Add a new entry to the list of factors that can exacerbate a cancer diagnosis: money. Paying for cancer treatment is expensive, and for many patients, the financial distress can be severe—so much so that, as recent evidence suggests, it could count as another cancer mortality risk factor, alongside smoking, diet, and exercise. So researchers began calling this distress “financial toxicity,” because of how it influences patients’ well-being, their treatment decisions, and health outcomes.
Yet video-recorded clinical interactions show oncologists and patients broaching the subject of expense in fewer than half of their discussions, and that omission can have enormous consequences both for patients and their relatives, says Lauren Hamel, a communication and organizational behavior researcher at the Karmanos Cancer Institute and Wayne State University, in Detroit.
In a recent study led by Hamel, analyzing those communications, she wrote, “As the cost of cancer care escalates and the burden of cost shifts to the patient, more patients are incurring debt, filing for bankruptcy, and forgoing treatment.” The study, published in the Journal of Oncology Practice, looked specifically at African-American patients, many of whom lived in poverty and lacked the time and education needed to have such frank conversations with their oncology team.
I was really struck by how much patients were worried about indirect costs.
Why are financial considerations discussed so infrequently? Whose job is it to bring them up? How can patients and doctors navigate this sensitive terrain in a more productive fashion? Hamel answered these and other questions in a recent conversation with Nautilus.
How can cancer costs be a toxin?
The term “financial toxicity” has been discussed as an additional side effect of cancer treatment. On top of diagnosis, people have this life-changing experience, even life-ending experience, and they and their families also can suffer severe financial consequences. There’s an argument to be made that if people actually talk about the financial cost of cancer, they could prevent or reduce that “financial toxicity.”
But it occurred to me that we don’t have objective evidence of what patients’ questions are regarding the financial impacts of cancer. So my collaborators and I wanted to begin to explore that.
How do you explore the effects of financial toxicity?
I had a dataset of videos from another study of patient and oncologist treatment discussions, and we got a grant to re-analyze those video data for financial discussions. We looked at 103 interactions at outpatient clinics at two urban cancer centers in Detroit, including a National Cancer Institute-designated Comprehensive Cancer Center. All of the patients were African-American, and most of them were low-income. Household incomes were less than $20,000 per year for 42 percent of our subjects.
We developed a coding system to measure the presence and nature of financial discussions and how long they lasted. As we reviewed the videos, we noted who initiated the discussion and what was said. We defined “cost” really broadly, to include mention of taking time off work, co-payments, insurance, losing a job, even parking.
What sorts of costs were these patients facing?
I was really struck by how much patients were worried about indirect costs, like taking time off from work for treatment. If you’re a low-income person working for an hourly wage and you take off one day for chemo, that’s 20 percent of your weekly income left unearned. That’s a big deal. And parking and transportation can be expensive. If you’re on a tight budget, parking and transportation costs can be a real issue.