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Evidence-Based Oncology July 2016

Understanding and Mitigating the Financial Burden of Cancer Patients

Surabhi Dangi-Garimella, PhD
Drug prices have developed into the fastest growing segment of healthcare costs and are a significant burden on the patient's wallet, in addition to the cost of healthcare services. An Education Session at the annual meeting of the American Society of Clinical Oncology discussed potential solutions to ease this problem.
Healthcare is expensive, and patients, as well as physicians are increasingly aware of the unsustainable nature of the rising cost. Drug prices are a significant piece of this equation, and have developed into the fastest growing segment of healthcare costs—however, the cost of healthcare services is also a burden on the patient’s wallet. So what can providers do? What can patients do? An Education Session on the second day of the annual meeting of the American Society of Clinical Oncology, held in Chicago, June 3-7, 2016, delved into these problems, queried their impact on patient behavior and clinical outcomes, and suggested potential solutions.  

The session was chaired by Veena Shankaran, MD, MS, a health policy researcher at the University of Washington. She was joined by Dawn L. Hershman, MD, MS, who heads the Breast Cancer Program at Columbia University Medical Center, and Yousuf Zafar, MD, MHS, a health policy researcher at Duke University Medical Center.

Shankaran, who authored an article on financial toxicity in Evidence-Based Oncology last year,1 spoke about Risk Factors and Clinical Implications of Financial Toxicity.

“Cancer drug spend, as well as cancer care spending surpasses overall healthcare spending, and simultaneously, annual insurance costs are rising at a steady pace,” Shankaran said. She shared data that showed the combination of premiums and out-of-pocket (OOP) costs rose from about $3000, in 2008, to more than $5000 in 2015. Patients are facing higher copays and coinsurance, while access to treatment has barriers, defined by restrictive prescription plans and 4-tier drug formularies. “This is particularly important in oncology where there’s been a sharp rise in the approval of oral anticancer agents,” she said. Shankaran shared data plots that showed the total annual spending per user is significantly higher in cancer ($80,466) over treatments outside cancer ($21,048), and the annual beneficiary cost share for patients with cancer is on average $6000 greater.

When comparing the OOP spending for cancer patients, a study by the LIVESTRONG foundation found that across a variety of insurance plans, a greater percentage of cancer patients spent more on their medical expenses compared with patients with other chronic conditions.2

“Financial toxicity is a constellation of symptoms. Patients face difficulty meeting household expenses, they face financial stress/strain, loss of employment and income, debt, and bankruptcy,” Shankaran said. This can also take a psychological toll on the patient and impact their quality of life, she said.

It’s important to consider what factors predispose cancer patients to financial hardships. Research by Shankaran’s own group at Fred Hutch has identified several such risk factors3:
  • Younger age
  • Lower income
  • Non-white
  • Advanced and/or aggressive cancers
  • Comorbidities
  • Lack of supplemental insurance
She stressed that younger age seems to be the most significant risk factor, and what this could ultimately lead to is an impact on clinical outcomes, resulting from issues with adherence, access, and trial participation, finally resulting in reduced survival. According to Shankaran, the problem requires a multifaceted solution, and lowering drug prices alone cannot mend the damage. A combination of short- and long-term interventions with contributions from policy makers, patients, providers, and payers are necessary. These would include addressing:
  • Sustainable drug pricing
  • Cost transparency
  • Communication on costs
  • Financial counseling and/or navigation
  • Medical debt reform
  • Changes within the Affordable Care Act
Hershman, who heads the Breast Cancer Program at Columbia University Medical Center, addressed adherence issues that crop up as patients try to cope with their copays and OOP costs, particularly the high OOP of oral medications.

“Adherence is a global issue, and in developed countries, studies have shown that adherence in chronic conditions is only about 50%,” Hershman said. However, adherence is a difficult outcome to measure, and patients are our best source of information, she said, emphasizing that patient-provided “information cannot be very reliable. We can also use [electronic health records] or microelectronic monitoring systems to follow patient adherence to the regimen.”

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