Are Clinicians Discussing Financial Toxicity With Breast Cancer Patients?

Many breast cancer patients report that clinicians do not engage adequately regarding management of financial toxicity associated with their diagnosis, according to a new survey.

“Patients with cancer can experience disruptions in employment that affect income as well as substantial out-of-pocket costs associated with their care, and studies have shown higher rates of bankruptcy filing among patients with cancer,” wrote study authors led by Reshma Jagsi, MD, DPhil, of the University of Michigan in Ann Arbor. “Financial burden also has been associated with overall distress, lower health-related quality of life, and lower satisfaction with cancer care.”

The researchers looked into the self-reported practices of cancer surgeons, medical oncologists, and radiation oncologists, as well as patients with early-stage breast cancer, regarding discussions and help with financial toxicity. The responses included 73% of surgeons contacted (370 surgeons in total), 61% of medical oncologists (306 in total), 67% of radiation oncologists (169 in total), and 68% of patients (2,502 in total) from a cohort drawn from the Surveillance, Epidemiology, and End Results (SEER) database. The results of the analysis were published in Cancer.

Of the responding medical oncologists, 50.9% reported that someone in their practice often or always discusses the financial issues related to cancer with patients; the same was true of 15.6% of surgeons, and 43.2% of radiation oncologists. Forty percent of medical oncologists “believed themselves to be quite or very aware of the out-of-pocket costs” of the various tests and/or treatments they recommended, compared with 27.3% of surgeons and 34.3% of radiation oncologists.

The patient responses varied significantly according to race/ethnicity. For example, 27.1% of white women reported debt from treatment, compared with 58.9% of black women, 33.5% of Latina women, and 28.8% of Asian women. Only 1.4% of white patients and 1.0% of Asian patients lost their homes due to breast cancer, compared with 4.7% of black patients and 6.0% of Latina patients. Around 21% of white patients reported cutting down in spending on food, compared with 22.5% of Asian patients, 45.2% of black patients, and 35.8% of Latina patients.

Among white patients, 15.2% expressed a desire to speak with clinicians about the impact of breast cancer on their employment or finances; this was true for 25.4% of Asian patients, 31.1% of black patients, and 30.3% of Latina patients. Of a total of 945 women who expressed worry about their finances, 72.8% indicated that cancer physicians and staff did not help “at least somewhat.” Of the 523 women who did not want to speak with clinicians about finances, 55.4% reported that they had no such relevant discussions.

“For many women, a breast cancer diagnosis no longer causes the physical devastation that it once did,” the authors wrote. “The results of the current study demonstrate that we have gone only part of the way toward our goal. … To cure a patient’s disease at the cost of financial ruin falls short of the physician’s duty to serve, and failure to recognize and mitigate a patient’s financial distress is no longer acceptable.”

Reginald Tucker-Seeley, MA, ScM, ScD, of the University of Southern California and a current Robert Wood Johnson Health Policy Fellow, has done extensive work on the social determinants of health and related topics, and he told Cancer Network that “this study is a much-needed contribution on the financial burden that cancer care causes patients.”

He noted that research into this area often misses an important aspect: a patient or family’s financial situation prior to the diagnosis, which obviously will contribute significantly to the financial toxicity of the diagnosis and treatment itself. “What the findings in this study on the loss of a personal home, food hardship, and financial worry highlight for some families (it seems especially black and Latina patients) is the substantial risk for downward social mobility when confronted with a cancer diagnosis and navigating/managing cancer care,” Tucker-Seeley said.

He said the findings are not particularly surprising, and that an increasing awareness of the potential for financial toxicity is obviously not enough to change practices with many clinicians. “I think we are going to have to figure out a team approach to first having the discussions (that is, what team members are involved and what is their role in facilitating the discussion), and then how to address the problem,” he said, adding that discussions and research should focus across the material, psychological, and behavioral domains.