Does Oral Chemotherapy Always Equate to Financial Distress?

July 2022 Vol 13, No 7


Financial Toxicity

FDA-approved oral cancer drugs are not cheap, and many patients are unable to afford these promising therapies with extremely high price tags. Depending on the type of cancer and the drug used to treat it, the price of oral cancer therapy can range from about $10,000 to $25,000 per month.

“Compared with other countries, more oncology drugs are available in the US,” said Nikki Barkett, BSN, RN, OCN, an oral antineoplastics nurse navigator at Banner Health University of Arizona Cancer Center, Tucson, AZ. “But just because they’re on the market doesn’t mean every patient has access to them.”

At the 2022 AONN+ Midyear Conference, Ms Barkett discussed the impacts of financial distress and toxicity on patients receiving oral cancer drugs and the crucial role of navigators in mitigating this incredibly distressing side effect of cancer treatment.

Defining Financial Distress

Financial distress is emotional distress about the ability to pay for care, and it is a common experience among patients with cancer. Being uninsured, underinsured, or facing a lack or loss of income can all lead to financial distress.

When patients are unable to cover the costs of cancer care, they are often forced to borrow money (regularly opening high-interest credit cards or taking out loans), deplete savings, go without basic necessities, skip mortgage or rent payments, or even file for bankruptcy.

But these are only the financial impacts. Clinically, patients will forego filling prescriptions, take smaller doses than prescribed, or skip doses to make it last longer, often resulting in emergency department visits or hospitalizations.

“And some simply say, ‘I can’t do this; I can’t leave my family bankrupt,’” she said.

The High Price of Oral Therapies

According to Ms Barkett, patients may be responsible for a larger share of the costs of oral therapies compared with IV therapies due to differences in coverage between Medicare Part B and Part D.

“Some patients don’t have prescription drug coverage,” she said. “And they’re scared out of their minds when they hear they have 2 options: IV or oral, but the oral is potentially going to cost a lot more.”

In a systematic review of financial toxicity among cancer survivors, 28% to 48% of survivors experienced financial toxicity using monetary measures, but 16% to 73% experienced financial toxicity using subjective measures (ie, perceptions of cancer-related financial burden and psychological impact). “That’s huge,” she noted.

The psychosocial impact of financial distress often has a ripple effect, causing significant distress or impairment in social, occupational, or other important areas of functioning.

“These patients are so worried that they can’t even go to work. They can’t concentrate; they can’t function,” she said. “And then financial toxicity is only compounded.”

This distress does not only impact mental health and quality of life but eventually treatment adherence, cancer outcomes, and long-term prognosis.

What Can Navigators Do?

“We’re going to teach these patients to think like advocates,” she said.

According to Ms Barkett, thinking like an advocate requires preparation, communication, documentation, and follow-up. Navigators can help patients to think like advocates by making sure they’re informed and have specific goals, helping them to identify key issues and possible workable solutions, and finding those who can help.

An advocate would also communicate clearly and concretely (though assertively), listen carefully and ask questions, and when appropriate, use stories or visual ways to communicate. They would take notes, and always follow up a visit with an e-mail, call, or letter.

Financial navigators in particular can help patients think more like advocates by providing education about a patient’s insurance plan and coverage, including deductibles, maximum out-of-pocket amounts, and copays. They should help patients to understand their employer benefits, including the Family and Medical Leave Act, short- and long-term disability, and critical illness insurance.

Patients should always ask their physician and care team any and all questions they might have; these questions might be related to the type of cancer and necessary treatment, the cost of treatment, or working during treatment. Navigators can help to answer these questions, but often, patients are overwhelmed and don’t know what questions to ask. Navigators are crucial at this juncture; they can help patients prepare for concerns that might arise later and start addressing them early on.

Helping patients prepare a list of questions to have on hand for other members of the care team can also be useful. For example, questions related to cost might include:

  • I’m worried about how much cancer treatment is going to cost me. Can we talk about it?
  • Will my health insurance pay for this treatment? How much will I have to pay myself?
  • I know this will be expensive. Where can I get an idea of the total cost of the treatment we’ve talked about?
  • If I can’t afford this treatment, are there others that might cost less but work as well?
  • Is there any way I can get help to pay for this treatment?
  • Does my health insurance company need to preapprove or precertify any part of the treatment before I start?

“Patients might not think of these, and this is a great place to start getting to know your patient,” she said.

The Role of the Financial Navigator

The navigator should intervene early at the patient’s first appointment—even though patients will want to talk about their cancer diagnosis—not their insurance.

“Ask them to sit down with you briefly and talk about their insurance, and send them home with a copy of what you talked about to refer to later,” she advised. “This will help them to optimize their insurance coverage.”

Navigators should discuss their patient’s treatment plan with the care team to enhance affordability when appropriate. “This is important,” she said. “I often get patients who think they’re going to start on oral chemo, and they have to find out that they have no prescription drug coverage.”

Navigators should also locate available patient assistance programs, including foundations (wherein funding is primarily available by diagnosis), charity organizations, drug replacement, copay assistance, and manufacturer assistance, as well as other resources such as GoodRx, NeedyMeds, CancerCare, American Cancer Society, Prescription Drug Assistance Network, and Donate Drugs.

Finally, it’s vital that navigators track their results, she emphasized. This shows the value of financial navigation programs and ensures that these important services are available to more patients in the future.

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Last modified: August 10, 2023

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