Financial toxicity, cost-coping strategies common among diverse gynecologic cancer cohort
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Nearly half of a geographically diverse cohort of women with gynecologic cancer reported financial toxicity, which appeared associated with cost-coping strategies, according to a study in International Journal of Gynecological Cancer.
Among the cohort of women from Beth Israel Deaconess Medical Center (BIDMC) in Boston and The University of Alabama at Birmingham (UAB), nearly 15% had severe financial toxicity and increased risk for medication noncompliance.
“There is some evidence that patients who experience severe financial toxicity may be at risk for worse health and cancer outcomes,” Katharine McKinley Esselen, MD, MBA, assistant professor of obstetrics and gynecology at BIDMC at Harvard Medical School, told Healio. “I am motivated to understand the complex problem better so that we might be able to intervene to improve the quality of care and quality of life for our patients struggling with serious illness and, in doing so, maybe even improve their cancer treatment outcomes.”
Esselen and colleagues analyzed survey data of 308 women with gynecologic cancer (median age, 61 years; range, 52-69; 79% white; 14% Black), including 187 at BIDMC who received gynecologic oncology care at any point during treatment, including during active therapy or surveillance, and 121 who started a new line of therapy for new or recurrent gynecologic cancer within the last 8 weeks.
“In this study, we combined data from two geographically and demographically diverse cohorts of [women with gynecologic cancer] to broaden our understanding of financial toxicity as measured by the Comprehensive Score for Financial Toxicity [COST] tool,” Esselen said. “We used the larger cohort of patients to examine different levels of financial toxicity to understand its impact on patients and their cost-coping behaviors.”
COST, a validated 11-item tool, measures financial distress as it relates to cancer diagnosis and treatment. The researchers used the survey data on patients’ economic and behavior cost-coping strategies and the COST tool to assess the frequency of financial toxicity at three COST levels — none/mild, moderate and severe — and associated risk factors. They also measured the association of financial toxicity with notable cost-coping strategies, such as medication noncompliance and economic behavior changes, stratified by financial toxicity severity.
Esselen and colleagues used chi-square, Fisher’s exact and Wilcoxon rank sum tests to compare groups, and calculated adjusted risk ratios (aRRs) for cost-coping strategies with Poisson regression.
Results showed 14.9% of all women had severe financial toxicity, 57% (n = 26) of whom were in the BIDMC cohort and 43% (n = 20) of whom were from UAB. In addition, nearly one-third (32.1%) of women had moderate financial toxicity, whereas 52.9% had mild or no financial toxicity.
Factors associated with worse financial toxicity included younger age (median, 54 years for severe vs. 60 years for moderate vs. 63 years for none/mild), “non-white” race, lower education, unemployment, lower household income (median, $37,500 for severe and moderate vs. $87,500 for none/mild), use of systemic therapy and shorter time since diagnosis (P < .05 for all).
Women with moderate or severe financial toxicity were significantly more likely to use economic cost-coping strategies, including changing spending habits (moderate, aRR = 2.7; 95% CI, 1.8-4; severe, aRR = 3.6; 95% CI, 2.4-5.4) and borrowing money (moderate, aRR = 5.5, 95% CI, 1.8-16.5; severe, aRR = 12.7; 95% CI, 4.3-37.1). Among the severe group, women had a significantly higher risk for behavioral cost-coping through medication noncompliance (aRR = 4.6; 95% CI, 1.2-18.1).
“I was surprised at the number of patients with severe toxicity and that those with severe toxicity were nearly five times as likely to employ behavioral changes such as medication noncompliance to cope with their financial toxicity,” Esselen said.
“We know there are some risk factors for financial toxicity ... [but] until there is universal screening for this, providers and the cancer care community need to be willing to discuss financial concerns with their patients,” Esselen added. “Simply asking if patients have any financial concerns may prove to enhance the relationship you are building with your patients. And like so many of the problems our patients face, we don’t have all the solutions, but we can acknowledge the problem, express empathy and work with our patients and local resources to address their concerns and hopefully decrease their need to use medication nonadherence as a cost-coping strategy.”
Limitations of the study include differences between the BIDMC and UAB groups in time since diagnosis and systemic therapy use and that the COST tool asked patients for their experience of the last 7 days at different points in their cancer trajectory. Researchers also noted that although the cohort was geographically diverse, it was limited to two institutions.
“There is so much work still to be done in understanding the drivers of financial toxicity, how financial toxicity may or may not change over the course of gynecologic cancer treatment and survivorship, and its true impact on survival and other health care outcomes,” Esselen said. “Ultimately, we aim to use all the knowledge from this study and ongoing areas of investigation to develop a more comprehensive financial navigation program through which we can streamline the support and care our patients receive, but also learn more about how to most effectively screen our patients and what study-specific interventions may ameliorate financial toxicity at local institutional and potentially health policy levels.”
For more information:
Katharine McKinley Esselen, MD, can be reached at Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA 02215; email: kesselen@bidmc.harvard.edu.
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