Financial toxicity associated with poorer head and neck cancer survival outcomes
Click Here to Manage Email Alerts
Patients with head and neck cancer who reported high financial toxicity at baseline appeared nearly twice as likely to experience poor outcomes, according to study results published in Oral Oncology.
The research is the first of its kind to examine patients’ financial worry as they begin cancer treatment and how it predicts the likelihood that treatment will be successful, according to the investigators.
“Does financial worry impact survival? The answer is, resoundingly, yes,” Anurag Singh, MD, professor of oncology and director of radiation research at Roswell Park Comprehensive Cancer Center, said in a press release.
The study by Singh and colleagues included 284 patients with head and neck cancer (median age, 61 years; 77.5% men), 41 (14.4%) of whom reported high baseline financial toxicity.
Results of a multivariable analysis showed patients with high financial toxicity had worse OS (HR = 1.75; 95% CI, 1.05-2.94) and cancer-specific survival (HR = 2.28; 95% CI, 1.31-3.96) than those with low financial toxicity. Additionally, in a matched-pair analysis of 66 patients, high financial toxicity remained associated with worse OS (HR = 2.72; 95% CI, 1.04-7.09) and cancer-specific survival (HR = 3.75, 95% CI, 1.22-11.5).
Healio spoke with Singh about the study, possible causes of financial toxicity among this patient population and what can be done to address this issue.
Healio: What motivated you to conduct this research?
Singh: Preclinical work by a colleague of mine, Elizabeth Repasky, PhD, showed the amount of physiological stress acting through the beta-adrenergic receptor that mice were under significantly impacted the function of T cells; specifically, it caused T cells to not leave the tumor-draining lymph node, and that really affected the efficacy of chemotherapy and radiation.
I was fortunate enough to participate in some of that preclinical work and had been thinking about how we could study this in our patients with head and neck cancer. I asked: if it was really beta-2 adrenergic stress preventing T-cell egress from the tumor-draining lymph node, then what are the conditions that might cause you to be really stressed out, to have that sympathetic response? That’s how we got to the financial toxicity question.
There is a host of literature on financial toxicity. One reason that it is so important is it’s thought to change the behavior of patients, such that they don’t make the same treatment choices because they’re concerned about their finances. But that wasn’t necessarily what drove the findings of our study.
In our study, all of the patients had chemotherapy and radiation and, for the most part, equivalent access to care. There were no financially determined decision-making processes involved to explain the decrease in survival. That was an indication that the psychological stresses that patients undergo may actually impact their sympathetic nervous system, which in turn can impact their immune system and their response to chemotherapy and radiation.
Healio: What are the root causes of financial toxicity in this patient population?
Singh: Head and neck cancer gets treated with surgery, chemotherapy and radiation. You don’t just have the cost of one or two modalities; these patients have to pay for all three treatments. Whether you have insurance or not, that makes it intensive in terms of the number of interactions you have with the health care system.
Patients with head and neck cancer have the highest level of financial toxicity. And it may not just be how much an actual treatment costs — but also from how they feel and their functional status during the treatment.
For instance, because patients feel quite unwell toward the end of treatment, a physically intense job, like construction work, is not really something you can continue to do if you’re undergoing chemotherapy and radiation.
So, you have these twin problems of all of these expenses and possible challenges to your income, which results in high levels of financial toxicity across the board. Patients with head and neck cancer have an exceptionally good survival rate, especially at high-volume centers like ours, and so these challenges are worth it.
Healio: Within the study, you write variables such as household income and education level were not available for analysis. How important is it to develop a comprehensive instrument to measure a patient’s financial difficulties?
Singh: There are a lot of factors that go into the financial toxicity and currently, none of the validated instruments cover all of the aspects that we’d want. There are social and psychosocial aspects to financial toxicity that aren’t well covered. We’re trying to take all of that into account and create our own instrument that will capture all of these aspects.
Healio: What do you think drives the association between poorer OS and financial toxicity?
Singh: I can’t say for sure. However, I suspect that financial worry triggers the stress of the sympathetic fight or flight response and the beta-2 adrenergic response from that impedes the immune system. Blood markers could be used to test that hypothesis. Unfortunately, not all of my patients have stored blood samples. We’ll have to do that in the future to answer the question.
Healio: Do you think this association could be replicated among patients with other cancer types?
Singh: We do. There is already some evidence suggesting that patients with cancer who undergo bankruptcy after treatment have worse survival outcomes. The next question has always been, “Yeah, but, were they doing less well and that’s why they went bankrupt?” In our case, the answer should be: They were not less well because we used match pairing to account for baseline differences except for financial toxicity. We’re already starting to collect financial toxicity information in breast and prostate cancer. Hopefully, as the data mature, we’ll be able to discuss it in even more specific types of cancers.
Healio: You wrote financial toxicity can alter a patient’s decision-making, potentially causing them to forgo therapy. That’s pretty concerning, right?
Singh: Absolutely. And although that’s not the context of our study, it is a major concern that, financial stress will alter patient behavior and keep them from choosing treatments that are proved to be beneficial. You see situations where a patient with a really high-deductible insurance policy who has paid through December changes decisions in January because their high deductible has kicked in again.
Healio: What are the steps the cancer care community can take to address and help alleviate financial toxicity?
Singh: For the last 3 years, we’ve offered all our patients financial counseling, letting them know exactly what their costs will be. That’s not necessarily changing the economics, which is really beyond our purview as physicians, but it is removing the unknown variable, so people aren’t being surprised. Often, you’re much more worried about costs that you don’t know are going to occur. Taking away the unknown tends to stabilize patients’ level of financial toxicity.
In this paper, we looked at baseline financial toxicity. For patients who didn’t have financial counseling, financial toxicity increased over time, whereas if you give financial counseling, it doesn’t.
If we’re eventually able to show the mechanism that changes patients’ outcomes from financial toxicity, we can address it. For instance, if it turns out to be the beta-2 adrenergic receptor, I could consider giving everyone with financial toxicity a drug that blocks that. A lot of antihypertension drugs that are very cheap and relatively safe do that.
We’re not going to make a change like that without evidence, but that’s why it’s so important to understand the physiological basis for the survival difference.
Healio: Is there anything else you would like to add?
Singh: This is a global issue, and we’re looking to not limit it to head and neck cancer. We look forward to analyzing it in other patients, as well.
References:
- Chen M, et al. Nat Comm. 2020;doi:10.1038/s41467-020-15676-0.
- Ma SJ, et al. Oral Oncol. 2021;doi:10.1016/j.oraloncology.2021.105196.
For more information:
Anurag Singh, MD, can be reached at Roswell Park Comprehensive Cancer Center, 665 Elm St., Buffalo, NY 14203; email: anurag.singh@roswellpark.org.
Collapse
Click Here to Manage Email Alerts