Financial Toxicity Hinders Breast Cancer Treatment
By Mark L. Fuerst
CHICAGO—The new dose-limiting toxicity in breast cancer is patient finances. That’s the thesis of a presentation by Michael J. Hassett, MD, MPH, a medical oncologist at the Dana-Farber Cancer Institute, at an Educational Session at the 2018 American Society of Clinical Oncology (ASCO) Annual Meeting.
Problems related to the cost of treatment include both societal and patient perspectives. The societal perspective includes questions such as: How much does the system spend on breast cancer? How much do breast cancer treatments cost? How do we determine the value of a treatment? For patients, questions include: How much do patients spend on health care? What problems do patients experience because of these costs?
Breast cancer expenditures in 2010 were $16.5 billion annually, which was 13 percent of all cancer spending. “This is more than any other cancer and is distributed across all phases of care,” said Hassett. Expenditures are expected to be more than $20 billion by 2020.
The average allowed costs per patient the year after a breast cancer diagnosis range from $60,000 for stage 0 to more than $130,000 for stage IV. Chemotherapy and non-cancer treatments are the major drivers of the cost differences based on stage at diagnosis, he said. Hospitalizations and chemotherapy are costly during the first 6 months after an advanced stage cancer diagnosis.
“Should a cancer treatment be paid for by a health care system, given competing priorities and constrained resources? asked Hassett. “Multiple value frameworks have been described to help make these difficult decisions.”
Factors for Patients
Several factors drive costs for patients. “Treatments are getting more expensive. Health care cost sharing is increasing, with more co-payments and high deductibles. And patients are living longer,” he said.
The cost of new cancer drugs is high and increasing. Total global spending on oncology medicines reached $100 billion in 2014. Growth in U.S. spending on cancer drugs increased at a compound annual growth rate of 5.3 percent over the past 5 years. The U.S. accounts for 42 percent of total spending in the oncology market, he noted.
Hassett cited data about the costs of breast cancer patients receiving chemotherapy, with or without trastuzumab. Median insurance payments for chemotherapy without trastuzumab are about $80,000; with trastuzumab, payments are about $160,000. Median out-of-pocket payments are about $2,700 without and $3,300 with trastuzumab.
High-deductible insurance has an impact on breast cancer diagnosis and treatment, in particular on adjuvant hormonal therapy. In a matched sample of women ages 25-64 with early-stage breast cancer and health insurance through their employer, 986 women transitioned from a low (up to $500 per year) to a high ($1,000 or more per year) deductible plan. They were compared to 3,479 matched controls with a low-deductible plan.
Out-of-pocket costs increased by 13.72 percent among high-deductible versus low-deductible patients. Hormone therapy use did not change, and out-of-pocket hormone therapy costs were relatively low, less than $100 per person per year.
Data from a recent Dana-Farber Cancer Institute patient intake questionnaire, which included 8,236 patients, show 19 percent reported it was somewhat difficult or worse to meet monthly payments on bills, said Hassett.
Cancer patients are 2.65 times more likely to go bankrupt than people without cancer. Patients have both material financial hardships and psychological financial hardships, measured as worrying about paying large medical bills. Nearly one-third of recently diagnosed cancer survivors change their prescription drug use for financial reasons, according to a nationally representative sample in the US, he said.
Questions remain about the optimal duration of adjuvant endocrine therapy, and drug costs vary. Daily tamoxifen for 5 years costs an estimated $1,342 and for 10 years $2,684. Daily tamoxifen for 5 years and then daily letrozole for 5 years costs an estimated $2,074. Daily letrozole alone for 5 years costs an estimated $732 and for 10 years $1,464. The cost per invasive disease-free survival (DFS) event prevented is $33,550 with tamoxifen for 5 additional years and $18,300 for letrozole for 5 additional years, he said.
There is a wide range of drug costs associated with therapies for HER2-positive breast cancer. Estimated drug costs of doxorubicin and cyclophosphamide followed by treatment with paclitaxel and trastuzumab if about $100,000. Just paclitaxel and trastuzumab is about $88,000. Docetaxel, carboplatin, and trastuzumab cost about $120,000. Add in pertuzumab and the costs goes up by $86,000, and add in neratinib and cost increases by $140,000.
The cost per invasive DFS event prevented is $9 million with pertuzumab for 1 year and $6 million for neratinib for 1 year, he noted.
What Clinicians Can Do
Clinicians need to be alert for patients who could be at risk for financial toxicity. Those risk factors include younger age, minority race, low income, unemployment, under or uninsured status, and recent diagnosis or underactive treatment.
Financial toxicity can be measured as a clinically relevant patient-reported outcome. The Comprehensive Score for Financial Toxicity (COST) has been validated in a survey of 233 patients with stage IV solid tumors receiving chemotherapy for at least 2 months. “The COST score was found to be a consistent, reliable measure of financial toxicity,” said Hassett.
COST values were correlated with income, psychosocial distress, and quality of life. Patient willingness to discuss costs was not associated with the degree of financial distress, he said.
Hassett noted a handful of potential resources for clinicians. “Site financial counselors, medication assistance programs, national service organizations, and local service organizations and charities,” he said.