WK 10 Discussion SOCW 8205: Psychosocial Aspects of Cancer Cancer is often synonymous with fear, uncertainty, and death. A diagnosis of cancer begins a long journey that affects physical health, menta

2017.028498; published online ahead of print atjop.ascopubs.orgon January 30, 2018. Price of Cancer Care and Its Tax on Quality of Life George Tran and S. Yousuf Zafar Although innovations in cancer therapy have led to less toxic treatments, these new drugs come with higher price tags, with many medications costing more than $100,000 annually. 1,2 As costs increase, a larger bur- den is being placed on patients in the form of higher out-of-pocket expenses, deductibles, coinsurance, and copayments. 3The increas- ing treatment-related costs place a significant strain on patients and their families. A growing body of evidence suggests that the financial burden of cancer treatment has a toxic impact on many aspects of patients’ lives, including their financial well-being, health-related quality of life, and mortality.

A cancer diagnosis can also have sig- nificant ramifications for patients’financial well-being. Hospitalizations, rising insur- ance premiums, prescription drug costs, lost work productivity and income, and annual out-of-pocket expenses that often exceed $5,000 4can ultimately result in untenable financial burden, even for patients with insurance, and—in a small minority— bankruptcy. Indeed, financial insolvency following a cancer diagnosis is a risk factor for mortality. 5Furthermore, patients who are dealing with significant financial bur- dens are more likely to ration their care or forego treatment altogether. 6Some patients delay or discontinue their medications, 7 take less medication than prescribed, use over-the-counter medications as an alter- native, or take medications prescribed for others to alleviate their financial burden. 8 Patients with cancer also experience significant alterations in their health-related quality of life (HRQOL) as a result of fi- nancial toxicity. A study by Park and Look 9 examines the relationship between objective measures of financial burden, HRQOL, and psychological health of patients with cancer in the United States. Financial burden was estimated by calculating the ratio of out-of- pocket expenditures to family income, with high financial burden defined as out-of- pocket expenditures exceeding either 10% or 20% of family income. Their findings illustrate the inverse relationship between high financial burden and HRQOL, with a stronger effect observed on physical health than on mental health. 9The patients studied were also more likely to experience non- specific psychological distress, were older, were more likely to be uninsured, and often had more chronic conditions than patients who did not experience high financial bur- den. These results highlight the powerful relationship between financial hardship and HRQOL. This study builds upon the results of previous studies that have shown that patients who report greater financial bur- den also report poorer general quality of life, physical health, mental health, and social life. 10-13 The interaction between the economic repercussions of cancer care and quality of life requires further exploration. The re- lationship between financial burden and quality of life is probably multifactorial and perhaps even bidirectional. One pos- sible explanation for this relationship is that patients who experience financial burdens are less able to afford necessary care and thus experience greater physical and mental stress. To address their shortage of finan- cial resources, patients may alter their life- style by reducing leisure activities, spending Copyright © 2018 by American Society of Clinical Oncology Volume 14 / Issue 2 / February 2018 njop.ascopubs.org 69 Editorial less on basic necessities such as food and clothing, depleting their savings, or selling off possessions or property. 8All of these compensatory strategies may result in poorer sub- jective well-being among patients with cancer. However, it may also be true that patients with worse quality of life at baseline (ie, those who are sicker and have worse outcomes) may deplete their financial resources faster and thus expe- rience a greater financial burden. 14 Coping mechanisms in response to cancer diagnoses and financial burdens may also play a role in mediating the re- lationship between HRQOL and financial toxicity. Perhaps patients who exhibit poor coping consequently experience greater financial burdens. Patients can use a myriad of coping mechanisms that are generally grouped into two major cate- gories: emotion-focused or problem-focused coping, as his- torically distinguished by Lazarus and colleagues (Lazarus and Folkman 15and Lazarus et al 16). Emotion-focused coping is the regulation of internal conflicts by methods such as positively reappraising the situation, avoiding thoughts related to the stressor, turning to religion, or using humor. Problem-focused coping involves managing the external components of a sit- uation. In patients with cancer, this may manifest as a strong desire to remain compliant with their medication regimen, seeking information about other treatments, or viewing their illness as a challenge to be surmounted. Patients often use a variety of coping mechanisms, but studies have found that patients who identified theircancer diagnosis as a threat tended to use problem-focused mechanisms, whereas those who viewed their diagnosis as a harm or a loss were more likely to implement emotion-focused or avoidance strategies. 17It has been shown that patients with advanced cancer use emotion- focused coping more often, perhaps because they no longer have the physical ability to deal with their disease via problem-focused mechanisms. 18 When faced with financial hardships, patients were more likely to use problem-focused strategies. 19 Further investigation into the relationship be- tween patients’ability to cope with their diagnosis and fi- nancial burdens is necessary to better characterize how they affect one another.

Although research continues to emerge on the impact of financial toxicity, there remains a great deal of work to be done in terms of finding the best solutions to implement and identifying which patient populations will benefit the most.

Interventions need to be targeted toward reducing financial toxicity, screening for both psychosocial distress and fi- nancial distress, and providing better psychosocial supportfor patients. The first step to reducing financial toxicity is to routinely include cost discussions as part of a patient’s care. In a study of 484 patients from academic and community general medicine practices, 63% of participants expressed a desire to discuss out-of-pocket costs of treatment with their physicians, but only 15% of those patients reported that they actually had those discussions. 20 In patients with cancer, data have indi- cated that concerns about both present and future costs are prevalent, even among those with insurance. 21 Furthermore, studies suggest that cost discussions can reduce out-of-pocket costs for patients, mostly without changing care.

22 Until both providers and patients engage in cost discussions, the eco- nomic impact of cancer care will continue to be an under- addressed issue.

Improved screening for both psychosocial and financial distress could benefit patients by allowing for early identifi- cation of toxicities from treatment that extend beyond phys- ical manifestations. This could lead to better allocation of resources to provide the appropriate interventions, giving psychosocial and financial support for patients in need. As discussed by Park and Look, 9patients with cancer who have high financial burden demonstrated greater nonspecific psy- chological distress. It is crucialto address psychosocial distress because it may lead to worse quality of life and poorer treatment adherence. 23 However, the challenge lies in finding the ap- propriate screening tools and standardizing their use among providers. Validated patient-reported measures have been de- veloped for financial distress screening, but those measures are long and require scoring. 24Often, a simple, brief question, such as,“Are you able to afford your care?”can go a long way toward identifying previously unnoticed financial strain.

The sequelae of financial toxicity are myriad and play a crucial role in patient outcomes and quality of life. As drug costs continue to rise and as patients are increasingly expected to shoulder the burden, we must find novel ways to mitigate this issue to provide patients with the best possible disease out- come. Until we find long-term policy solutions that reduce drug prices and improve insurance design, the solution lies in the patient-physician relationship. Authors’Disclosures of Potential Conflicts of Interest Disclosures provided by the authors are available with this article at jop.ascopubs.org.

Author Contributions Conception and design:All authors Manuscript writing:All authors Final approval of manuscript:All authors Accountable for all aspects of the work:All authors 70 Volume 14 / Issue 2 / February 2018 nJournal of Oncology Practice Copyright © 2018 by American Society of Clinical Oncology Tran and Zafar Corresponding author: S. Yousuf Zafar, MD, MHS, Duke Cancer Institute, 2424 Erwin Rd, Suite 602, Room 6046, Durham, NC 27705; e-mail:yousuf.zafar@ duke.edu.

References 1.Experts in Chronic Myeloid Leukemia: The price of drugs for chronic myeloid leukemia (CML) is a reflection of the unsustainable prices of cancer drugs: From the perspective of a large group of CML experts. Blood 121:4439-4442, 2013 2.Mailankody S, Prasad V: Five years of cancer drug approvals: Innovation, efficacy, and costs. JAMA Oncol 1:539-540, 2015 3.Goldman DP, Joyce GF, Zheng Y: Prescription drug cost sharing: Associations with medication and medical utilization and spending and health. JAMA 298:61-69, 2007 4.Bernard DS, Farr SL, Fang Z: National estimates of out-of-pocket health care expenditure burdens among nonelderly adults with cancer: 2001 to 2008. J Clin Oncol 29:2821-2826, 2011 5.Ramsey SD, Bansal A, Fedorenko CR, et al: Financial insolvency as a risk factor for early mortality among patients with cancer. J Clin Oncol 34:980-986, 2016 6.Kent EE, Forsythe LP, Yabroff KR, et al: Are survivors who report cancer-relatedfi- nancial problems more likely to forgo or delay medical care? Cancer 119:3710-3717, 2013 7.Kaisaeng N, Harpe SE, Carroll NV: Out-of-pocket costs and oral cancer medication discontinuation in the elderly. J Manag Care Spec Pharm 20:669-675, 2014 8.Zafar SY, Peppercorn JM, Schrag D, et al: Thefinancial toxicity of cancer treat- ment: A pilot study assessing out-of-pocket expenses and the insured cancer patient’s experience. Oncologist 18:381-390, 2013 9.Park J, Look KA: Relationship between objectivefinancial burden and the health- related quality of life and mental health of cancer patients. J Oncol Pract 14:

e113-e121, 2018 10.Fenn KM, Evans SB, McCorkle R, et al: Impact offinancial burden of cancer on survivors’quality of life. J Oncol Pract 10:332-338, 2014 11.Zafar SY, McNeil RB, Thomas CM, et al: Population-based assessment of cancer survivors’financial burden and quality of life: A prospective cohort study. J Oncol Pract 11:145-150, 201512.Delgado-Guay M, Ferrer J, Rieber AG, et al: Financial distress and its associations with physical and emotional symptoms and quality of life among advanced cancer patients. Oncologist 20:1092-1098, 2015 13.Kale HP, Carroll NV: Self-reportedfinancial burden of cancer care and its effect on physical and mental health-related quality of life among US cancer survivors.

Cancer 122:283-289, 2016 14.Lathan CS, Cronin A, Tucker-Seeley R, et al: Association offinancial strain with symptom burden and quality of life for patients with lung or colorectal cancer. J Clin Oncol 34:1732-1740, 2016 15.Folkman S, Lazarus RS: An analysis of coping in a middle-aged community sample.

J Health Soc Behav 21:219-239, 1980 16.Folkman S, Lazarus RS, Dunkel-Schetter C, et al: Dynamics of a stressful en- counter: Cognitive appraisal, coping, and encounter outcomes. J Pers Soc Psychol 50:

992-1003, 1986 17.Franks HM, Roesch SC: Appraisals and coping in people living with cancer: A meta- analysis. Psychooncology 15:1027-1037, 2006 18.Thomsen TG, Rydahl-Hansen S, Wagner L: A review of potential factors relevant to coping in patients with advanced cancer. J Clin Nurs 19:3410-3426, 2010 19.Head B, Harris L, Kayser K, et al: As if the disease was not enough: Coping with thefinancial consequences of cancer. Support Care Cancerhttps://doi.org/10.1007/ s00520-017-3918-y[epub ahead of print on October 11, 2017] 20.Alexander GC, Casalino LP, Meltzer DO: Patient-physician communication about out-of-pocket costs. JAMA 290:953-958, 2003 21.Stump TK, Eghan N, Egleston BL, et al: Cost concerns of patients with cancer.

J Oncol Pract 9:251-257, 2013 22.Zafar SY, Chino F, Ubel PA, et al: The utility of cost discussions between patients with cancer and oncologists. Am J Manag Care 21:607-615, 2015 23.Mehnert A, Hartung TJ, Friedrich M, et al: One in two cancer patients is sig- nificantly distressed: Prevalence and indicators of distress. Psychooncology, 2017 https://doi.org/10.1002/pon.4464[epub ahead of print on May 31, 2017] 24.de Souza JA, Yap BJ, Wroblewski K, et al: Measuringfinancial toxicity as a clinically relevant patient-reported outcome: The validation of the COmprehensive Score for financial Toxicity (COST). Cancer 123:476-484, 2017 Copyright © 2018 by American Society of Clinical Oncology Volume 14 / Issue 2 / February 2018 njop.ascopubs.org 71 Editorial AUTHORS’DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST Price of Cancer Care and Its Tax on Quality of Life The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I5Immediate Family Member, Inst5My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO’s conflict of interest policy, please refer towww.asco.org/rwcorascopubs.org/jop/site/ifc/journal-policies.html.

George Tran No relationship to discloseS. Yousuf Zafar Employment:Novartis (I) Stock or Other Ownership:Novartis (I) Consulting or Advisory Role:AIM Specialty Health Travel, Accommodations, Expenses:Genentech Volume 14 / Issue 2 / February 2018 nJournal of Oncology Practice Copyright © 2018 by American Society of Clinical Oncology Tran and Zafar Used withpermission. Copyright©American SocietyofClinical Oncology 2018.Allrights reserved.