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PHOENIX -- U.S. clinicians should routinely monitor women with metastatic breast cancer for signs and symptoms of "financial toxicity" related to the costs of treatment, according to researchers here.

A national survey of 1,054 women with breast cancer showed that nearly 100% of women without insurance either delayed or refused treatment because of cost, reported Stephanie Wheeler, PhD, MPH, of the University of North Carolina at Chapel Hill, and colleagues, at the American Society of Clinical Oncology (ASCO) Quality Care Symposium.

"Clinicians should be attentive to how financial toxicity may be differentially experienced by patients with metastatic disease, where treatment failure and rapidly changing treatment plans may add complexity and stress," Wheeler said.

Health insurance expansion is a necessary, but insufficient strategy to address this financial burden, she pointed out, adding that interventions to prevent and mitigate cancer-related financial harm are urgently needed.

The survey showed that 35% of women were uninsured, and that these women more often reported refusing or delaying treatment due to cost (96% versus 36% of insured patients, P<0.001). However, patients with insurance reported higher cost-related emotional distress. This included being "quite a bit" or "very" stressed about not knowing cancer costs (41% versus 24% for uninsured patients, P<0.001) and about financial stress on their family due to their cancer (36% versus 19%, respectively, P< 0.001).

"Our study shows that the financial toxicity of cancer is alarmingly high in many metastatic breast cancer patients and that having health insurance doesn't protect patients from the psychosocial impact of high cancer costs," said Wheeler. "High co-insurance and deductibles mean that many patients are still shouldering an enormous financial burden out-of-pocket and feeling anxious about what it will mean for their own and their families' finances and financial legacy."

Patients Prefer Upfront Cost Discussion

In a second survey of the financial burden experienced by women with breast cancer, 79% said they preferred to know the cost of treatment upfront before embarking on care. However, 78% also said that they never discussed costs with their cancer care team.

The findings were presented by Rachel Adams Greenup, MD, MPH, of Duke University Medical Center in Durham, North Carolina. "Cost transparency may improve the quality of preference-sensitive treatment decisions and reduce the risk of financial harm," she said.

In the study, 607 women with a history of breast cancer (stage 0-III) completed an 88-question electronic survey. Even though 70% had private insurance and 25% had Medicare and an annual household income of ≥$74,000, 15.5% still said they were struggling with a "significant" or "catastrophic" financial burden.

Greenup pointed out that the women who did report discussing costs with their cancer care teams were more likely to have stage II or III breast cancer (56% versus 40%), were less likely to be depressed (24% versus 30%), and had less insurance coverage compared with those who did not have discussions about treatment costs.

The survey showed that the highest risks of financial harm were associated with:

• Bilateral mastectomy with or without reconstruction versus lumpectomy: odds ratio 1.9 (P<0.03)
• Greater stage at diagnosis, stage III versus 0: OR 3.9 (P<0.01)
• Cost discussion during the clinical encounter: OR 2.3 (P<0.01)

Women who discussed costs during their medical visit may have proactively raised the issue because they faced greater financial vulnerability, Greenup explained.

While median out-of-pocket expenses were $3,500, 25% of women reported paying ≥$8,000 for additional treatment-related expenses, while 10% said they paid ≥$18,000, and 5% reported out extra care costs >$30,000.

Factors associated with a decreased risk of financial harm included older age (OR 0.95, P<0.01), increasing household income, better insurance coverage (OR 0.50, P<0.001), and longer time since diagnosis (OR 0.65, P<0.001).

Greenup emphasized that because the majority of women surveyed were white, well-educated and had insurance, women with breast cancer in general in the U.S. may experience even greater risk of financial harm than the study participants.

Nearly 20% of Older Patients Hit With Financial Toxicity

A third study in older patients with cancer showed that almost one-fifth experienced financial toxicity based on three outcome measures of anxiety, depression, and quality of life (QoL).

The secondary analysis of baseline data from an intervention study in 542 patients (mean age 77) revealed that 18% (98) delayed filling prescriptions, had insufficient monthly income for basic needs such as food and housing, and suffered from increased anxiety and depression as a result of paying for cancer care.

"The majority of patients with cancer are older, which means they're living on restricted incomes and often don't want to burden either their caregivers or kids," said Supriya Gupta Mohile, MD, of the University of Rochester Wilmot Cancer Institute in New York. "This is a vulnerable group we haven't paid enough attention to as a society but really need to, especially as the older population continues to grow."

Based on these findings, co-author Asad Arastu, a medical student at the University of Rochester, said clinicians can screen at-risk older patients by asking the following three questions:

• Have you ever delayed medications due to cost?
• Have you ever had insufficient income in a typical month for food or housing?
• Have you ever had insufficient income in a typical month for other basic needs?

"Older patients with advanced cancer who experience income and cost-related barriers to quality cancer care reported worse anxiety, depression, and QoL than those without financial toxicity," Arastu said. "Given the association between financial toxicity and these outcomes, these three financial questions may help identify vulnerable older patients and allow providers to intervene sooner and thereby enhance the quality of care patients receive."

When compared with patients without the financial burden of paying for cancer care, patients suffering from financial toxicity had more severe anxiety and, on average, scored 1.76 higher on the Generalized Anxiety Disorder-7 scale (P<0.01). They also had more severe depression, as indicated by a score that was on average 0.76 points higher on the Geriatric Depression Scale (P=0.02).

Finally, their QoL score was on average 5.16 points lower on the Functional Assessment of Cancer Therapy Scale-General (FACT-G scale) than those without financial toxicity (P<0.01).

The study also showed that oncologists discussed cost issues in only half of the patients experiencing financial toxicity.

"As oncologists, we see the burden of high treatment costs on our patients every day," said Timothy D. Gilligan, MD, ASCO expert and chair symposium news planning team in a statement. "Many of them are skimping on needed medication, liquidating their savings, and taking other extreme measures to control costs. These studies reaffirm the important role we can play in initiating and guiding conversations about cost of cancer care with our patients so that together we can make the best possible treatment decisions."