Patients with cancer are at high risk for "financial toxicity," and nurses need to be equipped to talk to them about the financial aspects of their care, according to Teresa Hagan Thomas, Ph.D., from the University of Pittsburgh School of Nursing.

It is not only the cost of treatment that contributes to financial stress; co-pays, lost wages, tolls, gas, transportation, food, parking, and childcare also play a role, Thomas said here at the Oncology Nursing Society 2018 Annual Congress.

And the problem is amplified in cancer patients because of the convergence of several factors: the higher cost of care, higher deductibles (including soaring expenses for new targeted treatments and immunotherapies), and a shift in care from community hospitals to hospital-based academic practices, which are often more expensive.

Also, because cutting-edge oral chemotherapy is considered a prescription drug benefit, whereas intravenous chemotherapy is a medical benefit, coinsurance rates are higher for patients taking oral chemotherapies, she explained.

Estimates of the number of cancer patients living with financial stress vary, depending on the measurement used. However, "when we're looking at strictly monetary measures, estimates suggest that between one-fourth and one-half of all adult patients with cancer experience financial toxicity," Thomas reported.

Women are at higher risk for financial toxicity, as are young patients not yet eligible for Medicare and who do not have a large pool of assets, people in ethnic or racial minority groups, and patients with high deductibles. Skipping medications, focusing on the cost of treatment, and wanting to change insurance are all warning signs of financial stress, she explained.

One study demonstrated that cancer patients in the state of Washington were, on average, about 2.5 times more likely to declare bankruptcy than people without cancer. And patients who did declare bankruptcy were 80% more likely to die.

Strategies to Help Patients

"Patient navigation has proven to be an effective strategy for reducing cancer mortality," said Rosenzweig. "Why not apply this to financial navigation?" She described four things that work well: asking patients about their worries; being transparent about costs; assessing distress, and knowing the referral systems.

"Additionally, providers should know the value of the care they are delivering and be well versed on what is considered low-value care," she said. Choosing Wisely recommendations from the American Society of Clinical Oncology target low-value care to decrease costs.

One recommendation suggests that one-drug chemotherapy is used instead of combination chemotherapy for the treatment of metastatic breast cancer unless the patient needs a rapid response to relieve tumor-related symptoms.

Another suggests the avoidance of routine screenings, routine PET scans, and the routine use of growth factors, which can drive up costs. However, even when the concerns of the patient are addressed, the structural problems of poor coverage and the cost of treatment remain, Rosenzweig pointed out.