How do the Resources Available to Patients With Cancer Differ by Treatment Settings?

State-specific support policies and hospital-led financial navigation programs serve as essential tools for mitigating the socioeconomic burden of oncology care, according to Loretta Nastoupil, MD. In an interview with CancerNetwork®, Nastoupil detailed the divergent financial challenges facing patients in rural community settings vs those at large academic metroplexes, highlighting that "hidden" costs, such as missed work and travel, can dictate treatment feasibility.

The logistical and financial frameworks of oncology care shift significantly based on the delivery setting. Nastoupil, who is currently an oncologist at Southwest Oncology in Durango, Colorado, a community center in a rural setting, but previously practiced at MD Anderson Cancer Center, one of the largest cancer centers in the world, noted that community oncologists in rural areas often provide the primary, long-term delivery of care, involving them deeply in the day-to-day financial intricacies of a patient’s life. Conversely, clinicians at large academic centers frequently serve as tertiary referral points, providing a single second opinion before a patient returns home for local treatment.

In the community setting, the clinical team is more acutely involved in the "cycle-by-cycle" cost management. This is where the risk of financial toxicity is most visible, particularly for patients "living paycheck to paycheck." For these individuals, the decision to continue treatment often hinges on their ability to maintain employment. Nastoupil observed that many patients face the impossible choice of keeping their job to preserve insurance or attending multiple monthly appointments that require missing work.

While community patients face workplace stability issues, those traveling to larger centers encounter high-accrual expenses. These patients, who often have the resources to fly in for consultation, still face significant pressure, like expenses related to hotel stays and transportation which can accrue rapidly if a patient must remain overnight. Large centers also face immense pressure to process high patient volumes efficiently, which can inadvertently increase the stress on the patient-provider relationship. Time becomes a critical resource, making any delays in the system costly both financially and emotionally.

Transcript:

What tools are available to patients with cancer who may need help paying for their treatment? How do those tools differ at community centers vs large centers?

For community oncologists, particularly, they're generally providing a service where the patient lives. In a rural setting, it's going to be a much smaller town, so it can be very rewarding in many ways. When you’re working in a large metroplex or a large academic center, you’re often at a tertiary referral center, so you may be seeing patients who come in for a single opinion and then return home to their community oncologists, where they’re going to be delivering that care. Those are vastly different approaches.

When you’re delivering care that is going to be multiple courses of treatment and not just providing a onetime second opinion, that’s when you’re going to be more involved in the day-to-day [work] in terms of how much a given cycle is going to [cost]. The other thing we sometimes don’t talk about is not just the cost of co-payments, visits, and treatments but the cost for the patient in terms of missed work opportunities. If you have patients who are generally living paycheck to paycheck, they now have a disease where they're going to be missing [work] multiple times a month. I’ve had several situations where patients are trying to decide whether they can keep their job so they can keep their insurance and continue treatment.

This is where oncologists need to become very familiar with state policies. In the state of Colorado, not everyone is eligible, but for most, [the state] can potentially provide some additional support while they're undergoing active treatment so [patients] don’t have to worry as much about missing work and not being able to provide for themselves or their family.

In larger centers, you’re often going to be seeing patients who have the financial resources to travel. Generally, that's a very different situation. Many of these patients are flying in and out, and their time is very critical. If they have to stay overnight, that’s more cost accrued in terms of hotel space. There’s a lot more pressure to get large volumes of patients through the system efficiently. That can also create some additional challenges that I don’t face anymore.