Bonnie J. Yap

Determinants of Patient-Centered Financial Stress in Patients With Locally Advanced Head and Neck Cancer

PURPOSE To prospectively estimate patient-centered financial stress and its relationship with health care utilization in patients with head and neck cancer. This was a survey-based, longitudinal, prospective study of treatment-naïve patients with stage III, IVa, or IVb locally advanced head and neck cancer at a single-institution tertiary care hospital from May 2013 to November 2014. With 121 patients approached, 73 (60%) agreed to participate. METHODS Self-reported data were collected on demographics, income, wealth, cost-coping strategies, out-of-pocket costs, supportive medication compliance, and perceived social isolation. Health care utilization was measured by hospital admissions and outpatient appointments on a 6-month timeline. Logistic regression models were constructed to identify factors associated with use of cost-coping strategies. Covariates included all demographics, measures of income, wealth, out-of-pocket costs, indirect costs, and perceived social isolation. RESULTS Fifty-one patients (69%) relied on at least one coping strategy. On multivariable analysis, Medicaid patients were more likely than privately insured patients to use cost-coping strategies (odds ratio, 42.3; P = .0042). Decreased wealth ( P = .002) and higher total out-of-pocket costs ( P = .003) were independently associated with using cost-coping strategies. Patients with high perceived social isolation were also more likely to use cost-coping strategies (odds ratio, 11.5; P = .01). Patients with high perceived social isolation were more likely to report nonadherence to supportive medications (21.4 v 5.45 days over 6 months; P = .0278) and missed appointments (seven v three; P = .0077). CONCLUSION A majority of patients used at least one cost-coping strategy during their treatment, highlighting the financial stress that patients experience. Perceived social isolation is an important social determinant of increased medication nonadherence, missed appointments, and use of cost-coping strategies. Interventions should be investigated in at-risk patients who may suffer from financial stress.

Grading financial toxicity based upon its impact on health-related quality of life (HRQol).

16 Background: Financial toxicity (FTox) is an important symptom. We hypothesized that FTox can be graded based on statistically significant and clinically meaningful changes in HRQoL. METHODS FTox was assessed by the COST (COmprehensive Score for financial Toxicity) in 2 sets of cancer patients (pts). Set 1(S1): pts with Stage IV cancers on chemotherapy. Gradations of FTox were determined by ROC analyses based on conventions for clinically meaningful small (0.2), medium (0.5) and large (0.8) effect sizes (e.s.) for the FACT-G HRQoL instrument. Demographics, income, mood disorders (POMS), and symptoms (EORTC QLQ-C30) were collected. We computed η2 (Eta squared) to estimate the magnitude of the variability in HRQoL explained by specific symptoms. Set 2 (S2): pts and survivors with thyroid cancer within 3 years of diagnosis. In S2, HRQoL was assessed by the thyroid-specific City of Hope HRQoL measure. RESULTS A total of 600 cancer pts were assessed (233 in the S1 and 367 in the S2). S1: the median COST value was 23 (range 0-44). ROC curve analyses produced 4 COST grades (G): G0 ≥ 26 (99 pts, 42%); G1: ≥ 14-26 (71 pts, 31%); G2: > 0-14 (58 pts, 25%); and G3: = 0 (5 pts, 2%). Pts with G0 had no impact of FTox on their HRQoL. Absolute e.s. decreases in FACT-G by grade compared to G0 were: G1, 0.59 (95% CI: 0.27 - 0.90); G2, 0.92 (CI: 0.59 - 1.26); G3, 1.77 (CI: 0.83 - 2.70). In multivariate analyses, mood explained 22% (CI 13-31%) of the variability in FACT-G; FTox, 7.6% (CI 2.2-15%); fatigue, 5.6% (CI 1.1-12%); pain, 3.6% (CI 0.3-9.6%); and loss of appetite, 3.4%(CI 0.3-9.3%). VS: applying the COST thresholds to S2, we had: G0: 154 pts (42%); G1: 126 (34%); G2: 84 (23%); and G3: 3(1%). The decreases in HRQoL measured in e.s. were: G1: 0.84 (CI: 0.68 - 1.00); G2: 1.88 (CI: 1.67 - 2.09); G3: 2.99 (CI: 2.29 - 3.68). The association between HRQoL and FTox was significant in multivariate models in both sets (p < 0.001). CONCLUSIONS We developed and validated a FTox grading system in 2 different set of patients. This grading was anchored on independent and clinically meaningful changes in HRQoL attributable to FTox. FTox is a meaningful event that can be objectively measured, and should be included in the assessment of patient-centered outcomes.

Relationship between financial toxicity and health-related quality of life in patients with advanced solid tumors.

31 Background: Financial toxicity is an important Patient-Reported Outcome (PRO). Its relationship with health-related quality of life (HRQOL) has not been previously described. Therefore, we report the relationship between financial toxicity and health-related quality of life (HRQOL) in patients with advanced cancers. METHODS The global HRQOL was measured by the Functional Assessment of Cancer Therapy-General (FACT-G) and its subscales Physical Well-Being (PWB), Social/Family Well-Being (SWB), Emotional Well-Being (EWB) and Functional Well-Being (FWB). Financial toxicity was assessed by the COST (COmprehensive Score for financial Toxicity), a PRO measure previously developed in 155 patients with advanced cancers. Correlations were calculated using Spearmans correlation. Subject data on tumor type, age, gender, race, income, insurance type and educational level were collected. RESULTS Fifty patients were assessed. All participants were diagnosed with advanced cancers, were receiving treatment at the time of participation, and had received treatment for at least 3 months. The median COST was 22 (range 0-44), and mean 22.51 (s.d. ±10.80). A negative correlation existed between the COST and HRQOL as measured by the FACT-G (r = -0.47, P <.001), and its subscales: PWB (r=-0.35, p < 0.05), SWB (r=-0.33, p < 0.05), EWB (r=-0.32, p < 0.05) and FWB (r=-0.41, p < 0.01). In this small sample, there were no correlations between the COST and sociodemographic characteristics. CONCLUSIONS Results demonstrate an inverse relationship between patient-reported HRQOL and financial toxicity, suggesting that higher financial toxicity is associated with worse HRQOL. A larger study is in progress to identify cancer patients at higher risk of financial toxicity.

Relationship between the cancer-specific comprehensive score for financial toxicity (COST), patient-reported outcome, and health-related quality of life (HRQOL) in patients with advanced cancers.

222 Background: Financial toxicity is an important Patient Reported Outcome (PRO). Its relationship with HRQOL has not been previously described. Therefore, we report the relationship between financial toxicity and HRQOL in patients with advanced cancers. METHODS HRQOL was measured by the EORTC QLC-C30 global health status and its functional scales. Financial toxicity was assessed by the COST (COmprehensive Score for financial Toxicity), a cancer-specific PRO measure developed in 155 patients with advanced cancers. The Personal Financial Wellness Scale (PFW), a non-cancer specific financial measure, as well as the EORTC perceived financial impact (FI), were used to assess convergent validity. The Marlowe-Crowne Social Desirability Scale and the Brief Profile of Mood States were included to demonstrate divergent validity (i.e., no significant relationship should exist between self-reported financial toxicity and social desirability and total mood disturbance). Spearmans correlation coefficients were used to assess the strength of relationships. RESULTS Fifty patients were assessed. All participants were diagnosed with advanced cancers, were receiving treatment at the time of participation, and had received treatment for at least 3 months. A negative correlation existed between the COST and HRQOL as measured by the EORTC (r = -0.32, p < 0.05). The highest correlation was found between COST and the EORTC Emotional Functioning Scale (r = - 0.34, p < 0.05). The COST had high correlations with the PFW scale (r = 0.86, p<0.0001) and FI (r = 0.74, p < 0.0001), indicating convergent validity. The association between financial toxicity and social desirability and mood states were not statistically significant (r = 0.16, p = 0.28 and 0.20, p = 0.15, respectively), indicating divergent validity. CONCLUSIONS Results demonstrate an inverse relationship between patient-reported HRQOL and financial toxicity, suggesting that higher financial toxicity is associated with worse HRQOL in this small sample of patients. There was no correlation between COST and social desirability and mood disturbances, as expected.