Social Isolation, Financial Toxicity Equate to Risk Factors in Head and Neck Cancer

Sunny Kung

Patients with locally advanced head and neck cancer (LAHNC) should be screened for social isolation and financial hardship, as these factors play a role in their ability to stay on medication, minimize hospital stays, and achieve optimal health outcomes, according to a study presented at the 2016 Multidisciplinary Head and Neck Cancer Symposium, sponsored by the American Society for Radiation Oncology (ASTRO).

The study also concluded that a majority of study patients with LAHNC—which is characterized by high morbidity and high medical costs—resorted to life-altering strategies to cope with the financial burden of their treatment.

These strategies included drawing down savings (62%), borrowing money or using credit (42%), selling possessions (25%), and relying on family members to work longer hours (23%), in order to compensate for the patient’s lower earnings capability (Figure 1). More than two-thirds of study participants (69%) said they resorted to one or more of these strategies.

“Patients with high perceived social isolation have more days in which they take less medication. They have suboptimal medication adherence, they have a higher number of missed appointments, and they also have longer stays in the hospital compared to their peers,” said Sunny Kung, lead author on the study and a second-year student at the University of Chicago’s Pritzker School of Medicine. Increased loneliness caused by isolation should also be considered a risk factor, she said.

There are approximately 60,000 new cases of head and neck cancer each year. Despite a high cure rate (80% at 5 years), physical morbidity and financial toxicity take a heavy and a lasting toll, Kung said. The study followed 73 patients with LAHNC by doing monthly surveys for a half-year period.

Most patients in the study were male (78 percent), Caucasian (74 percent) and covered by private health insurance (54.8 percent). Patients with Medicaid (n=14) had an odds ratio of 42.3 (95% CI, 4.19-4.28) for using more life-altering cost-coping strategies compared with other patients. Those under Medicare (n = 19) had an odds ratio of 0.91 (95% CI, 0.19-4.38) for using more financial coping strategies.

“Those with higher out-of-pocket costs were more likely to use these strategies,” Kung said. Patients had average out-of-pocket costs of $1589, of which $1287 was attributable to direct medical costs that included deductibles, hospital bills, and doctor’s visits; the remainder, $303, was for insurance premiums.

“What was surprising to us, however, was that patients who have perceived social isolation have an odds ratio of 11.5 (95% CI, 1.8-73.8) of using more of these lifestyle altering coping strategies, compared with their peers who have low or moderate perceived social isolation,” Kung said.

The study also examined the prevalence of perceived social isolation among LAHNC patients and its association with socioeconomic factors and healthcare utilization. Researchers identified perceived isolation in 7 of the 73 patients (9.5 percent) prior to treatment. Patients who reported high perceived social isolation were more likely to be unemployed (P = 0.02) and divorced or widowed (P < 0.001).

Among all patients enrolled in the study, the average number of days taking less medication was 6.99, whereas for those with low/moderate perceived social isolation the average was 5.45 days, and for those with high perceived social isolation the average was 21.4 days. The respective numbers of days for missed appointments was, all participants, 3.4; low/moderate, 3.02; high, 7. In-patient hospital days also trended higher for the high perceived social isolation patients: all, 28.1; low/moderate, 27.6; high, 32.7.

Authors of the study drew the following bulleted conclusions based on their findings:

• A majority of patients rely on lifestyle-altering cost-coping strategies to manage the financial side effects of head and neck cancer care.
• Lack of social support coupled with increased loneliness is a risk factor for sub-optimal medication adherence, missed appointments, and longer length of hospital stay.
• Assessing for factors such as financial burden, loneliness, and social support is imperative to provide optimal care for patients. “Physical side effects are not the only ones our patients endure,” said Kung. ”Our findings indicate that the majority of our patients have adopted or will adopt strategies to cope with the financial side effects of their care.”

“Social interventions can be introduced for patients who feel isolated in order to minimize financial burden while maximizing effective health care utilization. For example, providers can work with patient navigators to improve adherence to medical care among vulnerable populations,” she added.

S. Kung, J. O'Connor, B. J. Yap, et al. Cost-coping strategies and perceived social isolation in locally advanced head and neck cancer. Presented at: 2016 Multidisciplinary Head and Neck Cancer Symposium; February 18-20, 2016; Scottsdale, AZ. Abstract 323.

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