We’ve heard the figures before: the price of cancer drugs has risen by orders of magnitude per month over the past decades, deductibles have tripled in the past 6 years, and employer contribution to premiums has increased by nearly 300% over the past 15 years. In addition to cancer treatment becoming more expensive, insurance design and drug formularies have changed, resulting in a greater financial burden for patients.
Although policy interventions, price negotiation, and modifications to insurance design may help ease this burden down the line, how can clinicians help patients facing financial difficulties now? By communicating openly about costs, said Yousuf Zafar, MD, MHS, FASCO, Associate Professor of Medicine and Public Policy, Duke Cancer Institute, Durham, NC.
“I think we all got into this business to help patients, and our prime directive is to first do no harm,” said Dr Zafar at the 2018 Palliative and Supportive Care in Oncology Symposium.
“As we think about our patients, their experience, and the treatments that we prescribe them, we must also consider, first, doing no financial harm.”
Dr Zafar said that between 50% and 60% of patients across all ethnicities surveyed reported receiving little or no help with their financial concerns from their clinicians.1 In a separate study of 300 patients with cancer, when patients with insurance who received treatment were asked whether they wanted to talk about out-of-pocket costs with their oncologists, 52% said that they did, and yet only 19% actually had that cost discussion.2
“Our patients are clearly telling us that they’re not getting the help that they need in the clinic,” said Dr Zafar, who noted that fear of inferior treatment may explain some of the disconnect. “In my mind, patients are linking cost to quality; they’re shying away from the cost conversation, because they’re concerned that if they say that they can’t afford their care, [oncologists] will put them on something that’s less expensive but also less effective.”
In a survey of oncologists, although many oncologists surveyed indicated that they should consider their patients’ financial strain, only 42% reported discussing costs most of the time, and 26% rarely did or avoided cost discussion altogether.3
Treating Financial Toxicity
To overcome these barriers, said Dr Zafar, oncologists must learn to treat financial toxicity as they would any physical symptom. In other words, try to prevent it as they would with fatigue, for example.
According to Dr Zafar, the first step in preventing financial toxicity is to think about how to integrate it into goals-of-care discussions. Although this discussion may not be for everyone, he said, more patients definitely need to have it.
“I don’t know what the number needed to treat is, but for some people, the decision to receive treatment or not might absolutely hinge upon the affordability of that treatment,” said Dr Zafar.
The next step in preventing financial toxicity takes the cost discussion outside of the patient–clinician relationship and puts it in the hands of the health system, he said.
More price transparency is needed on the part of health systems and payers so that patients can have a cost discussion before starting treatment, Dr Zafar said.
“That discussion is almost impossible to have today, but we’re making some movement in that direction,” Dr Zafar said. “Blue Cross and Blue Shield of North Carolina, for example, has developed a new app called SmartShopper that enables greater price transparency at the point of treatment decision-making and reimburses patients for utilizing less expensive healthcare,” he added.
According to Blue Cross and Blue Shield of North Carolina, patients who have questions related to the SmartShopper program should call the Personal Assistant Team at 877-702-6661 or e-mail
Another step is assessing financial toxicity, and this can be done with patient-reported outcomes (PROs). A randomized controlled study of patients with advanced cancer demonstrated a 5-month improvement in overall survival by merely adding patient-reported symptom monitoring to the standard of care.4
“That 5-month improvement in overall survival with just PROs is better than what we see with many of these fancy—and expensive—immunotherapies and anticancer treatments that we spend most of our time talking about,” said Dr Zafar.
When it comes to assessing financial toxicity, however, this can be done effectively by simply asking patients, intermittently, whether they are able to afford their care.
“The answer might be scary,” said Dr Zafar, “but a simple question like that is really all we need to start.”
As with any symptom, however, no matter what is done to prevent it or to assess for it, patients are likely to experience it to some degree. So, what can oncologists do to reduce financial toxicity? In the study that showed that only 19% of patients actually had a cost discussion with their clinicians, 57% of those who did actually saw a reduction in their out-of-pocket costs.2 Moreover, this reduction happened without changing any treatment in most of the patients.2
Effective Team Communication
“We already are advocating for our patients with insurance companies, and we’re already referring our patients to financial assistance programs,” said Dr Zafar. “I would argue that we need to do it more effectively and more efficiently.”
Although oncologists may be concerned that introducing cost into the conversation could take over the entire clinical appointment, studies have shown that the vast majority of the time, cost conversations occurred within 2 minutes.5
“When I know I’m going to prescribe a patient an expensive oral anticancer drug or an expensive supportive care medication, I will bypass the patient’s room, go to the pharmacist first and let the pharmacist know that I’m going to make that prescription,” said Dr Zafar.
“The pharmacist then starts looking at the patient’s insurance. By the time I’m done talking to the patient about the side effects related to chemotherapy, the pharmacist comes in the room and says, ‘Your copay is going to be X at Y pharmacy,’” he added.
Whether it’s a pharmacist, a nurse, an advanced practice provider, a social worker, or a financial counselor, said Dr Zafar, this workflow could be easily integrated into one’s clinic.
“It’s important to rely on our entire team as we address the problem of financial toxicity. The clinician is just the point tip of the arrow. It’s critical to integrate financial counselors, pharmacists, and social workers as we think about having that cost discussion with our patients,” Dr Zafar concluded.
- Jagsi R, Ward KC, Abrahamse PH, et al. Unmet need for clinician engagement regarding financial toxicity after diagnosis of breast cancer. Cancer. 2018;124:3668-3676.
- Zafar SY, Chino F, Ubel PA, et al. The utility of cost discussions between patients with cancer and oncologists. Am J Manag Care. 2015;21:607-615.
- Schrag D, Hanger M. Medical oncologists’ views on communicating with patients about chemotherapy costs: a pilot survey. J Clin Oncol. 2007;25:233-237.
- Krzyzanowska MK. Symptom monitoring during cancer treatment: applying science to the art of medicine. Presented at the ASCO Annual Meeting; June 2-6, 2017; Chicago, IL.
- Hunter WG, Zafar SY, Hesson A, et al. Discussing health care expenses in the oncology clinic: analysis of cost conversations in outpatient encounters. J Oncol Pract. 2017;13:e944-e956.