Communication of Cost in Thyroidectomy: A Mixed-Methods Analysis of Financial Toxicity

Abstract

Objective

To assess cost information provided to patients undergoing thyroidectomy

Study Design

Explanatory sequential mixed-methods study

Setting

Single academic medical center

Methods

Adults who underwent thyroidectomy between 1/2021 and 1/2024 completed a survey about financial toxicity. Purposive sampling identified survey respondents for semi-structured interviews to explore experiences related to cost communication. Qualitative data were thematically analyzed.

Results

Of 167 survey respondents, most were female (77.8%), white (83.8%), and underwent total thyroidectomy (65.3%). Nearly one-third experienced moderate to severe financial toxicity. Forty-one percent felt “not at all” informed about costs, while 20% sought preoperative cost information, most commonly from insurers (82.4%). Education was significantly associated with feeling cost-informed, while lowest- and highest-income, younger, and female patients trended toward greater cost-seeking behavior.

Thirty-five respondents were invited for an interview; 20 consented. Almost all participants recalled no cost discussion with their care team. Several felt like they “had to” have surgery, regardless of cost, and many were surprised by copays, missed work, and medication costs. Some wished they had received estimates or information about financial resources. Participants identified insurers as a source for cost information but received vague communication regarding coverage. A few stated that while better cost information would not have changed their treatment decision, it would have better prepared them for the financial impact.

Conclusion

Patients undergoing thyroidectomy appear to be insufficiently informed of costs before surgery. Improved cost communication by care teams and hospital systems could improve preparedness and mitigate financial toxicity, as reliance on insurers alone appears inadequate.

Introduction

The rising cost of healthcare in the United States underscores the need for clear communication about expected costs to patients. Surgeries like thyroidectomy impose significant financial burden despite low complication rates.¹ Financial toxicity—the direct and indirect financial and emotional burdens patients experience—encompasses medical expenses, opportunity costs like time off work, and psychological burden.²

Patients welcome cost conversations with physicians and want to consider costs in treatment decisions, yet only a minority report engaging in these discussions.^3,4 Additionally, providers acknowledge the importance of discussing costs but few feel comfortable initiating this discussion.⁵

Strengthening care team training in cost communication and enhancing support from hospital systems and insurers could improve patient experiences, inform treatment decisions, and align expectations with reality. This study assessed what cost information was provided to patients who underwent thyroidectomy. Understanding current cost communication and patients’ specific needs will guide effective strategies to address financial circumstances.

Methods

Study Design

This study utilized an explanatory sequential mixed-methods design with connected integration. Quantitative data were collected first, then qualitative data contextualized the quantitative findings.⁶ A survey captured demographic, clinical characteristics, and the degree to which participants were informed or sought cost information prior to treatment. This was followed by semi-structured interviews to provide deeper context, with flexible conversation flow allowing participants to focus on their most important experiences.⁷

Adult participants (≥18 years old) were eligible if they underwent a thyroidectomy (total, partial, or lobectomy, with or without neck dissection) for benign or malignant thyroid disease between January 2021 and January 2024 at a high-volume, tertiary referral center. Participants were English-speaking with available mailing and email addresses. The University of Michigan Institutional Review Board deemed this study exempt (HUM00241948).

Eligible participants were first emailed a survey invitation and unique opt-out link. Remaining participants received a recruitment postcard with a small gift (worth <$2) followed by an email 1 week later. Up to 3 email reminders were sent to complete the survey. To better understand the current state of cost communication between patients and their care team, we performed semi-structured qualitative interviews with a subset of survey respondents who had expressed willingness to be contacted for future studies. Purposive sampling—deliberately selecting participants with relevant knowledge or experience—was used to recruit interview participants based on demographics (age, sex), thyroid diagnosis, surgery extent, and self-reported financial toxicity.⁸ Participants received $100 for completing an interview. The Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines and the Good Reporting of A Mixed Methods Study (GRAMMS) checklist guided reporting (Figure 1, Supplement A).^9,10

Figure 1. CONSORT Diagram for Survey Recruitment and Analysis.

Of 643 eligible participants contacted by email and mail, 180 responded. After exclusions, 167 surveys were analyzed, yielding a final response rate of 26.0%.

Data Collection

Surveys were administered online (Qualtrics, Provo, UT) from August to September 2024. Respondents reported demographics (age, sex, race/ethnicity, education, marital status, employment, income, insurance) and clinical data (thyroid malignancy risk, surgery extent). They rated how informed they felt about treatment costs on a 4-point Likert scale (“not at all,” “a little bit,” “somewhat,” or “very much”), reported whether they sought cost information and from which sources, and completed the 12-item validated COST-FACIT measure, which captures how the cost of illness and treatment affects a patient’s quality of life.¹¹

Interviews were conducted via video conference (Zoom Workplace, San Jose, CA, USA) in October 2024 by three members (CBJ–female, EMB–female, JDT–male) trained in semi-structured interview methods. Interviewers were not involved in clinical care and did not have prior knowledge of participants. Written and verbal consent was obtained. Interview guides were developed iteratively with qualitative methodologists (JDT, SEB). Interviews included open-ended questions about patients’ thyroid condition and treatment’s financial impact, with specific prompts about surgery costs and experiences (Supplement B). Interviews were audio-recorded and transcribed verbatim.

Analysis

Quantitative variables were summarized as median (interquartile range) for continuous and frequency (percentage) for categorical measures. Participants were dichotomized to distinguish those reporting no cost information (“no” = not at all) from those reporting any degree ( “yes” = a little bit, somewhat, or very much). This captured whether cost communication occurred at all rather than adequacy. Sensitivity analysis used a more conservative dichotomization, grouping “not at all” and “a little bit” together versus “somewhat” or “very much”. Cost-seeking was dichotomized (yes/no) based on pre-operative information seeking. Financial toxicity was categorized by COST-FACIT scores as none/mild (≥26), moderate (14–25), or severe (0–13).¹² Mild financial toxicity may appear as worrying about future costs, while severe toxicity may mean inability to afford necessities or depleted savings. Comparisons used Wilcoxon rank-sum (Mann–Whitney U) test for continuous variables and Chi-square or Fisher’s exact test for categorical variables. Multivariable logistic regression assessed whether demographic or clinical characteristics predicted cost-informed or cost-seeking status, adjusting for age, sex, race, education, marital status, employment, income, insurance, thyroid condition, and surgery type.

Qualitative transcripts were coded in MaxQDA24, a qualitative data management software, (VERBI GmbH, Berlin, Germany) by four investigators (CBJ, EMB, JDT, SEB) with expertise in surgery, public health, sociology, and qualitative methods. A coding taxonomy was deductively developed from interview questions and a financial toxicity framework, then refined through collective line-by-line coding of three transcripts and expanded inductively through group discussion.¹⁰ Remaining transcripts (n = 17) were coded in duplicate with discrepancies resolved by consensus. Memoing and data summaries informed theme development, and the broader team (DDK, EVC, CBJ, EMB, JDT, SEB, SCP) met throughout analysis to refine interpretations and integrate quantitative and qualitative data.

Results

Survey Respondent Demographics and Quantitative Analysis

Of 643 eligible patients, the 167 survey respondents (response rate 26.0%) had a median age of 54 years (IQR, 39–66), and most were female (77.8%) and white (83.8%) (Table 1). More than half reported annual household income ≥$75,000 (62.2%). Most reported being not at all informed about costs (41.3%), while fewer reported being a little bit (19.2%), somewhat (22.2%), or very much informed (17.4%). Only 20.4% of respondents reported seeking cost information, most often from their insurance carrier (82.4%), followed by the hospital (47.1%), websites or online cost calculators (17.6% each), and the surgeon or other care team members (14.7% each). Clinically, 65.9% of respondents had thyroid cancer or indeterminate cytology, and 65.3% underwent total thyroidectomy. Thyroid diagnosis and surgical extent did not differ significantly by either cost-informed or cost-seeking status.

Table 1.

Demographic and Clinical Characteristics of Study Cohort, Grouped by Cost-Informed and Cost-Seeking

	Overall	Cost Informed*			Cost Seeking
Characteristic	N = 167	No (n = 69)	Yes (n = 98)	p-value	No (n = 133)	Yes (n = 34)	p-value
Age, median (IQR)	54 (39, 66)	56 (40, 66)	52 (39, 65)	0.7	55 (41, 67)	50 (34, 59)	0.078
Female	130 (77.8)	57 (82.6)	73 (74.5)	0.2	106 (79.7)	24 (70.6)	0.3
Race				0.4			>0.9
White	140 (83.8)	56 (81.2)	84 (85.7)		111 (83.5)	29 (85.3)
Black/African-American	9 (5.4)	3 (4.3)	6 (6.1)		7 (5.3)	2 (5.9)
Asian	6 (3.6)	2 (2.9)	4 (4.1)		5 (3.8)	1 (2.9)
Multiracial/Other	12 (7.2)	8 (11.6)	4 (4.1)		10 (7.5)	2 (5.9)
Hispanic	7 (4.2)	2 (2.9)	5 (5.1)	0.7	7 (5.3)	0 (0.0)	0.3
Education				0.027			0.7
Completed high school or less	6 (3.6)	3 (4.3)	3 (3.1)		4 (3.0)	2 (5.9)
Post high school training	7 (4.2)	5 (7.2)	2 (2.0)		6 (4.5)	1 (2.9)
Some college	33 (19.8)	20 (29.0)	13 (13.3)		25 (18.8)	8 (23.5)
College graduate	64 (38.3)	21 (30.4)	43 (43.9)		50 (37.6)	14 (41.2)
Postgraduate	57 (34.1)	20 (29.0)	37 (37.8)		48 (36.1)	9 (26.5)
Marital Status				0.5			0.8
Married or living as married	115 (68.9)	49 (71.0)	66 (67.3)		92 (69.2)	23 (67.6)
Divorced or separated	25 (15.0)	11 (15.9)	14 (14.3)		20 (15.0)	5 (14.7)
Widowed	4 (2.4)	0 (0.0)	4 (4.1)		4 (3.0)	0 (0.0)
Single, never been married	23 (13.8)	9 (13.0)	14 (14.3)		17 (12.8)	6 (17.6)
Employment				0.6			0.4
Employed	97 (58.1)	37 (53.6)	60 (61.9)		74 (55.6)	23 (67.6)
Student	10 (6.0)	4 (5.8)	6 (6.2)		7 (5.3)	3 (8.8)
Retired	38 (22.8)	17 (24.6)	21 (21.6)		33 (24.8)	5 (14.7)
Other	22 (13.2)	11 (15.9)	11 (11.2)		19 (14.3)	3 (8.8)
Income †				0.3			0.082
$34,999 or less	24 (14.5)	14 (20.3)	10 (10.3)		17 (12.9)	7 (20.6)
$35,000 to $74,999	38 (22.8)	16 (23.2)	22 (22.7)		30 (22.7)	8 (23.5)
$75,000 to $99,999	26 (15.5)	11 (15.9)	15 (15.5)		25 (18.9)	1 (2.9)
$100,000 or more	78 (46.7)	28 (40.6)	50 (51.5)		60 (45.5)	18 (52.9)
Insured	159 (95.2)	64 (92.8)	95 (96.9)	0.3	126 (94.7)	33 (97.1)	>0.9
Thyroid Cancer	110 (65.9)	42 (60.9)	68 (69.4)	0.3	89 (66.9)	21 (61.8)	0.6
Treatment				0.5			0.7
Total thyroidectomy	109 (65.3)	47 (68.1)	62 (63.3)		86 (64.7)	23 (67.6)
Partial/Thyroid lobectomy	58 (34.7)	22 (31.9)	36 (36.7)		47 (35.3)	11 (32.4)

^*Recategorized as No = Not At All, Yes = A Little Bit, Somewhat, or Very Much

^†Missing n =1, Cost Informed = Yes, Cost Seeking = No

Educational attainment differed significantly by cost-informed status (p = 0.027). Those who reported being informed about costs were more likely to have completed college or postgraduate education (81.7% vs. 59.4%). In a sensitivity analysis that grouped “not at all” and “a little bit” together, the association between educational attainment and cost-informed status was no longer statistically significant. No other demographic or socioeconomic characteristics differed significantly by cost-informed status.

When examined by cost-seeking behavior, participants who actively sought cost information tended toward being younger (median 50 vs. 55 years, p = 0.078) and more often from lower- or higher-income households (≤$34,999: 20.6% vs. 12.9%, ≥$100,000: 52.9% vs. 45.5%, p = 0.082), although these differences did not reach statistical significance.

In multivariable analyses, no demographic or clinical characteristics, including educational attainment, were independently associated with being cost-informed (all p>0.05). Compared with patients who completed high school or less, post–high school training (OR 0.52, 95% CI 0.04–5.92, p = 0.6), some college (OR 0.54, 95% CI 0.08–3.84, p = 0.5), college graduation (OR 1.87, 95% CI 0.28–12.40, p = 0.5), and postgraduate education (OR 1.64, 95% CI 0.24–11.50, p = 0.6) were not significantly associated with cost-informed status. For cost-seeking behavior, lower income demonstrated a significant association; participants reporting household income of $75,000–$99,999 were less likely to seek information about costs compared to those in the lowest income group (OR 0.06, 95%CI 0.003–0.50, p=0.02). Female sex showed a borderline association with cost seeking (OR 2.72, 95% CI 0.97–7.78, p=0.057) while younger age trended toward significance (OR 0.98 per year, 95% CI 0.95–1.00, p=0.09). No other variables were significantly associated with cost-seeking status.

Interviewee Demographics and Qualitative Analysis

Of the 35 survey respondents invited for an interview, 20 consented and completed interviews (response rate 57.1%). Interviewees had a median age of 43.5 years (range 21–73) and were predominantly female (80%; Table 2). Overall, 30% reported severe financial toxicity, 45% moderate, and 25% none or mild. Most interviewees felt not at all informed about costs (55%), although 45% reported feeling at least somewhat cost informed. A minority (25%) reported actively seeking cost information.

Table 2.

Interview Participant Demographic and Clinical Characteristics

Participant ID	Age	Sex	Thyroid Diagnosis	COST-FACIT Severity	Cost Informed	Cost Seeking
P-1	21	Female	Benign	Severe	Not At All	No
P-2	50	Female	Benign	Severe	Not At All	No
P-3	24	Female	Malignant	Severe	Not At All	Yes
P-4	55	Female	Benign	Severe	Not At All	No
P-5	44	Female	Benign	Severe	Not At All	No
P-6	44	Female	Benign	Severe	Not At All	No
P-7	23	Female	Benign	Moderate	Not At All	Yes
P-8	24	Female	Benign	Moderate	Not At All	No
P-9	68	Female	Benign	Moderate	Very Much	No
P-10	25	Female	Malignant	Moderate	A Little Bit	No
P-11	27	Female	Benign	Moderate	Somewhat	No
P-12	33	Female	Malignant	Moderate	Very Much	No
P-13	54	Female	Malignant	Moderate	Not At All	No
P-14	33	Female	Malignant	Moderate	Not At All	No
P-15	36	Female	Malignant	Moderate	Somewhat	No
P-16	73	Male	Benign	None or Mild	Somewhat	No
P-17	61	Female	Benign	None or Mild	Not At All	Yes
P-18	54	Female	Benign	None or Mild	Somewhat	No
P-19	56	Female	Benign	None or Mild	Somewhat	Yes
P-20	43	Male	Malignant	None or Mild	Somewhat	Yes

Six themes emerged from the interviews. Three themes related to being cost-informed: (1) Lack of Cost Communication and Transparency, (2) Desire for Concrete, Personalized Cost Estimates, and (3) Unexpected and Long-Term Costs. Two themes related to cost-seeking: (4) Timing and Urgency Overshadowing Financial Considerations, (5) Difficulty Accessing or Navigating Financial Support. Interviewees also suggested (6) Recommendations for Improving Cost Communication that cut across being cost-informed and cost-seeking.

Lack of Cost Communication and Transparency

Interviewees consistently reported receiving little to no information about costs before their surgery (Table 3). Several participants described the experience as going in “blind,” with no opportunity to plan (P-3, 24F, severe financial toxicity (FT)). One participant called the situation a “predicament” of uncertainty (P-5, 44F, severe FT). The absence of clear details left one participant with only a “vague notion” of what to expect (P-12, 33F, moderate FT). Another participant summarized, “It was all unknown...you can’t really like plan for it” (P-7, 23F, moderate FT).

Table 3.

Themes and Representative Quotes Relating to Cost-Informed Status

Theme	Lack of Cost Communication and Transparency
Description	Patients frequently reported receiving little to no information about expected costs before surgery. Even when asked, cost estimates were often vague or deferred to insurance companies.
Quotes	“I don’t know that anybody ever actually sat down with me and talked about… this is what’s going to happen. Whenever you ask anyone about finances…it’s like, ‘call your insurance company’… That’s not really helpful.” (P-12, 33F, moderate FT) “They literally don’t give you or tell you anything. So it’s like a shot in the dark.” (P-15, 36F, moderate FT) “Looking back, I don’t believe we ever really had one conversation about the cost or anything.” (P-1, 21F, severe FT) “No, it wasn’t like going in to buy a car… Here are the line items. It was not that way at all.” (P-19, 56F, none/mild FT)
Theme	Desire for Concrete, Personalized Cost Estimates
Description	Patients expressed a strong desire for hospitals or care teams to provide tailored, realistic cost estimates based on their insurance, even if approximate.
Quotes	“It would be useful to people to say here's a round number…here’s what you should prepare for.” (P-19, 56F, none/mild FT) “I would have like to know the cost of things… based on your insurance, we’re estimating three to four thousand out-of-pocket.” (P-14, 33F, moderate FT) “It would be nice to know what it’s going to cost ahead of time, but…it wouldn’t have made difference because I had to get it done regardless.” (P-6, 44F, severe FT) “I would have liked to know…’hey, your wallet’s gonna suffer.’” (P-10, 25F, moderate FT)
Theme	Unexpected and Long-Term Costs
Description	Participants were often surprised by post-surgical expenses such as medications, follow-up testing, and copays, particularly for lifelong thyroid hormone replacement.
Quotes	“I wish I had known that the Synthroid was going to be more expensive… just take the generic.” (P-17, 61F, none/mild FT) “It’s no wonder that so many people end up with bankruptcy from medical costs.” (P-4, 44F, severe FT) “It wasn’t super clear to me what the cost of that medication would be…how frequently I would have to take that…how often I would have to refill that.” (P-8, 24F, moderate FT) “I did not qualify for FMLA…I just have to take my own paid time off.” (P-3, 24F, severe FT)

Desire for Concrete, Personalized Cost Estimates

Despite focusing on health needs, participants often strongly desired precise, personalized cost estimates to better prepare for the financial impact of treatment (Table 3). They wanted estimates of “out-of-[pocket] costs…based on [their] personal insurance” (P-4, 44F, severe FT), and said, “It would have been helpful if I knew what my bill was gonna be,” reflecting a longing for a concrete estimate (P-17, 61F, none/mild FT). Several participants expressed wanting to “know the cost of things,” even if that knowledge “wouldn’t have changed [their] outlook or decision to have the surgery” (P-14, 33F, moderate FT). The lack of personalized estimates was viewed as a missed opportunity to help patients prepare emotionally and financially.

Unexpected and Long-Term Costs

Participants were often surprised by additional costs after surgery, particularly for thyroid hormone replacement, copays, follow-up testing, and lost wages (Table 3). One participant admitted, “I did not know I was gonna be on medication for the rest of my life…it’s an extra expense” (P-3, 24F, severe FT). Others emphasized the financial strain of unanticipated recovery challenges, such as missed work and side effects, with one noting, “I didn’t know I was going to miss as much work as I did” due to fatigue (P-7, 23F, moderate FT).

Timing and Urgency Overshadowing Financial Considerations

For participants with a risk of thyroid cancer, the urgency of their surgery outweighed their financial concerns (Table 4). One participant described they “had to do it” because the surgery “wasn’t elective” (P-15, 36F, moderate FT, malignancy). Others echoed that “cost really wasn’t a factor” in decision-making (P-12, 33F, moderate FT, malignancy), with one adding, “When you’ve been diagnosed with anything of that nature…I don’t even think you think about the cost. You just think about your life” (P-14, 33F, moderate FT, malignancy). Participants with both benign and malignant diagnoses expressed urgency, with the highest being amongst those with malignancy or potential for malignancy (indeterminate nodules).

Table 4.

Themes and Representative Quotes Relating to Cost-Seeking Behavior and Potential Interventions

Theme	Timing and Urgency Overshadowing Financial Considerations
Description	Many patients prioritized the urgency of treatment or the severity of diagnosis over cost concerns, often deferring financial worries until after surgery.
Quotes	“You’ve just been told that you have this life-threatening condition… you’re not thinking about money… you’re in this emergency mode.” (P-12, 33F, moderate FT) “It wasn’t elective. I had to do it… whether it costs a dollar or 10,000, we’re gonna have to figure out how to do it.” (P-15, 36F, moderate FT) “I’m getting this thing out. I’m not risking cancer.” (P-11, 27F, moderate FT) “It wouldn’t have swayed me either way because money is just money. It comes and goes. I would like to keep my life for as long as I can.” (P-14, 33F, moderate FT)
Theme	Difficulty Accessing or Navigating Financial Support
Description	Patients described not knowing what assistance was available or how to access it, and sometimes avoiding seeking help due to pride or unclear processes.
Quotes	“The process is also not very clear on who to reach out to… sometimes the help is not very clear.” (P-14, 33F, moderate FT) “I didn’t know that any options were available for that kind of thing.” (P-12, 33F, moderate FT) “No one else was helping me out.” (P-10, 25F, moderate FT) “We have too much pride sometimes… but if that was noted… maybe the hospital [could] figure out a way to help.” (P-11, 27F, moderate FT)
Theme	Recommendations for Improving Cost Communication
Description	Participants suggested integrating cost discussions into preoperative planning, using written summaries, email communication, and proactive outreach from financial counselors.
Quotes	“Maybe some financial coaching around like what it’s like to have a chronic illness and how that impacts your finances…that would have been nice” (P-12, 33F, moderate FT) “Probably something written… clearly explaining the potential costs of treatments… and talking through it briefly.” (P-8, 24F, moderate FT) “I would have loved for my care team… to do a referral to the people who handle the financial aspects.” (P-14, 33F, moderate FT) “But somewhere within his team there must be a social worker or somebody who knows even round numbers. And I think it would be useful to people to say here's a round number.” (P-19, 56F, none/mild FT)

Difficulty Accessing or Navigating Financial Support

Several participants described challenges in accessing financial support systems, reporting vague or incomplete responses from their care team, or being redirected to insurance provider (Table 4). Some simply did not know what assistance existed or if “there is somebody to help you deal with it,” while others found the processes too confusing to follow (P-12, 33F, moderate FT). The lack of proactive help left participants uncertain about “who to reach out to” or how to begin addressing the costs (P-14, 33F, moderate FT). One participant noted the gap between resources and awareness: “I didn’t even know what was out there” (P-5, 44F, severe FT).

Recommendations for Improving Cost Communication

Participants suggested strategies to reduce financial stress, (Table 4). including the importance of having cost discussions during preoperative planning, ideally supported by a “financial liaison” or social worker (P-11, 27F, moderate FT). Participants suggested written summaries “through an email,” or structured checklists to clarify cost expectations (P-3, 24F, severe FT). Some even recommended financial coaching to help patients prepare for the long-term effects of managing a chronic condition. One participant suggested that the hospital could say, ‘Okay, do you need help with this?’” (P-14, 33F, moderate FT). Another emphasized the value of proactive communication in reducing patient anxiety by saying “I wouldn’t have… been freaking out as much,” (P-15, 36F, moderate FT). A framework for improving cost communication, guided by these suggestions, is shown in Figure 2.

Figure 2. Framework for Improving Cost Communication Based on Interview Responses.

Interviewees identified strategies across care teams, hospitals, and insurers to enhance cost discussions, referrals, transparency, and patient support in managing surgical and long-term financial burdens.

Mixed Methods Interpretation

Figure 3 shows the cost-informed and cost-seeking status of survey participants related to their degree of self-reported financial toxicity along with the corresponding themes from qualitative interviews. When analyzed statistically, neither cost-informed status nor cost-seeking behavior was associated with level of financial toxicity (p=0.66 and p=0.53, respectively). Nonetheless, graphic display and patient interviews suggest a potential pattern of lower levels of cost-informed status and higher likelihood of cost-seeking among participants with greater financial toxicity.

Figure 3. Joint Display: Cost Communication and Financial Toxicity.

Combined survey and interview findings show how cost communication experiences vary across levels of financial toxicity, highlighting where patients face greater financial strain and unmet communication needs.

Discussion

This explanatory sequential mixed-methods study highlights persistent gaps in cost communication for thyroidectomy patients. Quantitatively, only educational attainment was significantly associated with feeling cost-informed, although this association was attenuated with a stricter definition of cost-informed, while lowest- and highest-income, female, and younger patients trended toward greater cost-seeking. The observed divergence between educational attainment and income suggests that feeling cost-informed and actively seeking cost information may represent related but distinct constructs. Educational attainment was associated with reporting any degree of being cost-informed, possibly reflecting differences in health literacy, numeracy, and confidence in interpreting fragmented cost information. Therefore, more educated patients may perceive themselves as informed, even without explicit cost counseling. Notably, the attenuation of the association between education and cost-informed status under a stricter definition suggests that education may facilitate crossing from no perceived information to some information. In contrast, income was more closely linked to cost-seeking behavior, suggesting that financial circumstances influence the motivation or perceived agency to ask questions. Patients at lower income levels may experience greater financial vulnerability, while higher-income patients may feel more empowered to inquire about cost. Together, these findings underscore the importance of distinguishing between receipt, comprehension, and pursuit of cost information when designing interventions to reduce financial toxicity.

Participants with greater financial toxicity were less likely to feel informed yet more likely to seek information, underscoring a mismatch between need and support. Interviews revealed inadequate communication from surgeons, care teams, hospitals, and insurers, with patients describing vague or absent discussions and redirection to insurers unable to provide individualized estimates. Although surgical urgency often overshadowed financial concerns in our study, patients emphasized the need for concrete cost information, noted unexpected ongoing expenses, and reported difficulty accessing financial support. Together, these findings highlight the need for proactive, structured financial counseling, including financial navigators and transparency tools across all levels of care.

These findings align with prior work demonstrating that surgical patients receive little anticipatory financial counseling despite the prevalence of financial toxicity after thyroid surgery.^1,13 Less than one-third of cancer patients report discussing costs with their clinician, and cost conversations were identified in only 22% of visits and had a median duration of 33 seconds.^14,15 Yet, widespread interest in discussion of cost exists.^4,15,16 Our study adds that while patients often do not consider cost in their decision to undergo thyroidectomy, patients still valued financial information to reduce uncertainty and plan ahead. While the current study was not designed to examine the role of cost in treatment decision-making, in other settings, such as breast cancer surgery, patients have reported that costs of care are a factor in treatment decision-making.¹⁷

The lack of systematic cost counseling before thyroidectomy is a lost opportunity at patient-centered improvement. Surgeons are well situated to contextualize financial concerns with the acuity and outcomes in thyroid disease, since thyroidectomy for many benign thyroid conditions could be safely delayed to allow for financial planning.¹⁸ Even approximate out-of-pocket costs and education regarding long-term costs may reduce financial stress. Patients who have engaged in cost discussions also report higher satisfaction and a 33.8% reduction in average total out-of-pocket spending.^15,19

Patients prefer cost information from their physicians and prefer a physician who discusses cost.^20,21 Three-fourths of physicians considered discussions about costs their responsibility, but less than 30% felt comfortable with such communication, reporting insufficient time and the belief that they did not have a solution to offer as barriers to discussing costs with patients.^15,22 Improved training and education about having cost conversations and provision of cost conversation guides, like one published by the American College of Physicians, can help physicians overcome these obstacles.²³ However, cost-related discussions are constrained by healthcare price opacity, as surgeons rarely have access to accurate, patient-specific cost information, which is largely determined by insurance design and negotiated reimbursement rates.²⁴ These realities highlight the need for system-level solutions, such as payer-specific estimates or financial navigation support, rather than reliance on surgeons alone.

Strategies beyond patient-surgeon discussion of treatment costs have also been promising in oncology settings, such as hospital system-based approaches to implementing financial navigators or including computer-generated modules of cost estimation in the electronic medical records.²⁵ These strategies could help close the existing gap between patient expectations and financial means, but may be cost-prohibitive or infeasible in some settings. A lower-resource alternative is standardized patient handouts that highlight resources and potential unexpected costs and facilitate surgeon–patient discussions. Other low-cost, high-impact interventions may also help reduce financial toxicity.

Some limitations exist in this study. Participants were from a single, high-volume center and were predominantly female and white from high-income households. Therefore, practices or experiences in other settings may not be reflected, and these findings likely represent a “best-case scenario” compared to the financial burden faced by other patients. While we did not perform a direct comparison between respondents and the full pool of eligible patients, the demographic characteristics of our sample were similar to those reported in a published cohort of surgical patients in our state, providing some contextual reassurance, though selection bias cannot be excluded.²⁶ Reliance on a retrospective survey of a relatively homogeneous cohort introduces potential response and recall bias and limits generalizability. Financial toxicity disproportionately affects younger patients, those with lower socioeconomic status, racial and ethnic minorities, and individuals with high-deductible or no insurance, suggesting our findings may underestimate the burden in more vulnerable groups.^21,22 Nevertheless, the mixed-methods design provides novel, in-depth insight into cost communication experiences among thyroidectomy patients.

Conclusion

Improved cost communication is essential for thyroidectomy patients. While patients in our study report that costs likely do not impact their treatment decisions, they still desire proactive, individualized cost communication to prepare for surgery. Other patient populations may rely more on cost for treatment decisions, emphasizing the need for improved cost communication. Future research should focus on the development of standardized cost counseling pathways for thyroidectomy and education of surgeons and care teams in fundamental cost communication techniques, emphasizing the flexibility in timing of surgery given the unique excellent survival rate of thyroid cancer. Incorporation of financial navigators and standardized handouts in health systems may also better prepare patients through the financial toll of thyroidectomy, as encouraging patients to gather information from their insurers may be a failed strategy. Mitigating financial toxicity is key for delivering high-quality thyroid surgery care and a necessary step toward more equitable surgical practice.

Supplementary Material

Supplement A

Supplement A. Good Reporting of A Mixed Methods Study (GRAMMS) Checklist.

This checklist states the sections which fulfill the guidelines put forth by O’Cathan et al. for good reporting of a mixed methods study.

Supplement B

Supplement B. Select Questions from the Interview Guide Related to Cost Communication.

Interview questions prompting participants to discuss cost communication experiences during thyroidectomy are shown here, drawn from a broader interview exploring financial toxicity