Routine financial toxicity screening feasible during cancer treatment
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Routine screening for financial toxicity during active cancer treatment is feasible, according to study results presented at ASCO Quality Care Symposium.
However, efforts must be made to ensure that clinical workflows enable access and referrals to helpful resources for patients who screen positive, researchers concluded.
An interdisciplinary team — led by Emeline Aviki, MD, MBA, gynecologic oncologist and medical director of network integration and strategy at NYU Langone’s Perlmutter Cancer Center — assessed approaches to financial toxicity screening for patients with cancer.
They used the 12-item Comprehensive Score for Financial Toxicity (COST) tool, as well as a health-related social risk checklist, patient self-reports of cost-related medication nonadherence, and a visual analog quality of life scale.
The study took place from June 2022 through December 2023.
Researchers sent a combined 196,675 financial toxicity surveys to 78,289 patients undergoing active treatment for breast, gastrointestinal, gynecologic or thoracic malignancies.
COST scores of 20 or lower, or any reported social risk, resulted in a positive screen that prompted nurses to arrange a financial counseling referral.
In March 2023, machine learning models suggested reducing the screening threshold to COST scores of 16 or lower because several screening dispositions had been unproductive. The machine learning models also recommended decreasing the social risk checklist to food, transportation, medication and housing insecurity.
More than 45,000 patients completed a combined 75,526 surveys (38% completion rate). Survey responses prompted 9,612 financial screening referrals to help with insurance selection and applications for assistance with co-payments, nonmedical costs, and out-of-pocket expenses.
In 2024, researchers reduced the screening to two COST questions that had a 0.92 correlation with the full tool.
“The ability to accurately predict with two questions which patients we can help is not only saving time for providers who are already overworked and overburdened, [but] also saving patients time by decreasing the number who will have to spend time with financial counselors who aren’t necessarily going to help,” Aviki told Healio.
Healio spoke with Aviki about the study findings, their implications and the benefits of accurately matching patients experiencing financial toxicity with appropriate resources.
Healio: How prevalent is financial toxicity in cancer care, and what impact does it have on patients and families?
Aviki: Certain types of cancers have a higher prevalence of financial toxicity than others. Those that require multimodal therapy, multiple visits, multiple imaging studies and more expensive copays are going to be associated with a higher proportion of financial toxicity.
Financial toxicity affects patients in a number of ways. One is cost-coping strategies, which are the patient’s reaction to experiencing financial burdens associated with treatment. We found that many patients forego leisure activities that they might have undertaken otherwise. These are people with cancer who could have a shortened lifespan, and we want them to have experiences and activities that they enjoy. We also find people skipping their medications, people having to mortgage their homes or get a second mortgage on their homes, borrowing money from family members, and skipping appointments and diagnostic testing. We see the effects of this on patients’ daily lives as well as in their ability to complete their treatments.
Healio: Why did you develop and evaluate this screening program?
Aviki: Screening programs alone are not enough. To just screen and learn information without acting upon that information doesn’t help our patients. It helps us understand who they are, but it doesn’t help them in their ability to reduce their financial burden. Our rationale was, if we could identify patients at higher risk for financial toxicity or who are actively experiencing financial burden and get them to the resources that can help, we will break down that barrier. There is an asymmetry between information on patients’ needs and the programs that exist to meet those needs. It is a simple equation, but we learned early on that this connection did not exist. Our goal was to create that link. The first step is screening, and the second step is connection to services and supports.
Healio: How did you evaluate the program and what did you find?
Aviki: We measured how many patients ended up receiving the support that we offered. We called that a “productive visit” or a “productive referral.” Productivity was defined as them receiving either insurance counseling or actual financial resources, whether for medical or nonmedical costs, or copayment support for drugs. We ended up modifying our screening algorithm to improve the productivity of the visits. We changed how we would define financial toxicity and modified it based on how we could help them.
Healio: What is next in your research on this?
Aviki: Our next step is to evaluate the best time point in the course of diagnosis and treatment to initiate screening. Also, we’re currently delivering the survey at a 4-month cadence, and we want to evaluate whether that is too soon or too late. Those are two questions that remain in terms of optimizing our screening protocol. We also are hoping to develop the education piece — we’re hoping to implement an aspect of artificial intelligence to help provide education on insurance.
Healio: Is there anything else you’d like to mention?
Aviki: We are beyond the point of saying, “We need screening programs for financial toxicity.” We do need screening programs, but we also need to get patients we’ve identified based on prior screening efforts to resources that can actually help them. I hope to never again see a study that focuses on the need to screen patients.
Reference:
- Aviki E. Abstract 275. Presented at: ASCO Quality Care Symposium; Oct. 10-11, 2024; Chicago.
For more information:
Emeline Mariam Aviki, MD, MBA, can be reached at emeline.aviki@nyulangone.org.
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