This post was written by Teri Pollastro.
Over the last several years we have heard about precision medicine, payment reform and patient-centered care. While I was at ASCO this year, I heard a new buzz word; financial toxicity. The phenomenon of financial toxicity has been whispered about for years. Financial toxicity is described as: “the idea that the costs of treating cancer can be so severe they impact upon a patient's quality of life, becoming an adverse effect themselves.” Some of the symptoms of financial toxicity include difficulty meeting household expenses, loss of employment or income, anxiety/financial stress and strain, debt, or bankruptcy while going through cancer treatment.
In the 2011 Medical Expenditures Panel Survey (MEPS) Experiences with Cancer Supplement, 20% of patients reported having experienced financial hardship while 22% reported having experienced psychological hardship which is defined as anxiety or worry regarding finances while going through cancer treatment. The education session at ASCO titled, Financial Toxicity: Risks, Outcomes and Solutions chaired by Venna Shankaran, MD from the University of Washington addressed this phenomenon.
Dr. Shankaran began her session by showing how health care costs have changed. To demonstrate this, she showed several price comparisons. For example, if the price of eggs had grown as quickly as healthcare costs since 1945, we would be paying $55 for a dozen eggs today. A gallon of milk would now cost $48 and a dozen oranges would cost $134.
In addition, the annual out of pocket costs for an insured patient increased from $2943 in 2008 to $5138 in 2013. That’s approximately a 57% increase in just 5 years. Consequently, when a person is newly diagnosed with cancer and starts to use health insurance benefits they may be facing significant out of pocket costs consisting of deductibles, copays, and coinsurance.
Since 2013, approximately ¼ of all private health insurance plans have implemented a four-tier prescription drug formulary where higher priced drugs typically fall into higher tiers which are associated with higher copays. This is a significant increase from the early 2000’s when there were very few four-tier prescription drug formulary plans. This is particularly relevant in patients with cancer since in the last several years there have been many more oral chemotherapy drugs approved. While it would make sense to think that oral chemotherapies, which patients take at home, would help reduce some of the financial burden since there are no in-office Intravenous (IV) chemotherapy infusions required, that is simply not the case.
For example, Olaparib, an oral chemotherapy drug which was approved in 2015 for ovarian cancer, wholesales for approximately $14,400 for a one-month supply. These drugs tend to fall into the higher tiers of the prescription drug formulary coverage and consequently have higher copays. In addition, when a doctor prescribes an oral chemotherapy, the patient receives the pharmacy benefit for that drug and not the medical benefit which can also cost the patient more. Many pharmacy plans have their own coverage structure which may include some form of cost-sharing with the patient.
However, if the treatment is given in the clinic through an IV, their medical coverage benefit is applied. So a patient may not owe as much if the drug is administered in clinic and their medical coverage applies vs. having a prescription for the drug to be taken at home and their pharmacy benefit applies. The most effective cancer treatment may be for an oral chemotherapy. Yet, it may not be financially feasible for the patient to take that drug.
Dr. Dawn Hershman from Columbia University discussed how cost and financial toxicity relate to medical adherence. Dr. Hershman admitted that it is difficult to measure adherence because patients are often embarrassed and will not tell their doctors when they have stopped or reduced medication in order to save money. Medication adherence for long-term therapies drops significantly when patients cannot afford their cancer drugs. As costs go up, adherence goes down.
In one study that analyzed patients who were over 65, adherence dropped significantly when a three-month supply was over $30.00. Dr. Hershman described that when aromatase inhibitors became generic in 2010, which allowed for lower prices, adherence increased. Finally, Dr. Hershman referenced a breast cancer Medicare aromatase inhibitor study where drug costs for the patient were fully covered. When the drugs were fully covered, there were better outcomes both with adherence and long-term cost savings. Unfortunately, a recent study indicated that when aromatase inhibitors were stopped early, survival was impacted negatively.
Dr. Yousuf Zafar from Duke University proposed treating financial toxicity as a symptom that we can treat right now using a model of prevent, assess, and reduce. To begin with, Dr. Zafar suggested that each oncologist could help prevent financial toxicity by discussing the proposed treatment cost with the patient prior to beginning treatment and by considering the value of the treatment being provided. He also suggested having goals of care conversations with patients before care has begun so that financial issues can be discussed and patients know that their doctors understand.
Second, Dr. Zafar suggested checking in with patients during treatment to assess if finances have become an issue due to lost wages, changes in insurance, changes in treatment or other unforeseen costs. He referenced an assessment that is currently available named COST (Comprehensive Score for Financial Toxicity) which is an 11 item subjective measurement tool for financial toxicity. Finally, Dr. Zafar offered suggestions for how doctors can help patients reduce financial toxicity. Doctors can refer patients to financial assistance programs and by appealing to their insurance when needed.
Dr. De Souza from the University of Chicago discussed managing patient and provider financial toxicity. Dr. De Souza explained that financial toxicity has been shown to be associated with delays in care and treatment noncompliance. When a patient faces financial concerns during treatment, this has been linked to less favorable outcomes. The quality of life for the patient as well as their chance for a positive outcome diminish as well.
There are many variables to consider when attempting to reduce financial toxicity including: legislative policy changes, health insurance design, drug-company pricing, initiating conversations between doctors and patients related to cost, and patient education and responsibility. This is not an easy topic to discuss and explore. It is uncomfortable to talk about those two “C” words in the same conversation – cancer and cost.
Teri Pollastro has been living with metastatic breast cancer for 13 years and enjoys watching her daughters grow up, spending time with her husband, family and friends, and learning to become a more effective advocate for others living with metastatic disease.