Optimize Interventions to Get a Step Ahead of Financial Toxicity in Cancer Care

Fumiko Chino, MD

The issue of financial toxicity in cancer care is widespread, with approximately 50% of patients with cancer facing economic hardship related to their disease and/or treatment.¹ In response, investigators are developing preventive interventions that can be implemented at scale to identify patients most at risk for financial toxicity and offer them assistance.

“The National Cancer Institute defines financial toxicity as the problems that a patient has related to the cost of their care, and they highlight that patients with cancer are more likely to have problems with financial toxicity [compared] with [those with] other chronic diseases,” Fumiko Chino, MD, an assistant attending radiation oncologist at Memorial Sloan Kettering Cancer Center in Middletown, New Jersey, said in an interview with OncologyLive. “Financial toxicity is best studied and best categorized within cancer. Our treatments are intense and expensive. Even into survivorship, [patients] can still have chronic adverse effects, [such as] peripheral neuropathy, durable costs, or career effects related to treatment.”

Feasibility of Financial Toxicity Screening

During the 2024 American Society of Clinical Oncology Annual Meeting, Chino and coauthors presented findings from a financial toxicity and health-related social risks screening program that was implemented at an urban comprehensive cancer center from September 2022 to August 2023. The study included patients who received treatment for breast, gynecologic, gastrointestinal, or thoracic cancer.²

The authors employed a validated screening tool, the 11-item Comprehensive Score for Financial Toxicity (COST) tool, which assessed financial toxicity risk on a scale of 0 to 44. Lower scores indicated a patient was at a higher risk for financial toxicity. Additionally, patients responded to a health-related social risks checklist that aimed to identify food, housing, medicine, and transportation insecurity. Patients could respond to the survey via an online portal every 4 months and a COST score of 20 or less or any endorsement of a health-related social risks checklist item was considered a positive screen; these patients were offered a referral for financial assistance counseling.²

“We wanted to capture what’s happening with our patients in terms of financial toxicity and intervene early in order to stop the downstream effects that we know financial toxicity can drive,” Chino explained. “Financial toxicity can compromise cancer outcomes. Patients may skip scans or may just skip treatment altogether.”

Study results demonstrated that patients who completed screening (n = 28,606) screened positive at a rate of 32%. Patients indicated they were experiencing housing, transportation, food, and medicine insecurity at rates of 25%, 24%, 23%, and 21%, respectively. Most patients who screened positive (60%) also had a COST score of 20 or less.²

However, just 51% of patients who screened positive and were offered referral for counseling accepted it. Patients who accepted help cited out-of-pocket costs (68%), nonmedical expenses (39%), concerns about insurance (23%), and medication costs (18%) as financial concerns related to their cancer treatment. Patients with worse financial toxicity (β = 1.15; 95% CI, 1.13-1.16), more self-identified health-related social risks (β = 1.19; 95% CI, 1.13-1.25), or younger age (β = 1.01; 95% CI, 1.008-1.02), and those who were not White (β = 1.70; 95% CI, 1.49-1.93) were more likely to accept referral to the financial assistance team.²

Chino and her coauthors concluded that screening for financial toxicity and health-related social risks was feasible. However, they noted that additional work is needed to better integrate the patient voice in how to offer and provide financial toxicity assistance. In addition, including financial navigators in real-world workflows would be helpful, they said.

“[Our findings] indicate that screening is not enough; we need to make sure that we’re meeting people where they are and finding the best way of providing help,” Chino said. “One of the benefits of doing this type of research at scale—almost 30,000 patients had completed the screening—is to tease out some of that important information.”

Taking a Step Beyond Screening to Tackle Financial Toxicity

There are several randomized studies and pilot programs examining other interventions to address and mitigate the impact of financial challenges that patients with cancer can experience. “There’s a lot of work to be done. For example, there are education initiatives [concerned with] improving financial and health insurance literacy for patients. How do we educate [patients] to better advocate for themselves? How can we deliver care more efficiently?” Chino said.

In a randomized study (NCT03572374) being conducted at multiple Memorial Sloan Kettering Cancer Center sites in the United States, investigators are evaluating the impact of breast cancer treatment on patients’ employment status. The investigators are evaluating an early version of a mobile app that is designed to aid patients in maintaining their jobs during and following treatment.³

The app, known as TEAMWork, uses a 2-pronged approach that focuses on interactions with the patient’s employer and the clinical team. The app’s menu includes videos featuring actors demonstrating how to request accommodations from an employer, templates for letters to request accommodations, links to relevant websites, legal information, and contact information of law firms willing to provide pro bono assistance. The study is comparing TEAMWork with an informational booklet containing similar information to the app but without the multimedia components. The primary objective of the study is to evaluate how many patients are still employed after 2 years.³

In another randomized clinical trial, CAFÉ (NCT05018000), investigators are examining the impact of a novel financial navigation intervention on the financial hardship and health-related quality of life of patients who have received a cancer diagnosis within 120 days of enrollment. The CAFÉ intervention consists of patients meeting with a financial navigator who provides them with a comprehensive assessment of their financial needs and questions, as well as helping them plan for paying household expenses in addition to out-of-pocket treatment costs. The financial navigator also will offer proactive personalized referrals to community organizations and resources to further aid patients.

The CREDIT study (NCT04960787) is building upon the use of financial navigators by adding an online training component. In the study, patients will meet with a Consumer Education and Training Services counselor and a Patient Advocate Foundation case manager for approximately 1 hour every month for 6 months. Additionally, patients will complete questionnaires covering education, employment, finances, insurance, and quality of life, as well as have their credit reports assessed at baseline, 3 months, 6 months, and 1 year. Patients will receive financial literacy training via online videos and will have the option to have their spouse or caregiver participate.⁵

“Opening the conversation with patients is an important step to understand how their treatment burden is affecting their lives,” Chino said in conclusion. “Knowing details [such as] if a patient works full time vs part time, or if they have paid time off, makes a huge difference in the treatment recommendations because I’ll use that as an opportunity to have a discussion based on their specific needs. For some patients, it’s not a big deal to take off 2 months for treatment. Other patients don’t have that capacity. Even a simple thing such as streamlining treatments can have a large impact on combating financial toxicity.”

References

1. Smith GL, Banegas MP, Acquati C, et al. Navigating financial toxicity in patients with cancer: a multidisciplinary management approach. CA Cancer J Clin. 2022;72(5):437-453. doi:10.3322/caac.21730
2. Thom B, Aviki EM, Chino F. Implementing financial toxicity and health-related social risks screening and referral. J Clin Oncol. 2024;42(suppl 16):11006. doi:10.1200/JCO.2024.42.16_suppl.11006
3. Talking to employers and medical staff about breast cancer treatment and your job. ClinicalTrials.gov. Updated March 25, 2024. Accessed July 10, 2024. https://clinicaltrials.gov/study/NCT03572374
4. Cancer Financial Experience (CAFE). ClinicalTrials.gov. Updated April 19, 2024. Accessed July 10, 2024. https://clinicaltrials.gov/study/NCT05018000
5. Financial navigation program to improve understanding and management of financial aspects of cancer care for patients and their spouses (CREDIT). ClinicalTrials.gov. Updated May 6, 2024. Accessed July 10, 2024. https://clinicaltrials.gov/study/NCT04960787