Role of Financial Toxicity on Treatment Decisions

Mark Socinski, MD: What I struggle with a lot is that most financial toxicity is simply incurred by getting the diagnosis—being diagnosed with cancer, having to do radiation treatment, having to be admitted to the hospital. Jack mentioned grade 2 or 3 nausea, and vomiting. Do we consider the financial toxicity of antiemetic medication and all these sorts of things that we inflict on our patients? It’s easy for us to give a recommendation, or give a prescription, but there are things that are very stressful for patients. I’ve had many patients, over the years, talk about how their daughters run out of vacation time from work and they don’t have a ride to the infusion center to get treatment because she can’t take any more vacation days or she doesn’t have gas money. We all hear these stories. Gilberto, let me ask you, how much does this play into your day-to-day treatment decision-making factors?

Gilberto Lopes, MD: It depends on the setting I am practicing in that day. I practice both at the Sylvester Comprehensive Cancer Center, which is a university-based academic cancer center, and I also attend our fellows clinic at our county hospital, Jackson Memorial Hospital in Miami, Florida. It’s a slightly different world. Most of the time, at the cancer center, we have no issues accessing immunotherapies or targeted agents as long as the drug is approved and included in NCCN [National Comprehensive Cancer Network] or any standard guidelines. We usually don’t have any issues getting those approved. There are a couple of insurance companies that are a little less permissive in terms of allowing all NCCN-approved or NCCN-sanctioned, if you will, therapies to be included, but that’s usually not the routine. For most of my patients in the cancer center, we usually don’t have issues, except for co-pays and oral drugs. We can discuss that a little later. In the county hospital, it’s a little harder. We have a formulary, and it’s one of the few situations in the United States where an institution looks into cost effectiveness as a way of deciding what goes into our formulary. For instance, for patients who are PD-L1–negative in non–small cell lung cancer, I’m not allowed to use immunotherapy with chemotherapy. This isn’t because there isn’t a benefit in survival, but because the decision-making entity within that health care system decided it’s not something cost effective that they will pay for.

Mark Socinski, MD: Jack and Afsaneh, you’re both from the City of Hope in Duarte, California. Is there hope?

Jack West, MD: I would say, it’s interesting, in terms of factoring into our decision-making, I think of it like EGFR inhibitors and efficacy in the brain. When we didn’t have anything that worked in the brain, we didn’t agonize about it much because we couldn’t control it. It was like whining about the weather. It’s like, “What is it going to do for you?” But when you have choices, you can vote with your feet and say, “Wow, I can now choose an ALK inhibitor, or an EGFR inhibitor, and prioritize something that not only works extracranially, but works intracranially.” I think, if we have a choice of drugs that can be effective, tolerated, and aren’t extraordinarily aggressively priced, that’s wonderful. But historically, sadly, we haven’t seen that newer agents entering a market have led to a drop in cost.

Mark Socinski, MD: Yes.

Jack West, MD: That’s been really unfortunate, and I think it would be disruptive to change that.

Mark Socinski, MD: Yes.

Jack West, MD: But if we did, I think we would act accordingly.

Mark Socinski, MD: Yes. Afsaneh, thoughts?

Afsaneh Barzi, MD, PhD: I would say there are 2 different financial toxicities we are talking about. Gilberto, when you were talking, there’s an objective financial toxicity, which is from the perspective of a payer, or from a societal perspective, thinking about Medicare. There is also a subjective financial toxicity, or what a patient experiences. That isn’t something that can be easily measured in any cost effectiveness analysis. Even if you look at a large cost effectiveness model, such as what NICE [the National Institute for Clinical Excellence] does, there is still the patient portion of the care, transportation, or a care provider, or something like that. That’s not fully pictured into that cost effectiveness model. So, we have a massive objective financial toxicity. The portion of health care in the GDP [gross domestic product] continues to rise. I look at the graph and I’m like, “Oh my gosh, where are we going? What are we taking off the plate, education?” There is also subjective financial toxicity, and that varies by individual. Even those who have good insurance that would pay for anything and everything covered by the guidelines that we want to do, those patients still experience financial toxicity because of the loss of wages. It’s not uncommon for us to see our patients lose their job and ability to work, and with out-of-pocket costs, that is outrageous. With this oral prescription drug, that is something that worries me, because the IV [intravenous] drug model for out-of-pocket cost is a little different than it is for the oral drug. That is the direction oncology is going and is something we should pay attention to.

Mark Socinski, MD: Let me ask you this, maybe it’s because of where I’ve practiced historically, but I’ve never been in this situation and I’d be very interested in the 3 of you telling me if you have been in this situation. I’ve never been in the situation where the drug that I thought was in the best interest of the patient we couldn’t eventually get for the patient by some mechanism. I’m wondering if you’ve ever had, what must be a terrible experience for an oncologist, where what you believed to be the most effective therapy for the patient in front of you, you couldn’t get it for that patient. Has anyone had that experience?

Afsaneh Barzi, MD, PhD: I’ve had that experience.

Gilberto Lopes, MD : I have, too.

Afsaneh Barzi, MD, PhD: Gilberto, not similar to your situation, but I was with USC [University of Southern California] for many years, and we had a private cancer center. Across the street, we had the Los Angeles County Hospital, which is one of the largest hospitals, and we were providing specialist care. We had a GI [gastrointestinal] clinic, we had a lung clinic, and we had a GU [genitourinary] clinic, and all of those. There were prescriptions we couldn’t provide to these patients. These patients weren’t capable of reaching out to foundations that provide coverage for many of our patients who practice in large cancer centers. So, I have seen that, and that’s really unfortunate.

Mark Socinski, MD: Yes.

Afsaneh Barzi, MD, PhD: Unfortunately, the subjects of that group are those who are the most in need of any support we can provide them.

Mark Socinski, MD: Yes. We could spend a lot of time talking about health disparities, as we saw a little of that at ASCO [American Society of Clinical Oncology annual meeting] this year. It’s an important topic.

Transcript Edited for Clarity