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What Drives Patient Preferences When Facing Financial Toxicity?

February 2019, Vol 9, No 2

The economic burden caused by cancer and its treatment affects more than the patient’s bank account. As studies have shown, financial toxicity can lead to reduced quality of life, compromise treatment, and worsen clinical outcomes, and the associated devastation can extend to caregivers as well.

Although the impact of financial hardship on patients’ well-being has been documented, the choices patients make when faced with economic uncertainty are less well-­understood.

Difficult Choices

At the 2018 Palliative and Supportive Care in Oncology Symposium, Ian N. Olver, MD, PhD, FRACP, Director, University of South Australia Cancer Research Institute, Adelaide, described how financial toxicity requires patients to make choices concerning redistribution of their financial choices, with a long-term agenda of mitigating the underlying causes of the financial toxicity.

“The choices made with financial hardship can be determined by socioeconomic status and can be harmful to patients and their family,” said Dr Olver. “We need to understand those choices, so that we can more effectively counsel patients in advance. This is a problem that has to be owned by the whole sector,” Dr Olver emphasized.

He cited a 2016 study that was based on the 2011 Medical Expenditure Panel Survey data, showing that among the approximately 19.6 million cancer survivors in the United States at that time, 28.7% of survivors reported financial burden.1

Although interventions using patient navigators, social workers, financial counselors, or support groups have been explored, nothing has proved to help.

“We’re hoping that it might be possible to predict who’s going to be affected, and to counsel them ahead of time, because all the counseling afterwards doesn’t seem to alleviate the problem,” said Dr Olver.

Trading off Efficacy, Toxicity, and Cost

A 2013 study by Wong and colleagues examining patient trade-offs between efficacy, toxicity, and cost identified 3 groups of people among the 400 patients analyzed, including (1) those with a preference for survival; (2) those with an aversion to high drug cost; and (3) those with an aversion to financial toxicity.2 Those with a preference for survival were usually patients with higher income, whereas those who had an aversion to high drug cost typically had lower income. The third group of people, patients with an aversion to financial toxicity, was distributed between the first 2 groups.2

“It didn’t matter whether patients had a higher level of education or a lower level, whether they were employed or unemployed, their insurance status or their numeracy skills,” said Dr Olver. “What mattered was socioeconomic status, and that seemed to predict how patients would use these trade-offs in terms of cost.”

High Copayment

These trade-offs, according to Dr Olver, are particularly important in the context of new oral anticancer medications, which have higher copayments that are likely to lead to reduced adherence, as seen with adjuvant hormone therapies, which have high copayments.

“If higher copayments lead to applications for assistance, 20% of patients took less than prescribed, 19% partially filled the prescription, and 24% avoided filling the prescription altogether,” said Dr Olver. “That’s what these trade-offs mean.”

Given these data, Dr Olver and colleagues are currently working on a tool to predict household budget adjustments in response to financial shock, by predicting which are the patients who are most likely to exhibit this problem. The researchers plan to interview patients and set up a series of discrete choice experiments to understand how they deal with specific financial scenarios.

Looking for Effective Strategies

“We want to develop a ranking of the healthiest, most effective strategies, so that we can create a counseling tool that can be employed before patients get into the dire situation where they’re compromising their own treatment,” Dr Olver said. He noted that the researchers plan to pilot test the tool by using the qualitative interviews in patients who are experiencing shock.

Ultimately, said Dr Olver, it’s not just the government that should have a role in reducing financial toxicity. Clinicians should also intervene, by talking to patients about their options, including the use of generic drugs.

“Several studies have shown that if a doctor brings up financial toxicity, patients are far more likely to discuss it than if they don’t, so this has to come into the consultation,” said Dr Olver. “We need to understand more about the choices patients make when they face financial hardship, so that we can mitigate the effects by counseling them in advance.”


  1. Kale HP, Carroll NV. Self-reported financial burden of cancer care and its effect on physical and mental health-related quality of life among US cancer survivors. Cancer. 2016;122:1283-1289.
  2. Wong YN, Egleston BL, Sachdeva K, et al. Cancer patients’ trade-offs among efficacy, toxicity, and out-of-pocket cost in the curative and noncurative setting. Med Care. 2013;51:838-845. Erratum in: Med Care. 2013;51:1029.

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