SES AUA 2021: Financial Toxicity in Urologic Oncology

Urologic oncologists care for patients across a continuum of care through pre-diagnosis, treatment, survivorship, and end-of-life. At each stage, while we counsel patients on the pros and cons of various treatment options, we must consider many benefits and risks of each approach that, together, contribute to a patient’s quality and quantity of life.

While rarely considered, the costs of treatment may contribute significantly to risks and hurt the quality of life.

Highlighting data from the Kaiser Family Foundation, Dr. Filson emphasized that there has been significant growth in both out-of-pocket and total health spending for many individuals over the past ten years.

As a result, many patients lack the liquid financial assets necessary to cover the deductibles for significant medical events. When considering out-of-pocket limits, an even greater proportion of patients lack the assets necessary to cover these costs.

As a result, millions of Americans have had to turn to crowdfunding to support needed help care with more than 8 million people starting a campaign for themselves, 12 million starting a campaign for someone else, and more than 50 million contributing to a campaign to pay for medically necessary bills or treatments.

Beyond the direct costs and budget stressors, these entail, financial toxicity many contribute to significant subjective financial distress and adverse mental health effects. This situation may create a spiral and while there are numerous causes and consequences of financial toxicity, these costs spiral and contribute to more debt, lower quality of life, and worse financial toxicity.

Beyond the numbers cited above, others have shown that nearly two-thirds of Americans have no money saved for health care expenses or have avoided or delayed medical care in the past year due to the expected costs. Further, among all collections in the United States, nearly one-in-five are due to medical or health care bills. These collections are, for the most part, relatively small with a median of less than $500.

Dr. Filson then used the case of prostate biopsy as a case example. While the professional fees associated with a clinic based transrectal prostate biopsy are a little over $400, procedures may cost significantly more and have considerable variation based on the location (facility vs office), the use of MRI prior to biopsy, and whether anesthesia is used.

In theory, patients can shop around to maximize the value of their health care and minimize their costs. In the context of orthopedic patients undergoing lower limb MRI, work from the National Bureau of Economic Research shows, first, that there is a large variation in cost within hospital referral regions. Second, patients don’t typically gravitate to lower cost services, in large part because fewer than 1% actually search for cost information prior to accessing care. As a result, the average patient travels past six cheaper providers to receive their case and miss out of 27% savings.

Dr. Filson then cited a similar study of variation in cost across hospital referral regions for prostate biopsy. As with the orthopedic example, significant variation was identified. This variation was predominately driven by proportion of biopsies performed in the office, as compared to hospital/ASC facilities with their associated fees.

Consider surgical costs, he highlighted recent data suggesting that, for the individual patient, out-of-pocket costs are likely to be lower with robotic than open surgical approaches across a number of commonly performed procedures.

In cancer patients, there is a rapidly loss of wealth following diagnosis which has a considerable, long-term negative outcome. This effect is particularly relevant for those with more advanced disease (29% more likely to deplete savings) and more elderly patients (127% more likely to deplete savings). This financial toxicity can have important clinical implications. Assessing bladder cancer patients, 24% of patients self-reported financial toxicity and those that did were more likely to delay care, had worse physical and mental health, and have lower cancer-specific quality of life.

In contrast, in the CEASAR cohort, rates of financial toxicity were much lower, affecting only 8% of patients who reported a large or very large financial burden associated with their diagnosis and treatment. It is therefore important to consider differences that may contribute, including the intensity of care for disease, the affected patient population, and potentially differences in insurance coverage.

Considering how we may address financial toxicity for our patients, Dr. Filson highlighted approaches at three levels: the institution, the department, and the individual.

At the institution, it is important that we provide price transparency, provide options in terms of place-of-service for care, improve communication, and avoid punishing patients who are unable to bear the costs of care. Assessing the issue of transparency, Dr. Filson highlighted a recent publication which proposed clear metrics for hospitals to employ to optimize billing quality. A recent analysis of price transparency among National Cancer Institute-designated cancer centers demonstrated that, for routine prostate radiotherapy, publicly available prices displayed were more than 10 times above Medicare allowed charges, with a very large range. Thus, there are huge limitations to the applicability to so called transparent data. Beyond this, many hospitals are noncompliant (65%) with mandated transparency requirements and even among those that comply, there is evidence of “gaming of the system” to decrease the ability of individuals to find these data via Google search.

Moving to the departmental level, he emphasized the importance of avoiding low-value care within the context of consistent protocols and guideline driven care. Further departments have a critical role to motivate institutions to maintain transparency and provide financial support. Finally, they can benefit patients by offering accurate estimates of real prices.

Finally, at the individual level, we need to begin by being aware and assessing the baseline risk for financial toxicity among our patients. We need to further align the delivery of care to minimize low-value care, to seek lower cost options where these provide reasonable clinical outcomes, and to motivate the department and institution to provide transparency. In terms of quantifying financial toxicity, Dr. Filson highlighted the Comprehensive Score for financial Toxicity (COST) tool.

In conclusion, Dr. Filson highlighted that financial toxicity is an important, patient-reported outcome for cancer patients. It may differ according to the disease process. There is a critical onus on hospital systems, departments, and individuals to acknowledge and address this issue. 

Presented by: Christopher Filson, MD, MS, Assistant Professor, Department of Urology, Emory University School of Medicine