Park the Parking

Financial toxicity from cancer care is well recognized. Direct costs of clinic visits, hospitalizations, diagnostic interventions, and anticancer and supportive therapies contribute to financial toxicity, which can be compounded by loss of income (as a result of loss in productivity or loss of employment altogether) for patients and caregivers. Without discounting direct costs, recent publications have also highlighted the burden of indirect costs, such as those associated with transportation and parking. In contrast to direct costs, these indirect costs are not typically reimbursed by traditional payers, require day-to-day payment to continue to receive treatment (v piling medical bills that can potentially be paid later), and may not be captured using more traditional measurements such as medication out-of-pocket costs. These costs may be substantial; one analysis of > 1,000 GoFundMe campaigns for financial obligations in cancer care revealed that > 25% were for transportation costs.¹ They may also adversely impact therapy; in a study of > 2,000 individuals with cancer, an inability to pay for travel was associated with a delay in seeking cancer care.² In a 2019 survey of nearly 800 individuals with breast cancer, 48% reported that the cost of transportation was a barrier to receiving treatment.³

As oncologists, we often ask ourselves what we can do to combat financial toxicity on the front line. It will take years, if not decades, to enact policy-level solutions such as improved insurance coverage and drug pricing control. When we speak of counseling patients on expected financial burdens of treatment, a common lament is the lack of price transparency. If I do not know how much a 2-week supply of drug X will cost patients, how can I counsel them? In one study, authors were only able to determine the costs of a simple medical intervention, an electrocardiogram in 3 of 20 hospitals despite calling their offices.⁴ Determining costs of anticancer therapy is infinitely more complex. However, the cost of parking at our own cancer centers is often transparent—at least to the patient or caregiver who has to pay it, if not the oncology care team. In the electrocardiogram study mentioned earlier, authors were able to determine the costs of parking at 19 of the same 20 hospitals.⁴

In a similar vein, we determined the costs of parking at the top 20 2019 U.S. News Best Hospitals for Cancer.⁵ Two authors (N.P. and U.S.G.) independently reviewed cancer center Web sites and telephoned them to abstract the cost of parking. In case of multiple campuses or locations, we chose the primary campus. The median parking charge across cancer centers for a 24-hour period was $13 (range, $0-$36). Several cancer centers had higher charges for valet parking and additional charges for lost tickets. Most centers had rolling rates depending on the total number of hours spent in the garage. Several cancer centers also offered discounts for bulk purchases, weekly or monthly parking rates, and discounts or free parking for senior citizens and patients receiving anticancer therapy that day. In our personal experience caring for patients with cancer, parking vouchers are often available and given to patients who express difficulty in paying these expenses. We acknowledge that the figure of $13 is a crude measure of per-day parking costs for a patient at a top cancer center.

However, let us take a hypothetical patient with recently diagnosed node-negative, early-stage, hormone receptor–positive breast cancer. After a lumpectomy, the patient visits a medical and radiation oncologist on separate days and then undergoes 15 sessions of radiation therapy (hypofractionated radiation) and initiates an aromatase inhibitor. The cost of parking for this acute phase alone would be > $200 out-of-pocket (taking the daily cost of parking as $13). The costs, and the burden, for patients with advanced cancer who are undergoing more frequent and longitudinal clinic visits, blood work, imaging tests, and infusions will be higher. These cumulative costs can be substantial. A 2011 study described patient-reported out-of-pocket costs from 282 patients receiving care at various cancer clinics in Ontario, Canada.⁶ The 30-day parking costs ranged from CAD 0 to CAD 450, highlighting the variability and the potential magnitude of the problem.

Patients with cancer and their caregivers have enough on their plate without having to consider this additional source of financial toxicity. Whatever the exact costs of parking over a care period (whether $5 or $500), we believe an ethical approach is to provide free parking to all patients undergoing evaluation and treatment. It seems ethically incorrect to nickel and dime patients for parking charges. We understand the reasons for charging for parking are complex. Third-party agencies may run garages, and revenue from parking may pay for nonreimbursed but essential services that ultimately serve patients. In addition, the top 20 cancer centers are more likely to be in larger cities, with higher parking charges compared with the rest of the country, and providing free parking may result in a significant decline in revenue. Nevertheless, in 2020, with our multibillion-dollar cancer center budgets, we as health care systems should do everything we can to help patients and caregivers in their time of extreme distress. A patient or caregiver should not have to think about parking charges in determining how to help direct their treatment; this part became clear to us when one of us (A.G., personal communication) tweeted about an encounter with a patient:

Me: Would you like labs on Friday for chemo on Monday, or both on Monday and wait for labs to result?

Patient: Both Monday, please. Parking is $12/day. I can’t spend more on cancer. Need to buy Christmas presents.

I had NEVER considered this. These are out-of-pocket costs too!

This tweet has garnered > 600 retweets and 3,500 likes with dozens of patients sharing their stories about parking and related costs. “My parents paid over $2k for parking and my mom was on leave because I had cancer! Now when I go to clinic I sometimes find street parking far away but only if I feel well,” one patient reported.

Of course, not every patient needs help with costs. In addition, not every patient drives to appointments, and patients may use rideshare apps or public transit or have a caregiver drop them off, obviating the need for parking but incurring other potentially significant unreimbursed costs associated with accessing cancer care. Even for patients not parking their vehicles, reducing the burden of treatment includes consolidating appointments when possible and selecting less aggressive (or less frequent) therapies when appropriate (eg, using single-fraction radiation therapy for treating bone metastases instead of extended-fraction radiation therapy).⁷ As more centers network to provide high-quality cancer care closer to communities where patients live, the opportunity to relieve significant transportation costs along with the associated carbon footprint reduction should be recognized as another benefit in clinicians and health systems working together to optimize care delivery.

Organizations in the United Kingdom have already called to abolish costs of parking for patients with cancer.⁸ In response to the Irish Cancer Society initiative promoting hospital parking guidelines, almost 40% of public hospitals now provide free parking to patients with cancer.⁹ An admirable initiative to first document and then address financial toxicity at one US academic cancer center resulted in a grant to assist with patient parking costs.^10,11 Patients with other chronic conditions, such as cystic fibrosis, and families with children admitted to the neonatal intensive care unit (NICU) are other examples of uniquely vulnerable populations. Foundations such as the Jackson Chance Foundation focus on specifically defraying costs of parking for families with babies in the NICU.¹² Certain programs, such as the American Cancer Society Road to Recovery program and the Leukemia and Lymphoma Society Travel Assistance Program, specifically aim to help patients with travel costs.¹³ We need more such initiatives to encourage safe and convenient travel for patients with cancer. We can do our part by inquiring about parking costs at our own cancer centers, leading change within, and appealing to abolish parking charges for patients and caregivers. In essence, before taking off for the moonshot in our shiny spacecraft, we must first ensure our patients’ cars are parked.

AUTHOR CONTRIBUTIONS

Conception and design: All authors

Administrative support: Arjun Gupta

Collection and assembly of data: Naveen Premnath, Udhayvir Singh Grewal

Data analysis and interpretation: All authors

Manuscript writing: All authors

Final approval of manuscript: All authors

Accountable for all aspects of the work: All authors

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

Park the Parking

The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated unless otherwise noted. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/op/site/ifc/journal-policies.html.

Open Payments is a public database containing information reported by companies about payments made to US-licensed physicians (Open Payments).

No potential conflicts of interest were reported.