Cancer Care's Hidden Burden: Linking Financial Stress and Mortality in Cancer Treatment - Hiba Khan

June 26, 2023

Petros Grivas hosts a conversation with Hiba Khan, who has earned the prestigious ASCO Young Investigator Award for her work on financial toxicity in prostate cancer patients. Dr. Khan discusses the increasing cost of cancer treatments and the financial hardships that patients experience. This topic is also central to her review article published in the Journal of Clinical Oncology, which offers guidance to clinicians on mitigating financial toxicity for their patients. Highlighting the importance of policy reform, patient questioning, and institutional support, Dr. Khan outlines her vision for tackling this pervasive issue. Furthermore, she previews her presentation on a study linking adverse financial events to higher mortality rates among cancer patients.


Hiba Khan, MD, MPH, GU Medical Oncologist, Hematology/Oncology Fellow, Fred Hutch Cancer Center, University of Washington, Seattle, WA

Petros Grivas, MD, PhD., Professor, Clinical Director of Genitourinary Cancers Program, University of Washington, Associate Member, Clinical Research Division, Fred Hutchinson Cancer Research Center

Read the Full Video Transcript

Petros Grivas: Hello, I'm Dr. Petros Grivas. I'm a medical oncologist in Seattle. I'm serving as the Clinical Director of the GU Cancers Program. I'm a professor at the University of Washington Fred Hutchinson Cancer Center. I'm so excited and thrilled to host today, Dr. Hiba Khan. Dr. Khan is actually finishing her fellowship in the Hematology Oncology Program at UW Fred Hutch and is joining us, we're so excited, as an assistant professor at the University of Washington Fred Hutchinson Cancer Center. Hiba, welcome.

Hiba Khan: Thank you for having me. I'm excited to be here.

Petros Grivas: Exciting times and excited to have you here. You're doing such a great job already during your fellowship.

Hiba Khan: Thank you.

Petros Grivas: In an hour from now, we're actually getting an ASCO Young Investigator Award, very prestigious. Tell us a little bit more about what you're doing in research that led to this award.

Hiba Khan: Oh, well, I'm so grateful to Conquer Cancer Foundation and ASCO for supporting the work that I'm doing. My interest is in prostate cancer specifically and specifically about in financial toxicity and outcomes of care in prostate cancer patients. People that take care of prostate cancer patients know that as the medications for prostate cancer have improved, the treatments have improved over time, people are living longer and longer, but that also comes with some unintended consequences for our patients.

One of my specific interests is financial toxicity or the financial hardship that can occur for patients as they deal with the costs of their cancer care. Over the last couple of years, costs are being shifted more and more towards patients, and so my interest really is in diving a little bit deeper into this financial toxicity that patients experience. There's a lot of literature out there for cancer in general and other cancers, but really the effect on prostate cancer patients and financial toxicity hasn't really been well studied.

My ASCO YIA has been awarded to study the financial toxicity that's associated with oral AR-targeted agents. These are things like enzalutamide, abiraterone that can cost hundreds and hundreds of dollars. They retail for tens of thousands of dollars if you just pick them up at the pharmacy. And even with insurance, patients can often have a large co-payment that can be unaffordable. That's the premise of the ASCO YIA and I'm so excited to get started on this work.

Petros Grivas: So important work and thanks Hiba for putting the time, energy, and effort to do that work. We need urgently solutions, interventions after the diagnosis of the problem, the solution of the problem, and you're in the forefront of doing this work, and I'm so glad that ask when the Conquer Foundation recognized that. At the same time, you just published a paper on Journal of Clinical Oncology, JCO, I just saw it three days ago. Tell us a little bit more about your work there.

Hiba Khan: Yeah. That really is a review article on financial toxicity with the specific spin towards clinicians. And so it's really meant to be an informative how-to guide for clinicians. It's a short-ish read. We dive, first, into describing the problem of financial toxicity, doing a really brief review on the literature over the last 10 years that's shown the scope of the problem, the anticipated scope to come with more and more cancer cases being diagnosed. And then we really focus the meat of the article on what clinicians can do to mitigate financial toxicity, clinicians and their health systems. And so it feels like a big overreaching, large-scope problem, but really there are some things that clinicians can do that health systems can do to mitigate that toxicity for their patients. And so that's what the article is about, is to give clinicians a little bit of guidance on what to do for this very large-scale problem that seems really intense and overwhelming.

Petros Grivas: Absolutely. And guidance is needed because we have so many patients with limited means in even geographical areas with no access to care, financial concerns, as you mentioned, co-pay issues that exactly may limit access to life-saving medications, life-prolonging medications. So there are institutional resources and there are clinic-level resources, and it sounds like you're outlining those examples in this JCO article.

Hiba Khan: Exactly. And there's a lot of things that can be done also on a policy level. Organizations such as ASCO, the American Cancer Society, these are organizations that are leading us in terms of national policy advocacy and help on a larger scale. So things like state-level policy, national-level policy, insurance reform, prior authorization reform, all of these things will lead to huge impacts and be really far-reaching. But there's things that we can do in the clinic such as asking patients about their financial burden, asking them if the costs are unaffordable or too much, asking them if they have any behavioral things that they're doing. A lot of times patients will not volunteer, but if you ask them, they'll tell you, "I'm having a hard time affording my medication. I'm skipping doses of medication." This can be life-saving medication to treat cancer, but it can also be supportive care medications, things like pain medications, nausea medications.

So unless we ask, we don't know. And so that's really one of the key points in the article is to treat this as something that you would normally talk about in a clinical visit and sort of normalize this process. You don't really know until you ask, and so really the point is to ask patients what they're experiencing.

Petros Grivas: Very important point. And sometimes in the busy clinic, clinicians may forget to ask this very important question. So reminders and maybe a template in your notes, some tips.

Hiba Khan: Yeah, those are really good ideas. Those are things we dive into. There's digital health solutions, there are apps these days that can sort of help. I don't want this to be something to add to the never ending laundry list of things we clinicians have to ask our patients about too, and so the idea is really to partner with your institutions, to partner with health systems, to partner with your nursing teams, with your prior authorization folks in the pharmacy that can help. So it's about creating a team that can really help patients deal with this really big problem.

Petros Grivas: Fantastic. It takes a whole team, to your point, Hiba, and it's a nursing support, advanced practice providers, pharmacy, billing team, nurse navigators, and institutional resources on the macro scale of things.

Hiba Khan: Yeah, exactly.

Petros Grivas: Very important opportunity, and I think, as a society, we to do more about eliminating disparities. Thank you for choosing that as a significant part of your career.

Hiba Khan: Yeah, it's something I'm really passionate about. I think, as we've seen with prostate cancer specifically, disparities are growing and as we get more and more medications to help, they are costly medications, and so we're creating an even bigger divide in who can afford these medications, who can afford the treatment. And because of that, the disparities are growing. So that's really important to me. I hope that my small part can play a role in helping to ease some of these disparities we're facing.

Petros Grivas: Absolutely, no doubt about it, and I think all of us should do our part, right, addressing the problem, diagnosing the problem, being more sensitive into those issues and ask our patients. Sometimes patients may not offer the information unless they're explicitly asked, so having these reminders in the clinic, and even in our minds, I think makes sense to do that and implement. And now we are also very excited, you're having an oral presentation at ASCO on Tuesday, June 6th at 9:00 AM. Tell us about your talk.

Hiba Khan: That's right. Again, keeping with the theme of financial toxicity, I am lucky enough to work with the team at Fred Hutch called HICOR, they're the Hutchinson Institute for Cancer Outcomes Research, and really spearhead and lead a lot of the work that's been ongoing in the last several years for cancer, what we call cancer outcomes research. And so partnering with their team, we were able to form a unique and very novel linkage between our SEER Cancer registry data and TransUnion, which is one of the major credit reporting agencies in the US.

By using this linkage, we were able to ask questions about adverse financial events, we call them, that patients may face as a result of their cancer treatment. Prior work with the group has shown that patients that experienced bankruptcy, this was work that was published in 2016, this work has shown that patients who experience bankruptcy, patients with cancer who experience bankruptcy, tend to have a higher risk for mortality. And so we really were interested in using this novel linkage with TransUnion to explore this question one step further. Do patients who experience adverse financial events that are less severe than bankruptcy also have a risk of increased mortality?

What we found was that after using this novel linkage, we have about 65,000 patients that we were able to look at that were diagnosed with solid tumor cancers between 2013 and 2018, we're able to link their clinical cancer registry data with the TransUnion data, we found that those folks who experienced adverse financial events did have a higher risk for mortality compared to patients with cancer in the registry who did not experience adverse financial events. So I think this is one additional piece of evidence that we know, we can say financial toxicity is harming our patients, not only making it hard for them to live their day-to-day life, but may actually be impacting their survival and their life. And so, again, calls attention to the fact that this is a huge problem, that we really need more resources and we really need more mitigation strategies as a society to help deal with.

Petros Grivas: Absolutely, such an important and vast problem. It's a international issue, I would say, and sending life into it and create these mindsets and culture that we need to pay attention to those issues. And it sounds like there's a correlation between adverse financial events and outcomes. So it's a clear proof that this has to be intervened upon.

Hiba Khan: Yeah, and I think doing more of this research and sort of highlighting the impacts on the patients really helps us think about, here's the problem, what are some solutions? Because I think we've had a time of describing the problem, but the next step for me, and I think for the financial toxicity research community at large, is to think about mitigation strategies and to think about solutions and think about what we can do to actually make a difference in the lives of our patients.

Petros Grivas: Such an important opportunity. I think the impact of that could be tremendous and maybe more than an incremental benefit from a particular drug. This has a lot of implications in access to care in implementation science, how it can impact lives globally, I would say. it may also align with ASCO's vision about global oncology.

Hiba Khan: Yeah, that that's the goal, is to improve the lives of patients with cancer everywhere, both in their outcomes, helping them live longer, helping them live better with the cancer treatments that we have, and also making sure that the cancer treatment doesn't adversely impact the lives that they're trying to live.

Petros Grivas: Absolutely, and there's so many stakeholders here, as you mentioned, pharmaceutical companies, insurance companies, institutions, government. There are so many people and so much work to be done. And I think having this dialogue in a form like ASCO definitely helps a lot.

Hiba Khan: Yeah. Yes, exactly. I agree.

Petros Grivas: Looking forward for your talk Tuesday at 9:00 AM June 6th, and thank you so much for spending the time today and all the work you're doing.

Hiba Khan: Of course. Thank you for having me.