Financial toxicity is a growing concern in urologic oncology

Alexandria A. Spellman, MD, MS

The financial burden of cancer care experienced by patients is a growing concern. Health care costs are increasing, and a significant proportion of these costs is being shifted onto individual patients.¹ The term financial toxicity (FT) describes the consequences of the direct (eg, costs of diagnosis and treatment) and indirect (eg, lost wages, parking and transportation expenses) costs of cancer care. FT encompasses not only an individual’s financial debt but also the psychological distress and coping mechanisms that ensue due to the financial burden.² Patients with FT have decreased quality of life, higher treatment nonadherence, reduced spending on other life essentials, and overall worse health outcomes compared with those without FT.³

Deborah R. Kaye, MD, MS

FT is especially prevalent among patients with cancer.⁴ The cost of treating urologic cancers continues to increase due to an aging population, higher proportion of metastatic cancer cases, and the emergence of new and expensive treatments and diagnostic options.^5-8 Urologic cancers are critical to consider when evaluating FT, as prostate, bladder, and kidney cancer are the second, fifth, and sixth most common malignancies, respectively, in the United States.⁹

About 15% to 20% of men with localized prostate cancer experience FT.^10,11 Men who underwent external beam radiation therapy report worse FT than those who underwent radical prostatectomy or active surveillance.11 Younger patients (<65 years) are also at higher risk for FT.^1,10,11 This could be secondary to worse or no insurance coverage and/or more indirect medical costs, such as lost wages, greater number of financial obligations (dependents), and less savings.¹ Furthermore, men with more aggressive prostate cancer have more than twice the risk of FT compared with patients with less aggressive forms of prostate cancer.¹² This is not surprising given that health care costs attributable to metastatic prostate cancer are $5.2 billion to $8.2 billion per year.¹³ New and expensive treatments are being introduced for the treatment of metastatic castrate-resistant prostate cancer. This has resulted in some patients paying high out-of-pocket payments.⁵ Similarly, for patients with metastatic hormone-sensitive prostate cancer, a recent study showed that among commercially insured patients, novel hormonal therapy (apalutamide [Erleada], abiraterone [Zytiga], enzalutamide [Xtandi]) posed significantly higher out-of-pocket costs than both androgen deprivation therapy and nonandrogenic systemic agents (docetaxel, cabazitaxel [Jevtana], and sipuleucel-T [Provenge]).¹⁴

Although prostate cancer has a higher incidence, bladder cancer is the most expensive malignancy to treat, due to the often-required long-term surveillance.¹⁵ Nearly a quarter of patients with bladder cancer experience significant FT.^3,16 Noninvasive cancer at diagnosis, younger age, lower income, education level below a college degree, and either Medicare or lack of employer-sponsored health insurance are associated with worse FT.^3,15,16 Importantly, among patients with bladder cancer, FT is a stronger predictor of reduced quality of life than disease stage and/or type of treatment.¹⁷ Further, some costs are variable and dependent upon clinician decision-making. One study demonstrated that physicians in the highest spending quartile spent up to 3 times more than clinicians in the lowest spending quartile with no differences in health outcomes. This highlights potential areas for payment reduction strategies.¹⁸

Of all genitourinary cancers, FT in renal cell cancer (RCC) is the least understood. As with prostate cancer, several expensive treatments have recently been introduced to treat metastatic RCC with large clinician-level variation.¹⁹ The high costs of new treatments and greater insurance cost-sharing can lead to significantly increased patient out-of-pocket payments.²⁰ Like other cancers, high out-of-pocket costs for oral anticancer agents are associated with poor treatment adherence.^6,21

Although we, as clinicians, are not directly in control of the costs of cancer care, we can take meaningful actions to mitigate this burden. Awareness, communication, regular screening for FT, and proactive referral to financial services and counseling may reduce financial burden and improve health outcomes.²²

To promote awareness, we must be well informed about treatment costs and effectively communicate these costs to our patients. There is significant variation in treatment recommendations and payments among different clinicians and practices for treating the same condition, suggesting that clinician cost awareness can reduce patient out-of-pocket costs. Increased price transparency, where costs are publicly accessible, may also facilitate improved clinician awareness, but these mandates remain in flux. However, even without knowing exact costs, clinicians can reduce financial burden by not ordering tests or procedures that will not change management and/or outcomes and incorporating patients’ values into decision-making. Regularly revising and following updated guidelines, such as the revised American Urological Association microscopic hematuria guidelines (2020), also have the promise to decrease diagnostic and procedure volumes and significantly reduce total and per-patient costs.²³ Clinicians should also be cognizant of the indirect costs of medical appointments, such as travel, time off from work, and child care, and recommend follow-ups only as necessary and in accordance with patient values. If able and/or appropriate, one can also consider telehealth visits.

Communication between clinicians and patients about direct and indirect treatment costs are essential. In a study of patients with metastatic cancer, only 28% of patients discussed cost of treatment with their clinician.²⁴ Furthermore, only a quarter of clinicians feel comfortable discussing patient finances.^25,26 Oncologists should be reassured that most patients desire cost discussions with their clinicians.²⁷ Almost two-thirds of patients in a large bladder cancer study preferred that their physician review survival, adverse effects, and costs when discussing treatment preferences.¹⁵ Additionally, patients’ improved understanding of direct and indirect costs results in reduced FT.²⁸ Patients should also be counseled about modifiable risk factors to help decrease cost of care; these include obesity and smoking, which can increase operative times, length of inpatient stay, and cause complications with resultant higher financial burden.^29,30

Regular and recurrent screening for FT and early referral to financial counselors can also reduce FT.²² Although studies have identified certain risk factors associated with FT, all patients are susceptible and susceptibility can change throughout the course of treatment. Screening can be performed formally or informally. If identified, early acknowledgment and potential referral to financial counselors can mitigate financial distress.^31-34

Altogether, FT is highly prevalent among patients with urologic cancer. Clinicians have opportunities to reduce patient subjective and objective financial burden if they continue to self-educate and communicate with patients and consider FT an adverse effect of treatment.

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