properties of FT measures in cancer survivors. The psychometric properties of FT measures and study risk of bias were analysed using COSMIN. Each FT measure was compared against the six domains of FT recommended by Witte and colleagues. Results were synthesized narratively. The detailed search strategies are available in Table S1.

RESULTS

Six FT tools including the COST-FACIT, PROFFIT, FIT, SFDQ, HARDS, and ENRICh-Spanish were identified. The COST-FACIT measure had good measurement properties. No measure reached an excellent level for overall quality but was mostly rated as sufficient. The SFDQ, HARDS, and ENRICh-Spanish were the most comprehensive in the inclusion of the six domains of FT.

CONCLUSION

This review emphasizes the need for validated multidimensional FT measures that can be applied across various cancer types, healthcare settings, and cultural backgrounds. Furthermore, a need to develop practical screening tools with high predictive ability for FT is highly important, considering the significant consequences of FT. Addressing these gaps in future research will further enhance the understanding of FT.

Individualized radiology screening for newly diagnosed nasopharyngeal carcinoma

OBJECTIVES

Current guidelines recommend universal PET/CT screening for metastases staging in newly diagnosed nasopharyngeal carcinoma (NPC) despite the low rate of synchronous distant metastasis (SDM). The study aims to achieve individualized screening recommendations of NPC based on the risk of SDM.

METHODS AND MATERIALS

18 pre-treatment peripheral blood indicators was retrospectively collected from 2271 primary NPC patients. A peripheral blood risk score (PBRS) was constructed by indicators associated with SDM on least absolute shrinkage and selection operator (LASSO) regression. The PBRS-based distant metastases (PBDM) model was developed from features selected by logistic regression analyses in the training cohort and then validated in the validation cohort. Receiver operator characteristic curve analysis, calibration curves, and decision curve analysis were applied to evaluate PBDM model performance.

RESULTS

Pre-treatment Epstein-Barr viral DNA copy number, percentage of total lymphocytes, serum lactate dehydrogenase level, and monocyte-to-lymphocyte ratio were most strongly associated with SDM in NPC and used to construct the PBRS. Sex (male), T stage (T3-4), N stage (N2-3), and PBRS (≥1.076) were identified as independent risk factors for SDM and applied in the PBDM model, which showed good performance. Through the model, patients in the training cohort were stratified into low-, medium-, and high-risk groups. Individualized screening recommendations were then developed for patients with differing risk levels.

CONCLUSION

The PBDM model offers individualized recommendations for applying PET/CT for metastases staging in NPC, allowing more targeted screening of patients with greater risk of SDM compared with current recommendations.

"It was kind of a nightmare, it really was:" financial toxicity among rural women cancer survivors

PURPOSE

The purpose of this study was to examine how rural women cancer survivors experience and manage financial toxicity.

METHODS

A qualitative descriptive design was used to explore experiences of financial toxicity among rural women who received cancer treatment. We conducted qualitative interviews with 36 socioeconomically diverse rural women cancer survivors.

RESULTS

Participants were categorized into three groups: (1) survivors who struggled to afford basic living expenses but did not take on medical debt; (2) survivors who took on medical debt but were able to meet their basic needs; and (3) survivors who reported no financial toxicity. The groups differed by financial and job security and insurance type. We describe each group and, for the first two groups, the strategies they used to manage financial toxicity.

CONCLUSIONS

Financial toxicity related to cancer treatment is experienced differently by rural women cancer survivors depending on financial and job security and insurance type. Financial assistance and navigation programs should be tailored to support rural patients experiencing different forms of financial toxicity.

IMPLICATIONS FOR CANCER SURVIVORS

Rural cancer survivors with financial security and private insurance may benefit from policies aimed at limiting patient cost-sharing and financial navigation to help patients understand and maximize their insurance benefits. Rural cancer survivors who are financially and/or job insecure and have public insurance may benefit from financial navigation services tailored to rural patients that can assist with living expenses and social needs.

Age-related differences in employment, insurance, and financial hardship among colorectal cancer patients: a report from the ColoCare Study

PURPOSE

Employment and financial hardships are common issues for working-age colorectal cancer patients. We surveyed colorectal cancer survivors to investigate employment, insurance, and financial outcomes by age at diagnosis.

METHODS

Cross-sectional survey of six ColoCare Study sites regarding employment, insurance, and financial hardship outcomes. Eligible participants were 1 to 5 years from colorectal cancer diagnosis. Diagnosis age (18-49, 50-64, 65+ years) with outcomes of interest were compared using chi-square and t-tests. Multivariable logistic and Poisson regressions were fit to examine association of demographic factors with any material/psychological hardship (yes/no) and the count of hardships.

RESULTS

N = 202 participants completed the survey (age: 18-49 (n = 42, 20.8%), 50-64 (n = 79, 39.1%), 65+ (n = 81, 40.1%)). Most diagnosed age < 65 worked at diagnosis (18-49: 83%; 50-64: 64%; 65+ : 14%, p < 0.001) and continued working after diagnosis (18-49: 76%; 50-64: 59%; 65+ : 13%; p < 0.001). Participants age 18-49 reported cancer-related difficulties with mental (81.3%) and physical (89%) tasks at work more than those working in the older age groups (45%-61%). In regression models, among those reporting any hardship, the rates of material and psychological hardships were higher among those age 18-64 (Incidence Rate Ratios (IRR) range 1.5-2.3 vs. age 65+) and for those with < college (IRR range 1.3-1.6 vs. college +).

CONCLUSIONS

Younger colorectal cancer patients are more likely to work after a cancer diagnosis and during cancer treatment, but report higher levels of financial hardship than older patients.

IMPLICATIONS FOR CANCER SURVIVORS

Younger colorectal cancer patients may encounter financial hardship, thus may feel a need to work during and after treatment.

Survivorship in Advanced Lung Cancer: Understanding a New Landscape and Opportunities

People with advanced lung cancer represent a distinct group whose needs remain understudied, especially compared with people diagnosed with limited-stage disease. Fortunately, novel treatments such as tyrosine kinase inhibitors and immune checkpoint inhibitors are leading to significant advances in prognosis and survival, even among those with advanced disease at the time of diagnosis. However, there are known gaps in symptom management, psychosocial and nutritional support, complex care coordination, health behavior coaching, and health care delivery efforts among patients living with advanced lung cancer. Many of these patients would benefit from survivorship and palliative care approaches. In particular, survivorship care may include health care maintenance, treatment of immune-related adverse events and late- or long-term effects, frailty assessment and rehabilitation, and care coordination. Palliative care may be best suited to discuss ongoing symptom management, advanced care planning, and end-of-life considerations, as well as psychosocial well-being. To this end, we share a review of the current status of the palliative and survivorship care infrastructure for patients with advanced lung cancer and provide suggestions across the care continuum for this diverse group of patients and families.

For the Long Haul: Management of Long-Term Survivors after Melanoma Systemic Therapy

PURPOSE OF REVIEW

This review summarizes the latest advancements in survivorship care for patients with advanced melanoma who received systemic therapy and emphasizes the areas where more research is needed.

RECENT FINDINGS

Over the last decade there have been remarkable advances in the treatment of advanced and metastatic melanoma. Due to these novel treatments, including several immune checkpoint inhibitors and tyrosine kinase inhibitors, there are and will continue to be increasing numbers of long-term melanoma survivors who have been treated with systemic therapy. These patients will navigate new challenges are they are essentially among the first long term survivors after these novel therapies. Survivorship care focuses on improving the health-related quality of life of patients including the physical, emotional, social and functional effects of cancer that begin at diagnosis and continue through the end of life. Survivorship also includes screening for cancer recurrence and second cancers. As the number of melanoma survivors who received systemic therapy continues to grow, the survivorship care plan will become increasingly important for optimal care of patients even after their cancer treatments. Understanding the many domains of survivorship care for this group of patients is imperative for their care now and to identify unmet needs for future research.

Interventions to mitigate cancer-related medical financial hardship: A systematic review and meta-analysis

BACKGROUND

This study systematically reviewed interventions mitigating financial hardship in patients with cancer and assessed effectiveness using a meta-analytic method.

METHODS

PubMed, Cochrane, Scopus, CINAHL, and Web of Science were searched for articles published in English during January 2000-April 2023. Two independent reviewers selected prospective clinical trials with an intervention targeting and an outcome measuring financial hardship. Quality appraisal and data extraction were performed independently by two reviewers using a quality assessment tool. A random-effects model meta-analysis was performed. Reporting followed the preferred reporting items for systematic review and meta-analyses guidelines.

RESULTS

Eleven studies (2211 participants; 55% male; mean age, 59.29 years) testing interventions including financial navigation, financial education, and cost discussion were included. Financial worry improved in only 27.3% of 11 studies. Material hardship and cost-related care nonadherence remained unchanged in the two studies measuring these outcomes. Four studies (373 participants; 37% male, mean age, 55.88 years) assessed the impact of financial navigation on financial worry using the comprehensive score of financial toxicity (COST) measure (score range, 0-44; higher score = lower financial worry) and were used for meta-analysis. There was no significant change in the mean of pooled COST score between post- and pre-intervention (1.21; 95% confidence interval, -6.54 to 8.96; p = .65). Adjusting for pre-intervention COST, mean change of COST significantly decreased by 0.88 with every 1-unit increase in pre-intervention COST (p = .02). The intervention significantly changed COST score when pre-intervention COST was ≤14.5.

CONCLUSION

A variety of interventions have been tested to mitigate financial hardship. Financial navigation can mitigate financial worry among high-risk patients.

ESMO expert consensus statements on the screening and management of financial toxicity in patients with cancer

BACKGROUND

Financial toxicity, defined as both the objective financial burden and subjective financial distress from a cancer diagnosis and its treatment, is a topic of interest in the assessment of the quality of life of patients with cancer and their families. Current evidence implicates financial toxicity in psychosocial, economic and other harms, leading to suboptimal cancer outcomes along the entire trajectory of diagnosis, treatment, supportive care, survivorship and palliation. This paper presents the results of a virtual consensus, based on the evidence base to date, on the screening and management of financial toxicity in patients with and beyond cancer organized by the European Society for Medical Oncology (ESMO) in 2022.

METHODS

A Delphi panel of 19 experts from 11 countries was convened taking into account multidisciplinarity, diversity in health system contexts and research relevance. The international panel of experts was divided into four working groups (WGs) to address questions relating to distinct thematic areas: patients with cancer at risk of financial toxicity; management of financial toxicity during the initial phase of treatment at the hospital/ambulatory settings; financial toxicity during the continuing phase and at end of life; and financial risk protection for survivors of cancer, and in cancer recurrence. After comprehensively reviewing the literature, statements were developed by the WGs and then presented to the entire panel for further discussion and amendment, and voting.

RESULTS AND DISCUSSION

A total of 25 evidence-informed consensus statements were developed, which answer 13 questions on financial toxicity. They cover evidence summaries, practice recommendations/guiding statements and policy recommendations relevant across health systems. These consensus statements aim to provide a more comprehensive understanding of financial toxicity and guide clinicians globally in mitigating its impact, emphasizing the importance of further research, best practices and guidelines.

Cancer diagnosis and treatment in working-age adults: Implications for employment, health insurance coverage, and financial hardship in the United States

The rising costs of cancer care and subsequent medical financial hardship for cancer survivors and families are well documented in the United States. Less attention has been paid to employment disruptions and loss of household income after a cancer diagnosis and during treatment, potentially resulting in lasting financial hardship, particularly for working-age adults not yet age-eligible for Medicare coverage and their families. In this article, the authors use a composite patient case to illustrate the adverse consequences of cancer diagnosis and treatment for employment, health insurance coverage, household income, and other aspects of financial hardship. They summarize existing research and provide nationally representative estimates of multiple aspects of financial hardship and health insurance coverage, benefit design, and employee benefits, such as paid sick leave, among working-age adults with a history of cancer and compare them with estimates among working-age adults without a history of cancer from the most recently available years of the National Health Interview Survey (2019-2021). Then, the authors identify opportunities for addressing employment and health insurance coverage challenges at multiple levels, including federal, state, and local policies; employers; cancer care delivery organizations; and nonprofit organizations. These efforts, when informed by research to identify best practices, can potentially help mitigate the financial hardship associated with cancer.

Bridging biological samples to functional nucleic acid biosensor applications: current enzymatic-based strategies for single-stranded DNA generation

The escalating threat of emerging diseases, often stemming from contaminants and lethal pathogens, has precipitated a heightened demand for sophisticated diagnostic tools. Within this landscape, the functional nucleic acid (FNA) biosensor, harnessing the power of single-stranded DNA (ssDNA), has emerged as a preeminent choice for target analyte detection. However, the dependence on ssDNA has raised difficulties in realizing it in biological samples. Therefore, the production of high-quality ssDNA from biological samples is critical. This review aims to discuss strategies for generating ssDNA from biological samples for integration into biosensors. Several innovative strategies for ssDNA generation have been deployed, encompassing techniques, such as asymmetric PCR, Exonuclease-PCR, isothermal amplification, biotin-streptavidin PCR, transcription-reverse transcription, ssDNA overhang generation, and urea denaturation PAGE. These approaches have been seamlessly integrated with biosensors for biological sample analysis, ushering in a new era of disease detection and monitoring. This amalgamation of ssDNA generation techniques with biosensing applications holds significant promise, not only in improving the speed and accuracy of diagnostic processes but also in fortifying the global response to deadly diseases, thereby underlining the pivotal role of cutting-edge biotechnology in public health and disease prevention.

Cost-effectiveness of pembrolizumab plus chemotherapy for advanced endometrial cancer

OBJECTIVE

To assess the cost-effectiveness of pembrolizumab in combination with chemotherapy compared to chemotherapy alone, based on the results of the NRG-GY018 trial, in patients with advanced or recurrent endometrial cancer (EC), stratified by mismatch repair-deficient (dMMR) and mismatch repair-proficient (pMMR) subgroups.

METHODS

A Markov model was used to simulate patients receiving either pembrolizumab plus chemotherapy or chemotherapy alone. Lifetime costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER) were calculated using a willingness-to-pay (WTP) threshold of $150,000/QALY. Univariate and probabilistic sensitivity analyses were conducted to assess the robustness of our findings.

RESULTS

The addition of pembrolizumab to chemotherapy led to an incremental gain of 4.05 QALYs at an additional cost of $167,224, resulting in an ICER of $41,305.09/QALY compared to chemotherapy alone in dMMR EC. Additionally, there were 0.93 additional QALYs at an additional cost of $83,661, which resulted in an ICER of $90,284.80/QALY in pMMR EC. Sensitivity analyses indicated that the cost of pembrolizumab, utility of progressed disease, and utility of progression-free survival had the greatest impact on the results. Probabilistic sensitivity analysis showed that pembrolizumab was considered cost-effective at a 100% probability at a WTP threshold of $150,000 per QALY.

CONCLUSION

Pembrolizumab, when combined with chemotherapy, was found to be cost-effective compared to chemotherapy alone both for patients with advanced or recurrent dMMR and pMMR EC from the perspective of a payer in the United States.

Dedicated financial hardship screening adds value to routine distress screening among gynecologic cancer patients

OBJECTIVES

To evaluate existing distress screening to identify patients with financial hardship (FH) compared to dedicated FH screening and assess patient attitudes toward FH screening.

METHODS

We screened gynecologic cancer patients starting a new line of therapy. Existing screening included: (1) Moderate/severe distress defined as Distress Thermometer score ≥ 4, (2) practical concerns identified from Problem Checklist, and (3) a single question assessing trouble paying for medications. FH screening included: (1) Comprehensive Score for Financial Toxicity (COST) tool and (2) 10-item Financial Needs Checklist to guide referrals. FH was defined as COST score < 26. We calculated sensitivity (patients with moderate/severe distress + FH over total patients with FH) and specificity (patients with no/mild distress + no FH over total patients with no FH) to assess the extent distress screening could capture FH. Surveys and exit interviews assessed patient perspectives toward screening.

RESULTS

Of 364 patients screened for distress, average age was 62 years, 25% were Black, 45% were Medicare beneficiaries, 32% had moderate/severe distress, 15% reported ≥1 practical concern, and 0 reported trouble paying for medications. Most (n = 357, 98%) patients also completed FH screening: of them, 24% screened positive for FH, 32% reported ≥1 financial need. Distress screening had 57% sensitivity and 77% specificity for FH. Based on 79 surveys and 43 exit interviews, FH screening was acceptable with feedback to improve the timing and setting of screening.

CONCLUSIONS

Dedicated FH screening was feasible and acceptable, but sensitivity was low. Importantly, 40% of women with FH would not have been identified with distress screening alone.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

IMPLICATIONS FOR CANCER SURVIVORS

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

A radiogenomic multimodal and whole-transcriptome sequencing for preoperative prediction of axillary lymph node metastasis and drug therapeutic response in breast cancer: a retrospective, machine learning and international multicohort study

BACKGROUND

Axillary lymph nodes (ALN) status serves as a crucial prognostic indicator in breast cancer (BC). The aim of this study was to construct a radiogenomic multimodal model, based on machine learning and whole-transcriptome sequencing (WTS), to accurately evaluate the risk of ALN metastasis (ALNM), drug therapeutic response and avoid unnecessary axillary surgery in BC patients.

METHODS

In this study, conducted a retrospective analysis of 1078 BC patients from The Cancer Genome Atlas (TCGA), The Cancer Imaging Archive (TCIA), and Foshan cohort. These patients were divided into the TCIA cohort ( N =103), TCIA validation cohort ( N =51), Duke cohort ( N =138), Foshan cohort ( N =106), and TCGA cohort ( N =680). Radiological features were extracted from BC radiological images and differentially expressed gene expression was calibrated using technology. A support vector machine model was employed to screen radiological and genetic features, and a multimodal model was established based on radiogenomic and clinical pathological features to predict ALNM. The accuracy of the model predictions was assessed using the area under the curve (AUC) and the clinical benefit was measured using decision curve analysis. Risk stratification analysis of BC patients was performed by gene set enrichment analysis, differential comparison of immune checkpoint gene expression, and drug sensitivity testing.

RESULTS

For the prediction of ALNM, rad-score was able to significantly differentiate between ALN- and ALN+ patients in both the Duke and Foshan cohorts ( P <0.05). Similarly, the gene-score was able to significantly differentiate between ALN- and ALN+ patients in the TCGA cohort ( P <0.05). The radiogenomic multimodal nomogram demonstrated satisfactory performance in the TCIA cohort (AUC 0.82, 95% CI: 0.74-0.91) and the TCIA validation cohort (AUC 0.77, 95% CI: 0.63-0.91). In the risk sub-stratification analysis, there were significant differences in gene pathway enrichment between high and low-risk groups ( P <0.05). Additionally, different risk groups may exhibit varying treatment responses ( P <0.05).

CONCLUSION

Overall, the radiogenomic multimodal model employs multimodal data, including radiological images, genetic, and clinicopathological typing. The radiogenomic multimodal nomogram can precisely predict ALNM and drug therapeutic response in BC patients.

Financial Toxicity in Radiation Oncology

Financial toxicity details the financial burden patients face due to a variety of medical costs. Cancer patients, especially those receiving radiation therapy, are at a much higher risk of experiencing economic hardships than healthy people or people with other conditions. There are a variety of risk factors associated with financial toxicity as well as numerous tools to assess the toxicity experienced by patients. In this review article, we present a concise overview of contributors, risk factors, case studies, tools, impacts, and potential interventions of financial toxicity.

High Financial Hardship among Patients with Advanced Ovarian Cancer

Ovarian cancer is considered the most fatal and costly gynecologic cancer. Although personalized therapies have improved ovarian cancer prognosis, they have resulted in increased financial toxicity concerns among this population. This study evaluated financial toxicity in patients with advanced ovarian cancer. Using secondary data from a study of barriers to palliative care, financial toxicity (FT) was measured through the Comprehensive Score for Financial Toxicity scale. Univariate and bivariate analyses were used to assess the relationship between selected demographic (i.e., age, race, ethnicity, education, place of birth, insurance type, yearly household income, employment status) and treatment-specific variables (i.e., years since diagnosis, surgery, chemotherapy, radiation, hormonal and targeted therapy) with clinically relevant financial toxicity. Characteristics were compared using Fisher's exact or chi squared tests. A total of 38 participants with advanced ovarian cancer were included in this study; 24% (n = 9) reported clinically significant FT. Income (p = .001), place of birth (p = .048) and employment status (p = .001) were related to FT. Study findings highlight that advanced ovarian cancer patients experience high FT, particularly those with low income, who are not able to work and were born outside the US. Further research using larger datasets and more representative samples is needed to inform intervention development and implementation.

The impact of caregiver burden on quality of life in family caregivers of patients with advanced cancer: a moderated mediation analysis of the role of psychological distress and family resilience

BACKGROUND

The caregiver burden frequently experienced by family members tending to advanced cancer patients significantly impacts their psychological well-being and quality of life (QoL). Although family resilience might function as a mitigating factor in this relationship, its specific role remains to be elucidated. This study aims to probe the mediating effect of psychological distress on the relationship between caregiver burden and QoL, as well as the moderating effect of family resilience.

METHODS

A cross-sectional study was conducted between June 2020 and March 2021 in five tertiary hospitals in China. Data were collected on caregiver burden, family resilience, psychological distress (including anxiety and depression), and QoL. Moderated mediation analysis was performed.

RESULTS

Data analysis included 290 caregivers. It confirmed the mediating role of psychological distress in the caregiver burden-QoL relationship (P < 0.001). Both overall family resilience and the specific dimension of family communication and problem-solving (FCPS) demonstrated significant moderating effects on the "psychological distress/anxiety-QoL" paths (P < 0.05). The utilization of social and economic resources (USER) significantly moderated the association between depression and QoL (P < 0.05).

CONCLUSIONS

The study corroborates psychological distress's mediation between caregiver burden and QoL and family resilience's moderation between psychological distress and QoL. It underscores the need for minimizing psychological distress and bolstering family resilience among caregivers of advanced cancer patients. Accordingly, interventions should be tailored, inclusive of psychological assistance and promotion of family resilience, particularly focusing on FCPS and USER, to augment the caregivers' well-being and QoL.

Health Insurance Navigation Tools Intervention: A Pilot Trial Within the Childhood Cancer Survivor Study

PURPOSE

Childhood cancer survivors are at increased risk for underinsurance and health insurance-related financial burden. Interventions targeting health insurance literacy (HIL) to improve the ability to understand and use health insurance are needed.

METHODS

We codeveloped a four-session health insurance navigation tools (HINT) intervention, delivered synchronously by a patient navigator, and a corresponding booklet. We conducted a randomized pilot trial with survivors from the Childhood Cancer Survivor Study comparing HINT with enhanced usual care (EUC; booklet). We assessed feasibility, acceptability, and preliminary efficacy (HIL, primary outcome; knowledge and confidence with health insurance terms and activity) on a 5-month survey and exit interviews.

RESULTS

Among 231 invited, 82 (32.5%) survivors enrolled (53.7% female; median age 39 years, 75.6% had employer-sponsored insurance). Baseline HIL scores were low (mean = 28.5; 16-64; lower scores better); many lacked knowledge of Affordable Care Act (ACA) provisions. 80.5% completed four HINT sessions, and 93.9% completed the follow-up survey. Participants rated HINT's helpfulness a mean of 8.9 (0-10). Exit interviews confirmed HINT's acceptability, specifically its virtual and personalized delivery and helpfulness in building confidence in understanding one's coverage. Compared with EUC, HINT significantly improved HIL (effect size = 0.94. P < .001), ACA provisions knowledge (effect size = 0.73, P = .003), psychological financial hardship (effect size = 0.64, P < .006), and health insurance satisfaction (effect size = 0.55, P = .03).

CONCLUSION

Results support the feasibility and acceptability of a virtual health insurance navigation program targeted for childhood survivors to improve HIL. Randomized trials to assess the efficacy and sustainability of health insurance navigation on HIL and financial burden are needed.

Financial Toxicity and Health-Related Quality of Life Profile of Patients With Hematologic Malignancies Treated in a Universal Health Care System

PURPOSE

We investigated the association of financial toxicity (FT) with the health-related quality of life (HRQoL) profile of patients with hematologic malignancies treated in a universal health care system.

METHODS

We did a secondary analysis of six multicenter studies enrolling patients with hematologic malignancies. FT was evaluated using the financial difficulties item of the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30). Multivariable linear regression models were used to assess the mean differences in HRQoL scores between patients with or without FT, while adjusting for key potential confounding factors. We also examined the prevalence of clinically important problems and symptoms by the experience of FT, using established thresholds for the EORTC QLQ-C30. Multivariable binary logistic regression analysis was performed to explore the risk factors associated with FT.

RESULTS

Overall, 1,847 patients were analyzed, of whom 441 (23.9%) reported FT. We observed statistically and clinically relevant worse scores for patients with FT compared with those without FT for all the EORTC QLQ-C30 scales. The three largest clinically relevant mean differences between patients with and without FT were observed in pain (∆ = 19.6 [95% CI, 15.7 to 23.5]; P < .001), social functioning (∆ = -18.9 [95% CI, -22.5 to -15.2]; P < .001), and role functioning (Δ = -17.7 [95% CI, -22.1 to -13.3]; P < .001). Patients with FT tended to report a higher prevalence of clinically important problems and symptoms across all EORTC QLQ-C30 scales. In the univariable and multivariable analyses, the presence of FT was associated with the presence of comorbidities, an Eastern Cooperative Oncology Group performance status ≥1, and not receiving a salary.

CONCLUSION

Patients with hematologic malignancies treated in the setting of a universal health care system who experience FT have a worse HRQoL profile compared with those without FT.

Global prevalence of poor sleep quality in cancer patients: A systematic review and meta-analysis

OBJECTIVE

Poor sleep quality is common in patients with cancer, but the prevalence rates varied widely across studies. This systematic review and meta-analysis examined the pooled prevalence of poor sleep quality among patients with cancer.

METHODS

Systematic literature searches were independently conducted in the major databases (Web of Science, PubMed, EMBASE and PsycINFO). Studies that reported the prevalence of poor sleep quality in patients with cancer were analyzed using a random effects model. Funnel plots and Egger's tests were used to assess publication bias. Statistical analyses were performed using R software.

RESULTS

A total of 59 epidemiological studies involving 16,223 patients were included. The pooled prevalence of poor sleep quality in patients with cancer was 57.4% [95% confidence interval (CI): 53.3% - 61.6%]. Additionally, three comparative studies with 372 patients and 412 healthy controls were included. Compared to healthy controls, patients with cancer had a significantly higher risk for poor sleep quality [odd ratio (OR) = 3.0; 95%CI: 1.2-7.2; P < 0.05]. Subgroup analyses of the studies revealed that studies from Middle East & North Africa region and low income countries, and on gynecological cancer as well as those with a lower cut-off value of sleep quality (all P < 0.01) reported a higher prevalence of poor sleep quality. Meta-regression analyses showed that higher prevalence of poor sleep quality was associated with higher prevalence of comorbid depression (P < 0.05) and anxiety (P < 0.01), but was associated with a lower education level (P < 0.05) and alcohol use ratio (P < 0.05).

CONCLUSION

Poor sleep quality is common among patients with cancer. Considering the overall high prevalence rate and negative impact of poor sleep quality, appropriate measures to identify and improve poor sleep quality are needed to enhance the clinical outcomes in this group.

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

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

Predictors of Financial Toxicity Risk Among Patients Undergoing Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy (CRS-HIPEC)

BACKGROUND

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is the preferred treatment for select patients with peritoneal malignancies. However, the procedure is resource intensive and costly. This study aimed to determine the risk of financial toxicity for patients undergoing CRS-HIPEC.

PATIENTS AND METHODS

We performed a retrospective cohort study of patients undergoing CRS-HIPEC at a single institution from 2016 to 2022. We utilized insurance status, out-of-pocket expenditures, and estimated post-subsistence income to determine risk of financial toxicity. A multivariable logistic regression was used to determine risk factors for financial toxicity.

RESULTS

Our final study cohort consisted of 163 patients. Average age was 58 [standard deviation 10] years, and 52.8% (n = 86) were male. A total of 52 patients (31.9%) were at risk of financial toxicity. A total of 36 patients (22.1%) were from the lower income quartiles (first or second) and 127 patients (77.9%) were from the higher income quartiles (third or fourth). A total of 47 patients (29%) were insured by Medicare, and 116 patients (71%) had private insurance. The median out-of-pocket expenditure across the study cohort was $3500, with a median of $5000 ($3341-$7350) for the at-risk group and $3341 ($2500-$4022) for the not at-risk group (p < 0.001). Risk factors for financial toxicity included high out-of-pocket expenditures and a lower income quartile.

CONCLUSIONS

An estimated one-third of patients undergoing CRS-HIPEC at our institution were at risk for financial toxicity. Several preoperative factors were associated with an increased risk and could be utilized to identify patients who might benefit from interventions.

Effects of Wildfire Events on California Radiation Oncology Clinics and Patients

Purpose

The effect of climate-driven events, such as wildfires, on health care delivery and cancer care is a growing concern. Patients with cancer undergoing radiation therapy are particularly vulnerable to treatment interruptions, which have a direct effect on survival. We report the results of a study characterizing the effect of wildfires on radiation oncology clinics and their patients.

Methods and Materials

A survey of California radiation oncologists was used to evaluate emergency preparedness and the effect of wildfires on the delivery of radiation therapy services between 2017 and 2022. Descriptive statistics and Pearson's χ2 tests were performed to investigate potential relationships between provider characteristics, practice settings, and perceptions of the effect of wildfire events. California Department of Forestry and Fire Protection data were employed to map the geographic distribution of wildfires to clinic locations.

Results

Response rate was 12.3% (51/415 radiation oncologists), representing 25% of clinics (43/176) in 41% (24/58) of California counties. Sixty-one percent (31/51) of respondents reported being affected by a wildfire, 2 of which are rural clinics (100%, 2/2) and 29 are (59%, 29/49) metropolitan practices. Of these, 18% (9/51) reported a clinic closure, and 29% (15/51) reported staffing shortages. Respondents reported effects on patients, including having to evacuate (55%, 28/51), cancel/reschedule treatments (53%, 27/51), and experiencing physical, mental, or financial hardship due to wildfires (45%, 23/51). Respondents described effects on clinical operations, including being forced to transfer patients (24%, 12/51), transportation interruptions (37%, 19/51), regional/community evacuations (35%, 18/51), and physical/mental health effects (27%, 14/51) on clinic personnel. Less than half of the respondents (47%, 24/51) reported their workplace had a wildfire emergency preparedness plan. Additionally, geographic analysis revealed that 100% (176/176) of clinics were located within 25 miles of a wildfire.

Conclusions

This study highlights the effects of wildfires on radiation oncology clinics and patients and underscores the need for emergency preparedness planning to minimize the consequences of such disasters.

Medical financial hardship between young adult cancer survivors and matched individuals without cancer in the United States

BACKGROUND

Young adult cancer survivors face medical financial hardships that may lead to delaying or forgoing medical care. This study describes the medical financial difficulties young adult cancer survivors in the United States experience in the post-Patient Protection and Affordable Care Act period.

METHOD

We identified 1009 cancer survivors aged 18 to 39 years from the National Health Interview Survey (2015-2022) and matched 963 (95%) cancer survivors to 2733 control individuals using nearest-neighbor matching. We used conditional logistic regression to examine the association between cancer history and medical financial hardship and to assess whether this association varied by age, sex, race and ethnicity, and region of residence.

RESULTS

Compared with those who did not have a history of cancer, young adult cancer survivors were more likely to report material financial hardship (22.8% vs 15.2%; odds ratio = 1.65, 95% confidence interval = 1.50 to 1.81) and behavior-related financial hardship (34.3% vs 24.4%; odds ratio = 1.62, 95% confidence interval = 1.49 to 1.76) but not psychological financial hardship (52.6% vs 50.9%; odds ratio = 1.07, 95% confidence interval = 0.99 to 1.16). Young adult cancer survivors who were Hispanic or lived in the Midwest and South were more likely to report psychological financial hardship than their counterparts.

CONCLUSIONS

We found that young adult cancer survivors were more likely to experience material and behavior-related financial hardship than young adults without a history of cancer. We also identified specific subgroups of young adult cancer survivors that may benefit from targeted policies and interventions to alleviate medical financial hardship.

Financial Toxicity, Time Toxicity, and Quality of Life in Multiple Myeloma

BACKGROUND

Patients with multiple myeloma (MM) may be on therapy for years, which can lead to financial toxicity (FinTox) or time toxicity (TimeTox). The prevalence, predictors, and quality of life (QOL) impacts of FinTox and TimeTox during different phases of MM treatment have not been characterized.

PATIENTS AND METHODS

We conducted a single-center cross-sectional survey of patients with MM who had undergone transplantation. FinTox+ was defined as a COST-FACIT score <23, TimeTox+ as MM-related interactions (including phone calls) ≥1x weekly or ≥1x monthly in-person among far-residing patients, QOL using PROMIS Global Health, and functional status using patient-reported Karnofsky performance status (KPS).

RESULTS

Of 252 patients, 22% and 40% met FinTox+ and TimeTox+ criteria respectively. Respective FinTox+ and TimeTox+ proportions were 22%/37% for patients on maintenance, 22%/82% with active therapy, and 20%/14% with observation. FinTox+ predictors included annual income (P < .01) and out-of-pocket costs (P < .01). TimeTox+ predictors included disease status (P < .001), caregiver status (P = .01), far-residing status (P < .001), and out-of-pocket costs (P = .03). FinTox+ was associated with a clinically meaningful decrease in mental QOL, while TimeTox+ patients were more likely to have KPS ≤ 80.

CONCLUSIONS

In our large study, monetary status but not disease status predicted FinTox. Over a third of patients on maintenance reported TimeTox. FinTox+ was associated with decreased mental health, while TimeTox+ was associated with worse performance status. These two toxicities may negatively impact patient wellbeing, and studies of strategies to mitigate their impact are in development.

Lay healthcare worker financial toxicity intervention: a pilot financial toxicity screening and referral program

PURPOSE

Financial toxicity is a source of significant distress for patients with urologic cancers, yet few studies have addressed financial burden in this patient population.

METHODS

We developed a financial toxicity screening program using a lay health worker (LHW) and social worker (SW) to assess and mitigate financial toxicity in a single academic medical clinic. As part of a quality improvement project, the LHW screened all newly diagnosed patients with advanced stages of prostate, kidney, or urothelial cancer for financial burden using three COST tool questions and referred patients who had significant financial burden to an SW who provided personalized recommendations. The primary outcome was feasibility defined as 80% of patients with financial burden completing the SW consult. Secondary outcomes were patient satisfaction, change in COST Tool responses, and qualitative assessment of financial resources utilized.

RESULTS

The LHW screened a total of 185 patients for financial toxicity; 82% (n = 152) were male, 65% (n = 120) White, and 75% (n = 139) reported annual household income >$100,000 US Dollars; 60% (n = 114) had prostate cancer. A total of 18 (9.7%) participants screened positive for significant financial burden and were referred to the SW for consultation. All participants (100%) completed and reported satisfaction with the SW consultation and had 0.83 mean lower scores on the COST Tool post-intervention assessment compared to pre-intervention (95% confidence interval [0.26, 1.41]).

CONCLUSION

This multidisciplinary financial toxicity intervention using an LHW and SW was feasible, acceptable, and associated with reduced financial burden among patients with advanced stages of urologic cancers. Future work should evaluate the effect of this intervention among cancer patients in diverse settings.

Access to Financial Assistance Programs and Their Impact on Overall Spending on Oral Anticancer Medications at an Integrated Specialty Pharmacy

PURPOSE

Financial assistance (FA) programs are increasingly used to help patients afford oral anticancer medications (OAMs), but access to such programs and their impact on out-of-pocket (OOP) spending has not been well explored. This study aimed to (1) characterize the impact of receipt of FA on both OOP spending and likelihood of catastrophic spending on OAMs and (2) evaluate racial/ethnic disparities in access to FA programs.

METHODS

Patients with a cancer diagnosis prescribed an OAM anytime between January 1, 2021, and December 31, 2021 were included in this retrospective, single-center study at an integrated specialty pharmacy affiliated with a tertiary academic cancer center. Fixed-effect regression models were used to characterize the impact of receipt of FA on overall spending and likelihood of catastrophic spending on OAMs, as well as explore the association of race/ethnicity with receipt of FA.

RESULTS

Across 1,186 patients prescribed an OAM, 37% received FA. Receipt of FA was associated with lower annual spending on OAMs (β = -$1,236 US dollars [USD; 95% CI, -$1,841 to -$658], P < .001) but not reduced risk of catastrophic spending (odds ratio [OR], 0.442 [95% CI, 0.755 to 3.199], P = .23). Non-White patients (OR, 0.60 [95% CI, 0.43 to 0.85], P = .004) and patients who spoke English as a second language (OR, 0.46 [95% CI, 0.23 to 0.90], P = .02) were less likely to receive FA compared with White and English-speaking patients, respectively.

CONCLUSION

FA programs can mitigate high OOP spending but not for patients who spend at catastrophic levels. There are racial/ethnic and language disparities in access to such programs. Future studies should evaluate access to FA programs across diverse delivery settings.

Enhancing Symptom Screening and Patient Education Among Patients with Metastatic Lung Cancer: a Qualitative Analysis

We explored perspectives of patients with metastatic non-small cell lung cancer (mNSCLC) on symptom screening and population-level patient-reported outcome (PRO) data regarding common symptom trajectories in the year after diagnosis. A qualitative study of patients with mNSCLC was conducted at a Canadian tertiary cancer centre. English-speaking patients diagnosed ≥ 6 months prior to study invitation were recruited, and semi-structured one-on-one interviews were conducted. Patient and treatment characteristics were obtained via chart review. Anonymized interview transcripts underwent deductive-inductive coding and thematic content analysis. Among ten participants (5 (50%) females; median (range) age, 68 (56-77) years; median (range) time since diagnosis, 28.5 (6-72) months; 6 (60%) with smoking histories), six themes were identified in total. Two themes were identified regarding symptom screening: (1) screening is useful for symptom self-monitoring and disclosure to the healthcare team, (2) screening of additional quality-of-life (QOL) domains (smoking-related stigma, sexual dysfunction, and financial toxicity) is desired. Four themes were identified regarding population-level symptom trajectory PRO data: (1) data provide reassurance and motivation to engage in symptom self-management, (2) data should be disclosed after an oncologic treatment plan is developed, (3) data should be communicated via in-person discussion with accompanying patient-education resources, and (4) communication of data should include reassurance about symptom stabilization, acknowledgement of variability in patient experience, and strategies for symptom self-management. The themes and recommendations derived from the patient experience with mNSCLC provide guidance for enhanced symptom screening and utilization of population-level symptom trajectory data for patient education.

Health Care Access Barriers and Self-Reported Health Among Adolescent and Young Adult Cancer Survivors

Purpose: Adolescents and young adult (AYA) cancer survivors (15-39 years at diagnosis) are at risk for treatment-related late effects but face barriers in accessing survivorship care. We examined the prevalence of five health care access (HCA) barriers: affordability, accessibility, availability, accommodation, and acceptability. Methods: We identified AYA survivors from the University of North Carolina (UNC) Cancer Survivorship Cohort who completed a baseline questionnaire in 2010-2016. Participants had a history of cancer, were ≥18 years of age, and receiving care at a UNC oncology clinic. The sample was restricted to AYA survivors who were interviewed ≥1 year postdiagnosis. We used modified Poisson regression to estimate prevalence ratios (PRs) for the association between HCA barriers and self-reported fair or poor health, adjusted for sociodemographic and cancer characteristics. Results: The sample included 146 AYA survivors who were a median age of 39 at the time of the survey. The majority (71%)-and 92% of non-Hispanic Black survivors-reported at least one HCA barrier, including acceptability (40%), accommodation (38%), or affordability (31%). More than one-quarter of survivors (28%) reported fair or poor health. Affordability barriers (PR: 1.89, 95% confidence interval [CI]: 1.13-3.18) and acceptability barriers (PR: 1.60, 95% CI: 0.96-2.66) were associated with a higher prevalence of fair/poor health, as were the cumulative effects of multiple HCA dimensions reported as barriers. Conclusions: Barriers across multiple HCA dimensions were prevalent and associated with worse health in AYA survivors. Findings highlight the need to better understand and target specific barriers to care for diverse AYA survivors to improve their long-term health.

Fear of progression, loneliness, and hope in patients with gastrointestinal cancer: a cross-sectional relational study

Introduction

In recent years, fear of disease progression (FoP) has become one of the most common psychological problems in cancer patients. However, there are fewer studies on the FoP in patients with gastrointestinal tumors. We aimed to assess the level of FoP in patients with gastrointestinal tumors and analyze the factors related to FoP. We also aimed to examine the relationship among loneliness, hope and FoP in patients with gastrointestinal cancer.

Methods

A cross-sectional survey was conducted on three Grade A hospitals in southwestern China from November 2021 to July 2022. The demographic and clinical characteristics questionnaire, Fear of Disease Progression Scale (FoP-Q-SF), Cancer Loneliness Scale (CLS), and Herth Hope Index (HHI) were included in this study. Data analysis included descriptive statistics, independent samples t-tests, one-way analysis of variance, and multiple linear regression analysis.

Results

In total, 245 gastrointestinal cancer patients participated in this study. The average (standard deviation) FoP score in patients was 32.94 ± 10.64. In total, 245 gastrointestinal cancer patients participated in this study. The average (standard deviation) FoP score in patients was 32.94  ±  10.64. The average score of CLS was 17.65  ±  6.71, and that for the HHI was 31.27  ±  7.73. Pearson correlation analysis showed that FoP was negatively significant correlated with hope level (r = -0.522) and FoP was positively significant correlated with loneliness (r = 0.545). Linear regression analysis showed that educational level, age, living condition, hope, and loneliness were the significant predictors of FoP and explained 53.10% of the variability in FoP (F = 16.372).

Conclusion

Findings highlight the need to strengthen attention to FoP in gastrointestinal cancer patients. Our study showed that gastrointestinal cancer patients who have a high school education, are age 45 to 59, live alone, high level of loneliness, and low level of hope have higher FoP. Medical staff should enhance clinical screening of FoP and consider the formulation of relevant interventions for high-risk groups to reduce loneliness among patients, raise their hope level, and reduce their FoP.

Health Insurance Literacy Improvements Among Recently Diagnosed Adolescents and Young Adults With Cancer: Results From a Pilot Randomized Controlled Trial

PURPOSE

Adolescents and young adults (AYAs; age 18-39 years) with cancer report needing support with health insurance. We conducted a pilot randomized controlled trial to assess the feasibility and acceptability of a virtual health insurance navigation intervention (HIAYA CHAT) to improve health insurance literacy (HIL), awareness of Affordable Care Act (ACA) protections, financial toxicity, and stress.

MATERIALS AND METHODS

HIAYA CHAT is a four-session navigator delivered program; it includes psychoeducation on insurance, navigating one's plan, insurance-related laws, and managing costs. Participants were eligible if they could access an internet-capable device, were <1 year from diagnosis, and received treatment from University of Utah Healthcare or Intermountain Health systems. We assessed the feasibility, acceptability, and preliminary efficacy of HIAYA CHAT compared with usual navigation care, including HIL (nine items), insurance knowledge (13 items), ACA protections (eight items), COmprehensive Score for financial Toxicity (COST; 11 items), and Perceived Stress Scale (PSS; four items), using t tests and Cohen's d.

RESULTS

From November 2020 to December 2021, N = 86 AYAs enrolled (44.6% participation) and 89.3% completed the 5-month follow-up survey; 68.6% were female, 72.1% were White, 23.3% were Hispanic, 65.1% were age 26-39 years, and 87.2% were privately insured. Of intervention participants (n = 45), 67.4% completed all four sessions; among an exit interview subset (n = 10), all endorsed the program (100%). At follow-up, compared with usual navigation care, intervention participants had greater improvements in HIL, insurance and ACA protections knowledge, and PSS; effect sizes ranged from moderate to large (0.42-0.77). COST did not differ.

CONCLUSION

The results support the feasibility and acceptability of HIAYA CHAT with related improvements in HIL.

The unmet rehabilitation needs of colorectal cancer survivors after surgery: A qualitative meta-synthesis

AIM

To systematically review and synthesize the findings of qualitative research on the unmet rehabilitation needs of colorectal cancer survivors (CRC) after surgery.

DESIGN

A qualitative meta-synthesis registered with PROSPERO (CRD42022368837).

METHODS

CNKI, Wanfang Data, PubMed, Scopus, Embase, Cochrane, Medline, PsychINFO and CINAHL were systematically searched for qualitative studies on the rehabilitation needs of CRC survivors after surgery from the inception of each database to September 2022.

RESULTS

A total of 917 relevant reports were initially collected and 14 studies were finally included. A total of 49 needs were extracted and divided into 15 categories in 6 integrated findings: (1) the need to adopt healthy eating habits; (2) the need for exercise motivation and exercise guidance; (3) the conflicting needs to return to work; (4) unaddressed physiological needs; (5) spiritual needs; (6) the need for multi-dimensional social support.

PATIENT OR PUBLIC CONTRIBUTION

Not applicable.

Exploring the dynamics of perioperative symptom networks in colorectal cancer patients: a cross-lagged panel network analysis

BACKGROUND

Colorectal cancer incidence is on the rise, necessitating precise symptom management. However, causal relationships among symptoms have been challenging to establish due to reliance on cross-sectional data. Cross-lagged panel network (CLPN) analysis offers a solution, leveraging longitudinal data for insight.

OBJECTIVE

We employed CLPN analysis to construct symptom networks in colorectal cancer patients at three perioperative time points, aiming to identify predictive relationships and intervention opportunities.

METHODS

We evaluated the prevalence and severity of symptoms throughout the perioperative period, encompassing T1 the first day of admission, T2 2-3 days postoperatively, and T3 discharge, utilizing the M. D. Anderson Symptom Inventory Gastrointestinal Cancer Module (MDASI-GI). To identify crucial nodes in the network and explore predictive and interactive effects among symptoms, CLPNs were constructed from longitudinal data in R.

RESULTS

The analysis revealed a stable network, with disturbed sleep exhibiting the highest out-EI (outgoing expected influence) during T1. Distress had a sustained impact throughout the perioperative. Disturbed sleep at T1 predicted T2 bloating, fatigue, distress, and pain. T1 distress predicted T2 sadness severity. T2 distress primarily predicted T3 fatigue, disturbed sleep, changes in taste, and bloating. T2 shortness of breath predicted T3 changes in taste and loss of appetite. Furthermore, biochemical markers like RBC and ALB had notable influence on symptom clusters during T1→T2 and T2→T3, respectively.

CONCLUSION

Prioritizing disturbed sleep during T1 and addressing distress throughout the perioperative phase is recommended. Effective symptom management not only breaks the chain of symptom progression, enhancing healthcare impact, but also eases patient symptom burdens.

Care Delivery Interventions for Individuals with Cancer: A Literature Review and Focus on Gastrointestinal Malignancies

BACKGROUND

Gastrointestinal malignancies represent a particularly challenging condition, often requiring a multidisciplinary approach to management in order to meet the unique needs of these individuals and their caregivers.

PURPOSE

In this literature review, we sought to describe care delivery interventions that strive to improve the quality of life and care for patients with a focus on gastrointestinal malignancies.

CONCLUSION

We highlight patient-centered care delivery interventions, including patient-reported outcomes, hospital-at-home interventions, and other models of care for individuals with cancer. By demonstrating the relevance and utility of these different care models for patients with gastrointestinal malignancies, we hope to highlight the importance of developing and testing new interventions to address the unique needs of this population.

Financial Toxicity among Patients with Breast Cancer during the COVID-19 Pandemic in the United States

This study reported the prevalence of financial distress (financial toxicity (FT)) and COVID-19-related economic stress in patients with breast cancer (BC). Patients with BC were recruited from the Ciitizen platform, Breastcancer.org, and patient advocacy groups between 30 March and 6 July 2021. FT was assessed with the COmprehensive Score for financial Toxicity (COST) instrument. COVID-19-related economic stress was assessed with the COVID-19 Stress Scale. Among the 669 patients, the mean age was 51.6 years; 9.4% reported a COVID-19 diagnosis. The prevalence rates of mild and moderate/severe FT were 36.8% and 22.4%, respectively. FT was more prevalent in patients with metastatic versus early BC (p < 0.001). The factors associated with FT included income ≤ USD 49,999 (adjusted odds ratio (adj OR) 6.271, p < 0.0001) and USD 50,000-USD 149,999 (adj OR 2.722, p < 0.0001); aged <50 years (adj OR 3.061, p = 0.0012) and 50-64 years (adj OR 3.444, p = 0.0002); living alone (adj OR 1.603, p = 0.0476); and greater depression severity (adj OR 1.155, p < 0.0001). Black patients (adj OR 2.165, p = 0.0133), patients with income ≤ USD 49,999 (adj OR 1.921, p = 0.0432), or greater depression severity (adj OR 1.090, p < 0.0001) were more likely to experience COVID-19-related economic stress. FT was common in patients with BC, particularly metastatic disease, during COVID-19. Multiple factors, especially lower income and greater depression severity were associated with financial difficulties during COVID-19.

The Risk of Catastrophic Healthcare Expenditures Among Prostate and Bladder Cancer Survivors in the United States

INTRODUCTION

Little is known about the rates of catastrophic health care expenditures among survivors of prostate and bladder cancer or the factors that place patients at highest risk for undue cost.

MATERIALS AND METHODS

The Medical Expenditure Panel Survey was utilized to identify prostate and bladder cancer survivors from 2011 to 2019. Rates of catastrophic health care expenditures (out-of-pocket health care spending >10% household income) were compared between cancer survivors and adults without cancer. A multivariable regression model was used to identify risk factors for catastrophic expenditures.

RESULTS

Among 2620 urologic cancer survivors, representative of 3,251,500 (95% CI 3,062,305-3,449,547) patients annually after application of survey weights, there were no significant differences in catastrophic expenditures among respondents with prostate cancer compared to adults without cancer. Respondents with bladder cancer had significantly greater rates of catastrophic expenditures (12.75%, 95% CI 9.36%-17.14% vs. 8.33%, 95% CI 7.66%-9.05%, P = .027). Significant predictors of catastrophic expenditures in bladder cancer survivors included older age, comorbidities, lower income, retirement, poor health status, and private insurance. Though White respondents with bladder cancer had no significantly increased risk of catastrophic expenditures, among Black respondents the risk of catastrophic expenditures increased from 5.14% (95% CI 3.95-6.33) without bladder cancer to 19.49% (95% CI 0.84-38.14) with bladder cancer (OR 6.41, 95% CI 1.28-32.01, P = .024).

CONCLUSIONS

Though limited by small sample size, these data suggest that bladder cancer survivorship is associated with catastrophic health care expenditures, particularly among Black cancer survivors. These findings should be taken as hypothesis-generating and warrant further investigation with larger sample sizes and, ideally, prospective investigation.

Cervical cancer treatment update: A Society of Gynecologic Oncology clinical practice statement

Cervical cancer is the most commonly diagnosed gynecologic cancer worldwide. Although the incidence has declined with increased screening and higher uptake of human papillomavirus (HPV) vaccination in high-income countries, this disease remains the second highest cause of cancer mortality among women in low- and middle-income countries. In this clinical practice statement, we describe therapies for cervical cancer by treatment setting, as well as quality of life, financial toxicity, and disparities associated with this disease. In addition to chemotherapy and radiation, therapeutic strategies for cervical cancer include immune checkpoint blockade, antiangiogenics, and antibody-drug conjugates. Optimal treatment for recurrent cervical cancer remains an area of unmet need, necessitating further exploration of rational and innovative treatment approaches, including cell and immune-based therapies. Importantly, development of effective therapies for cervical cancer must incorporate strategies to ensure universal equitable access to HPV vaccination, screening, and treatment. Important consequences of the disease and treatment that impact quality of life must also be addressed. Patients with cervical cancer are at increased risk for financial toxicity, which can lead to downstream detrimental effects on physical, financial, and career outcomes. Underrepresentation of racial and ethnic minorities in gynecologic oncology clinical trials highlights the urgent need for collaborative and focused initiatives to bridge the significant divide and alleviate inequalities in the prevention and treatment of cervical cancer.

Symptom clusters and characteristics of cervical cancer patients receiving concurrent chemoradiotherapy: A cross-sectional study

Background

Cervical cancer patients have a high symptom burden during concurrent chemoradiotherapy (CCRT) and urgently need precise symptom management strategies. Nonetheless, the symptom profile and influencing factors are unclear.

Methods

A total of 234 patients with cervical cancer who underwent CCRT in a tertiary care hospital clinical oncology center in Guangxi Zhuang Autonomous Region from March 2022 to March 2023 were included in the study. The general information questionnaire, M.D. Anderson symptom inventory, Fatigue Scale-14, Pittsburgh Sleep Quality Index, and grip strength test were used for the investigation. Symptom clusters were extracted by exploratory factor analysis, and latent profile analysis was performed using Mplus 8.0 software. Multinomial logistic regression was used to explore the factors influencing the potential categories of symptom clusters.

Results

Exploratory factor analysis extracted four symptom clusters: a fatigue-related symptom cluster, a gastrointestinal-related symptom cluster, a mood-related symptom cluster, and a physical-related symptom cluster, of which the fatigue-related symptom cluster was more severe and was divided into three potential categories: low fatigue-good muscle fitness type (25.63%), general fatigue-moderate muscle fitness type (68.37%) and high fatigue-low muscle fitness type (6%). Multinomial logistic regression analysis showed that hemoglobin levels, tumor stage, absence of complications, and unemployment were factors influencing the fatigue-related symptom cluster in patients undergoing CCRT for cervical cancer.

Conclusions

Cervical cancer patients experience multiple symptom clusters during CCRT. Different characteristics appeared in different clusters. Among them, fatigue-related symptom clusters were more severe and heterogeneous. In clinical practice, we should pay attention to and use high symptom feature predictors, focusing on the core symptoms that play a dominant role, achieving early identification and management, and reducing patients' symptom burden.

Interventions for financial toxicity among cancer survivors: A scoping review

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Ganciclovir as a potential treatment for glioma: a systematic review and meta-analysis

BACKGROUND

Glioma is a challenging malignant tumor with a low survival rate and no effective treatment. Recently, ganciclovir, an antiviral drug, combined with gene therapy and its own antiviral ability, has been proposed as a potential treatment for glioma. However, there are differences in the results of various clinical trials. In this study, we conducted a systematic review and meta-analysis to evaluate the efficacy of ganciclovir in treating glioma.

METHODS

We searched databases such as PubMed, EMBASE, and Cochrane Library before March 30, 2023. The search terms included glioma, ganciclovir, valganciclovir and treatment. Calculated 1, 2 and 4-year survival rate by risk difference (RD), and overall survival (OS) by odds ratio (OR).

RESULTS

Five randomized controlled trials (RCTs) with a total of 606 high-grade glioma patients were included. The results showed that ganciclovir can improve 2-yeaer (RD = 0.179, 95% CI 0.012-0.346, P = 0.036) and 4-year survival rate (RD = 0.185, 95% CI 0.069-0.3, P = 0.002) and OS (OR 2.393, 95% CI 1.212-4.728, P = 0.012) compared with the control group.

CONCLUSIONS

This meta-analysis showed that ganciclovir significantly improved the prognosis of glioma patients. Therefore, we suggest that more cases of ganciclovir as a glioma treatment can be conducted, or a large clinical trial can be designed.

An Overview of Cancer in Djibouti: Current Status, Therapeutic Approaches, and Promising Endeavors in Local Essential Oil Treatment

Djibouti, a developing economy, grapples with significant socioeconomic obstacles and the prevalence of infectious pathologies, including certain forms of neoplasms. These challenges are exacerbated by limited access to affordable medical technologies for diagnosis, coupled with a lack of preventive interventions, particularly in disadvantaged areas. The attention devoted to local phytotherapeutic treatments underscores the uniqueness of Djibouti's flora, resulting from its distinctive geographical position. International focus specifically centers on harnessing this potential as a valuable resource, emphasizing the phytoconstituents used to counter pathologies, notably carcinomas. This comprehensive overview covers a broad spectrum, commencing with an examination of the current state of knowledge, namely an in-depth investigation of oncological risk factors. Essential elements of control are subsequently studied, highlighting the fundamental prerequisites for effective management. The significance of dietary habits in cancer prevention and support is explored in depth, while traditional methods are examined, highlighting the cultural significance of indigenous essential oil therapies and encouraging further research based on the promising results.

Financial Hardship in Childhood Cancer Survivors Treated with Hematopoietic Cell Transplantation: A Report from the Childhood Cancer Survivor Study

Long-term survivors of childhood cancer are at risk for financial hardship. However, it is not known if HCT leads to an incremental change in financial hardship for survivors who received it versus those who did not. We examined financial outcomes among adult survivors of childhood cancer who had undergone HCT. Using a cross-sectional survey in the Childhood Cancer Survivor Study population between 2017 and 2019, self-reported financial hardship was compared between survivors who received HCT, survivors treated without HCT ("non-HCT"), and siblings and categorized into 3 domains: material hardship/financial sacrifices, behavioral, and psychological hardship. The standardized score of each domain of financial hardship was calculated by adding the item responses and dividing by the standard deviation among siblings. Multivariable linear and logistic regression were used to evaluate associations between sociodemographic characteristics, cancer diagnosis, post-treatment complications, and financial hardship among survivors. The mean adjusted score for each hardship domain was not significantly different between HCT survivors (n = 133) and non-HCT survivors (n = 2711); mean differences were .18 (95% confidence interval [CI], -.05 to .41) for material hardship/financial sacrifices, .07 (95% CI, -.18 to .32) for behavioral hardship, and .19 (95% CI, -.04 to .42) for psychological hardship. Within specific items, a higher proportion of survivors treated with HCT reported greater financial hardship compared to non-HCT survivors. HCT survivors also had significantly higher mean domain scores compared to sibling controls (n = 1027) in all domains. Household income and chronic health conditions, but not HCT, were associated with financial hardship among all survivors. Adult survivors of childhood cancer treated with HCT do not report greater overall financial hardship compared to non-HCT survivors but do report greater overall financial hardship compared to sibling controls. Surveillance and intervention may be necessary for all survivors regardless of HCT status.

Find Meaning and Help: The Lived Experiences and Support Needs of Iranian Muslim Husbands of Women Undergoing Mastectomy From Diagnosis to the End of Life

The husbands of women undergoing mastectomy have been introduced as the patient's primary caregivers. This research was conducted to investigate the lived experiences of Iranian Muslim husbands of women undergoing mastectomy. In this phenomenological research, 18 participants were interviewed, and Van Menan's method of interpretation was used to interpret the data. 8 themes were extracted from the data analysis: physical problems, living in the shadow of fear and discomfort, and destiny is not blameless, modified roles, marital coldness, imposing a financial burden, spiritual care, and support failure. It is concluded that the husbands of these patients need comprehensive support, and the current support is not enough.

Leveraging national and global political determinants of health to promote equity in cancer care

Health and politics are deeply intertwined. In the context of national and global cancer care delivery, political forces-the political determinants of health-influence every level of the cancer care continuum. We explore the "3-I" framework, which structures the upstream political forces that affect policy choices in the context of actors' interests, ideas, and institutions, to examine how political determinants of health underlie cancer disparities. Borrowing from the work of PA Hall, M-P Pomey, CJ Ho, and other thinkers, interests are the agendas of individuals and groups in power. Ideas represent beliefs or knowledge about what is or what should be. Institutions define the rules of play. We provide examples from around the world: Political interests have helped fuel the establishment of cancer centers in India and have galvanized the 2022 Cancer Moonshot in the United States. The politics of ideas underlie global disparities in cancer clinical trials-that is, in the distribution of epistemic power. Finally, historical institutions have helped perpetuate disparities related to racist and colonialist legacies. Present institutions have also been used to improve access for those in greatest need, as exemplified by the Butaro Cancer Center of Excellence in Rwanda. In providing these global examples, we demonstrate how interests, ideas, and institutions influence access to cancer care across the breadth of the cancer continuum. We argue that these forces can be leveraged to promote cancer care equity nationally and globally.

COVID-19-Related Employment Disruptions and Increased Financial Burden Among Survivors of Adolescent and Young Adult Cancer

Background: Financial burden is a major concern for survivors of adolescent and young adult (AYA) cancers. We identified if employment disruptions during the COVID-19 pandemic affected AYA survivors' financial burden. Methods: AYAs who were enrolled in a cancer patient navigation program were e-mailed a survey in fall 2020. Survey items included sociodemographics, employment disruption, and two measures of financial burden: COmprehensive Score for Financial Toxicity (COST) and material and behavioral financial hardship items (for any reason, COVID-19 induced, cancer induced). Financial burden outcomes were dichotomized at the median (COST = 21; financial hardship = 3). The association of employment disruptions and sociodemographics with financial burden was assessed using multivariable logistic regression models. Results: Reduced hours/job loss was reported by 24.0% of 341 participants. Survivors with a high school education or less (odds ratio [OR]: 2.70; 95% confidence interval [CI]: 1.21-6.03) or who had decreased hours or job loss (OR: 3.97; 95% CI: 2.01-7.84) had greater odds for high financial toxicity. Reduced hours/job loss was the only factor associated with high material and behavioral financial hardship for both any reason (OR: 2.75; 95% CI: 1.41-5.33) and owing to COVID-19 (OR: 4.98; 95% CI: 2.28-10.92). Cancer treatment since March 2020 was associated with cancer-induced high material and behavioral financial hardship (OR: 3.31; 95% CI: 1.96-5.58). Conclusion: Employment disruptions owing to the COVID-19 pandemic, lower education levels, and cancer treatment were associated with high financial burden among AYA cancer survivors. Our findings suggest the need for multilevel interventions to identify and address financial burden among vulnerable cancer survivors.