Financial Toxicity Associated with Cancer Care Impacts Nearly 50% of Women with Gynecologic Cancer and Disproportionately Affects Young, Non-White Patients

To cope with costs, patients report medication non-adherence which may lead to worse health outcomes

BOSTON – The cost of cancer care in United States was an estimated $183 billion in 2015 and is projected to rise by 30 percent by 2030, according to the American Cancer Society. While private and government insurance may cover much of the cost of care, even patients with insurance can struggle to pay for office visit co-payments, prescription medications or other cancer-related expenses. Yet limited data describes how financial hardship impacts patient behavior and how that in turn may impact patient health.

In a new study designed to provide a more comprehensive picture of how a diverse cohort of gynecologic cancer patients are affected by financial distress — also called “financial toxicity” in acknowledgment of the health hazards it can pose — researcher-physicians at Beth Israel Deaconess Medical Center (BIDMC) and the University of Alabama at Birmingham (UAB) analyzed previously collected survey data of gynecologic oncology patients from their respective institutions. Their findings are reported in the International Journal of Gynecological Cancer.

“To broaden our understanding of financial toxicity in gynecologic oncology, we combined data from our two very geographically distinct institutions – Beth Israel Deaconess Medical Center in Boston and the University of Alabama at Birmingham – to create a diverse cohort of patients,” said corresponding author Katharine M. Esselen, MD, MBA, a physician-researcher in the Division of Gynecologic Oncology in the Department of Obstetrics and Gynecology at BIDMC. "Yet despite the many differences in the demographic characteristics of the surveyed patients at each institution — including important risk factors for financial toxicity, such as race, income, education, employment status, and insurance status — patients had a similar risk of financial toxicity.”

Using the Comprehensive Score for Financial Toxicity (COST) to measure the economic burden experienced by patients with cancer, Esselen and colleagues analyzed previously collected survey data from 308 patients with gynecologic cancer — 240 patients surveyed at BIDMC and 121 surveyed at UAB. The team adapted a proposed grading scale to define three groups: no/mild, moderate, and severe financial toxicity and evaluated the frequency of financial toxicity among each group. They found that nearly half of patients with gynecologic cancer re-ported experiencing moderate to severe financial toxicity.

Further analysis of survey data revealed that younger patients were at greater risk of experiencing financial toxicity for a variety of reasons. Younger patients are not eligible for Medicare, and diagnosis and treatment may impact their ability to work. They have also had fewer earning years to accumulate a financial safety net.

Patients reporting severe financial toxicity accounted for 15 percent of those surveyed. Esselen and colleagues found this group more likely to report changing spending habits and borrowing money due to the costs of cancer care. Most alarmingly, those reporting severe financial hardship were nearly five times more likely to attempt to cope with the high cost of care through medication non-compliance.

“Our study confirms that financial toxicity is a very common problem among patients with gynecologic cancers and that there are increasingly worrisome cost-coping strategies employed with increasing severity of the financial toxicity, including medication non-adherence as a cost-coping strategy.,” said Esselen. “As this is a relatively new area of investigation, we need to continue to identify patient and disease characteristics that most contribute to the development of financial toxicity. Further, we need to identify which risk factors are potentially modifiable and begin to design and test interventions to learn how we can better treat financial toxicity.”

Co-authors included senior author Margaret I. Liang of University of Alabama at Birmingham; Annika Gompers, Michele R. Hacker and Meghan Shea of BIDMC; Sara Bouberhan of Massachusetts General Hospital; and Sarah S. Summerlin, Lindsay R. Rucker and Warner K. Huh and Maria Pisu of University of Alabama at Birmingham.

This work was supported in part by the National Institute of Child and Human Development (5K12HD001258), the Retention and Recruitment Shared Facility at O’Neal Comprehensive Cancer Center (P30CA013148), the National Center for Advancing Translational Sciences, National Institutes of Health (UL 1TR002541), Harvard University and its affiliated academic healthcare centers and the Eleanor and Miles Shore 50th Anniversary Fellowship Program.

The authors declare no competing interests.