Psychosocial Aspects of Cancer

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Duke University School of Medicine; Duke CancerInstitute;andDuke-MargolisCenter for Health Policy, Durham, NC

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See accompanying article on page e113

DOI: https://doi.org/10.1200/JOP. 2017.028498; published online ahead of print at jop.ascopubs.org on January 30, 2018.

Price of Cancer Care and Its Tax on Quality of Life George Tran and S. Yousuf Zafar

Although innovations in cancer therapy have led to less toxic treatments, these new drugscomewithhigherpricetags,withmany medications costing more than $100,000 annually.1,2 As costs increase, a larger bur- denisbeingplacedonpatientsintheformof higher out-of-pocket expenses, deductibles, coinsurance, and copayments.3 The increas- ing treatment-related costs place a significant strain on patients and their families. A growing body of evidence suggests that the financial burden of cancer treatment has a toxic impact on many aspects of patients’ lives, including their financial well-being, health-related quality of life, and mortality.

A cancer diagnosis can also have sig- nificant ramifications for patients’ financial well-being. Hospitalizations, rising insur- ancepremiums,prescriptiondrugcosts, lost work productivity and income, and annual out-of-pocket expenses that often exceed $5,0004 can ultimately result in untenable

financial burden, even for patients with insurance, and—in a small minority— bankruptcy. Indeed, financial insolvency following a cancer diagnosis is a risk factor for mortality.5 Furthermore, patients who are dealing with significant financial bur- dens are more likely to ration their care or forego treatment altogether.6 Some patients delay or discontinue their medications,7

take less medication than prescribed, use over-the-counter medications as an alter- native, or take medications prescribed for others to alleviate their financial burden.8

Patients with cancer also experience significant alterations in their health-related quality of life (HRQOL) as a result of fi- nancial toxicity. A study by Park and Look9

examines the relationship between objective measures of financial burden, HRQOL, and psychological health of patients with cancer in the United States. Financial burden was estimated by calculating the ratio of out-of- pocket expenditures to family income, with high financial burden defined as out-of- pocket expenditures exceeding either 10% or 20% of family income. Their findings illustrate the inverse relationship between high financial burden and HRQOL, with a stronger effect observed on physical health than on mental health.9 The patients studied were also more likely to experience non- specific psychological distress, were older, were more likely to be uninsured, and often had more chronic conditions than patients who did not experience high financial bur- den. These results highlight the powerful relationship between financial hardship and HRQOL. This study builds upon the results of previous studies that have shown that

patients who report greater financial bur- den also report poorer general quality of life, physical health, mental health, and social life.10-13

The interaction between the economic repercussions of cancer care and quality of life requires further exploration. The re- lationship between financial burden and quality of life is probably multifactorial and perhaps even bidirectional. One pos- sible explanation for this relationship is that patients who experience financial burdens are less able to afford necessary care and thus experience greater physical and mental stress. To address their shortage of finan- cial resources, patients may alter their life- style by reducing leisure activities, spending

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less on basic necessities such as food and clothing, depleting their savings, or selling off possessions or property.8 All of these compensatory strategies may result in poorer sub- jective well-being among patients with cancer. However, it may also be true that patients with worse quality of life at baseline (ie, those who are sicker and have worse outcomes) may deplete their financial resources faster and thus expe- rience a greater financial burden.14

Coping mechanisms in response to cancer diagnoses and financial burdens may also play a role in mediating the re- lationship between HRQOL and financial toxicity. Perhaps patients who exhibit poor coping consequently experience greater financial burdens. Patients can use a myriad of coping mechanisms that are generally grouped into two major cate- gories: emotion-focused or problem-focused coping, as his- torically distinguished by Lazarus and colleagues (Lazarus and Folkman15 and Lazarus et al16). Emotion-focused coping is the regulation of internal conflicts by methods such as positively reappraising the situation, avoiding thoughts related to the stressor, turning to religion, or using humor. Problem-focused coping involves managing the external components of a sit-

uation. In patients with cancer, this may manifest as a strong desire to remain compliant with their medication regimen, seeking information about other treatments, or viewing their illness as a challenge to be surmounted. Patients often use a variety of coping mechanisms, but studies have found that patients who identified their cancer diagnosis as a threat tended to use problem-focused mechanisms, whereas those who viewed their diagnosis as a harm or a loss were more likely to implement emotion-focused or avoidance strategies.17 It has been shown that patients with advanced cancer use emotion- focused coping more often, perhaps because they no longer have the physical ability to deal with their disease via problem-focused mechanisms.18 When faced with financial hardships, patients were more likely to use problem-focused strategies.19 Further investigation into the relationship be- tween patients’ ability to cope with their diagnosis and fi- nancial burdens is necessary to better characterize how they affect one another.

Although research continues to emerge on the impact of financial toxicity, there remains a great deal of work to be done in terms of finding the best solutions to implement and identifying which patient populations will benefit the most. Interventions need to be targeted toward reducing financial toxicity, screening for both psychosocial distress and fi- nancial distress, and providing better psychosocial support

for patients. The first step to reducing financial toxicity is to routinelyincludecostdiscussionsaspartofapatient’s care. In a study of 484 patients from academic and community general medicine practices, 63% of participants expressed a desire to discuss out-of-pocket costs of treatment with their physicians, but only 15% of those patients reported that they actually had those discussions.20 In patients with cancer, data have indi- cated that concerns about both present and future costs are prevalent, even among those with insurance.21 Furthermore, studies suggest that cost discussions can reduce out-of-pocket costs for patients, mostly without changing care.22 Until both providers and patients engage in cost discussions, the eco- nomic impact of cancer care will continue to be an under- addressed issue.

Improved screening for both psychosocial and financial distress could benefit patients by allowing for early identifi- cation of toxicities from treatment that extend beyond phys- ical manifestations. This could lead to better allocation of resources to provide the appropriate interventions, giving psychosocial and financial support for patients in need. As discussed by Park and Look,9 patients with cancer who have

high financial burden demonstrated greater nonspecific psy- chological distress. It is crucial to address psychosocial distress because it may lead to worse quality of life and poorer treatment adherence.23 However, the challenge lies in finding the ap- propriate screening tools and standardizing their use among providers. Validated patient-reported measures have been de- veloped for financial distress screening, but those measures are long and require scoring.24 Often, a simple, brief question, such as, “Are you ableto afford yourcare?” can go a long way toward identifying previously unnoticed financial strain.

The sequelae of financial toxicity are myriad and play a crucialroleinpatientoutcomesandqualityoflife.Asdrugcosts continue to rise and as patients are increasingly expected to shoulder the burden, we must find novel ways to mitigate this issue to provide patients with the best possible disease out- come. Until we find long-term policy solutions that reduce drug prices and improve insurance design, the solution lies in the patient-physician relationship.

Authors’ Disclosures of Potential Conflicts of Interest Disclosures provided by the authors are available with this article at jop.ascopubs.org.

Author Contributions Conception and design: All authors Manuscript writing: All authors Final approval of manuscript: All authors Accountable for all aspects of the work: All authors

Tran and Zafar

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Correspondingauthor:S.YousufZafar,MD,MHS,DukeCancerInstitute,2424 Erwin Rd, Suite 602, Room 6046, Durham, NC 27705; e-mail: yousuf.zafar@ duke.edu.

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AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

Price of Cancer Care and Its Tax on Quality of Life

The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I 5 Immediate Family Member, Inst 5 My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO’s conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jop/site/ifc/journal-policies.html.

George Tran No relationship to disclose

S. Yousuf Zafar Employment: Novartis (I) Stock or Other Ownership: Novartis (I) Consulting or Advisory Role: AIM Specialty Health Travel, Accommodations, Expenses: Genentech

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