Financial Toxicity of Cancer Ryan Nipp, MD, MPH Massachusetts - - PowerPoint PPT Presentation

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Financial Toxicity of Cancer Ryan Nipp, MD, MPH Massachusetts - - PowerPoint PPT Presentation

Feb 15, 2024 234 likes •551 views

Financial Toxicity of Cancer Ryan Nipp, MD, MPH Massachusetts General Hospital Cancer Center Cancer Outcomes Research (CORe) Disclosures Ryan Nipp, MD, MPH, discloses no relevant financial relationships. Full Disclosure: Out-of-Pocket

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Ryan Nipp, MD, MPH

Financial Toxicity of Cancer

Massachusetts General Hospital Cancer Center • Cancer Outcomes Research (CORe)

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Disclosures

Ryan Nipp, MD, MPH, discloses no relevant financial relationships.

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Full Disclosure:

Out-of-Pocket Costs as Side Effects

N Engl J Med. 2013 Oct 17;369(16):1484-6.

Consider a Medicare patient with metastatic colorectal cancer Addition of bevacizumab to standard chemo extends life by an average of ~5 months over chemotherapy alone. Over the course of a median of 10 months of therapy, bevacizumab may cost ~ $44,000.00

N Engl J Med. 2004;350(23):2335.

Patient may be responsible for paying 20% of that cost, or $8,800, out of pocket – plus other meds, tests, visits

We discuss the risk of cardiovascular effects associated with bevacizumab, but do we discuss the potential financial effects?

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bankruptcy

Ramsey et al, Health Aff 2013

2.65x

more likely cancer patients

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Cancer Patients At Greater Risk For Bankruptcy Than People Without A Cancer Diagnosis

Ramsey S. Health Aff (Millwood). 2013 Jun;32(6):1143-52.
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Financial Toxicity

  • Financial burden can negatively impact health outcomes,

including QOL, symptom burden, and potentially survival.

Effect of Financial Burden on QOL, Symptom Burden, and Survival

Kale - Cancer 2016 B 95% CI Financial Burden  Quality of Life (SF-12 PCS)

  • 2.45
  • 3.75 to -1.15

OR 95% CI Financial Burden  Depressed Mood (PHQ-2) 1.95 1.29 to 2.95 Lathan - JCO 2016 Mean difference 95% CI Financial Reserves  Pain 5.03 3.29 to 7.22 Financial Reserves  Symptom Burden 5.31 3.58 to 7.04 Ramsey - JCO 2016 HR 95% CI Bankruptcy  Survival 1.79 1.64 to 1.96

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677

419 declined

258

participants eligible

4 excluded

254 full cohort

190

applied for copay assistance

64

did NOT apply for copay assistance

Financial Toxicity of Cancer Treatment

  • Zafar. Oncologist. 2013;18(4):381-90.
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SLIDE 8 Zafar et al. Oncologist 2013

42%

report financial burden

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USE OF ANY LIFESTYLE

78% 57% 54% 50% 28%

89% 39%

Reduced spending on leisure Reduced spending on basics Borrowed money for meds Used savings Sold possessions Family worked more Missed an appointment Missed a procedure Missed a test Took less medication Didn’t fill a Rx

18% 15% 6% 8% 10% 22%

100% 50%

ALTERING STRATEGY

Nipp et al. Psychooncology 2016

ALTERING STRATEGY ANY MEDICAL CARE

Lifestyle Altering Strategies Medical Care Altering Strategies

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identify

patients at can we greatest risk for financial burden?

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Which patients are more likely to alter their

Demographic More Likely Less Likely

EDUCATION

Beyond High School High School and Less

CHEMOTHERAPY DURATION

Less than 1 Year 1 Year or More

AGE

Under Age 65 Age 65 and Over

Which patients are more likely to alter their MEDICAL CARE?

Demographic More Likely Less Likely

INCOME

Under $20,000 yearly Over $20,000 yearly

AGE

Under Age 65 Age 65 and Over

Characteristics associated with financially motivated behavior

LIFESTYLE MEDICAL CARE

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What about

  • ut-of-pocket

expenses?

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Survivors of childhood cancer were more likely to have out-of-pocket medical costs ≥ 10% of annual income (10.0% v 2.9%; P < .001).

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Potential Solutions

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Local efforts at MGH Cancer Center have targeted clinical trial participants…

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7

Ramsey et al, J Natl Cancer Inst. 2010

participate in clinical trials

%

<

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SLIDE 18 Sateren et al, JCO 2002 Murthy et al, JAMA 2004

cancer clinical trial accrual lower for certain subgroups

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Can we improve clinical trial participation by targeting financial burden?

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  • Education to build

awareness of available cancer care options, especially clinical trials

Cancer Care Equity Program (CCEP)

  • In 2013 Massachusetts General Hospital (MGH)

partnered with the Lazarex Cancer Foundation.

community

  • utreach

financial assistance patient navigation

  • Ensure appropriate

cancer screening and follow-up of results

  • Reimbursement for

trial participants struggling with travel and lodging costs

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Lazarex Foundation Patient Referral

CCEP

Oncology provider • Social work • New patient access nurse • Research nurse

  • Determines need for assistance
  • Reimburses patients monthly
  • Liaise with Lazarex Foundation, patient & team
  • Track patient outcomes and collect data

Patient Selection:

  • enrolled in or being screened

for a clinical trial

  • referred to CCEP by their cancer team
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Average Monthly Clinical Trial Enrollment by Year

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What patient characteristics might have contributed to higher participation?

  • 2013 and 2014 differed in the overall distribution of

patient characteristics (p<0.02)*

*Accounting for the temporal changes in the proportions of metastatic disease,

cancer type and enrollment in phase I trials

  • Specifically, higher proportions of minority (p<0.01)

patients and those living > 50 miles from MGH (p<0.01)

  • Suggests CCEP targeted an underserved population
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Monthly Reimbursement per Participant Enrolled in the CCEP

Local Regional National

$185 $300 $900

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Baseline Financial Barriers

All p-values <0.01

CCEP (N=49) non-CCEP (N=38)

56.3% 69.4% 60.4% 46.9% 42.9% 38.8% 34.7%

11.1% 11.4% 9.1% 14.3% 14.3% 8.6% 2.9%

10 20 30 40 50 60 70 80

Bothered by any financial concerns Concerned about travel costs for the trial Concerned about lodging costs for the trial Worried about affording medical costs of trial Afraid health insurance would not pay for trial Thought I wouldn't be able to keep up with trial schedule Thought I wouldn't be able to find transportation to trial center

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Longitudinal Financial Concerns

  • From 7/2016-1/2017, we enrolled clinical trial

patients who expressed interest in the CCEP and a group of control patients

– Matched by trial, sex, age, cancer type, & trial phase

  • Surveyed patients at baseline and day 45
  • We used GLM, generalized estimating equations,

to evaluate changes from baseline to day 45 between the intervention and control groups

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Longitudinal Financial Concerns

Outcome CCEP x time* P-value

Not filling a prescription for a medication 0.18 0.009 Concerned about costs for clinical trial-related travel

  • 0.53

0.023 Concerned about costs for clinical trial-related lodging

  • 0.41

0.074 * Change from baseline to day 45

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Summary

  • After implementation of the CCEP, cancer

clinical trial participation increased greater than what would have been expected.

  • The CCEP served a population in need of

financial assistance.

– Younger patients, lower incomes, traveling farther – Surveys illustrate their financial concerns

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Conclusions

  • Costs are a major concern for cancer clinical trial

participants

  • The CCEP represents a novel way to potentially

improve trial participation

  • Future directions:

– Address the financial burden of trial participants – Develop tools to identify those needing financial aid – Encourage key stakeholders to support efforts to remove financial barriers to trial participation

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Ryan Nipp, MD, MPH

Thank you

Massachusetts General Hospital Cancer Center • Cancer Outcomes Research (CORe)