One-third of GI cancer patients have high levels of financial toxicity

Last Updated: 2020-04-07

By Lisa Rapaport

(Reuters Health) - Many patients with gastrointestinal (GI) cancers experience biopsychosocial distress related to treatment costs or money troubles associated with their diagnosis, a recent U.S. study suggests.

Researchers administered a proprietary 48-question biopsychosocial distress screening tool to 1,027 patients with GI malignancies between 2009 and 2015. Responses were recorded on a 5-point Likert scale from 1 (not a problem) to 5 (very severe problem), with responses rated at 3 or higher indicative of distress.

Overall, 34% of patients indicated that they had a high level of biopsychosocial distress with respect to their financial situation. Similarly, approximately 40% of patients reported high levels of distress with difficulties related to pain, fatigue, and sleeping. In addition, problems with anxiety and depression caused high levels of distress in 27% and 23% of patients, respectively.

"Income and stress were directly related," said senior author Dr. Susanne Warner of City of Hope Comprehensive Cancer Center in Duarte, California.

Numerous direct and indirect costs of cancer care have a great impact on patients and their families, Warner and colleagues write in Surgery. Direct out-of-pocket expenditures can include medications, medical equipment and supplies, physical or other therapies, nutritional supplements, new clothing to accommodate weight fluctuations, and travel expenses to and from treatment appointments. Indirect costs can include lost wages for patients and family members who help care for them.

On multivariable logistic regression analysis, age greater than 65, completing a college education, and an income greater than $40,000 per year were all protective against financial toxicity.

Across the board, income of greater than $100,000 was protective against stress about social concerns like finances, insurance, and accessing community resources, Warner said by email. This protection extended in to biological and psychological concerns as well, with people making more than $100,000 a year reporting less fatigue, pain, trouble sleeping, trouble climbing stairs, swelling, anxiety, and depression.

"Simply put, having cancer is hard," Warner said. "But having cancer and being poor is a lot harder than having cancer and being rich."

Heavy smokers and patients who spoke languages other than English also had a higher risk of financial toxicity than other people in the study.

One limitation of the study is that researchers lacked data to link responses in distress screenings to individual patient clinical information such as stage of cancer or initial date of diagnosis, the study team notes.

In addition, patients who participated in the study were seen at a tertiary referral center (NCCN member institution and NCI-designated comprehensive cancer center) and may not be representative of a broader population of patients including those served at safety net hospitals.

The questionnaire used in this study was also given to patients at different points along their cancer trajectories, which could influence how they respond to questions about distress and financial hardship, said Dr. Ryan Nipp, an assistant professor at Harvard Medical School and Massachusetts General Hospital in Boston who wasn't involved in the study.

"Limited tools are available that have been validated to screen for financial toxicity, and thus this limits clinicians' ability to implement financial toxicity screens into routine practice and also restricts researchers' ability to compare rates of financial toxicity across studies," Nipp said by email. "Additionally, the study design limits our ability to establish causal links or determine mechanisms of the results of this study."

At the same time, the results add to the evidence from prior research suggesting that financial toxicity can contribute to negative physical and mental health outcomes for cancer patients, Nipp said.

"Collectively, findings from this study highlight the need to develop and test interventions targeting the financial toxicity experienced by patients with cancer," Nipp said. "Patients and families experiencing financial distress should communicate their concerns with their oncology team and inquire about the availability of resources such as social work, patient navigation, and/or financial assistance."

SOURCE: https://bit.ly/2JNdfl1 Surgery, online March 18, 2020.