Dr. Hope Rugo and Dr. Kamaria Lee discuss the prevalence of financial toxicity in cancer care in the United States and globally, focusing on breast cancer, and highlight key interventions to mitigate financial hardship.

TRANSCRIPT

Dr. Hope Rugo: Hello, and welcome to By the Book, a podcast series from ASCO that features engaging conversations between editors and authors of the ASCO Educational Book. I'm your host, Dr. Hope Rugo. I'm the director of the Women's Cancer Program and division chief of breast medical oncology at the City of Hope Cancer Center, and I'm also the editor-in-chief of the Educational Book.

Rising healthcare costs are causing financial distress for patients and their families across the globe. Patients with cancer report financial toxicity as a major impediment to their quality of life, and its association with worse outcomes is well documented. Today, we'll be discussing how patients with breast cancer are uniquely at risk for financial toxicity. Joining me for this discussion is Dr. Kamaria Lee, a fourth-year radiation oncology resident and health equity researcher at MD Anderson Cancer Center and a co-author of the recently published article titled, "Financial Toxicity in Breast Cancer: Why Does It Matter, Who Is at Risk, and How Do We Intervene?"

Our full disclosures are available in the transcript of this episode.

Dr. Lee, it's great to have you on this podcast.

Dr. Kamaria Lee: Hey, Dr. Rugo. Thank you so much for having me. I'm excited to be here today. I also would like to recognize my co-authors, Dr. Alexandru Eniu, Dr. Christopher Booth, Molly MacDonald, and Dr. Fumiko Chino, who worked on this book chapter with me and did a fantastic presentation on the topic at ASCO this past year.

Dr. Hope Rugo: Thanks very much. We'll now just jump into the questions. We know that rising medical costs contribute to a growing financial burden on patients, which has [GC1] [JG2] been documented to contribute to lower quality-of-life, compromised clinical care, and worse health outcomes. How are patients with breast cancer uniquely at risk for financial toxicity? How does the problem vary within the breast cancer population in terms of age, racial and ethnic groups, and those who have metastatic disease?

Dr. Kamaria Lee: Breast cancer patients are uniquely at risk of financial toxicity for several reasons. Three key reasons are that breast cancer often requires multimodal treatment. So this means patients are receiving surgery, many receive systemic therapies, including hormonal therapies, as well as radiation. And so this requires care coordination and multiple visits that can increase costs.

Secondly, another key reason that patients with breast cancer are uniquely at risk for financial toxicity is that there's often a long survivorship period that includes long-term care for toxicities and continued follow-ups, and patients might also be involved in activities regarding advocacy, but also physical therapy and mental health appointments during their prolonged survivorship, which can also add costs.

And a third key reason that patients with breast cancer are uniquely at risk for financial toxicity is that the patient population is primarily women. And we know that women are more likely to have increased caregiver responsibilities while also potentially working and managing their treatments, and so this is another contributor.

Within the breast cancer population, those who are younger and those who are from marginalized racial/ethnic groups and those with metastatic disease have been shown to be at an increased risk. Those who are younger may be more likely to need childcare during treatment if they have kids, or they're more likely to be employed and not yet retired, which can be disrupted while receiving treatment. And those who are racial/ethnic minorities may have increased financial toxicity due to reasons that exist even after controlling for socioeconomic factors. And some of these reasons have been shown to be increased risk of job or income loss or transportation barriers during treatment. And lastly, for those with metastatic breast cancer, there can be ongoing financial distress due to the long-term care that is needed for treatment, and this can include parking, transportation, and medications while managing their metastatic disease.

Dr. Hope Rugo: I think it is really important to understand these issues as you just outlined. There has been a lot of focus on financial toxicity research in recent years, and that has led to novel approaches in screening for financial hardship. Can you tell us about the new screening tools and interventions and how you can easily apply that to clinical practice, keeping in mind that people aren't at MD Anderson with a bunch of support and information on this but are in clinical practice and seeing many, many patients a day with lots of different cancers?

Dr. Kamaria Lee: You're exactly right that there is incredible nuance needed in understanding how to best screen for financial hardship in different types of practices. There are multiple financial toxicity tools. The most commonly used tool is the Comprehensive Score for Financial Toxicity, also known as the COST tool. In its full form, it's an 11-item survey. There's also a summary question as well. And these questions look at objective and subjective financial burden, and it uses a five-point Likert scale. For example, one question on the full form is, "I know that I have enough money in savings, retirement, or assets to cover the cost of my treatment," and then patients are able to respond "not at all" to "very much" with a threshold score for financial toxicity risk.

Of course, as you noted, one critique of having an 11-item survey is that there's limited time in patient encounters with their providers. And so recently, Thom et al validated an abbreviated two-question version of the COST tool. This validation was done in an urban comprehensive cancer center, and it was found to have a high predictive value to the full measure. We note which two questions are specifically pulled from the full measure within the book chapter. And this is one way that it can be easier for clinicians who are in a busier setting to still screen for financial toxicity with fewer questions.

I also do recommend that clinicians who know their clinic's workflow the best, work with their team of nurses, financial navigators, and others to best integrate the tool into their workflow. For some, this may mean sending the two-item survey as a portal message so that patients can answer it before consults. Other times, it could mean having it on the tablet that can be done in the clinic waiting room. And so there are different ways that screening can be done, even in a busy setting, and acknowledging that different practices have different amounts of resources and time.

Dr. Hope Rugo: And where would people access that easily? I recognize that that information is in your chapter, or your article that's on PubMed that will be linked to this podcast, but it is nice to just know where people could easily access that online.

Dr. Kamaria Lee: Yes, and so you should be able to Google 'the COST measure', and then there is a website that also has the forms as well. So it's also beyond the book chapter, Googling 'the COST measure', and then online they would be able to find access to the form.

Dr. Hope Rugo: And how often would you do that screening?

Dr. Kamaria Lee: So, I think it's definitely important that we are as proactive as possible. And so initially, I recommend that the screening happens at the time of diagnosis, and so if it's done through the portal, it can be sent before the initial consult, or again, however, is best in the workflow. So at the time of diagnosis and then at regular intervals, so throughout the treatment process, but then also into the follow-up period as well to best understand if there's still a financial burden even after the treatments have been completed.

Dr. Hope Rugo: I wonder if in the metastatic setting, you could do it at the change of treatment, you know, a month after somebody's changed treatment, because people may not be as aware of the financial constraints when they first get prescribed a drug. It's more when you hear back from how much it's going to cost. And leading into that, I think it's, what do you do with this? So, you know, this cost conversation is really important. You're going to be talking to the patient about the cost considerations when you, for example, see that there are financial issues, you're prescribing treatments. How do we implement impactful structured cost conversations with our breast cancer patients, help identify financial issues, and intervene? How do we inter...