ABSTRACT
Objectives: Financial toxicity (FT) impacts approximately 50% of patients with gynecologic malignancies. Still, little is known about factors that predispose patients receiving radiation therapy to financial distress or what impact the COVID-19 pandemic had on their financial well-being. We evaluated FT in patients with gynecologic cancer treated with radiation before and after the start of the COVID- 19 pandemic. Methods: Patients from an urban, academic gynecologic radiation oncology practice completed a survey one month after completing radiation from August 2019-March 2020 and November 2020-June 2021. The survey included demographic questions, the Comprehensive Score for Financial Toxicity (COST) tool, and the EQ-5D to measure the quality of life (QOL). Pandemic-related questions were added during the second survey period (pandemic cohort). As with our prior work, high FT was defined as a COST score of ≤23. We assessed the correlation of COST scores with QOL. We used logbinomial regression to examine associations between FT and costcoping strategies, adjusting for age and insurance. Results: Of 97 respondents (92% response rate), 49% completed the survey before, and 51% completed it after the pandemic started. Among the participants, 76% identified as White, 11% as Black, and 8% as Asian. Most patients had uterine (64%), followed by cervical (24%) and vaginal (6%) cancer. Two-thirds (60%) received external beam radiation with or without brachytherapy;the remaining 40% had brachytherapy alone. The median COST score was 15 (IQR: 7-19) in the high FT group (n=27) and 33 (IQR: 28-36) in the low FT group (n=70). High FT correlated with worse QOL (r=-0.37, p<0.01) and was associated with younger age and type of insurance (both p <0.03). Patients with high FT were more likely to move from full- to parttime employment (22% vs 1%, p<0.01), six (95% CI: 1.0-36) times more likely to delay/avoid medical care, 14 (95% CI: 3-64) times more likely to borrow money, and seven (95% CI: 2-27) times as likely to reduce spending on basic goods. Patients with high FT were more likely to report that decreased ability to work (48% vs 13%), medical bills (41% vs 13%), and transportation or parking (15% vs 3%) mostly contributed to their financial stress (p<0.05 for all). The pandemic cohort had fewer patients with high FT than the pre-pandemic cohort (20% vs 35%, p=0.10) and a higher median COST score (32 [IQR: 25-35] vs 27 [IQR: 19-34], p=0.07). The use of cost-coping strategies did not differ between cohorts. Conclusions: Privately insured, younger patients who received radiation for gynecologic cancer were at risk for FT. High FT correlated with worse QOL and was associated with delays or avoidance of medical care and other cost-coping strategies. The prevalence of high FT was not statistically different before and during the pandemic, though we observed less FT in the pandemic cohort. More work is needed regarding the impact of the COVID-19 pandemic on the financial well-being of patients with cancer.
ABSTRACT
Objectives: We aimed to better understand how treatment-related financial burden affects gynecologic cancer patients and identify targets for future interventions to reduce financial toxicity. Methods: Patients with invasive gynecologic cancer diagnoses were invited to participate in a qualitative focus group study. Each participant first completed an online, secure survey that included questions regarding diagnosis, mode of treatment, employment status, and income. The Comprehensive Score for Financial Toxicity (COST) tool was used to measure economic burden (COST score 0-44), with lower scores demonstrating worse financial toxicity. Each participant then took part in one of four virtual semi-structured focus groups through a secure video platform with a social worker and a study staff member. Three investigators independently analyzed the transcripts for common themes and reconciled disagreement through consensus. Results: Of the 13 participants, over 60% had private insurance, and 54% had moderate to high financial toxicity (COST scores <23). The five most commonly discussed themes included the extent of insurance coverage, out-of-pocket health expenses, changes in employment status, inefficient care coordination, and opportunity costs. Other themes that were discussed included stress associated with diagnosis, delays in care, confusion with medical bills, and impacts of COVID-19. Three participants suggested consolidation of bills to decrease obscurity with billing, and two attributed a slower recovery process to financial stress. Participants with worse financial toxicity (COST score <23) reported strain associated with opportunity costs, confusion with billing, and employment status changes more often than those with mild financial toxicity (COST score ≥23). Concerns about insurance coverage were universally reported, irrespective of participant financial toxicity score. Conclusions: Financial toxicity is an increasingly recognized obstacle for patients with gynecologic cancer, though efforts to alleviate patient burdens are lacking. The findings of this study suggest that patient-centered interventions to optimize insurance coverage and enhance care coordination could reduce financial toxicity. This is important given that both targets are potentially immediately actionable and could have downstream effects on health outcomes. Meanwhile, advocacy efforts to improve work leave policies and reduce out-of-pocket health expenditures through insurance reform are broader system-level interventions that also should be considered to curtail financial toxicity.