Financial Distress, Use of Cost-Coping Strategies, and Adherence to Prescription Medication Among Patients With Cancer
by Dr. Zullig and Dr. Zafar
When patients are first diagnosed with cancer, understandably, their minds immediately leap to the potential physical symptoms and emotional devastation caused by the disease and its treatment. They reflect on visible symptoms and physical toxicity–fatigue and nausea, among others–and missed opportunities for quality time with friends and family as the illness and treatment run their course. While these are serious and potentially life-altering concerns, for many people with cancer the physical toxicity of treatment is only one aspect of their disease. The financial toxicity related to high treatment costs adds another layer to the cancer burden.
As systemic costs for cancer-related treatment soar, and as third-party payers shift a portion of that cost burden to patients in the form of cost sharing, many patients face burgeoning out-of-pocket, treatment-related costs. As a result of this increased financial burden, many patients–even those with insurance–change behaviors and habits to cope with costs, and some of these cost-coping strategies can have potentially harmful consequences. Patients who experience financially motivated, unanticipated lifestyle changes might see their quality of life and quality of cancer care suffer. Cost-coping strategies can range from the seemingly harmless (e.g., shopping around at pharmacies to get a medication at the lowest price), to those with serious lifestyle consequences (e.g., reduced spending on basics like food or clothing in order to pay for a medication). Other strategies may negatively impact the fidelity and quality of a patient’s cancer treatment (e.g., taking less of a medication that was prescribed to save money).
In our recent study we found that cancer patients who were non-adherent (i.e., who did not take their medications as instructed by their cancer doctor) were more likely to have reduced spending on basic life necessities and borrowed money to pay for their medications. We identified that patients who may already be more financially vulnerable (e.g., young, unemployed, and without an insurance plan to cover prescription medications) are also at greater risk for treatment non-adherence. Non-adherent patients were also more likely to report having asked their doctor for a less expensive medication than initially prescribed. One would expect that this could result in a candid discussion about cancer care costs and, therefore, attenuate patients’ financial distress. We found the opposite, but the timing of the cost conversations in our study is not known. Are patients broaching the subject of treatment-related cost with their doctor as part of the treatment decision-making process, or is the discussion happening too late–after patients have already suffered financial hardship?
Initiating discussions about financial distress and financially motivated treatment non-adherence is complex. Lack of price transparency makes discussions around cost difficult, and even if physicians had cost and insurance details, they may be inadequately trained to facilitate a cost discussion. Our studies suggest that patients are uncertain about the appropriateness of cost-related discussion with their doctor or simply may not know how to broach the topic. Physicians and patients alike must become attuned to the issue of “financial toxicity.” We must strive to make this issue more visible and must work together to identify cost-saving solutions to minimize patients’ financial distress. Doing so may improve adherence, quality of care, and patient well-being.
Dr. Zullig is a health services researcher at the Durham Veterans Affairs Center for Health Services Research in Primary Care and a recent graduate of the Department of Health Policy and Management at the University of North Carolina at Chapel Hill. Her dissertation research focused on evaluating potential racial disparities in cancer care quality and timeliness of care in a large integrated healthcare system. Dr. Zullig has advanced training in health services research methodology and has participated in studies focusing on the reduction of healthcare disparities, improvement of cancer care quality, increased access to care, and examination of the costs of care. Her current research focuses on helping patients with cancer engage with their providers to appropriately self-manage their care. She has received funding from the National Cancer Institute.
Dr. Zafar is a gastrointestinal medical oncologist and health services researcher at the Duke Cancer Institute and Duke Clinical Research Institute. His research explores ways to improve care delivery for patients with cancer. He has advanced training in health services research and has participated in studies focusing on access to care, cost of care, and comparative effectiveness of care delivery between health systems. His primary area of interest is in the cost of cancer care. He has conducted institutional and national studies on how treatment-related costs impact cancer patients’ experience. His current work focuses on how the cost of care can drive medical decision-making and impact the physician-patient relationship. Dr. Zafar is a member of the American Society of Clinical Oncology’s Health Disparities Committee. He is a member of the Alliance for Clinical Trials in Oncology’s Health Disparities and Health Outcomes Committees. Dr. Zafar’s work has been funded by the American Cancer Society, the HealthWell Foundation, the Duke Cancer Institute, the Duke Clinical Research Institute, and the CALGB Foundation.