Prevalence of Financial Toxicity in Older Adults with Cancer Suggests Need for Interventions

The results of one study suggested that older adults with advanced cancer may be at a higher risk for financial toxicity compared with those undergoing treatments for other chronic conditions.

A study published in JAMA Network Open suggested that older adults with advanced cancer may be at a higher risk for financial toxicity, or unintended and unanticipated financial burden related to the receipt of cancer care, compared with those undergoing treatments for other chronic conditions.

In addition, the study also revealed the prevalence of cost conversations among patients experiencing financial toxicity, advocating for health care providers to have direct conversations with patients and their families.

“Based on our results, discussions for themes of statements about cost of care, indirect consequences associated with the inability to work, and cost burden in nontreatment domains are more likely to be initiated by the patient or caregiver,” explained the authors led by Asad Arastu, MD.

In this cross-sectional secondary analysis, investigators evaluated data from the Improving Communication in Older Cancer Patients and Their Caregivers study (NCT02107443), a cluster-randomized trial from 31 community oncology practices across the United States that was conducted from October 29, 2014 to April 28, 2017. In total, 536 patients with advanced cancer who were 70 years or older and answered 3 questions regarding financial toxicity were included.

Among the study participants, 98 (18.3%) reported experiencing financial toxicity, including 59 (60.2%) who were female, 14 (14.3%) who were Black/African American, 91 (92.9%) who were not employed, and 29 (29.6%) who had Medicare as their sole insurance coverage. The mean age was 76.4 years, with a standard deviation of 5.4 years.

On multivariate regression analyses, financial toxicity was correlated with higher levels of depression (β = 0.81; 95% CI, 0.15-1.48), anxiety (β = 1.67; 95% CI, 0.74-2.61), and distress (β = 0.73; 95% CI, 0.08-1.39), as well as lower health-related quality of life (β = -5.30; 95% CI, -8.92 to -1.69).

Of the participants who reported financial toxicity, only 49% indicated they had a conversation with their health care provider about costs. The majority of conversations (79%) were found to be initiated by oncologists or patients, suggesting a possible gap between patient desires and practice.

Ultimately, 4 themes were generated from the studied cost conversations, including:

  • comments regarding cost of care
  • capacity to afford medical prescriptions
  • indirect consequences associated with inability to work and provide for family
  • cost burden in nontreatment domains

“Patients and oncologists may be reluctant to bring up costs for a variety of reasons,” the study authors noted. “Patients may feel ashamed or embarrassed discussing personal finances and oncologists may not feel equipped to handle or comfortable with these conversations.”

In the current analysis, the investigators found that when concerns were addressed, patients were referred to social workers, financial specialists, and medication assistance programs. However, one barrier for use of such programs is difficulty in assessing financial toxicity.

The investigators indicated that it is therefore critical that an efficient screening tool is provided moving forward to pinpoint patients at high risk for financial toxicity. It was recommended that providers implement a screening tool such as the 3-question survey employed in this study to broach the topic of financial toxicity among older patients with cancer.

“Ultimately, an intervention may need to be implemented to help those at risk avoid [financial toxicity] from ever developing,” the authors concluded. “Future directions of study may include validation of our 3-question tool, and eventually a multi-institutional collaborative effort to hypothesize and implement strategies to decrease the chance of [financial toxicity] developing.”


Arastu A, Patel A, Mohil SG, et al. Assessment of Financial Toxicity Among Older Adults With Advanced Cancer. JAMA Network Open. 2020;3(12):e2025810. doi:10.1001/jamanetworkopen.2020.25810

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