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COST: A New Tool to Measure Financial Toxicity as a PRO


Researchers at the University of Chicago have developed a clinically relevant patient-centered tool that can measure a patient’s risk for financial stress.

In a new study published in the journal Cancer, researchers, several of whom are at the University of Chicago, shared data acquired from using a COmprehensive Score for financial Toxicity (COST) questionnaire. The study confirmed that COST is a clinically relevant patient-centered tool that can measure a patient’s risk for financial stress.

The trial enrolled 233 patients diagnosed with a stage IV solid tumor who had been receiving chemotherapy treatment at the University of Chicago for at least 2 months. The following patient information was collated for the study:

  • Patient characteristics
  • Clinical trial participation
  • Healthcare use
  • Willingness to discuss costs
  • Psychological distress (Brief Profile of Mood States [POMS])
  • Health-related quality of life (HRQOL) as measured by the Functional Assessment of Cancer Therapy: General (FACT-G) and the European Organization for Research and Treatment of Cancer (EORTC) QOL questionnaires

The COST questionnaire is short and includes 11 brief statements about costs, resources, and concerns. For each question, patients were asked to circle 1 of 5 possible responses that helped determine their level of concern.

“As expected, we found a strong association between a patient’s use of healthcare resources and his or her sense of financial toxicity,” Jonas de Souza, MD, MBA, a head-and-neck cancer specialist and health services researcher at the University of Chicago Medicine, who led the study, said in a statement. “This is something we need to look for, to recognize early and make sure it does not become a barrier to care.” de Souza will be a panelist at the 5th Annual Patient-Centered Oncology Care® meeting to be held November 17-18, 2016, in Baltimore. He will participate on a panel on the influence of cost sharing on patient adherence and outcomes.

In their current study, the researchers found that COST values correlated with income (correlation coefficient [r], 0.28; P <.001), psychosocial distress (r&thinsp;=&thinsp;-0.26; P<.001), and HRQOL, when measured by the FACT-G (r&thinsp;=&thinsp;0.42; P <.001) and by the EORTC QOL instruments (r&thinsp;=&thinsp;0.33; P <.001). Other factors that influenced financial toxicity included race, employment status, income, number of inpatient admissions, and psychological distress.

Speaking to the association of financial toxicity with the number of hospital admissions, de Souza said, “Hospital care is much more expensive than office-based care. We now know that it also impacts a patient’s self-reported financial feelings.” A surprise finding of their study was that clinical trial participation did not influence a patient’s perception of how it could impact their financial situation.

“Usually the maker of an innovative device or the company that supplies a new drug will pick up the costs related to the investigational drug,” de Souza said. "But that did not reduce our patients’ sense of financial toxicity. We’ve added that to our model."

The authors conclude that the COST measure is reliable and was validated by their study as an adequate measure of financial toxicity. Further, the correlation of financial toxicity and HRQOL makes it a clinically relevant patient-centered outcome.


de Souza JA, Yap BJ, Wroblewski K, et al. Measuring financial toxicity as a clinically relevant patient-reported outcome: The validation of the COmprehensive Score for financial Toxicity [published online October 7, 2016]. Cancer. doi: 10.1002/cncr.30369.

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