Alleviating the Burden of Financial Toxicity Begins at the Point of Care

Safety profiles of anticancer drugs represent only one piece of the toxicity puzzle patients grapple with following a cancer diagnosis. Financial toxicity, the unspoken burden, has come under the spotlight over the past 5 years as a topic that more clinicians are broaching not only with each other but with their patients.

“Financial toxicity has completely changed the way we view the patient, it’s changed the way we do business,” said Kathy Oubre, MS, CEO of Pontchartrain Cancer Center in Covington, Louisiana, in an interview with OncologyLive^®. “Oncology practices really have transformed over the past decade to treating the patient as a whole individual vs simply treating their disease.”

With nearly one-fourth of patients with cancer reporting treatment-related financial harm during their cancer journey,¹ understanding determinants of financial toxicity at the point of care has become a pressing issue facing practices. “Cancer care has been expensive for a really long time, and it keeps getting more and more expensive,” said Amy Valley, PharmD, vice president of clinical strategy and technology solutions at Cardinal Health Specialty Solutions, in an interview. “But the good thing is that as an industry, there is a lot of focus on how we can ease the financial burden on patients with cancer.”

The Stark Reality of Cancer Costs

Valley noted that it is not uncommon for anticancer drugs to cost upward of $10,000 per month––and surgeries and other treatment expenses can send costs even higher. “The costs of care have [become] more expensive and insurance companies have pushed more of that cost down to the patients,” she said. “Imagine you are getting a really expensive therapy that your life depends on and there’s no alternative. The out-of-pocket costs, even for an individual who is insured, are not affordable and sustainable for many patients. It is…a really huge problem.”

For example, Valley pointed to an uptick in data tackling the burden of financial toxicity, such as the comprehensive report compiled by the National Cancer Institute.² The report cites a 2012 survey indicating that among 4719 cancer survivors, 39.7% had made financial sacrifices to accommodate the costs of their cancer care and 33.1% had gone into debt, with 3.1% of respondents filing for bankruptcy.³

“The No. 1 cause of bankruptcy in the United States is medical bills,” Tanya Park, director of innovation solutions at Cardinal Health said. “If you think about how expensive cancer care is…some patients reach the breaking point financially. Individuals with a cancer diagnosis have just gone through this extraordinarily stressful clinical situation and now they have this additional financial stress…on top of it.” Park noted that patients with cancer who have declared bankruptcy are at an 80% higher risk of mortality.⁴

If patients are concerned about stretching their dollars, treatment adherence will begin to suffer and contribute to an increased mortality rate. “Prescription costs associated with cancer treatment play a role in treatment adherence,” Oubre said. “We know that [some] patients cannot afford their prescriptions, so they might cut their pills in half. They may miss doses in order to keep those pills longer."

In a report on nonadherence, among 524 patients who reported financial toxicity, 17.7% needed but were unable to afford prescription medication compared with 3.4% of those who did not report financial toxicity (n = 1464).¹ This translated to a relative risk of 3.55 (95% CI, 2.53-4.98).¹

The challenges are not confined to therapeutic costs, hospitalization, and co-pays at practice visits. Transportation, lodging, reductions in employment hours, time off for appointments and procedures, as well as reduced efficiency are additional factors that feed into a patient’s comprehensive financial burden.⁵

“Although drug costs are certainly a driver of the increasing out-of-pocket cost for patients, these individuals are also getting a lot of different treatments,” Valley said. “Treatments may require them to be hospitalized, they can receive radiation therapy, they may have surgery, there are a lot of tests that are done for monitoring and ongoing observation…. It’s a lifetime impact for these individuals in terms of the cost they incur.”

Widening the scope of care begins with the treating physician. Valley noted that throughout her career, there has been debate over whether it is up to the treating oncologist to have financial conversations with the patients at the point of care. “I think that physicians are now realizing financial conversations are a part of the informed decision-making process,” she said. “Providers need to be equipped with the information to have a conversation with patients about the financial aspects of the treatment options. That’s a big shift in medical care, and there’s still a gap in getting the information to the provider at the right time so they can have those conversations about treatment options.”

Integrating Solutions in Practice

A gap in translating financial discussion into point-of-care decision-making is the lack of available data for oncologists. This includes gathering a comprehensive portrait of the patient and their unique social determinants of health in addition to the financial costs of care that will be incurred once treatment commences. It also includes navigating care parameters that provide the most appropriate treatment solutions for a patient by adhering to treatment guidelines but also empower oncologists to make value-based decisions.

“At Pontchartrain Cancer Center [patients receive] a social health screening tool…in addition to their other intake forms,” said Oubre. The tool builds a profile of potential patient needs based on information concerning transportation, financial assistance, food, housing, and other social determinants of health, she explained. “These factors affect outcomes, [treatment] adherence, and the whole cancer care journey for the patient and their families.”

In terms of tools available beyond intake, leveraging information already available to oncologists in electronic health records (EHRs) may provide a path forward. For example, Decision Path, developed by Cardinal Health’s innovation arm, Fuse, is built into the EHR workflow. It aims to provide estimates and comparisons by clinical indication and cost between different treatment regimens to enable clinicians to make optimal decisions at the point of care. “Decision Path is designed to be built into the EHR workflow, so that [the information is] right there at the point [a clinician] will be making a treatment decision,” Park explained. “It’s designed to allow oncologists to compare different treatment options by clinical indications and risk and then provide them with a window into the cost of care as they’re making that decision.”

With the determinants that Oubre highlighted, Valley added that Decision Path coupled with value-based care platforms such as Cardinal Health’s Navista TS (Tech Solutions) can help to paint the full patient picture. “There are so many different aspects that can ultimately affect the financial hardship that patients experience,” Valley said. “Looking at the social and behavioral determinants of health can help clinicians identify patients who are at risk for various adverse effects such as hospital and emergency department visits, pain, and others, which are likely to influence outcomes and add to cost of care."

Decision Path compares a variety of aspects of treatment regimen choices beyond financials, including clinical risk factors, and provides information on available biosimilar options. “Biosimilars are one way in which practices can address some of the increasing cost of drugs,” Park said. Decision Path will also provide oncologists with preloaded, practice-approved biosimilar substitutions allowing for cost-to-practice and cost-to-patient comparisons during the treatment decision process.

“Biosimilars have really played a role in helping patients afford cancer treatments,” Oubre said. “It is important to keep in mind that by using these lower-cost products, we’ve seen an increase in access to care—more patients are able to afford treatments than before the advent of biosimilars.”

Small but Monumental Steps Forward

Finally, Valley noted that although the data surrounding financial toxicity have been enlightening and long overdue, she is more excited that actions are being taken to address the issues. “That’s what I love most about the work I’m involved with…we’re designing tools to operationalize an action plan that helps individuals do something about financial toxicity and make a difference,” she said. “The past 5 years have been about measuring, quantifying, producing statistics, and selecting some of the low-hanging–fruit action plans. Now we are asking: how can we go to the next level? These tools are one of many things that I think are going to start really moving the needle on addressing financial toxicity.” Although Valley notes that these tools are not a cure-all, presenting the information to clinicians in a way that facilitates early discussions and provides opportunities to address issues of financial burden upfront is “what’s really important to us.”

Oubre also expressed optimism at the future of care for her patients but noted that with change comes room to reflect on what is and is not working in daily practice. “When I first started [seeing patients], you just saw the patients deliberate their cancer treatments,” Oubre said. “It segmented the way we did business. Now we have a financial assistance team and we work very hard with our patients and their families to help them manage and afford their cancer treatments.”

“We’ve come a long way by embedding programs such as financial assistance, distress screening, and survivorship care. We always need to strive to do better by our patients and their families by stressing to our cancer care teams the importance of these programs and pulling them through [the process]. We need to walk the walk and make these programs part of what we live and breathe and do every day in practice.”

To learn more about Cardinal Health Navista TS, visit http://cardinalhealth.com/navista.

 References

1. Knight TG, Deal AM, Dusetzina SB, et al. Financial toxicity in adults with cancer: adverse outcomes and noncompliance. J Oncol Pract. 2018;14(11):e665-e673. doi:10.1200/JOP.18.00120
2. Financial toxicity and cancer treatment (PDQ)–health professional version. National Cancer Institute. Updated June 22, 2021. Accessed February 19, 2022. https://www.cancer.gov/about-cancer/managing-care/track-care-costs/financial-toxicity-hp-pdq
3. Banegas MP, Guy GP Jr, de Moor JS, et al. For working-age cancer survivors, medical debt and bankruptcy create financial hardships. Health Aff (Millwood). 2016;35(1):54-61. doi:10.1377/hlthaff.2015.0830
4. Ramsey SD, Bansal A, Fedorenko CR, et al. Financial insolvency as a risk factor for early mortality among patients with cancer. J Clin Oncol. 2016;34(9):980-986. doi:10.1200/JCO.2015.64.6620
5. Desai A, Gyawali B. Financial toxicity of cancer treatment: moving the discussion from acknowledgement of the problem to identifying solutions. EClinicalMedicine. 2020;20:100269. doi:10.1016/j.eclinm.2020.100269