Correlation Identified Between Financial Toxicity and Disparities in Psychosocial, Physical, and Mental Quality of Life in Breast Cancer

Contemporary Concepts | <b>Contemporary Concepts in Breast Cancer</b>

Investigators identified a correlation between financial toxicity significant differences in mental and physical quality of life, and patient satisfaction with breast reconstruction among patients with breast cancer.

Financial toxicity appears to have a correlation with statistically significant and meaningful differences inf BREAST-Q psychosocial wellbeing, as well as well as satisfaction with breast reconstruction and SF-12 global mental and physical quality of life, according to findings from a retrospective study published in the Journal of American College of Surgeons.

The comprehensive score for financial toxicity (COST) for the total population was 28.0 and 27.8 for the reconstruction cohort. Additionally, the BREAST-Q psychosocial well-being score was 72.1, as well as a 92.5 for satisfaction with surgeon. Investigators reported that the SF-12 mental component score was 50.7 and that the physical score was 44.8. Findings were similar for those in the reconstruction cohort. For patients who had reconstructive surgery, satisfaction with breasts received a score of 68.4. Patients who had lower a COST also had lower BREAST-Q and SF-12 scores, with the strongest relationship being BREAST-Q psychosocial well-being, as investigators observed a hazard ratio of 0.89 (95% CI, 0.76-1.03) change per unit in COST score.

A total of 2293 patients were identified, 647 of whom returned their surveys and 532 met inclusion criteria. These criteria excluded male patients, those without breast cancer, who could not be linked to clinical records, or did not complete either the BREAST-Q or COST questionaires.

Among these patients, 64.3% (n = 342) had previously undergone breast reconstruction surgery. Patients had a median age of 58 and the majority were employed at the time of diagnosis (63.7%). Additionally, patients had a median household income of $80,000 to $120,000 and did not experience a change in work hours following their diagnosis. Patients who received reconstruction surgery trended towards being younger and had a higher annual income in addition to being employed at the time of diagnosis.

At the time of diagnosis, 82.1% of patients were stage 0 to II, 57.1% had a lumpectomy, 66.7% underwent radiation, and 66.4% received hormonal therapy. Additionally, 54.7% of patients did not receive neoadjuvant or adjuvant chemotherapy. Of the patients who received breast reconstruction, 98.5% were less likely to undergo treatment with adjuvant chemotherapy and more likely to have a bilateral mastectomy.

The univariant analysis highlighted a positive relationship for all the outcomes. Investigators reported that COST and BREAST-Q psychosocial well-being yielded a moderate correlation in addition to a moderate correlation with the SF-12 mental component (r = 0.52) and physical component (r = 0.41). Additionally, a very weak correlation was noted in the reconstruction group with regard to COST and BREAST-Q satisfaction with surgeon (r = 0.19), as well as a weak correlation with BREAST-Q satisfaction with breasts (r = 0.25).

There was a 5-point difference in COST, which translated to a decrease in BREAST-Q psychosocial well-being (minimal important differences [MID] = 4). There was also a 10-point difference in COST for the SF-12 mental component, which translated to a clinically important difference. Investigators also reported a 10-point difference in BREAST-Q satisfaction with breasts, as well as a 13-point change in COST for the SF-12 physical component; this represented a detrimental correlation with each patient-reported outcomes measure with the exception of satisfaction with surgeon.

Investigators completed a sensitivity analysis for patients with more than 1-year of follow-up and patients who received a mastectomy only. For patients who had more than 1-year of follow-up, a 6-point change in COST was reported compared with 10 points in the overall population. There was no longer an association observed for those who received a mastectomy and COST and BREAST-Q analysis. 

“This study informs the definition of ‘value’ in breast cancer management from the patient perspective. Breast cancer surgery is associated with financial toxicity, and it correlates with significant decreases in both condition- specific and global quality of life. Even small changes in [financial toxicity] are associated with important quality of life reductions,” the investigators concluded.


Coroneos CJ, Lin YL, Sidey-Gibbons C, et al. Correlation between financial toxicity, quality of life, and patient satisfaction in an insured population of breast cancer surgical patients: A single-institution retrospective study. J Am Coll Surg. 2021;232(3):253-263. doi:10.1016/j.jamcollsurg.2020.10.023