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Objectives: Head and neck cancer (HNC) patients experience greater financial toxicity than other cancer patients. Research on financial toxicity has concentrated on patients despite many informal caregivers sharing finances and reducing work hours to provide patient care. Thus, our pilot study: (1) assessed the feasibility of financial toxicity screening of HNC patients and their caregivers, and (2) described financial toxicity levels of HNC patients and their caregivers. Methods: We surveyed English‐speaking adult HNC patients initiating treatment at a National Cancer Institute‐designated Comprehensive Cancer Center and their informal caregivers. This survey assessed demographics and financial toxicity through the Comprehensive Score for Financial Toxicity (COST) measure (0–44 range; lower score indicates higher financial toxicity). Screening feasibility was defined as ≥50% consent rate and ≥60% data completion rate. Results: Our sample included 27 HNC patients and 9 caregivers. They both had slightly lower consent and completion rates than our goals. Patients reported a median COST score of 27 while caregivers reported a median COST score of 16. Approximately 25.9% of patients and 44.4% of caregivers reported high financial toxicity (COST < 17.5). Caregivers reported high concerns about their future financial health and their ability to control the amount of their financial contributions to the patient's care. Conclusions: Patients and caregivers may require additional outreach approaches beyond emailed questionnaires to screen for their financial toxicity systematically. Future research is needed to replicate our results to determine whether differences in financial toxicity occur between patients and caregivers and identify areas of focus for interventions. Level of evidence: IV. Our pilot study administered the Comprehensive Score for Financial Toxicity (COST) measure to head and neck cancer patients and their caregivers. We found that approximately 25.9% of patients and 44.4% of caregivers reported high financial toxicity (COST<17.5). Caregivers reported high concerns about their future financial health and their ability to control the amount of their financial contributions to the patient's care. [ABSTRACT FROM AUTHOR]

Background: Previous research has found that individuals may travel outside their home countries in pursuit of alternative cancer therapies (ACT). The goal of this study is to compare individuals in the United States who propose plans for travel abroad for ACT, compared with individuals who seek ACT domestically. Methods: Clinical and treatment data were extracted from campaign descriptions of 615 GoFundMe® campaigns fundraising for individuals in the United States seeking ACT between 2011 and 2019. We examined treatment modalities, treatment location, fundraising metrics, and online engagement within campaign profiles. Clinical and demographic differences between those who proposed international travel and those who sought ACT domestically were examined using two‐sided Fisher's exact tests. Differences in financial and social engagement data were examined using two‐sided Mann–Whitney tests. Results: Of the total 615 campaigns, 237 (38.5%) mentioned plans to travel internationally for ACT, with the majority (81.9%) pursuing travel to Mexico. Campaigns that proposed international treatment requested more money ($35,000 vs. $22,650, p < 0.001), raised more money ($7833 vs. $5035, p < 0.001), had more donors (57 vs. 45, p = 0.02), and were shared more times (377 vs. 290.5, p = 0.008) compared to campaigns that did not. The median financial shortfall was greater for campaigns pursuing treatments internationally (−$22,640 vs. ‐$13,436, p < 0.003). Conclusions: Campaigns proposing international travel for ACT requested and received more money, were shared more online, and had more donors. However, there was significantly more unmet financial need among this group, highlighting potential financial toxicity on patients and families. [ABSTRACT FROM AUTHOR]

The development and use of immunotherapy in the last decade have led to a drastic improvement in results in the onco-haematological field. This has implied, on the one hand, the need for clinicians to manage a new type of adverse event and, on the other hand, a significant increase in costs. However, emerging scientific evidence suggests that, as with other drugs in the recent past, the registry dosage can be drastically reduced for immunotherapies without penalizing their effectiveness. This would also lead to an important reduction in costs, expanding the audience of cancer patients who could access immunotherapy-based treatments. In this "Commentary", we analyze the available evidence of pharmacokinetics and pharmacodynamics and the most recent literature in favor of low-dose immunotherapy. [ABSTRACT FROM AUTHOR]

Background: Oncology patients have had to make many changes to minimise their exposure to COVID-19, causing stress. Despite education, some patients still do not recognise potential COVID symptoms. Aims: We assessed patient knowledge of COVID, and its impact on their behaviours, concerns, and healthcare experience. Methods: A 16-page questionnaire was distributed to 120 oncology patients attending the day unit of a tertiary Irish cancer centre for systemic anti-cancer therapy (May/June 2020). The Irish 7-day COVID incidence during this period ranged from 2 to 11 cases/100,000 people. Results: One hundred and one responses were received, 1% had tested positive for COVID, and 31% had undergone testing. Participant insight into their knowledge about COVID and their own behaviour was limited in some cases. Seventy-five percent reported total compliance with restrictions, but many were not fully compliant. Self-reported confidence in knowledge was high, but did not predict demonstrated knowledge. Sixty percent did not recognise two or more symptoms; 40% did not self-identify as high-risk. Patients reported more health-related worry (72%), loneliness (51%), and lower mood (42%) since the pandemic began. Financial toxicity worsened, with increased financial worry (78%), reductions in household income (40%), and increased costs due to lockdown (62%). Use of facemasks introduced new communications barriers for 67% of those with hearing loss. Conclusions: Despite self-reported confidence in knowledge, some patient's recognition of COVID symptoms and the preventative strategies they should use are not optimal, highlighting the need for further education in this regard. COVID has been a significant stressor for patients and more practical, financial, and psychological supports are needed. [ABSTRACT FROM AUTHOR]

ABSTRACT Objective: to assess the financial toxicity of people with chronic kidney disease undergoing hemodialysis treatment. Method: a descriptive analytical cross-sectional study, carried out with 214 people, between February and May 2022. For data collection, a sociodemographic and clinical instrument and the COmprehensive Score for financial Toxicity were used. For analysis, the Odds Ratio, ANOVA and Cronbach’s alpha tests were used. Results: the mean financial toxicity score was 20.30. Women with a monthly family income of at most two minimum wages are more likely to have some degree of financial toxicity (Odds Ratio: 0.85; 0.76). Conclusion: financial toxicity was identified to different degrees and varied according to sociodemographic and clinical characteristics. Measuring financial toxicity can help nurses plan care and develop strategies to avoid interrupting treatment.

BackgroundAcute care (AC) visits by cancer patients are costly sources of healthcare resources and can exert a financial burden of oncology care both for individuals with cancer and healthcare systems. We sought to identify whether cancer patients who reported more severe initial financial toxicity (FT) burdens shouldered excess risks for acute care utilization.MethodsIn 225 adult patients who participated in the Economic Strain and Resilience in Cancer (ENRICh) survey study of individuals receiving ambulatory cancer care between March and September 2019, we measured the baseline FT (a multidimensional score of 0–10 indicating the least to most severe global, material, and coping FT burdens). All AC visits, including emergency department (ED) and unplanned hospital admissions, within 1-year follow-up were identified. The association between the severity of FT and the total number of AC visits was tested using Poisson regression models.ResultsA total of 18.6% (n = 42) of patients had any AC visit, comprising 64.3% hospital admissions and 35.7% ED visits. Global FT burden was associated with the risk of repeat AC visits within 1-year follow-up (RR = 1.17, 95% CI 1.07–1.29, P < 0.001 for every unit increase), even after adjusting for sociodemographic and disease covariates. When examining subdimensions of FT, the burden of depleted FT coping resources (coping FT) was strongly associated with the risk of repeat AC visits (RR = 1.27, 95% CI 1.15–1.40, P < 0.001) while material FT burden showed a trend toward association (RR = 1.07, 95% CI 0.99–1.15, P = 0.07).ConclusionIn this prospective study of acute oncology care utilization outcomes among adult cancer patients, FT was a predictor of a higher burden of acute care visits. Patients with severely depleted material and also practical and social coping resources were at particular risk for repeated visits. Future studies are needed to identify whether early FT screening and intervention efforts may help to mitigate urgent acute care utilization burdens.

Immune checkpoint inhibitors (ICI) were approved in June 2018 for second line treatment of metastatic cervical cancer after progression on platinum-based chemotherapy. A cohort of 10 patients who received single agent ICI as second line treatment was examined, with an initial analysis published in July 2021. We performed an updated review of the duration of treatment response, outcome off treatment after 2 years of therapy, and outcome after re-initiation of ICI. Excluding 4 patients from the original report who subsequently experienced progression of disease and/or death, 6 patients were followed for 40 months (range, 39.2–50.8 months), and all achieved complete response (CR) as their best response after prolonged treatment, including 3 with initial partial response (PR). Four patients discontinued treatment, and two developed asymptomatic recurrence, were both re-initiated on ICI, and reached a CR and PR. The combined positive score (CPS) was variable among responders and non-responders, but levels were highest among the 2 patients off treatment who remained without evidence of disease. This update on prolonged follow up demonstrates that patients who respond to immune checkpoint inhibitors may deepen their response with prolonged treatment, have durable response off treatment and respond again to re-treatment in the event of recurrent disease. A higher CPS score may predict prolonged remission off treatment.

The Emotional Well-Being and Economic Burden (EMOT-ECON) Research Network is one of six research networks funded by the National Institutes of Health (NIH) to advance research about emotional well-being (EWB), and the only one that focuses on addressing how economic burden due to disease or illness affects EWB. The network convened researchers, patients, patient advocates, health care providers and other stakeholders from across the US to discuss the significance of addressing the impact of the economic burden of disease on EWB, the complexity of this prevalent problem for patients and families, and the research gaps that still need to be studied to ultimately develop strategies to reduce the impact of economic burden of disease on EWB and health. Participants identified some important future areas of research as those investigating: (i) prevalent and relevant emotions for patients experiencing economic burden of disease and financial hardship, and how their broader outlook on life is impacted; (ii) constructs and contexts that influence whether the economic burden is stressful; (iii) strategies to deal and cope and their positive or negative effects on EWB and health; and (iv) multi-level and multi-stakeholder interventions to address economic factors (e.g., costs, ability to pay), administrative burdens, education and training, and especially patients’ emotional as well as financial status.

BackgroundFinancial toxicity (FT) reflects multi-dimensional personal economic hardships borne by cancer patients. It is unknown whether measures of FT—to date derived largely from English-speakers—adequately capture economic experiences and financial hardships of medically underserved low English proficiency US Hispanic cancer patients. We piloted a Spanish language FT instrument in this population.MethodsWe piloted a Spanish version of the Economic Strain and Resilience in Cancer (ENRICh) FT measure using qualitative cognitive interviews and surveys in un-/under-insured or medically underserved, low English proficiency, Spanish-speaking Hispanics (UN-Spanish, n = 23) receiving ambulatory oncology care at a public healthcare safety net hospital in the Houston metropolitan area. Exploratory analyses compared ENRICh FT scores amongst the UN-Spanish group to: (1) un-/under-insured English-speaking Hispanics (UN-English, n = 23) from the same public facility and (2) insured English-speaking Hispanics (INS-English, n = 31) from an academic comprehensive cancer center. Multivariable logistic models compared the outcome of severe FT (score > 6).ResultsUN-Spanish Hispanic participants reported high acceptability of the instrument (only 0% responded that the instrument was “very difficult to answer” and 4% that it was “very difficult to understand the questions”; 8% responded that it was “very difficult to remember resources used” and 8% that it was “very difficult to remember the burdens experienced”; and 4% responded that it was “very uncomfortable to respond”). Internal consistency of the FT measure was high (Cronbach’s α = 0.906). In qualitative responses, UN-Spanish Hispanics frequently identified a total lack of credit, savings, or income and food insecurity as aspects contributing to FT. UN-Spanish and UN-English Hispanic patients were younger, had lower education and income, resided in socioeconomically deprived neighborhoods and had more advanced cancer vs. INS-English Hispanics. There was a higher likelihood of severe FT in UN-Spanish (OR = 2.73, 95% CI 0.77–9.70; p = 0.12) and UN-English (OR = 4.13, 95% CI 1.13–15.12; p = 0.03) vs. INS-English Hispanics. A higher likelihood of severely depleted FT coping resources occurred in UN-Spanish (OR = 4.00, 95% CI 1.07–14.92; p = 0.04) and UN-English (OR = 5.73, 95% CI 1.49–22.1; p = 0.01) vs. INS-English. The likelihood of FT did not differ between UN-Spanish and UN-English in both models (p = 0.59 and p = 0.62 respectively).ConclusionIn medically underserved, uninsured Hispanic patients with cancer, comprehensive Spanish-language FT assessment in low English proficiency participants was feasible, acceptable, and internally consistent. Future studies employing tailored FT assessment and intervention should encompass the key privations and hardships in this population.

BackgroundMany individuals undergoing cancer treatment experience substantial financial hardship, often referred to as financial toxicity (FT). Those undergoing prostate cancer treatment may experience FT and its impact can exacerbate disparate health outcomes. Localized prostate cancer treatment options include: radiation, surgery, and/or active surveillance. Quality of life tradeoffs and costs differ between treatment options. In this project, our aim was to quantify direct healthcare costs to support patients and clinicians as they discuss prostate cancer treatment options. We provide the transparent steps to estimate healthcare costs associated with treatment for localized prostate cancer among the privately insured population using a large claims dataset.MethodsTo quantify the costs associated with their prostate cancer treatment, we used data from the Truven Health Analytics MarketScan Commercial Claims and Encounters, including MarketScan Medicaid, and peer reviewed literature. Strategies to estimate costs included: (1) identifying the problem, (2) engaging a multidisciplinary team, (3) reviewing the literature and identifying the database, (4) identifying outcomes, (5) defining the cohort, and (6) designing the analytic plan. The costs consist of patient, clinician, and system/facility costs, at 1-year, 3-years, and 5-years following diagnosis.ResultsWe outline our specific strategies to estimate costs, including: defining complex research questions, defining the study population, defining initial prostate cancer treatment, linking facility and provider level related costs, and developing a shared understanding of definitions on our research team.Discussion and next stepsAnalyses are underway. We plan to include these costs in a prostate cancer patient decision aid alongside other clinical tradeoffs.

CONTEXT:Financial toxicity (FT) is used to describe the financial distress/hardship associated with cancer and its treatment. OBJECTIVES:The aim of this review was to explore the relationship between FT and symptom burden. METHOD:A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE, EMBASE, and CINAHL (from January 2000 to January 2018) and accepted quantitative, mixed-methods and qualitative studies. Data were extracted and appraised by two reviewers. Owing to significant heterogeneity in the included studies, a narrative synthesis was performed. RESULTS:Nine studies involving 11,544 cancer survivors were included. Of these nine studies, eight were of high quality. The relationships between FT and psychological symptoms and physical symptoms were examined in eight and three studies, respectively. Six studies reported a positive relationship between FT and depression. Three studies found a positive association between FT and anxiety. Limited evidence was found for an association between FT and stress, fear of recurrence, spiritual suffering, pain, and overall symptom burden. CONCLUSIONS:A relatively clear association exists between FT and psychological symptoms. Clinicians should regularly screen for, assess, and manage emotional distress that may be attributed to FT. Although the causal pathway is not known, future intervention studies aimed at minimizing or preventing FT should evaluate psychological symptoms as secondary outcomes. Little is known about the relationships between FT and physical symptoms. Future research should overcome methodological limitations by incorporating longitudinal data collection, use of mixed-methods approaches, and homogeneity of samples.

Background Cancer patients experience financial hardship due to rising expenses related to cancer treatment and declining income levels associated with reduced employability. Employment Insurance Sick Benefits (EI-SB) is a social income support program which provides temporary income replacement to Canadians when they fall ill. Although EI-SB is designed to maintain continuity of income during an illness, little is known about the perspectives of cancer patients who receive EI-SB. This knowledge can inform the development of public policies which are responsive to the needs and priorities of cancer patients. Methods We conducted a theory-informed thematic analysis of data collected from twenty semi- structured interviews with participants who were receiving care in a cancer centre in Cape Breton, Nova Scotia and had received EI-SB. A coding framework was developed using Taplin and colleagues’ intermediate outcomes of patient care across the cancer care continuum. Interpretation of findings was guided by the synergies of oppression theoretical lens. Results Three overarching themes describe the experiences of cancer patients receiving social income support: Economic exclusion, in which the structure of the labour market and social welfare system determine access to workplace benefits and continuity of reasonable income; financial toxicity, a vicious cycle of financial burden and increasing financial distress; and constrained choices, where cancer influences employability and lowered income influences the need to be employed. Conclusion Cancer patients need income support programs that are tailored to match their healthcare priorities. In addition, policies which strengthen working conditions and facilitate a reintegration to work when possible will be important in addressing the structural drivers of income insecurity experienced by cancer patients.

Abstract Aim We sought to explore unmet needs in transitions of care for critical illness survivors that concern primary care physicians. Findings Semi-structured interviews with primary care physicians identified three categories of concerns about unmet transition needs after patients’ ICU stays: patients’ understanding of their ICU stay and potential complications, treatments or support needs not covered by insurance, and starting and maintaining needed rehabilitation and assistance across transitions of care. Conclusion Given current constraints of access to coordinated post-ICU care, efforts to identify and address the post-hospitalization needs of critical illness survivors may be improved through coordinated work across the health system.

The rising cost of cancer care has shed light on an important aspect of healthcare delivery. Financial toxicity of therapy must be considered in clinical practice and policy-making. One way to mitigate the impact of financial toxicity of cancer care is by focusing on an approach of healthcare delivery that aims to deliver value to the patient. Should value of therapy be one of the most important determinants of cancer care? If so, how do we measure it? How can we implement it in routine clinical practice? In this viewpoint, we discuss value-based care in systemic therapy in oncology. Strategies to improve the quality of care by incorporating value-based approaches are discussed: use of composite tools to assess the value of drugs, alternative dosing strategies, and the use of Health Technology Assessment in regulatory procedures. We propose that there must be a greater emphasis on value of therapy in determining its use and its cost.

BackgroundThe rising economic burden of cancer on patients is an important determinant of access to treatment initiation and adherence in India. Several publicly financed health insurance (PFHI) schemes have been launched in India, with treatment for cancer as an explicit inclusion in the health benefit packages (HBPs). Although, financial toxicity is widely acknowledged to be a potential consequence of costly cancer treatment, little is known about its prevalence and determinants among the Indian population. There is a need to determine the optimal strategy for clinicians and cancer care centers to address the issue of high costs of care in order to minimize the financial toxicity, promote access to high value care and reduce health disparities.MethodsA total of 12,148 cancer patients were recruited at seven purposively selected cancer centres in India, to assess the out-of-pocket expenditure (OOPE) and financial toxicity among cancer patients. Mean OOPE incurred for outpatient treatment and hospitalization, was estimated by cancer site, stage, type of treatment and socio-demographic characteristics. Economic impact of cancer care on household financial risk protection was assessed using standard indicators of catastrophic health expenditures (CHE) and impoverishment, along with the determinants using logistic regression.ResultsMean direct OOPE per outpatient consultation and per episode of hospitalization was estimated as ₹8,053 (US$ 101) and ₹39,085 (US$ 492) respectively. Per patient annual direct OOPE incurred on cancer treatment was estimated as ₹331,177 (US$ 4,171). Diagnostics (36.4%) and medicines (45%) are major contributors of OOPE for outpatient treatment and hospitalization, respectively. The overall prevalence of CHE and impoverishment was higher among patients seeking outpatient treatment (80.4% and 67%, respectively) than hospitalization (29.8% and 17.2%, respectively). The odds of incurring CHE was 7.4 times higher among poorer patients [Adjusted Odds Ratio (AOR): 7.414] than richest. Enrolment in PM-JAY (CHE AOR = 0.426, and impoverishment AOR = 0.395) or a state sponsored scheme (CHE AOR = 0.304 and impoverishment AOR = 0.371) resulted in a significant reduction in CHE and impoverishment for an episode of hospitalization. The prevalence of CHE and impoverishment was significantly higher with hospitalization in private hospitals and longer duration of hospital stay (p

Introduction: Rural women with cancer are at heightened risk of financial toxicity. Financial assistance is an important, yet underexamined, aspect of how patients with cancer cope with financial toxicity. This study aims to examine the types of financial assistance rural women with cancer received during cancer treatment and how they described the impact of that assistance. Material and methods: Using data from interviews with 36 rural women with cancer histories, this study used a qualitative descriptive design to explore the types of financial assistance participants received during cancer treatment. Results: Participants described two forms of financial assistance they received: informal and formal financial assistance. Informal financial assistance was provided by social networks and local communities and included cash support, community fundraisers, and in-kind donations. Formal financial assistance was provided by healthcare systems and charitable organizations and included resource navigation and cash grants. Both forms of financial assistance were helpful for many patients with cancer; however, not all participants who needed financial assistance received it. Discussion: Informal and formal financial assistance are significant forms of support for some rural women undergoing cancer treatment. However, such support is unequally distributed and may exacerbate existing inequalities. Financial assistance is not an adequate substitute for public policy that reduces the economic toll of cancer treatment on patients.

Cancer-related financial hardship (i.e., financial toxicity) has been associated with anxiety and depression, greater pain and symptom burden, treatment nonadherence, and mortality. Out-of-pocket healthcare costs and lost income are primary drivers of financial toxicity, however, income loss is a pronounced risk factor for cancer patients with low incomes. There has been little progress in developing an income intervention to alleviate financial toxicity cancer patients with low incomes. Unconditional cash transfers (UCT), or guaranteed income, have produced positive health effects in experiments with general low-income populations, but have not yet been evaluated in people with cancer. The Guaranteed Income and Financial Treatment (GIFT) Trial will use a two-arm randomized controlled trial to compare the efficacy of a 12-month UCT intervention providing $1000/month to treatment as usual on financial toxicity, health-related quality of life and treatment adherence in people with cancer who have low-incomes. The study will recruit 250 Medicaid beneficiaries with advanced cancer from two comprehensive cancer centers in Philadelphia, obtain informed consent, and randomize patients to one of two conditions: (1) $1,000/month UCT or (2) treatment as usual. Both arms will receive information on financial toxicity and the contact information for their hospital social worker or financial advocate upon enrollment. Participants will complete online surveys at baseline, 3, 6, 9, and 12 months from enrollment to collect patient-reported data on primary (i.e., financial toxicity, health-related quality of life, and treatment adherence) and secondary outcomes (i.e., anxiety, depression, food insecurity, housing stability). Social security records will be used to explore the effect on mortality at 2, 3, and 5 years post-enrollment. Linear mixed-models will be used to analyze all primary and secondary continuous outcomes over time and general estimating equations with a logit link and binary distribution for all binary outcomes over time. Differences between treatment and control groups and treatment effects will be determined using models that control for age, gender, race, baseline food security, baseline housing stability, and baseline ECOG. Findings from this study will have significant implications for the development and implementation of programs and policies that address the financial burden of cancer and other serious illnesses.

BackgroundCancer-related financial hardship is associated with negative clinical outcomes, which may be partially explained by cost-related delayed or forgone care in response to financial barriers. We sought to understand patient experiences facing financial barriers to medical care following a cancer diagnosis.MethodsWe conducted virtual, semi-structured interviews in Fall 2022 with 20 adults with a history of cancer who had experienced cancer-related financial hardship in the prior year. We used template analysis within a pragmatic paradigm, combining constructivist and critical realist theoretical perspectives, to analyze interview transcripts and adapt an existing conceptual framework of financial barriers to care.ResultsThe majority of interviewees identified as women (70%), non-Hispanic white (60%), and reported an annual household income of

Financial toxicity describes the adverse impact patients experience from the monetary and time costs of cancer care. The financial burden patients experience comes from substantially increased out-of-pocket spending that often occurs concurrent with reduced income due to sick leave from work. Financial toxicity is common affecting approximately half of patients with a gynecological cancer depending on the validated instrument used for measurement. Financial toxicity is experienced by patients in three domains: economic hardship affecting patients' material conditions (i.e., medical debt), psychological response (i.e., distress), and health-related coping behaviors that patients adopt (i.e., foregoing care due to costs). Higher financial toxicity among cancer patients has been associated with decreased quality of life, impaired adherence to recommended care, and worse overall survival. In this review, we describe the current literature on financial toxicity, including how it can be assessed with validated tools, the downstream impact on patients, risk factors, and employment concerns of survivors. Whenever possible, we highlight data from research featuring patients with gynecologic cancer specifically. We also review studies with interventions aimed to mitigate financial toxicity and offer the reader real world examples of interventions currently being used. Lastly, we provide an overview of health policy developments relevant to financial toxicity and advocate for innovation in the development and implementation of strategies to decrease the financial toxicity patients experience following a diagnosis of gynecologic cancer. • Financial toxicity results from increased out-of-pocket costs and potential reduced income from work absenteeism. • Universal financial toxicity screening identifies individuals who would benefit from financial navigation services. • Patients may face substantially higher out-of-pocket spending for oral cancer drugs compared to intravenous drugs. • Multi-level interventions are needed to mitigate financial toxicity and improve patients' quality of life. [ABSTRACT FROM AUTHOR]

Financial toxicity (FT), the cumulative financial burden experienced due to medical care, is a well-established adverse effect of healthcare. Patients with BRCA mutations have significantly increased cancer risks compared to non-affected individuals, requiring more frequent screenings and, at times, prophylactic surgery, increasing their risk for FT. Our primary aim in this study was to describe rates of FT among BRCA carriers. We performed a novel, cross-sectional study of FT in BRCA1/2 carriers. Participants were recruited via phone and/or email to complete consents and surveys on REDCap. The FACIT-COST tool, a validated tool for measuring FT, was used to assess FT; scores were divided into tertiles, with high FT defined as COST score < 24. 265 BRCA positive female participants met enrollment criteria; 76 (28.7%) consented to participate and completed the survey. Participants were primarily non-Hispanic White (97.4%), privately insured (82.9%), and employed full time (67.1%). A significant proportion (22.7%) of participants reported delaying or avoiding care secondary to finances. No statistically significant association was seen between financial toxicity groups and analyzed demographics. Participants with high FT were more likely to engage in all surveyed cost-saving measures, with 41.7% of participants reporting delays/avoidance of care due to cost (p = 0.02). This study of FT in BRCA carriers shows that financial toxicity exists as an issue in this high-risk patient population. This work serves as the first description of FT in BRCA mutation carriers and highlights the importance of incorporating routine counseling on cost when discussing recommendations for screening and clinical care with this patient population. • BRCA mutation carriers are at high risk of financial toxicity (FT) due to regular screenings and prophylactic surgery • No studies have evaluated FT in genetic mutation carriers despite known FT risk in patients with breast & ovarian cancers • Financial toxicity exists among BRCA carriers • BRCA carriers with high FT are statistically significantly more likely to engage in all cost-saving measures • 41.7% of patients in our study with high FT report delay or avoidance of care due to cost [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study was to synthesize qualitative research regarding communication of costs and financial burdens between patients and healthcare providers to provide evidence for the subsequent development of intervention programs. Methods: Studies published prior to 11 February 2023 were collected from electronic databases, including PubMed/MEDLINE, MEDLINE (Ovid), Web of Science, EMBASE (Ovid), CINAHL (EBSCO), and ProQuest. A checklist for qualitative research drawn from the Joanna Briggs Institute Reviewer’s Manual was applied to assess the quality of the included studies. Meta-aggregation was performed to synthesize the findings of the included studies. Results: Four synthesized findings were derived from 15 studies: cost communication offered more benefits than drawbacks, and most patients were willing to engage in cost communication; cost communication has been implemented in clinical practice but continued to face shortcomings and barriers; an expected cost communication should take into account timing, location, personnel, personality, and content; healthcare providers required education, information, tools, standardized processes, and policy and organizational support to increase their ability to deliver cost communication. Conclusions: Cost communication can help optimize decision-making and reduce the risk of financial difficulties, as has been widely recognized by patients and healthcare providers. However, a complete clinical practice plan to facilitate cost communication has not yet been created. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this exploratory sequential mixed methods study was to describe the sources of informal financial support used by adolescent and young adult (AYA) cancer survivors and how financial toxicity and demographic factors were associated with different types and magnitudes of informal financial support. Methods: This analysis is part of a larger health insurance literacy study that included pre-trial interviews and a randomized controlled trial (RCT) for AYA cancer survivors. Eligible study participants were 18 years of age, diagnosed with cancer as an AYA (15–39 years), insured, and for the RCT sample less than 1 year from diagnosis. Interview audio was transcribed, quality checked, and thematically analyzed. RCT baseline and follow-up surveys captured informal financial support use. Chi-squared and Fisher’s exact tests were used to assess differences in informal financial support type use and frequency by financial toxicity and AYA demographics. Results: A total of N = 24 and N = 86 AYAs participated in pre-trial interviews and the RCT respectively. Interview participants reported a variety of informal financial support sources including savings, community, family/friends, and fundraisers. However, only half of participants reported their informal financial support to be sufficient. High financial toxicity was associated with the most types of informal financial support and a higher magnitude of use. The lowest income group accessed informal financial supports less frequently than higher income groups. Conclusion: Our study demonstrates that AYA survivors experiencing financial toxicity frequently turn to informal sources of financial support and the magnitude is associated with financial toxicity. However, low-income survivors, and other at-risk survivors, may not have access to informal sources of financial support potentially widening inequities. [ABSTRACT FROM AUTHOR]

Objectives: Patients often struggle with their financial situation during cancer treatment due to treatment-related costs or loss of income. This resulting negative effect is called financial toxicity, which is a known as a side effect of cancer care. This study aimed to evaluate the association between financial toxicity and health-related quality of life among patients with gynecologic cancer using validated questionnaires. Methods: In this multicenter study, patients with gynecologic cancer receiving anti-cancer drug treatment for > 2 months were recruited. Patients answered the COmprehensive Score for Financial Toxicity (COST) tool, EORTC-QLQ-C30, disease-specific tools (EORTC-QLQ-OV28/CX24/EN24), and EQ-5D-5L. Spearman's rank correlation coefficient was used to determine associations. Results: Between April 2019 and July 2021, 109 cancer patients completed the COST questionnaire. The mean COST score was 19.82. Strong associations were observed between financial difficulty (r = − 0.616) in the EORTC-QLQ-C30 and body image (r = 0.738) in the EORTC-QLQ-CX24, while weak associations were noted between the global health status/quality of life (r = 0.207), EQ-5D-5L index score (r = 0.252), and several function and symptom scale scores with the COST score. Conclusions: Greater financial toxicity was associated with worse health-related quality of life scores, such as financial difficulty in gynecologic cancer patients and body image in cervical cancer patients as strong associations, and weakly associated with general health-related quality of life scores and several function/symptom scales. [ABSTRACT FROM AUTHOR]

Objective: To develop a comprehensive understanding of financial toxicity (FT) among patients with lung cancer in China and the major factors affecting FT. Methods: Drawing from a national cross‐sectional survey, which used the validated comprehensive score for financial toxicity (COST) questionnaire, we estimated the prevalence and degree of FT. Patient coping actions were investigated. Pearson's chi tests and multinomial logistic regression were used to evaluate the predictors of FT in patients with lung cancer. Results: The median score of FT was 20 (scored on a range of 0–44, with lower scores indicating more severe toxicity). Altogether, 77% of the sample patients had FT (COST <26), 54.5% had mild FT (COST 14–25), and 22.5% had moderate and severe FT (COST 0–13). Living in the less‐developed western region of China, being male, having a lower educational level, lower annual family income, and advanced stage or worse self‐reported health status were significantly related to higher FT than their counterparts (p < 0.05). Patients with higher FT tended to have a lower level of medical compliance, a higher risk of incurring debts, and reduced living expenditures relative to those with lower FT. Conclusion: Despite China's remarkable progress in the past two decades with regard to Universal Healthcare Coverage, FT still presents a serious challenge for patients with lung cancer. Keen attention must be paid to reducing the disproportionate high financial risks of patients with low socioeconomic status. [ABSTRACT FROM AUTHOR]

Background: Cancer patients with financial toxicity experience psychological distress and often miss medical appointments and quit treatments early, which could be a barrier to the effective management of oral chemotherapy drugs at home. This study explores whether financial toxicity predicts symptoms and unplanned healthcare utilization among cancer patients taking oral chemotherapy at home, which will contribute to the safe management of oral chemotherapy. Methods: Data in this study was from a prospective observational study, which was conducted between October 2018 and December 2019. 151 patients completed the Comprehensive Score for Financial Toxicity at discharge and completed the MD Anderson Symptom Inventory and unplanned healthcare utilization questionnaires after finishing one cycle of oral chemotherapy at home. Regression analyses were conducted to explore the associations of financial toxicity with symptoms and unplanned healthcare utilization. Results: Among 151participants, 88.08% reported severe or moderate financial toxicity, 43.05% reported symptom interference, and 31.79% reported unplanned healthcare utilization while taking oral chemotherapy at home. Patients between the age of 45-60y (p = 0.042) have higher financial toxicity, while those living in urban areas (p = 0.016) have lower financial toxicity. Patients with worse financial toxicity suffered increased symptoms of fatigue, emotional distress, disturbed sleep, and lack of appetite. Consequently, their mood and personal relation with other significant suffered. However, no statistical differences in unplanned healthcare utilization were found among patients with different levels of financial toxicity. Conclusion: Middle-aged adults and those living in suburban or rural areas experienced worse financial toxicity than other groups. Patients with worse financial toxicity experienced more severe psychological symptoms (e.g., fatigue, distress, disturbed sleep, and lack of appetite) and affective interference (e.g., mood and relations with others). Identifying at-risk patients is necessary to offer tailored support for psychological symptom management. [ABSTRACT FROM AUTHOR]

Financial toxicity is recognized as an important adverse effect of cancer treatment that may decrease patients' health-related quality of life (HRQOL). We aim to perform a systematic review and meta-analysis on studies investigating the association of HRQOL and financial toxicity measured with the Comprehensive Score for Financial Toxicity in patients with cancer and survivors. A systematic literature search was completed in PubMed, Web of Science, Cumulative Index to Nursing and Allied Health Literature, and PsycInfo (last update April 2022). Methodological quality of included studies was assessed using the Appraisal Tool for Cross-Sectional Studies and the Critical Appraisal Skills Program Cohort Study Checklist. Where possible, study outcomes were pooled by random-effects meta-analysis. Thirty-one studies were included with a combined sample of 13 481 patients and survivors with more than 25 cancer types from 9 countries. Nineteen different validated HRQOL instruments were used in these studies, with the Functional Assessment of Cancer Therapy – General (n = 9), the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (n = 5), and EQ-5D (n = 5) being the most common. All but one included studies reported that higher financial toxicity was significantly associated with worse HRQOL. Ten HRQOL domains were correlated with financial toxicity, including physical health (r = 0.34-0.66), social health (r = 0.16-0.55), mental health (r = 0.21-0.54), and daily functioning (r = 0.23-0.52). The meta-analysis indicated a moderate correlation between financial toxicity and overall HRQOL as measured by the Functional Assessment of Cancer Therapy instruments (r = 0.49, 95% confidence interval 0.44-0.54). This is the first systematic review and meta-analysis to summarize the literature on the association of financial toxicity and HRQOL in patients with cancer and survivors. Our findings substantiate financial toxicity as a relevant outcome of cancer care that is associated with a decline of HRQOL. • Health-related quality of life (HRQOL) is a key outcome in oncology. Financial toxicity is recognized as an important adverse effect of cancer care that may decrease patients' HRQOL. This is the first systematic review and meta-analysis on the association of HRQOL and financial toxicity as measured by the Comprehensive Score for Financial Toxicity, the most widely used and validated cancer-specific measure of financial toxicity. • Overall, 31 studies were included with a total sample of 13 481 patients and survivors with more than 25 cancer types from 9 countries. Ten different HRQOL domains were identified to be related to financial toxicity. A moderate correlation was demonstrated between financial toxicity and overall HRQOL through random-effects meta-analysis. Nine studies reported financial toxicity as a significant predictor of HRQOL using multivariate regression models after controlling for sociodemographic characteristics. • Our findings contribute to the understanding of the burden patients with cancer experience and substantiate financial toxicity as a relevant outcome of cancer care that decreases HRQOL. Reducing financial toxicity may contribute to the improvement of HRQOL in patients with cancer and survivors. [ABSTRACT FROM AUTHOR]

Purpose: Studies have shown that financial toxicity can reduce survival, decrease quality of life, and reduce compliance with treatments. The aim of this retrospective study was to investigate material markers of financial toxicity, including insurance coverage, financial assistance, and balances due among adolescent and young adult (AYA) (18–39), adult (40–64), and senior adult (>65) patients with a sarcoma diagnosis after the Affordable Care Act became effective. Methods: This study performed a retrospective analysis of possible indicators within the material domain of financial toxicity in sarcoma patients, a common diagnosis in young adult patients. Indicators of financial toxicity included: insurance status and number of insurances, charity care, accessing financing options, or having an unpaid balance referred to a collection's agency. Results: The cumulative charges per patient were similar between AYA, adult, and senior adult populations at an average of $194,329 (standard deviation [SD] = $321,425), $236,724 (SD = $368,345), and $188,030 (SD = $271,191), respectively. AYA patients were more likely than adult and senior adult patients to have Medicaid coverage (income-based government insurance) (22.1% vs. 8.4% vs. 1.2%), receive charity care (5.3% vs. 2.6% vs. 1.2%), or have a balance referred to a collection's agency (9.2% vs. 5.8% vs. 1.2%). Conclusions: This study suggests that younger cancer patients are more likely to suffer material financial strain and additional financial resources may need to be made available to ensure they can receive care without an increase of financial toxicity markers and undue financial stress. [ABSTRACT FROM AUTHOR]

Purpose: Adolescents and young adults (AYA) with advanced cancer have unequal access to and enrollment in clinical trials. Many AYA use online platforms to share their treatment experiences. The purpose of this analysis was to explore how AYA discuss clinical trials and their access to novel therapeutics through their blogs. Methods: We studied illness blogs from 22 AYA (ages 16–38 years old) with advanced cancer who specifically discussed experiences enrolling in a clinical trial. Nearly 500 excerpts were abstracted from their blogs, and we used qualitative descriptive methodology and thematic analysis to explore their longitudinal perspectives. Results: We describe three themes: (1) "Blinded", which represents the uncertainty in treatment pathway and underrepresentation of AYA in clinical trials, (2) "Totally healthy except for the damn cancer", which represents the numerous challenges associated with meeting eligibility criteria and lack of available clinical trials, and (3) "Go ahead and send me the bill!", which represents the precarious financial challenges associated with participating with clinical trials (both direct costs and indirect costs associated with travel, time away from work) as well as the costs of novel therapeutics. Conclusions: By studying AYA online narratives, we can outline several gaps in accessing clinical trials and generate future research priorities. AYA with advanced cancer are known to have aggressive trajectories, and there are opportunities to integrate patient-reported outcomes and supportive care frameworks embedded within clinical trial study design. [ABSTRACT FROM AUTHOR]

Purpose: This study aims to investigate the factors that influence financial toxicity and its effects on both quality of life and psychological distress in Turkish cancer patients. Methods: Data from 400 cancer patients receiving chemotherapy at a public university in Turkey was analyzed. The Comprehensive Score for Financial Toxicity (COST), Patient Health Questionnaire for Depression and Anxiety (PHQ-4), and Functional Assessment of Cancer Therapy-General (FACT‐G) were used to measure financial toxicity, psychological distress, and health quality of life, respectively. Results: Patients’ median COST score was 22 (SD = 10.1; range: 1–44) and was consistent with mild financial toxicity. Financial toxicity was associated with lower education level (p < 0.001), lower monthly income (p < 0.001), being a woman (p = 0.021), living in another city (p = 0.012), and previous cancer surgery (p = 0.02). A negative and statistically significant correlation was found between financial toxicity and quality of life (r = − 0.139; p = 0.005) and psychological distress (r = − 0.398; p < 0.001). Conclusion: This investigation demonstrated that financial toxicity was a significant determinant of quality of life and psychological distress. [ABSTRACT FROM AUTHOR]

Purpose: Financial toxicity has become a global public health issue. The purpose of the study is to investigate and analyze the influencing factors of financial toxicity in patients with non-metastatic colorectal cancer. Methods: A convenient sample of 250 patients with stage I-III colorectal cancer was investigated in the study. They completed a set of questionnaires, including the Comprehensive Score for Financial Toxicity questionnaire, the Perceived Social Support Scale, and the Hospital Anxiety and Depression Scale. Univariate and multivariate linear regression were performed to investigate the influencing factors of financial toxicity. Results: Over half (52.8%, n = 132) of the colorectal cancer survivors experienced financial toxicity. Multivariate regression analysis showed that the factors associated with financial toxicity were young age, unemployment, low annual household income, chemotherapy, and the lack of sufficient social support (p < 0.05). Conclusions: Financial toxicity is common among non-metastatic colorectal cancer survivors. Young age, lower annual household income, unemployment, chemotherapy, and insufficient social support were associated with financial toxicity. [ABSTRACT FROM AUTHOR]

Introduction: Following 2016 legislation permitting limited access to cannabis for research and medicinal purposes, the number of randomized clinical trials (RCTs) investigating the effectiveness of medicinal cannabis (MC) on symptom burden relief in cancer contexts has increased in Australia. This study aimed to understand the perceptions, hopes and concerns of people with advanced cancer regarding the future availability and regulation of MC in Australia. Methods: This qualitative study draws on semistructured interviews conducted between February 2019 and October 2020 in Brisbane, Australia, as part of an MC RCT substudy. Interviews were undertaken on 48 patients with advanced cancer in palliative care eligible to participate in an MC trial (n = 26 participated in an RCT; n = 2 participated in a pilot study; n = 20 declined). Interviews included a discussion of patients' decision‐making regarding trial participation, concerns about MC and perceptions of future availability, including cost. Transcribed interviews were analysed inductively and abductively, informed by constructivist thematic analysis conventions. Results: Overall, participants supported making MC legally accessible as a prescription‐only medication. Fear of financial toxicity, however, compromised this pathway. Steep posttrial costs of accessing MC prompted several people to decline trial participation, and others to predict—if found effective—that many would either access MC through alternative pathways or reduce their prescribed dosage to enable affordable access. Conclusions: These findings suggest that—despite a relatively robust universal healthcare system—Australians are potentially vulnerable to and fearful of financial toxicity. Prevalent in the United States, financial toxicity occurs when disadvantaged cancer patients access necessary but expensive medications with lasting consequences: bankruptcy, ongoing anxiety and cancer worry. Interview transcripts indicate that financial fears—and the systems sustaining them—may pose a threat to RCT completion and to equitable access to legal MC. Such findings support calls for embedding qualitative substudies and community partnerships within RCTs, while also suggesting the importance of subsidisation to overcoming injustices. Patient or Public Contribution: A patient advisory committee informed RCT design. This qualitative substudy foregrounds patients' decision‐making, perceptions and experiences. [ABSTRACT FROM AUTHOR]

Aim: To understand the opinions and current practices of health professionals on the topic of addressing cancer‐related financial toxicity among patients. Methods: A cross‐sectional online survey was distributed through Australian clinical oncology professional organizations/networks. The multidisciplinary Clinical Oncology Society of Australia Financial Toxicity Working Group developed 25 questions relating to the frequency and comfort levels of patient–clinician discussions, opinions about their role, strategies used, and barriers to providing solutions for patients. Descriptive statistics were used and subgroup analyses were undertaken by occupational groups. Results: Two hundred and seventy‐seven health professionals completed the survey. The majority were female (n = 213, 77%), worked in public facilities (200, 72%), and treated patients with varied cancer types across all of Australia. Most participants agreed that it was appropriate in their clinical role to discuss financial concerns and 231 (88%) believed that these discussions were an important part of high‐quality care. However, 73 (28%) stated that they did not have the appropriate information on support services or resources to facilitate such conversations, differing by occupation group; 7 (11%) social workers, 34 (44%) medical specialists, 18 (25%) nurses, and 14 (27%) of other occupations. Hindrances to discussing financial concerns were insufficient resources or support systems to refer to, followed by lack of time in a typical consultation. Conclusion: Health professionals in cancer care commonly address the financial concerns of their patients but attitudes differed across occupations about their role, and frustrations were raised about available solutions. Resources supporting financial‐related discussions for all health professionals are urgently needed to advance action in this field. [ABSTRACT FROM AUTHOR]

Purpose: To explore the financial impact of cancer in young adults (YAs) compared to matched non-cancer peers. Methods: Five hundred seventy-five YAs from the Young Adults with Cancer in their Prime (YACPRIME) study reported on out-of-pocket cancer costs and missed work. YA cancer survivors were compared to matched peers without cancer on key financial indices based on current age (< 35 vs. 35 + years) and time since diagnosis (< 5 vs. 5 + years). Descriptive statistics, Chi-square tests, and prevalence ratios (PR) were used to compare groups on financial variables. Results: Almost 60% of YA survivors spent at least $100/month on cancer-related expenses, and 49% missed at least one year of work. YA survivors were more likely to have outstanding credit card ((< 35 (PR = 1.37, p = 0.001); 35 + (PR = 1.33, p = 0.001)) and line of credit (< 35 (PR = 1.42, p = 0.008); 35 + (PR = 1.27, p = 0.016)) balances. Home ownership was higher among non-cancer peers ((< 35: PR = 1.42, p < 0.001); 35 + (PR = 1.69, p < 0.001); < 5 years (PR = 1.39, p < 0.001); 5 + years (PR = 1.41, p = 0.005)). YA survivors were more likely to not own assets ((< 5 years (PR = 2.25, p < 0.001); 5 + years (PR = 2.25, p = 0.004)). Those diagnosed within 5 years had higher rates of payday loans (PR = 3.91, p = 0.021). Conclusion: While exploratory, results suggest that YAs are disadvantaged compared to their peers in type and value of assets owned and debts carried. Implications for Cancer Survivors: Survivorship care plans for YA survivors should include resources to manage the financial impacts of cancer. [ABSTRACT FROM AUTHOR]

Background: In the context of rising healthcare costs, formal education on treatment-related financial hardship is lacking in many medical schools, leaving future physicians undereducated and unprepared to engage in high-value care. Method: We performed a prospective cohort study to characterize medical student knowledge regarding treatment-related financial hardship from 2019 to 2020 and 2020–2021, with the latter cohort receiving a targeted educational intervention to increase cost awareness. Using Kirkpatrick's four-level training evaluation model, survey data was analyzed to characterize the acceptability of the intervention and the impact of the intervention on student knowledge, attitudes, and self-reported preparedness to engage in cost-conscious care. Results: Overall, N = 142 medical students completed the study survey; 61 (47.3%) in the non-intervention arm and 81 (66.4%) in the intervention arm. Of the 81 who completed the baseline survey in the intervention arm, 65 (80.2%) completed the immediate post-intervention survey and 39 (48.1%) completed the two-month post-intervention survey. Following the educational intervention, students reported a significantly increased understanding of common financial terms, access to cost-related resources, and level of comfort and preparedness in engaging in discussions around cost compared to their pre-intervention responses. The majority of participants (97.4%) reported that they would recommend the intervention to future students. A greater proportion of financially stressed students reported considering patient costs when making treatment decisions compared to their non-financially stressed peers. Conclusions: Targeted educational interventions to increase cost awareness have the potential to improve both medical student knowledge and preparedness to engage in cost-conscious care. Student financial stress may impact high-value care practices. Robust curricula on high-value care, including treatment-related financial hardship, should be formalized and universal within medical school training. [ABSTRACT FROM AUTHOR]

Background: Cancer treatment often results in financial burdens for patients including healthcare costs as well as treatment-induced disability leading to "financial toxicity" (FT) and decreased quality of life. The purpose of this review is to describe FT related to head and neck cancer (HNC) treatment, including quantifications of direct and indirect costs and descriptions of measurement tools. Methods: PubMed, Embase, Cochrane Library, and Web of Science databases were searched to identify articles published before April 2022. Full-text published studies were included if they assessed direct or indirect costs of HNC treatment; studies were excluded if they did not focus on HNC or financial burden. The risk of bias was assessed, and the results of the studies were synthesized. Results: Database searches yielded 530 unique studies, and 33 studies met the criteria for inclusion. Medical expenses for patients with HNC were higher than for patients with other cancers or controls in several studies. Major surgical procedures, neck dissection, free-flap reconstruction, and intensive care unit admission increased hospital costs. Trimodal therapy with surgery plus chemoradiation represented the most expensive treatment, and chemoradiation increased complication-related health care costs. In several studies, >50% of patients treated for HNC were disabled and did not return to work. One of the greatest contributors to the indirect cost of HNC treatment is the loss of lifetime wages. Patients with HNC are at risk for depression, anxiety, and social isolation, which are linked to a decreased quality of life and treatment non-adherence. The only tools used to assess FT in patients with HNC are the Comprehensive Score for financial Toxicity (COST) and the Financial Index of Toxicity (FIT). Conclusion: Financial toxicity is highly prevalent among patients with HNC. Further research is needed to validate the assessment tools for quantifying FT in HNC patients. [ABSTRACT FROM AUTHOR]

Objectives: The primary outcome measures evaluated the financial toxicity and mental well‐being of the oral cancer survivors. Methods: A cross‐sectional study of oral cancer survivors who were disease‐free for more than 6 months after treatment and visited the hospital for a routine follow‐up is included in the study. Mental well‐being and financial toxicity were evaluated using the Depression, Anxiety, and Stress Scale ‐ 21 (DASS 21) and Comprehensive Score for financial Toxicity (COST‐ Functional Assessment of Chronic Illness Therapy) questionnaires. A literature review was done to compare the results with financial toxicity and mental health in cancer patients from the pre‐pandemic era. Results: A total of 79 oral cancer survivors were included in the study, predominantly males (M: F = 10:1). The age ranged from 26 to 75 years (The median age is 49). The full‐time employment dropped from 83.5% in the pre‐treatment period to 21.5% post‐treatment. Depression was observed in 58.2% and anxiety in 72.2%. Unemployed survivors were observed to have more depression (OR = 1.3, 95% confidence interval (CI) = 0.3–5.4, p = 0.6), anxiety (OR = 3.5, 95% CI = 0.3–21.2, p = 0.1) and stress (OR = 1.6, 95% CI = 0.3–6.6, p = 0.5) than rest of the cohort. On univariate analysis, unemployed survivors (M = 11.8 ± 3.8, p = 0.01) had significantly poorer financial toxicity scores. Survivors with depression (M = 16.4 ± 7.1, p = 0.06) and stress (M = 14.4 ± 6.8, p = 0.002) had poor financial toxicity scores. On multifactorial analysis of variance, current employment (p = 0.04) and treatment modality (p = 0.05) were significant factors impacting the financial toxicity. Conclusion: There is a trend towards increased incidence of depression, anxiety, and stress among oral cancer survivors compared to the literature from the pre‐COVID era. There is significant financial toxicity among either unemployed or part‐time workers. This calls for urgent public/government intervention to prevent the long‐term impact of financial toxicity on survival and quality of life. [ABSTRACT FROM AUTHOR]

Although the economic burden of cancer care is an emerging concern in the United States, the potential financial toxicity of breast cancer care at the patient level remains poorly understood. This study aims to characterize the scope of the contributors to financial distress on breast cancer patients and the resources utilized to address them. Adult female patients diagnosed with invasive breast cancer or ductal carcinoma in situ between 2014 and 2019 at a single institution were retrospectively evaluated. Those who enrolled in copay assistance or indicated financial concerns on an intake distress screen were provided a web-based survey assessing financial changes, resources used, and financial engagement with providers. Semi-structured interviews further explored sources of financial distress and were analyzed by two researchers using grounded theory methodology. Sixty-eight patients completed the online survey, 15 of the 68 also participated in semi-structured phone interviews. On the online survey 74% of participants endorsed a financial distress score ≥5 on a scale of 0-10. Seventy-four percent changed their budget, 72% used their savings, and 60% cut down on spending. However, only 40% used resources such as financial counseling or financial assistance. Interviews revealed three major contributors to financial distress: (1) unexpected medical and nonmedical expenses, (2) lost revenue from missed work, and (3) altered budgeting. Many breast cancer patients experience significant financial distress without access to the resources they need. This study highlights the need for financial transparency, supportive financial services counseling at the time of diagnosis, throughout treatment and beyond. [ABSTRACT FROM AUTHOR]

Purpose: Financial distress and financial toxicity are recognized challenges in cancer survivorship. Financial toxicity includes both objective measures of hardship and subjective distress. We hypothesized that subjective financial distress is correlated to overall holistic financial toxicity. We compared two widely accepted instruments to measure financial distress and financial toxicity. Methods: Patients in the follow-up phase of care at a single institution were surveyed regarding demographic and economic status. Financial toxicity was measured using the comprehensive score for financial toxicity–functional assessment of chronic illness (COST-FACIT) and financial distress using the personal financial wellness (PFW) scale. Surveys were analyzed for correlation and internal consistency. Patient score distributions were compared. Associations between survey scores and patient factors were assessed using multivariable linear regression models. Results: A total of 116 patients were included. Scores from the COST-FACIT showed a strong correlation with PFW scores (r = 0.90, p < 0.0001). Scale reliability was high for both the COST-FACIT (α = 0.92) and PFW (α = 0.97) surveys. Score distributions exhibited left skew for both surveys, with 9.5% of patient scores falling in the worst quartile of possible scores on each respective survey. The strongest predictors of financial distress and financial toxicity included young age, lower monetary savings, lower household income, and less perceived social support during cancer treatment. Conclusions: The COST-FACIT measure of financial toxicity correlated strongly with PFW measure of financial distress. Although these instruments were designed to assess different concepts (financial distress vs financial toxicity), they gave strikingly similar results. Either instrument may be used as a meaningful patient-reported outcome for study of financial distress in cancer survivors. However, the COST-FACIT construct of financial toxicity does not appear to add additional information beyond financial distress. [ABSTRACT FROM AUTHOR]

Purpose: No single pharmacy in an urban zip code is consistently the least expensive across medications. If medication prices change differently across pharmacies, patients and clinicians will face challenges accessing affordable medications when refilling medications. This is especially pertinent to people with cancer with multiple fills of supportive care medications over time. We evaluated if the lowest-priced pharmacy for a formulation remains the lowest-priced over time. Methods: We compiled generic medications used to manage nausea/vomiting (14 formulations) and anorexia/cachexia (12 formulations). We extracted discounted prices in October 2021 and again in March 2022 for a typical fill at 8 pharmacies in Minneapolis, Minnesota, USA (zip code 55,414) using GoodRx.com. We examined how prices changed across formulations and pharmacies over time. Results: Data were available for all 208 possible pharmacy-formulation combinations (8 pharmacies × 26 formulations). For 172 (83%) of the 208 pharmacy-formulation combinations, the March 2022 price was within 20% of the October 2021 price. Across pharmacy-formulation combinations, the price change over time ranged from − 76 to + 292%. For 12 (46%) of the 26 formulations, at least one pharmacy with the lowest price in October 2021 no longer was the least costly in March 2022. For one formulation (dronabinol tablets), the least expensive pharmacy became the most expensive, with an absolute and relative price increase of a fill of $22 and 85%. Conclusion: For almost half of formulations studied, at least one pharmacy with the lowest price was no longer the least costly a few months later. The lowest price for a formulation (across pharmacies) could also change considerably. Thus, even if a patient accesses the least expensive pharmacy for a medication, they may need to re-check prices across all pharmacies with each subsequent fill to access the lowest prices. In addition to safety concerns, directing medications to and accessing medications at multiple pharmacies can add time and logistic toxicity to patients with cancer, their care partners, prescribers, and pharmacy teams. [ABSTRACT FROM AUTHOR]

Objective: to evaluate and correlate the quality of life and financial toxicity of adult patients undergoing hematopoietic stem cell transplantation during the COVID-19 pandemic. Method: observational, analytical study, carried out with 35 patients in a reference hospital for transplantation in Latin America. For data collection, the Functional Assessment Cancer Therapy Bone Marrow Transplantation and COmprehensive Score for Financial Toxicity questionnaires were used. Spearman and Mann-Whitney correlation tests were used for data analysis. Results: general quality of life during COVID-19 had a low score (67.09/108) with greater impairment in functional well-being (14.47/28), social well-being (16.76/28) and additional concerns (23.41/40). The means of the allogeneic group were lower than those of the autologous group in all domains, showing a significant difference in relation to additional concerns (p=0.01) and in the treatment evaluation index (p=0.04). Financial toxicity was considered to have a slight impact (22.11/44). There was a relationship, albeit not significant, between quality of life and financial toxicity (p=0.051). Conclusion: the quality of life of the sample was low; there is a correlation between quality of life and financial toxicity, although not significant. The higher the financial toxicity, the lower the quality of life. [ABSTRACT FROM AUTHOR]

Objective: Adherence to lung cancer screening (LCS) is central to effective screening. We evaluated the likelihood of repeat annual LCS in a national commercially-insured population and associations with individual characteristics, insurance characteristics, and annual out-of-pocket costs (OOPC) burden.Methods: Using claims data from an employer-insured population (Clinformatics®), individuals 55-80 years receiving LCS between 1/1/2015-9/30/2019 with "negative" LCS were included. Repeat LCS was defined as LDCT occurring 10-15 months after the preceding LCS. Analysis was conducted over a six-year period. Multivariable logistic regression was used to evaluate associations between repeat LCS and individual characteristics, insurance characteristics, and total OOPC incurred by the individual in the year of the index LCS, even if unrelated to LCS.Results: Of 14,943 individuals with negative LCS, 4,561 (30.5%) received repeat LCS. Likelihood of repeat LCS was decreased for males (aOR, 95%CI: 0.91, 0.86-0.97), Hispanic ethnicity (aOR, 95%CI: 0.82, 0.69-0.97), and indemnity insurance plans (aOR, 95%CI: 0.36, 0.25-0.53). Relative to New England, individuals in nearly all U.S. geographic regions were less likely to receive repeat LCS. Finally, individuals with total OOPC in the highest two quartiles were less likely to receive repeat LCS (aOR, 95%CI: 0.85, 0.77-0.92 for OOPC >$1,069.02 - $2,475.09 vs $0.00 - $351.82; aOR, 95%CI: 0.75, 0.68-0.82 for OOPC >$2,475.09 vs $0.00 - $351.82).Discussion: While federal policies facilitate LCS without cost-sharing, individuals incurring high OOPC, even when unrelated to LCS, are less likely to receive repeat LCS. Future policy design should consider the permeative burden of OOPC across the health continuum on preventive services use. [ABSTRACT FROM AUTHOR]

Using national surveys, we longitudinally studied imaging costs—and specifically those paid out-of-pocket (OOP) by patients—over two decades. Using 2000 to 2019 Medical Expenditure Panel Survey data, we identified all imaging-focused encounters (mammography, radiography, ultrasonography, and CT and MR [surveyed together in Medical Expenditure Panel Survey]) and calculated mean overall and OOP encounter costs. Effects of sociodemographic, personal, and clinical factors were measured using logistic regression and generalized linear modeling. We identified 102,717 patients (mean 45.6 years; 64.8% female; 58.8% White) undergoing 229,010 imaging-focused encounters. Between 2000 and 2019, mean costs of mammography, radiography, and ultrasonography increased 14.5%, 24.5%, and 40% and total mean cost of CT or MR decreased by 15.1%. OOP costs were incurred by 51%. Overall mean OOP costs increased 89.8% from 2000 to 2019. Mean OOP costs for mammography decreased by 32.9%; mean OOP costs for radiography, ultrasonography, and CT or MR increased 81%, 123.2%, and 61%, respectively. Patients were less likely to incur OOP costs when older, of racial and ethnic minorities, female, or recipients of public only (versus private) insurance. Among those with OOP costs, the presence of comorbidities, lack of insurance, younger age, and history of cancer significantly increased OOP costs. Mean overall patient OOP costs for imaging examinations increased significantly and substantially over the last two decades. Lack of insurance, younger age, history of cancer, and other comorbidities were associated with higher OOP costs. As diagnostic imaging utilization increases, patient financial hardship considerations merit further attention. [Display omitted] [ABSTRACT FROM AUTHOR]

The Patient Protection and Affordable Care Act (ACA), enacted in March 2010, was comprehensive health care reform legislation aimed to improve health care access and quality of care and curb health care–related costs. This review focuses on key provisions of the ACA and their impact on financial toxicity. We will focus our review on cancer care, because this is the most commonly studied disease process in respect to financial toxicity. Patients with cancer face rising expenditures and financial burden, which in turn impact quality of life, compliance to treatment, and survival outcomes. Health insurance expansion include dependent-coverage expansion, Medicaid expansion, and establishment of the Marketplace. Coverage reform focused on reducing financial barriers by limiting cost sharing. Payment reforms included new innovative payment and delivery systems to focus on improving outcomes and reducing costs. Challenges remain as efforts to reduce costs have led to the expansion of insurance plans, such as high-deductible health plans, that may ultimately worsen financial toxicity in cancer and high out-of-pocket costs for further diagnostic testing and procedures. Further research is necessary to evaluate the long-term impacts of the ACA provisions—and threats to the ACA—on outcomes and the costs accrued by patients. [ABSTRACT FROM AUTHOR]

Purpose of Review: Urinary incontinence (UI) is a common global condition that has been noted to disproportionately affect women. In this review, the authors present discussion of factors contributing to cost of care and various modalities of cost-effective care for UI for female patients. Recent Findings: We found insurance and out-of-pocket (OOP) costs strongly impact of costs for patients. Further, in evaluation of UI, diagnosis can be a costly multi-step process for effective treatment. Treatment can be multimodal, including non-surgical (e.g., pessary, vaginal insert, pelvic floor muscle training, or PFMT), of which PFMT is a cost-effective, effective, and accessible treatment. Pharmacologic management is generally second-line for overactive bladder, but anti-muscarinic drugs and beta-3 agonists are cost-effective depending on willingness-to-pay and the health system in which they are acquired, respectively. Surgical management is considered the most cost-effective treatment as willingness-to-pay increased, with minimally invasive slings being the mainstay. Other relatively novel treatments are also discussed (e.g., EMSELLA) but require further research. Additionally, we discuss systematic barriers in decisions to seek care for urinary incontinence. Summary: Urologists are key agents in treating UI for their female patients, and seeking cost-effective options for treatment remains pivotal for quality care. [ABSTRACT FROM AUTHOR]

Abstract Background The study purpose is to describe trajectories of financial distress for parents of children (ages 1–14.9 years) with newly diagnosed acute lymphoblastic leukemia (ALL). The secondary aim is to identify multilevel factors (child, parent, household, treating institution) that influence change in financial distress over time. Methods The study uses a prospective cohort design, repeated measurements, and mixed methods. The settings are Children’s Oncology Group (COG) institutions participating in the National Cancer Institute Community Oncology Research Program (NCORP). Eligible participants are English- and/or Spanish-speaking parents or legal guardians (hereafter “parents”) of index children. Parents are asked to complete a survey during their child’s induction (T1) and maintenance therapy (T2), and near treatment completion (T3). Study surveys include items about (a) the child’s cancer and clinical course, (b) parental socio-economic status, financial distress and financial coping behaviors, and (c) household material hardships. At least 15 parents will be invited to participate in an optional semi-structured interview. NCORP institutions that enroll at least one parent must complete an annual survey about institution resources that could influence parental financial distress. Discussion The results will inform future interventions to mitigate financial distress for parents of children diagnosed with ALL and could be instructive beyond this disease group. Trial registration This trial was initially registered with the NCI Clinical Trial Reporting Program ID: NCI-2021–03,567 on June 16, 2021. The study can be found on clinicaltrials.gov, Identifier NCT04928599 .

Traditionally, economic evaluations are based on clinical trials with well-defined patient populations that exclude many patient types. By contrast, studies that incorporate general patient populations end up including those in lower income categories, some of whom have significant financial burdens (often described as financial toxicity) related to their care. Consideration of these patient burdens when examining the incremental cost-effectiveness of newer treatments from a clinical trial perspective can result in differing conclusions regarding cost-effectiveness. The challenge is to reliably assess the link between financial toxicity, quality of life and potential decisions to forego or delay care. It is also well-documented that these financial effects are not evenly distributed across populations, with those with low income and of black or Latino decent being most affected. There is a paucity of literature in this space, but some of the early work has suggested that for lung, breast, colorectal and ovarian cancers there are poorer quality-of-life scores and/or shorter overall survival for those experiencing financial toxicity. Hence, we may see both a lower quality of life and a shorter duration of life for these populations. If this is the case, additional considerations include: are the benefits of newer, more-expensive treatment strategies muted by the lack of adherence to these newer treatments due to financial concerns, and, if true, can these effects be effectively quantified as “real-world” outcomes? This rapid review examines these possibilities and the steps that may be required to examine this reliably.

Abstract Amit Joshi Background Cancer is one of the most expensive and exhaustive medical conditions with a huge impact on the financial condition of the patient and their family members. A lot of advancements have led to improvement in the survival of the patients but at a raised cost. Comprehensive Score for financial Toxicity - Functional Assessment of Chronic Illness Therapy (COST - FACIT Version 2) is one such validated and widely used tool. Assessing the financial burden in our country is still far more challenging as COST - FACIT is available in the English language but not in any regional language. Hence, we decided to validate this tool in Hindi and Marathi languages. Material and Methods A single-center, cross-sectional study was conducted in the Department of Uro-Oncology at the Tata Memorial Hospital. The original version of the COST - FACIT (Version 2) was translated from English into Hindi and Marathi languages, following the FACIT translation method and tested for content validity that included two forward translations, followed by reconciliation and a backward translation. The questionnaires were then approved by the FACIT team, and pilot testing was done for 20 patients (10 for each Hindi and Marathi language). Each of these 20 patients, after filling up the questionnaire themselves, was interviewed for any difficulty encountered during answering the questionnaire. Based on the suggestions or interpretations of this pilot testing, the necessary changes were incorporated in the final Hindi and Marathi questionnaires. Results A total of 20 patients (10 each for Hindi and Marathi) were included for pilot testing of the questionnaire. The median age of the entire cohort was 61 years (27–79). The questionnaires showed good content and face validity and demonstrated a high internal consistency (Cronbach's α: 0.85 for Hindi, 0.89 for Marathi). Conclusion The questionnaire COST - FACIT (Version 2) has been approved and validated in Hindi and Marathi languages by the FACIT team for use in clinical practice and studies.

Background: Financial toxicity impacts the treatment choices, daily life, and health-related quality of life (HRQoL) of cancer patients. We investigated future variations in financial toxicity and HRQoL of patients with gynecologic cancer, evaluated using the COmprehensive Score for financial Toxicity (COST) questionnaire.This multicenter study enrolled patients with gynecologic cancer incurring co-payments for anti-cancer drug treatment for over 2 months. Questionnaires were administered at baseline and at the end of follow-up. Patients completed the COST, EORTC-QLQ-C30, EORTC-QLQ-OV28, EORTC-QLQ-CX24, EORTC-QLQ-EN24, and EQ-5D-5L. Paired t-tests were used to compare the initial and follow-up responses. Spearman’s rank test was used to examine correlations between COST and HRQoL scores.Ninety-one patients (ovarian, 40; cervical, 18; endometrial, 33) completed the questionnaires at baseline and follow-up. The mean COST score was not significantly different between baseline and end of follow-up (19.56 ± 6.63 and 19.97 ± 7.47, respectively; p = 0.439). Significant correlations were found between COST scores and emotional functioning (r = 0.251, p = 0.023), cognitive functioning (r = 0.254, p = 0.020), and financial difficulties (r = − 0.298, p = 0.006), attitude toward disease/treatment (r = 0.356, p = 0.033), poor body image (r = − 0.362, p = 0.042), back and pelvis pain (r = − 0.451, p = 0.010), and taste change (r = − 0.359, p = 0.040).During anticancer drug therapy for gynecologic cancer, the COST score remained stable and did not correlate with overall HRQoL, although higher scores were associated with worse HRQoL for specific functions and symptoms.Methods: Financial toxicity impacts the treatment choices, daily life, and health-related quality of life (HRQoL) of cancer patients. We investigated future variations in financial toxicity and HRQoL of patients with gynecologic cancer, evaluated using the COmprehensive Score for financial Toxicity (COST) questionnaire.This multicenter study enrolled patients with gynecologic cancer incurring co-payments for anti-cancer drug treatment for over 2 months. Questionnaires were administered at baseline and at the end of follow-up. Patients completed the COST, EORTC-QLQ-C30, EORTC-QLQ-OV28, EORTC-QLQ-CX24, EORTC-QLQ-EN24, and EQ-5D-5L. Paired t-tests were used to compare the initial and follow-up responses. Spearman’s rank test was used to examine correlations between COST and HRQoL scores.Ninety-one patients (ovarian, 40; cervical, 18; endometrial, 33) completed the questionnaires at baseline and follow-up. The mean COST score was not significantly different between baseline and end of follow-up (19.56 ± 6.63 and 19.97 ± 7.47, respectively; p = 0.439). Significant correlations were found between COST scores and emotional functioning (r = 0.251, p = 0.023), cognitive functioning (r = 0.254, p = 0.020), and financial difficulties (r = − 0.298, p = 0.006), attitude toward disease/treatment (r = 0.356, p = 0.033), poor body image (r = − 0.362, p = 0.042), back and pelvis pain (r = − 0.451, p = 0.010), and taste change (r = − 0.359, p = 0.040).During anticancer drug therapy for gynecologic cancer, the COST score remained stable and did not correlate with overall HRQoL, although higher scores were associated with worse HRQoL for specific functions and symptoms.Results: Financial toxicity impacts the treatment choices, daily life, and health-related quality of life (HRQoL) of cancer patients. We investigated future variations in financial toxicity and HRQoL of patients with gynecologic cancer, evaluated using the COmprehensive Score for financial Toxicity (COST) questionnaire.This multicenter study enrolled patients with gynecologic cancer incurring co-payments for anti-cancer drug treatment for over 2 months. Questionnaires were administered at baseline and at the end of follow-up. Patients completed the COST, EORTC-QLQ-C30, EORTC-QLQ-OV28, EORTC-QLQ-CX24, EORTC-QLQ-EN24, and EQ-5D-5L. Paired t-tests were used to compare the initial and follow-up responses. Spearman’s rank test was used to examine correlations between COST and HRQoL scores.Ninety-one patients (ovarian, 40; cervical, 18; endometrial, 33) completed the questionnaires at baseline and follow-up. The mean COST score was not significantly different between baseline and end of follow-up (19.56 ± 6.63 and 19.97 ± 7.47, respectively; p = 0.439). Significant correlations were found between COST scores and emotional functioning (r = 0.251, p = 0.023), cognitive functioning (r = 0.254, p = 0.020), and financial difficulties (r = − 0.298, p = 0.006), attitude toward disease/treatment (r = 0.356, p = 0.033), poor body image (r = − 0.362, p = 0.042), back and pelvis pain (r = − 0.451, p = 0.010), and taste change (r = − 0.359, p = 0.040).During anticancer drug therapy for gynecologic cancer, the COST score remained stable and did not correlate with overall HRQoL, although higher scores were associated with worse HRQoL for specific functions and symptoms.Conclusions: Financial toxicity impacts the treatment choices, daily life, and health-related quality of life (HRQoL) of cancer patients. We investigated future variations in financial toxicity and HRQoL of patients with gynecologic cancer, evaluated using the COmprehensive Score for financial Toxicity (COST) questionnaire.This multicenter study enrolled patients with gynecologic cancer incurring co-payments for anti-cancer drug treatment for over 2 months. Questionnaires were administered at baseline and at the end of follow-up. Patients completed the COST, EORTC-QLQ-C30, EORTC-QLQ-OV28, EORTC-QLQ-CX24, EORTC-QLQ-EN24, and EQ-5D-5L. Paired t-tests were used to compare the initial and follow-up responses. Spearman’s rank test was used to examine correlations between COST and HRQoL scores.Ninety-one patients (ovarian, 40; cervical, 18; endometrial, 33) completed the questionnaires at baseline and follow-up. The mean COST score was not significantly different between baseline and end of follow-up (19.56 ± 6.63 and 19.97 ± 7.47, respectively; p = 0.439). Significant correlations were found between COST scores and emotional functioning (r = 0.251, p = 0.023), cognitive functioning (r = 0.254, p = 0.020), and financial difficulties (r = − 0.298, p = 0.006), attitude toward disease/treatment (r = 0.356, p = 0.033), poor body image (r = − 0.362, p = 0.042), back and pelvis pain (r = − 0.451, p = 0.010), and taste change (r = − 0.359, p = 0.040).During anticancer drug therapy for gynecologic cancer, the COST score remained stable and did not correlate with overall HRQoL, although higher scores were associated with worse HRQoL for specific functions and symptoms. [ABSTRACT FROM AUTHOR]