What Oncologists Must Account for: The Financial Burden of Cancer-Associated Symptom Relief

The costs of cancer care in the United States are significant and rising.¹ With the implementation of the Affordable Care Act a decade ago, cancer survivors have had increased health insurance coverage and decreased out-of-pocket expenses relative to the overall increase in health care expenditures.^2,3 However, the costs of diagnosis and therapeutic management of patients with active cancer continue to be highlighted as rising causes of financial burden, especially in the era of novel (and expensive) treatments.^4-7 The majority of previous research on cost burden has focused on the financial toxicity of anticancer therapies, despite the fact that direct out-of-pocket costs also include the costs from both prescribed and over-the-counter supportive medications,⁸ clinic visits,⁹ hospitalizations, and nonmedical costs such as travel and lodging.^10,11 Studies documenting these other direct costs that patients face are relatively few in number, but are essential for elucidating the full complexity of costs driving financial toxicity and what additional potential targets exist for intervention by oncologists, cancer centers, or advocacy groups outside of traditional pharmacy assistance programs.

In the article that accompanies this editorial, Gupta et al¹² bring to the forefront the financial toxicity that oncologists may unknowingly cause for patients in their management of common cancer-associated symptoms. The financial burden from symptom management, while less documented than that of anticancer therapy, remains an important consideration in patients' out-of-pocket expenses. In a cross-sectional study of self-pay costs from prescription medications frequently used to control cancer treatment toxicities, the authors highlight the extreme variability in out-of-pocket burden that patients may face for medications that may be written for without much thought by the prescribing physician. The authors use established clinical practice guidelines to identify medications recommended for the management of anorexia, peripheral neuropathy, constipation, diarrhea, exocrine pancreatic insufficiency, fatigue, and nausea and/or vomiting. Recognizing the high percentage of inadequately insured adults in 2018, they used the GoodRx website¹³ to document cash prices of both brand name and generic medications and demonstrate an astonishingly wide range of costs on the basis of type and formulation. Overall, the prices are remarkably high and the authors point out that the most expensive medications do not necessarily correlate with any evidence-based medicine proven increased benefit over cheaper alternatives.

The potential benefit to patients of supportive medications is clear as uncontrolled symptoms reduce quality of life,¹⁴ increase risk of hospitalization,¹⁵ and may lead to cancer progression because of treatment breaks.¹⁶ When used wisely, even expensive supportive care medications may actually prevent higher overall health care costs from uncontrolled symptoms requiring additional supportive care interventions.¹⁷ The unique benefit of this study is that it raises prescriber awareness of not only the variance of cost between generic and brand-name formulations but also the differences in cost between medications to treat similar symptomatology. Importantly, they highlight the physician responsibility to discern the true clinical benefit, putative clinical benefit, and out-of-pocket costs especially in the context of limited available clinical evidence demonstrating superiority of certain drugs over others and steep financial costs, which may alter the risk-benefit ratio of a prescription.

Defining the various components of out-of-pocket expenses for patients is important in the development of potential solutions to this multidisciplinary issue, as clinical practice guidelines urge clinicians to become involved in the management of financial burden and cost of care discussions.¹⁸ The varying coverage of prescription medications across insurance companies, plans, and benefit phases makes discerning exact prescription costs for individual patients challenging although there are physician-pharmacist interventions such as real-time benefit tools that may work to simplify and assist in streamlining prescribing workflow.¹⁹ Even cash prices for medications vary widely by pharmacy type and geographic location, according to another cross-sectional study using the GoodRx online tool.²⁰ These system-level factors may leave individual physicians with questions on how to appropriately integrate cost conscious prescribing into their daily clinical practice. Separately, physician response to patient symptom crises and individual patient response to certain supportive medications may influence the immediate choice of medical management of cancer-related symptoms.

Ultimately, developing a trusting physician-patient relationship with open communication is crucial to the development of not only shared goals of care through cancer-directed therapy but also a shared understanding of important quality-of-life measures for each patient, including financial toxicity. In one study of insured patients receiving anticancer therapy at a single institution, medication nonadherence was associated with both financial distress and oncologist-patient discussions of out-of-pocket costs, suggesting that doctor-patient relationships may be important to developing reasonable alternatives to proposed care.^21,22 Another study using the Medical Expenditure Panel Survey found that only about 10% of surveyed patients reported having a cost discussion with their providers and having this discussion was associated with a significant reduction in their out-of-pocket expenses.²³ Although there is a role for involvement of available supportive services such as social work, pharmacy, and even app-based financial assistance in helping navigate patient financial toxicity,^24-27 ultimately, the buck stops here with the provider and the decision to change mediations because of patient cost concerns can only be made by the prescriber. Despite some provider hesitancy on the role of cost conversations²⁸ and potential lack of resources to guide discussions,²⁹ when a medication is unaffordable, it is the oncologist's responsibility to learn how to address this concern in clinic and not leave a patient bereft with uncontrolled nausea or painful peripheral neuropathy. As providers, we must not forget about the physical, emotional, spiritual, and financial symptoms that we cause in the wake of cancer control—they all play significant roles in the overall quality of our patients' and their caregivers' lives. If, on a blinded path to treat disease at all costs, we end up destroying patient's lifesavings or leave them homeless,²² we have not fulfilled our duties to first, do no harm.

AUTHOR CONTRIBUTIONS

Conception and design: All authors

Financial support: Fumiko Chino

Administrative support: Fumiko Chino

Collection and assembly of data: Fantine Giap

Data analysis and interpretation: Fantine Giap

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

What Oncologists Must Account for: The Financial Burden of Cancer-Associated Symptom Relief

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/authors/author-center.

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