Veena Shankaran, MD, on Major Financial Hardship in Patients with Metastatic Colorectal Cancer
Even those with health insurance needed help navigating the financial consequences of cancer treatment, study showed
Multiple studies show that cancer care costs contribute to financial toxicity in patients undergoing treatment. Now, recent results from the SWOG S1417CD trial in patients with newly diagnosed metastatic colorectal cancer (mCRC) add to the evidence on how many patients are affected and how bad things can get.
In the study, reported at ASCO’s Quality Care Symposium, data was gathered from 377 patients with mCRC treated with systemic therapies at 126 clinic sites within the National Cancer Institute Community Oncology Research Program (NCORP). A primary endpoint analysis showed that after 12 months, 71.5% patients experienced major financial hardship, even though 98% had access to health insurance.
Major financial hardship was defined as one or more occurrences of self-reported increases in debt, new loans, refinancing or selling a home, or a drop of 20% or more in annual income. Cumulative incidence of the financial hardship was determined using both self-reported and objective financial measures and estimated to account for the competing risk of death.
“These findings underscore the need for clinic and policy solutions such as early financial navigation and elimination of cost sharing to protect patients from financial devastation as they continue with treatment,” concluded Veena Shankaran, MD, MS, of the Seattle Cancer Care Alliance and Fred Hutchinson Cancer Research Center, who presented the findings in an oral session.
Age, race, marital status, employment, and annual income were not significantly associated with major financial hardship. However, a post-hoc analysis showed that income and total assets of less than $100,000 were both adversely associated with the financial hardship. Each increase in the number of these two risk factors was associated with a 49% increased risk of financial problems (P<0.001).
The dominant components were new debt, seen in 56.7% of patients, and decline in income of more than 20%, seen in 26.7% of those in the study. A total of 104 patients (41%) reported having two or more elements of major financial hardship.
In the following interview, Shankaran, who is also co-director of the Hutchinson Institute for Cancer Outcomes Research, elaborates on the team’s findings.
You describe the financial hardship documented in a cohort of mostly white male patients, 98% of whom had health insurance, as “devastation.” Were you surprised by the severity of the financial impact, particularly when so many patients were insured?
Shankaran:Yes, I was surprised that the cumulative incidence of financial hardship was so high in this insured population. Clearly, the presence of health insurance coverage does not shield patients from experiencing significant financial challenges during treatment. This is likely related to a variety of factors — potentially including cost sharing, non-medical costs, and the impact of cancer on employment and income.
Given that your sample was primarily male, do you suspect your results might have differed in women with mCRC?
Shankaran:The sample was primarily male because colorectal cancer is slightly more common in men than in women. I do not know if the findings would have been different had the population been mostly women. It is possible there may be differences between older men and women in terms of employment and primary household income earner status such that the impact on household finances in partnered/married women could be less. I think we need further investigation to be able to say anything definitively.
Do your findings have relevance for clinicians treating patients with other types of cancer?
Shankaran:I do not think our findings are unique to mCRC patients. All cancer patients are likely at risk for financial hardship, and it is likely much more common than we previously realized. Clinics and cancer centers need to develop strategies to identify patients and families at risk for financial hardship and provide them with financial counseling, assistance with high-cost drugs, transparency about upcoming costs, and help with navigating employment and benefits.
Are there other steps that need to be taken?
Shankaran:The problem is multifactorial. The first step is recognizing how widespread this problem is. The next step is working towards solutions at the clinic and patient level.
Along with this, we need to normalize conversations around cost so that patients and families feel comfortable talking to their providers about their financial concerns. At a macro level, there need to be policy changes that improve access to health coverage, lower drug prices, and improve the robustness of available health plans.
At the payer level, there should be consideration given to minimizing or eliminating cost sharing, particularly for chronic diseases such as metastatic cancer that require ongoing treatment.
In your opinion, could financial hardship in mCRC affect survival outcomes?
Shankaran:I think it potentially could, to the extent that financial challenges might affect things like treatment adherence, access to clinical trials, etc. We did not specifically look at the association between financial hardship and survival in this study. However, it would not be hard to imagine that financial hardships, like other social determinants of health, lead to worse outcomes.
Are you planning any other studies on the impact of financial hardship on cancer patients?
Shankaran:In March/April 2021, we are launching the SWOG S1912 study to examine the impact of financial counseling on the financial status of newly diagnosed cancer patients and their spouses. We will also be looking at outcomes such as quality of life, healthcare utilization, and treatment adherence. The study will be conducted at NCORP sites throughout the country.
Read the study here and expert commentary about the clinical implications here.
This study was funded by ASCO’s Conquer Cancer Foundation, The Other Foundation, and the National Institutes of Health.
Shankaran reported financial relationships with Merck & Co., Bristol Myers Squibb, Merck, Lilly, and AstraZeneca; several co-authors also disclosed relationships with industry.
Source: MedPageToday. By Kristin Jenkins
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