Financial Toxicity and Cancer Treatment (PDQ®)–Health Professional Version

Introduction

A number of studies demonstrate that individuals with cancer are at higher risk of experiencing financial difficulty than are individuals without cancer.[1-7] This summary reviews the extant literature on financial toxicity among American cancer patients and survivors.

Background

Cancer is one of the most costly medical conditions to treat in the United States.[8] Patients can receive multiple types of treatment, including surgery, radiation therapy, and systemic treatment. Historically, inpatient hospitalizations have been the major drivers of the costs of cancer care. Compared to a decade ago, patients with cancer are receiving increasingly expensive chemotherapy and biologics, both alone and in combination.[9,10] The use of expensive supportive agents and hematopoietic growth factors has also increased.[9] The list price of newly introduced systemic therapies and supportive drug-based treatments is growing,[9-11] and prices of both infusion and oral drugs continue to increase after product launch.[12,13] Although prices can vary dramatically among treatments, often data are lacking about the differences in outcomes. Prices higher than $10,000 a month for individual drugs and biologic agents are common.

At the same time, commercial insurers in the United States are shifting more direct medical care costs to patients through higher premiums, deductibles, and coinsurance and copayment rates. The 2016 Commonwealth Fund Biennial Health Insurance Survey indicated that 33% of insured adults aged 19 to 64 years had medical bill problems or accrued medical debt.[14] Infused chemotherapy and supportive agents covered under patients’ medical benefits entail high out-of-pocket costs; these costs also appear to be growing as care shifts from the community into hospital-based outpatient departments.

Oral cancer drug–based treatments are frequently covered under patient pharmacy benefits’ specialty tier, requiring high coinsurance that patients pay out of pocket. High cost-sharing plans, including tiered outpatient prescription formularies (i.e., copays that escalate depending on whether the drug is generic or branded, and by price) may be particularly troublesome for patients with cancer who are prescribed expensive oral chemotherapeutics. The proportion of health care plans with multitiered (>3) prescription formularies, in which expensive oral specialty drugs are associated with the highest cost sharing, increased from 3% in 2004 to nearly 88% in 2017.[15] These trends in treatment cost and changes in insurance coverage suggest that financial distress associated with acute and chronic cancer is highly prevalent, even among people with health insurance.

Compared with individuals without a cancer history, cancer survivors have higher out-of-pocket costs, even many years after initial diagnosis,[1-4] reflecting ongoing cancer care and care for any late or lasting treatment effects. In addition, cancer survivors are more likely to report being unable to work because of their health,[1-4] including more missed work days or additional days spent in bed because of poor health.[1-4] Limited ability to work may also reduce employment-based health insurance options and resources to pay for medical care, further magnifying the financial impact of cancer. Combined, these factors contribute to financial toxicity—the phenomenon of adverse financial effects of cancer treatment.

A number of other terms have been used to describe the financial impact of cancer, its treatment, and the lasting effects of treatment, including financial distress, financial stress, financial hardship, financial burden, economic burden, and economic hardship.[16,17]

Etiology and Risk Factors

The interplay between cancer and financial distress is complex and related to a number of factors, as shown in Figure 1.[18,19]

Enlarge

Several factors in a household at the time a member of that household is diagnosed with cancer influence vulnerability to financial distress. The risk of severe financial distress and the period between illness and these outcomes are influenced by the following factors:

At the time of cancer diagnosis, several factors that determine the long-range risk of financial hardship include the following:

Components of these measures include material conditions that arise from increased out-of-pocket expenses, lower income from the inability to work, and psychological response to increased household expenses and reduced income.[16,17]

The material conditions of patients and their families that may be adversely affected by a cancer diagnosis and treatment are typically measured as follows:[16,17]

In addition, a patient's psychological response to increased financial burden associated with a cancer diagnosis and treatment is typically measured as financial stress, distress, or worry.[16,17]

Prevalence

A number of studies have measured components of at least one aspect of financial hardship,[1,4-6,20-32] although methods and measures vary widely, limiting comparisons across studies. In addition, most studies that have evaluated financial hardship were conducted at single institutions, which are geographically defined, or in other selected samples of cancer survivors. Nationally representative estimates of financial hardship from survey data are generally reported for all cancer survivors, and scant information is available by cancer site or stage of disease at diagnosis. Household surveys generally include few newly diagnosed cancer patients, those with rare cancers, or those with projected short-term survival. Because data about financial hardship are not routinely collected and can be difficult to measure, few studies have reported incidence of financial hardship among the newly diagnosed or newly treated.

The following sections describe the prevalence of specific measures of financial hardship, including out-of-pocket costs, productivity loss, asset depletion and medical debt, bankruptcy, and financial distress and worry.

Disease- and Treatment-Related Risk Factors

Patients with advanced-stage cancers, cancers requiring chemotherapy or radiation therapy, and underlying comorbidities have a higher risk of financial hardship after diagnosis than those without these characteristics.[1-4] In a study of 1,556 cancer survivors identified from the 2010 National Health Interview Survey (NHIS) who responded to a single survey item assessing financial burden, survivors were more likely to report high financial burden if they received chemotherapy (47.2% vs. 30.8%; P < .001), received radiation therapy (44.7% vs. 31.4%; P < .001), and had recurrent or multiple cancers (40.9% vs. 33.7%; P < .049).[3]

A similar association was seen in an analysis using data from the 2008–2010 Medical Expenditures Panel Survey (MEPS) Household Component to measure loss of employment and productivity in individuals with and without cancer.[1] In this study, survivors with more-aggressive disease processes (i.e., recurrent, multiple, or poor-prognosis cancers) had the highest rates of lost productivity relative to individuals without cancer. Specifically, individuals with cancers associated with short survival were less likely to be employed (66.8% vs. 81.4%; P < .0001) and more likely to face limitations on their ability to participate in activities at home, work, or school (17.5% vs. 8.5%; P < .001) than individuals without cancer. Productivity among survivors of breast, prostate, colorectal, and other single cancers was not as decreased as productivity among those with higher-risk disease.

Another study used multiple years of the MEPS (2008‒2013) to evaluate the associations between cancer history, chronic conditions, and productivity losses.[5] Adult cancer survivors were significantly more likely to have chronic conditions, including heart disease, diabetes, asthma, and arthritis, than were adults without a cancer history. They were also more likely to have multiple chronic conditions. Cancer survivors who had multiple chronic conditions were more likely to be limited in their ability to work than cancer survivors without these other conditions. Among cancer survivors, those with four or more chronic conditions had annual productivity loss of $9,099 (95% confidence interval [CI], $7,224‒$10,973) compared with those without any additional chronic conditions (in 2013 dollars).

Receipt of cancer-directed treatment and the presence of other comorbidities were also found to be associated with higher out-of-pocket spending in the Medicare population. In a study using data from the Medicare Current Beneficiary Survey linked to Medicare claims (1997–2007), 2-year mean out-of-pocket spending was higher by $1,526 among patients receiving chemotherapy and by $1,470 among patients receiving radiation therapy compared with patients who did not receive treatment (P < .01).[6]

These studies suggest that cancer survivors across a broad age range with advanced cancers, recurrent cancers, or cancers that require treatment (likely a marker of more-advanced disease) are more likely to face higher out-of-pocket spending and are at higher risk of financial hardship. Chronic treatment-related spending in combination with inability to regain employment and income resulting from progressive disease and debility may contribute to the association between advanced disease and greater financial burden.

Sociodemographic Risk Factors

Health Insurance

Patients who lack health insurance coverage are at elevated risk of many adverse experiences, including substantial financial hardship, particularly in an era of rapidly rising costs for cancer care. However, the presence of health insurance does not completely shield enrollees from high levels of out-of-pocket spending on health care services.

In the Medicare population, access to supplemental insurance and Medicare Part D plans has helped shield patients from some of the out-of-pocket cost burden. In an analysis of data from MEPS 2002–2010, outpatient prescription costs for adults older than 65 years decreased by 43% after the introduction of Medicare Part D, while younger patients (not yet Medicare-eligible) did not experience a similar decline in out-of-pocket expenditures for prescription drugs over the same period.[39] Another study found that supplemental insurance decreased older Medicare beneficiaries' risk of high out-of-pocket expenditures on cancer care.[6] Whether these protections against high out-of-pocket spending may translate into other decreases in material financial hardship, financial distress, debt, and bankruptcy is not clearly known.

As the number of high-price orally administered anticancer drugs has increased, so has awareness of differences in coverage across infused and orally administered drugs for Medicare beneficiaries. Specifically, Medicare Part D, which covers orally administered or self-administered drugs, requires very high cost sharing for cancer drugs, with no out-of-pocket spending limit. One study showed that the price for a single fill of some of the most common cancer drugs under Medicare Part D (e.g., lenalidomide, ibrutinib, palbociclib, or enzalutamide) would cost a patient over $3,000 out-of-pocket. Cumulative spending over a year would exceed $10,000 for nearly all of these drugs.[40] In a study of fee-for-service Medicare beneficiaries treated at one of 11 geographically diverse academic medical centers, nearly one in three beneficiaries did not initiate the orally administered anticancer drugs prescribed by their doctors within 90 days of the prescription order date.[41] In that study, the initiation rate was 35% lower among individuals who did not have subsidies that lowered their out-of-pocket costs (adjusted RR, 0.65; 95% CI, 0.52–0.81), suggesting that costs influenced drug initiation.

The influence of type of insurance plan on the risk of financial hardship among patients younger than 65 years has not been thoroughly explored. One study found that patients with public insurance (Medicaid or Medicare) have an increased risk of financial hardship compared with patients who have private insurance (OR, 1.95; P < .0001).[8] However, having public health insurance may also be associated with lower savings and assets and, therefore, increased financial vulnerability, factors that were not controlled for in this analysis.

Access and Adherence to Treatments

Several retrospective cohort studies have evaluated the effect of prescription copayment amounts for cancer drugs on patient compliance with therapy.[1,2]

A cross-sectional study using data from the 2011 to 2014 National Health Interview Survey found that individuals aged 18 to 64 years with a recent or previous cancer diagnosis were more likely to report changing their prescription drug use (e.g., not filling prescriptions or skipping doses) for financial reasons than individuals without a history of cancer.[3] Another study examined the association between imatinib copayment and medication adherence among patients with chronic myeloid leukemia, from 2002 to 2011, using MarketScan health plan claims.[1] Over the study period, monthly copayments for imatinib ranged from $0 to $4,792, with a mean and median of $108 and $30, respectively. Patients in the highest quantile of monthly copayments for imatinib (mean, $53) compared with patients in the lowest quantile (mean, $17) had a statistically significant adjusted risk ratio (RR) of 1.70 (95% confidence interval [CI], 1.30–2.22) for discontinuing imatinib during the first 180 days of treatment.[1] Similarly, patients with higher copayments for imatinib (vs. the lower copayment group) had an adjusted RR of 1.42 (95% CI, 1.19–1.69) for nonadherence to their imatinib therapy.[1]

Other studies examined the association between copayment amounts for adjuvant endocrine therapy, aromatase inhibitors, and tamoxifen and noncompliance in women with breast cancer.[2,4,5] Studies have been relatively consistent in showing that at the highest levels of copayment, cancer patients become less likely to take cancer-related medications on a daily basis (nonadherence), or they discontinue their medications over the long term (nonpersistence of use). Reduced adherence to cancer medications may be worse when the total out-of-pocket cost of all prescription drugs taken by the patient is considered.[5]

A cross-sectional survey study of adult patients (N = 300) receiving cancer therapy at Duke Cancer Institute found that 16% of patients reported high or overwhelming financial distress, 27% reported medication nonadherence, and 4.67% reported chemotherapy nonadherence.[6] Among patients reporting medication nonadherence, 14% specified skipping medication doses to make the prescription last longer, 11% stated they took less medication than prescribed to make the prescription last longer, and 22% indicated that they did not fill a prescription because of cost.[6] Among the patients reporting chemotherapy nonadherence, 1% skipped chemotherapy doses to make the prescription last longer, 1.67% took less chemotherapy to make the prescription last longer, and 3.33% did not fill a chemotherapy prescription because of cost.

This study also found that an increased likelihood of nonadherence was associated with the following characteristics:

A statistically significant decreased risk of nonadherence was associated with having private insurance (adjusted OR, 0.31; 95% CI, 0.14–0.72).

A cross-sectional cohort study of 10,508 patients who started oral chemotherapy between 2007 and 2009 examined the association between prescription abandonment rates and cost sharing.[7] Abandonment was defined as a paid prescription claim gap of more than 90 days. An adjusted analysis found that claims with cost sharing of $251 to $350 had 2.3 times the likelihood of abandonment (95% CI, 1.59–3.36); $351 to $500 had 3.28 times the likelihood of abandonment (95% CI, 2.20–4.88); and more than $500 had 4.46 times the likelihood of abandonment (95% CI, 3.80–5.22) when compared with cost sharing of $100 or less.[7] Additionally, the study identified a substantially higher proportion of patients who paid more than $500 out of pocket for their first oral chemotherapy claim in the Medicare group compared with the commercially insured group (45.5% vs. 10.7%; P < .001).[7]

Anecdotal reports also suggest that terminally ill cancer patients are foregoing the opportunity to obtain lethal doses of barbiturates in states with death-with-dignity laws because the price of these generic medications has increased to approximately $3,000 for a typical prescription.[8]

Quality of Life and Perceived Quality of Care

In a prospective, observational, population- and health care systems–based cohort study, the associations between financial burden, quality of life, and perceived quality of care were investigated using Cancer Care Outcomes Research and Surveillance Consortium (CanCORS) II data. Patient-reported health-related quality of life was measured using the EuroQol five-dimensions questionnaire (EQ-5D).

From 2003 to 2006, patients were enrolled in the U.S. CanCORS study within 3 months of receiving either a colorectal or lung cancer diagnosis. For the CanCORS II study, among the surviving CanCORS patients, one disease-free subcohort and one advanced-disease subcohort were selected and resurveyed about their quality of life. The median time from diagnosis was 7.3 years. An adjusted structural equation modeling analysis found that higher financial distress was negatively associated with health-related quality of life (adjusted beta, -0.06 per burden category; 95% CI, -0.08 to -0.05); however, financial distress was not associated with perceived quality of care (OR, 1.09; 95% CI, 0.93–1.29).[9] A lower perceived quality of care was associated with a poorer health-related quality of life (OR, 0.85; 95% CI, 0.79–0.92).[9] Moreover, having advanced disease was strongly associated with a poorer health-related quality of life (OR, -0.04; 95% CI, -0.08 to -0.01), but no association was observed with financial distress (OR, 1.25; 95% CI, 0.79–1.98).[9]

Another cohort study using CanCORS data [10] found that financial strain was negatively associated with health-related quality of life and positively associated with symptom burden among patients with a lung or colorectal cancer diagnosis. Among patients with lung cancer, those with fewer than 12 months of financial reserves to continue their current standard of living reported increased symptom burden (adjusted mean difference, 5.25; 95% CI, 3.29–0.22), increased pain (adjusted mean difference, 5.03; 95% CI, 3.29–7.22), and lower quality of life (adjusted mean difference, 4.70; 95% CI, 2.82–6.58) compared with patients with more than 12 months of financial reserves.[10] Similarly, colorectal cancer patients with fewer than 12 months of financial reserves to continue to live at their current standard of living reported increased symptom burden (adjusted mean difference, 5.31; 95% CI, 3.58–7.04), increased pain (adjusted mean difference, 3.45; 95% CI, 1.25–5.66), and lower quality of life (adjusted mean difference, 5.22; 95% CI, 3.61–6.82) compared with those who reported more than 12 months of financial reserves.[10]

Several cross-sectional studies evaluated the impact of the financial burden of cancer care on patient quality of life. A survey analysis involving 149 patients with advanced-stage cancer in Texas at a public hospital (n = 72) and a comprehensive cancer center (n = 77) found that the median intensity of financial distress was double among patients treated in a public hospital compared with those treated in a comprehensive cancer center (on a scale of 0 = best to 10 = worst; 8 vs. 4; P = .0003).[11] More than 30% of patients perceived financial distress as being more severe than physical, emotional, social, or family distress.[11] Additionally, advanced-stage cancer patients in the public hospital reported the impact of financial distress relative to the impact of social and family distress as "strongly agree", "agree", or "somewhat agree" more frequently compared with patients treated in the comprehensive cancer center (54% vs. 33%, P = .0085).[11] Financial distress was inversely correlated with quality of life (r = -0.23; P = .0057).

Another study analyzed answers to the question, "To what degree has cancer caused financial problems for you and your family?" Among 2,108 patients from the 2010 National Health Interview Survey (NHIS), those who responded "a lot" (8.6%) were more likely to report the following when compared with those who reported no financial burden:[12]

Using the 2011 Medical Expenditure Panel Survey (MEPS) data, one study [13] found that among 1,380 identified cancer survivors, 28.7% reported cancer-related financial burden. Additionally, cancer survivors who reported financial burden when compared with those who reported no financial burden were found to have the following outcomes:[13]

Satisfaction With Care

A review study documented that approximately 60% of people across a wide range of studies reported positive attitudes about cost-related discussions with their health care providers. Despite this finding, less than one-third of patients have had these discussions.[14] One study among women with breast cancer documented unmet need for engagement. Specifically, 72.8% of the 945 women who expressed worrying about finances at least somewhat indicated that cancer physicians and their staff did not help "at least somewhat".[15] Additionally, 55.4% of the 523 women in the same study who expressed a desire to talk to health care providers about the impact of breast cancer on employment or finances reported that they had not had a relevant discussion with their cancer physicians, primary care providers, social workers, or other professionals.[15]

Adverse Financial Events, Debt, and Bankruptcy

The impact of the financial burden of cancer care on adverse financial events, debt, and bankruptcy has been studied.[16-18]

One cross-sectional study, using the Livestrong 2012 survey data of 4,719 cancer survivors, reported that 63.8% of the survivors had worried about paying large bills related to cancer, 33.6% had gone into debt, 3.1% had filed for bankruptcy, and 39.7% had to make other kinds of financial sacrifices because of their cancer, its treatment, or the lasting effects of treatment.[16] Of those who reported going into debt, 9.1% had filed for bankruptcy, 55% incurred debt that totaled $10,000 or more, and 68% had to make other kinds of financial sacrifices.[16]

Furthermore, this study found that an increased likelihood of filing for bankruptcy was associated with the following characteristics of cancer patients:[16]

Similar patient characteristics were reported for those going into medical debt.[16]

A retrospective cohort study, using data from the 1995–2009 western Washington Surveillance, Epidemiology, and End Results (SEER) Cancer Registry–linked U.S. Bankruptcy Court for the Western District of Washington, found that patients with cancer diagnoses were more likely (hazard ratio [HR], 2.65; P < .05) to file for bankruptcy compared with patients without cancer.[17] Patients with thyroid cancer had the highest HR (HR, 3.46; P < .05).[17]

Another retrospective cohort study evaluated the risk of adverse financial events among patients with cancer. Investigators used data from the western Washington SEER Cancer Registry linked with TransUnion quarterly credit records, along with data from a control group selected from state voter registration records.[18] Adverse financial events reported on credit records included an inability to pay bills (collections or charge-offs), tax liens and delinquent mortgage payments, and foreclosures or repossessions of personal property. Also evaluated were past-due credit card payments as a secondary outcome. The rate of adverse financial events was nearly twice as high for people with cancer than for the control group (4.3% vs. 2.4%; P < .001). The severity of adverse financial events was greater for those with cancer than for the control group (3.8% vs. 1.9%). In addition, Black patients were more likely than White patients to experience adverse financial events (15.2% vs. 4.2%; P < .001).

A clearly worded grading system has been developed to identify different levels of financial toxicity.[19] The usefulness of this system for categorizing and monitoring financial outcomes after cancer treatment has not been evaluated.

Impact on Caregivers

Informal cancer caregivers often share in the experience of financial toxicity by spending money on food, medications, and other patient needs in addition to taking time off from work to provide logistical, emotional, and medical support. In a recent survey of over 5,000 cancer patients whose caregivers were friends or family members, approximately 25% reported that their caregivers made significant employment changes after the cancer diagnosis, and 8% of survivors had caregivers who took at least 2 months of leave from work.[20] Evidence suggests that the cumulative financial and employment impacts of cancer caregiving can lead to higher caregiver burden, poorer quality of life, and poorer mental health among cancer caregivers.[21-27]

Terminally ill cancer patients from households reporting financial hardship had a higher likelihood of receiving intensive life-prolonging care (defined as receiving ventilation or resuscitation to prolong life) than did those who did not report financial hardship (OR, 3.22; 95% CI, 1.38−7.53). In a longitudinal survey of 281 terminally ill cancer patients, 29% reported using most or all of their household’s financial savings because of illness.[28]

Survival

In one retrospective cohort study, using data in the western Washington SEER Cancer Registry, cancer patients who filed for bankruptcy had an increased risk of mortality compared with those who did not file for bankruptcy (adjusted HR, 1.79; 95% CI, 1.64–1.96).[29] Hazard ratios were highest for patients with prostate cancer (adjusted HR, 2.07; 95% CI, 1.56–2.74) and colorectal cancer (adjusted HR, 2.47; 95% CI, 1.85–3.31).[29]

Internal and External Validity Concerns With Observational Studies

Data from randomized controlled trials offer the strongest evidence for establishing the efficacy of treatment on cancer outcomes. However, because cancer patients cannot ethically be subjected to financial toxicity through randomization, the current body of evidence is primarily from observational data, particularly from cross-sectional and cohort studies. Large nationally representative surveys provide the best estimates of the prevalence of certain conditions.

However, observational studies are prone to biases that may limit the validity of their findings. Several sources of bias are likely to be particularly important in observational studies assessing the association of financial toxicity with future outcomes, creating a challenge in interpreting the results of such studies.

In cross-sectional survey studies, high nonresponse rates may lead to possible nonresponse bias in reported estimates if the potential answers of nonrespondents vary from those who did respond. Another source of bias in survey research is reporting bias, which occurs when respondents reveal selective information that they believe is more socially desirable.

Another source of bias in observational studies is reverse causality, which may weaken any true association between financial toxicity and its potentially related outcomes. In one study,[29] investigators provided an example of how reverse causality should be addressed in this type of work. In this instance, the authors performed a sensitivity analysis limiting their sample to early-stage cancer patients who declared bankruptcy within 1 year of diagnosis. They fit their previously developed Cox models, regressing survival on bankruptcy filing status, using this new population sample.

Risk Factors

Although many individual risk factors for financial hardship have been identified, the evidence that demonstrates the degree to which these factors contribute to the risk of later financial hardship is insufficient, as is information about the interplay between these factors and clinical factors at the time of diagnosis.

Specific areas in need of further study to address their influence on the risk of financial distress after a cancer diagnosis include the following:

Because ample evidence shows that financial distress occurs even among patients with health insurance, the role of different forms of insurance in protecting individuals from financial distress requires further study. Medicare may at least partially protect older people from financial harm. However, other factors associated with older age might also reduce the risk of financial distress, namely, retired adults typically have higher levels of assets (e.g., owning a home outright), pensions or retirement accounts, and Social Security. Another factor is that physicians may treat older patients less intensively and thus less expensively.

For adults of working age, characteristics of work-sponsored or individually purchased commercial insurance that vary from plan to plan—specifically, deductibles, copay levels, and coverage exclusions—may influence the risk of financial distress. These factors also warrant further study.

After patients are diagnosed with cancer and miss work during treatment, their ability to continue to work or return to work greatly influences their risk of financial hardship. Studies are needed that relate particular treatments, modalities of treatment (e.g., infusional therapy vs. oral therapy), and toxicities of treatments with work absenteeism, loss of productivity, and likelihood of returning to the workforce.

Implementation of the U.S. Affordable Care Act in 2008 provided a natural experiment to determine whether expanding access to health insurance for millions of Americans had an impact on rates of financial distress or insolvency for people with cancer. Proposed pilots for different Medicare payment systems may also offer opportunities for quasi-experimental approaches that compare implementation with nonimplementation.[3]

After diagnosis, treatment choice could, in theory, influence the likelihood of financial difficulties. For many cancers, guidelines include options that are considered equivalent therapeutically, yet the costs of the treatments might vary by 50-fold or more.[4] For example, oral medications may come under a different copay structure than office-administered medicines. No retrospective or prospective evidence exists to show that, within an indication such as tumor type and stage, choice of treatment has a differential impact on out-of-pocket expenditure or level of financial distress. Because treatment choice is influenced by many factors, possibly including a patient's financial situation, prospective studies with detailed clinical and financial information are needed to investigate this issue.

Cancer management is unusual among medical interventions because it often involves intensive treatment at specialized facilities for weeks or months. For many patients, nonmedical costs associated with seeking treatment, such as the cost of transportation and lodging during treatment, can take a financial toll on families. The role that nonmedical costs play in financial hardship is an area in need of further study.

Financial Distress and Outcomes

Evidence from multiple retrospective studies shows that patients experiencing financial distress have reduced adherence to planned therapies, lower quality of life, and diminished survival. These studies have limitations because certain unmeasured clinical and financial factors that may influence treatment choice might also influence outcomes. Prospective or retrospective studies that include a more-comprehensive picture of financial status at diagnosis and clinical and patient factors that might influence treatment choice would provide a more accurate picture of the causal pathway between financial distress and outcomes.

Interventions Aimed at Reducing Financial Distress Among Cancer Patients

Several interventions specifically designed to reduce rates of financial distress among cancer patients have been proposed. Some are being implemented, but, to date, there have been no prospective studies evaluating the impact of these interventions on the rates and severity of financial distress, care choices, quality of life, or survival. Several of the most commonly discussed interventions are reviewed below.

Cancer Treatment Costs References

Cancer treatment cost information can be difficult to access. Listed below are links to publicly available websites that contain updated information on costs related to cancer care:

Purpose of This Summary

This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the treatment of cancer and financial toxicity. It is intended as a resource to inform and assist clinicians in the care of their patients. It does not provide formal guidelines or recommendations for making health care decisions.

Reviewers and Updates

This summary is reviewed regularly and updated as necessary by the PDQ Adult Treatment Editorial Board, which is editorially independent of the National Cancer Institute (NCI). The summary reflects an independent review of the literature and does not represent a policy statement of NCI or the National Institutes of Health (NIH).

Board members review recently published articles each month to determine whether an article should:

Changes to the summaries are made through a consensus process in which Board members evaluate the strength of the evidence in the published articles and determine how the article should be included in the summary.

The lead reviewers for Financial Toxicity and Cancer Treatment are:

Any comments or questions about the summary content should be submitted to Cancer.gov through the NCI website's Email Us. Do not contact the individual Board Members with questions or comments about the summaries. Board members will not respond to individual inquiries.

Levels of Evidence

Some of the reference citations in this summary are accompanied by a level-of-evidence designation. These designations are intended to help readers assess the strength of the evidence supporting the use of specific interventions or approaches. The PDQ Adult Treatment Editorial Board uses a formal evidence ranking system in developing its level-of-evidence designations.

Permission to Use This Summary

PDQ is a registered trademark. Although the content of PDQ documents can be used freely as text, it cannot be identified as an NCI PDQ cancer information summary unless it is presented in its entirety and is regularly updated. However, an author would be permitted to write a sentence such as “NCI’s PDQ cancer information summary about breast cancer prevention states the risks succinctly: [include excerpt from the summary].”

The preferred citation for this PDQ summary is:

PDQ® Adult Treatment Editorial Board. PDQ Financial Toxicity and Cancer Treatment. Bethesda, MD: National Cancer Institute. Updated <MM/DD/YYYY>. Available at: https://www.cancer.gov/about-cancer/managing-care/track-care-costs/financial-toxicity-hp-pdq. Accessed <MM/DD/YYYY>. [PMID: 27583328 ]

Images in this summary are used with permission of the author(s), artist, and/or publisher for use within the PDQ summaries only. Permission to use images outside the context of PDQ information must be obtained from the owner(s) and cannot be granted by the National Cancer Institute. Information about using the illustrations in this summary, along with many other cancer-related images, is available in Visuals Online, a collection of over 2,000 scientific images.

Disclaimer

Based on the strength of the available evidence, treatment options may be described as either “standard” or “under clinical evaluation.” These classifications should not be used as a basis for insurance reimbursement determinations. More information on insurance coverage is available on Cancer.gov on the Managing Cancer Care page.

Contact Us

More information about contacting us or receiving help with the Cancer.gov website can be found on our Contact Us for Help page. Questions can also be submitted to Cancer.gov through the website’s Email Us.