The Inescapable Reality of Financial Toxicity

More and more studies are examining how out-ofpocket health care costs such as co-payments and deductibles affect patients. These studies typically find that many patients have difficulty buying the medications they need and paying their household bills. Numerous studies on the topic were presented at the recent annual meeting of the American Society of Clinical Oncology.

In one such study of 1108 patients with cancer who received charitable co-pay assistance (CPA), Jeffrey M. Peppercorn, MD, of Massachusetts General Hospital in Boston, and colleagues found that, despite having insurance, 17% and 18% reported delays in starting therapy and skipping medical services, respectively, due to cost. Further, prior to receiving CPA, 66% believed their insurance (mostly Medicare) would shield them from paying high drug costs. Three-quarters of study participants agreed or strongly agreed that doctors should be aware of costs when making decisions.

The problem of medication affordability is especially acute for patients with cancer, but it certainly is not limited to them. A study of 80,807 adult patients with type 2 diabetes and established cardiovascular disease found that those in the highest vs lowest quartile of out-of-pocket costs were 13% and 20% less likely to initiate a GLP-1RA or SGLT2 inhibitor, respectively, according to a recent report in JAMA Network Open. The researchers, led by Jing Luo, MD, MPH, of the University of Pittsburgh School of Medicine, categorized patients into quartiles of out-of-pocket costs for a 1-month supply of these medications. The mean costs for the highest vs lowest quartile were $118 vs $25 for a GLP-1RA and $91 vs $23 for an SGLT2 inhibitor. The median delay in initiation of these drugs for the highest vs lowest quartile ranged from 3 to 6 months, according to the researchers.

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Despite the negative impact of financial toxicity on patients, research suggests that it is often ignored in medical practices. For example, in a survey of women with early-stage breast cancer and their physicians, 50.9% of responding medical oncologists indicated that “someone in their practice often or always discusses financial burden with patients, as did 15.6% of surgeons and 43.2% of radiation oncologists,” Reshma Jagsi, MD, DPhil, of the University of Michigan in Ann Arbor, and colleagues reported in a 2018 article in Cancer

In an article published online in Renal & Urology News, Daniel D. Joyce, MD, a urologic oncology fellow at Mayo Clinic in Rochester, Minnesota, said financial toxicity, like drug toxicity, should be included in physicianpatient discussions about treatment options. “Indeed, financial toxicity has been associated with worse quality of life, symptom burden, and even survival, further supporting its inclusion in shared decision-making.”

Allowing patients’ finances to guide treatment is not ideal, but that is the reality until ability to pay is removed from the therapeutic equation.

Jody A. Charnow Editor

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