He summarized the complex interplay between cancer and financial distress, which is related to many factors as shown in figure 1 from NCI review on FT (1-3).
All these factors can influence the health outcomes of a patient and are therefore essential considerations while making treatment decisions for any patient.
Dr. Strope then talked about a recent systemic review, which observed a total of 28-48% of patients reported FT using monetary measures and 16-73% using subjective measures (4). The most commonly reported factors associated with FT were: being female, younger age, low income at baseline, adjuvant therapies and more recent diagnosis. Relative to non-cancer comparison groups, cancer survivors experienced significantly higher FT.
FT is a significant concern among patients with bladder cancer as shown in a study from UNC, Chapel Hill (5). Dr. Strope highlighted the conclusions from this study which showed that younger patients were more likely to experience financial toxicity. Those who endorsed financial toxicity experienced delays in care and poorer health-related quality of life, suggesting that treatment costs should have an important role in medical decision making.
Dr. Strope also stressed on the need for more studies on FT within urology. He highlighted his work which showed urologists have higher expenditures on initial BPH related care than primary care physicians. The expenditures are driven by medication use by patients and evaluative testing done by urologists and decreases to the same expenditure as primary care by the third and fourth quarter after initial medical therapy for BPH. This upfront treatment cost should be expected within the urologic cancer realm too.
As urologists, we are responsible for the diagnosis, treatment, and follow-up of our patients. The complex follow-up algorithm in prostate cancer patients undergoing active surveillance adds to the direct and indirect costs to the patients, without actually knowing how this added cost affects morbidity and mortality from their disease. Similarly, in patients who underwent cystectomy, standardization of care to current established guidelines would create higher expenditures by almost five times on follow-up care than current practice patterns (6).
He concluded by summarizing the strategies for mitigating FT from an article in the Journal of Urology (7). Urologist should 1) initiate an open discussion about finances with patients and their families, 2) offer decision aids and patient-centered resources to help patients understand options, 3) routinely discuss risks, benefits and costs of all therapy options early, 4) consider measuring financial toxicity using patient-reported outcomes measures, 5) integrate financial counseling as a part of multidisciplinary cancer care, and 6) appoint local stewards to act as leaders focused on addressing this issue. Dr. Strope also stressed that we as physicians are impacting both medical and non-medical costs which leads to financial distress for the patients, and we need to identify and provide solutions to improve overall patient health outcomes.
Presented By: Fumiko Chino, MD, Duke University Medical Center
References:
Financial Toxicity and Cancer Treatment (PDQ®)–Health Professional Version https://www.cancer.gov/about-cancer/managing-care/track-care-costs/financial-toxicity-hp-pdq
Smith R, Clarke L, Berry K, et al.: A comparison of methods for linking health insurance claims with clinical records from a large cancer registry. [Abstract] Med Decis Making 21 (6): 530, 2001.
Fay S, Hurst E, White MJ: The household bankruptcy decision. Am Econ Rev 92 (3): 706-18, 2002.
Gordon LG, Merollini KMD, Lowe A, Chan RJ, A Systematic Review of Financial Toxicity Among Cancer Survivors: We Can't Pay the Co-Pay. Patient. 2017 Jun;10(3):295-309
Casilla-Lennon MM, Choi SK, Deal AM, Bensen JT, Narang G, Filippou P, McCormick B, Pruthi R, Wallen E, Tan HJ, Woods M, Nielsen M, Smith A.,Financial Toxicity among Patients with Bladder Cancer: Reasons for Delay in Care and Effect on Quality of Life. J Urol. 2018 May;199(5):1166-1173.
Vemana G, Vetter J, Chen L, Sandhu G, Strope SA. Sources of variation in follow-up expenditure after radical cystectomy. Urol Oncol. 2015 Jun;33(6):267.e31-7.
Mossanen M, Smith AB. Addressing Financial Toxicity: The Role of the Urologist. J Urol. 2018 Jul;200(1):43-45.
Written by: Abhishek Srivastava, MD, Society of Urologic Oncology Fellow, Fox Chase Cancer Center, Philadelphia, PA, at the 19th Annual Meeting of the Society of Urologic Oncology (SUO), November 28-30, 2018 – Phoenix, Arizona