Main Article Content
Background: Healthcare providers have an influential role in the experience of financial toxicity among their cancer patients, yet patients commonly report unmet needs and dissatisfaction regarding communication with their providers about financial concerns.
Aims: The purpose of this study is to develop a novel financial navigation pathway that leverages existing patient financial services and resources with corresponding patient-centered, community-informed strategies, via study participants, that may be utilized in routine care to reduce financial hardship among cancer patients.
Methods: We conducted in-depth interviews (n=50) with 34 cancer patients and 16 cancer care professionals at a National Cancer Institute designated comprehensive cancer center located in a dense urban area of the US between December 2022 to June 2023.
Results: Content analyses resulted in emergent themes and representative quotations on experiences of financial hardship within the material, behavioral, and psychosocial domains. Investigators used emergent themes to develop financial strategies and construct a financial navigation pathway to screen patients for and intervene upon the financial toxicity of cancer in routine care.
Conclusion: This study followed an innovative approach by constructing a financial navigation pathway tool that follows the oncological workflow at a National Cancer Institute designated comprehensive cancer center. Future research is needed to test the tool’s impact on financial toxicity, cancer outcomes, and other health-related outcomes, and to better understand how much patient navigation is needed to bring about meaningful change.
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
2. PDQ Adult Treatment Editorial Board. Financial Toxicity and Cancer Treatment (PDQ®): Health Professional Version. In PDQ Cancer Information Summaries. National Cancer Institute. Published 2022. Accessed August 31, 2023. https://www.cancer.gov/about-cancer/managing-care/track-care-costs/financial-toxicity-pdq
3. de Souza JA, Yap BJ, Wroblewski K, et al. Measuring financial toxicity as a clinically relevant patient-reported outcome: The validation of the Comprehensive Score for financial Toxicity (COST). Cancer. 2017;123(3):476-484. doi:10.1002/cncr.30369
4. Ehsan AN, Wu CA, Minasian A, et al. Financial toxicity among patients with breast cancer worldwide: A systematic review and meta-analysis. JAMA Netw Open. 2023; 6(2):e2255388. doi:10.1001/jamanetworkopen.2022.55388
5. Harris JP, Ku E, Harada G, et al. Severity of financial toxicity for patients receiving palliative radiation therapy. Am J Hosp Palliat Care. Published online July 5, 2023: 10499091231187999. doi:10.1177/10499091231187999
6. Surachman, A., Tucker-Seeley, R. & Almeida, D.M. (2023). The association between material-psychological-behavioral framework of financial hardship and markers of inflammation: A cross-sectional study of the Midlife in the United States (MIDUS) Refresher cohort. BMC Public Health, 23(1), 1845. https://doi.org/10.1186/s12889-023-16745-x
7. Alcaraz KI, Wiedt TL, Daniels EC, Yabroff KR, Guerra CE, Wender RC. Understanding and addressing social determinants to advance cancer health equity in the United States: A blueprint for practice, research, and policy. CA Cancer J Clin. 2020;70(1):31-46. doi:10.3322/caac.21586
8. Biddell CB, Waters AR, Angove RSM, et al. Facing financial barriers to healthcare: patient -informed adaptation of a conceptual framework for adults with a history of cancer. Front Psychol. 2023;14. Accessed August 31, 2023. https://www.frontiersin.org/articles/10.3389/fpsyg.2023.1178517
9. Benedict C, Fisher S, Schapira L, et al. Greater financial toxicity relates to greater distress and worse quality of life among breast and gynecologic cancer survivors. Psychooncology. 2022;31(1):9-20. doi:10.1002/pon.5763
10. Liang MI, Harrison R, Aviki EM, Esselen KM, Nitecki R, Meyer L. Financial toxicity: A practical review for gynecologic oncology teams to understand and address patient-level financial burdens. Gynecol Oncol. 2023;170:317-327. doi:10.1016/j.ygyno.2023.01.035
11. Haier J, Schaefers J. Economic Perspective of Cancer Care and Its Consequences for Vulnerable Groups. Cancers. 2022; 14(13):3158.
12. 9. Hong YR, Salloum RG, Yadav S, Smith G, Mainous AG. Patient–provider discussion about cancer treatment costs and out-of-pocket spending: Implications for shared decision making in cancer care. Value Health. 2020;23(12):1592-1598. doi:10.1016/j.jval.2020.08.002
13. Jagsi R, Momoh AO, Qi J, et al. Impact of radiotherapy on complications and patient-reported outcomes after breast reconstruction. J Natl Cancer Inst. 2018;110(2):157-165. doi:10.1093/jnci/djx148
14. Kronfli D, Savla B, Lievers A, et al. Identifying psychosocial needs of patients with cancer undergoing curative radiation therapy in an inner-city academic center to address racial disparities. Int J Radiat Oncol Biol Phys. 2022;114(2):185-194. doi:10.1016/j.ijrobp.2022.04.003
15. Khera N, Holland JC, Griffin JM. Setting the stage for universal financial distress screening in routine cancer care. Cancer. 2017;123(21):4092-4096. doi:10.1002/cncr.30940
16. Delgado-Guay M, Ferrer J, Rieber AG, et al. Financial distress and its associations with physical and emotional symptoms and quality of life among advanced cancer patients. The Oncologist. 2015;20(9):1092-1098. doi:10.1634/theoncologist.2015-0026
17. Lee EM, Jiménez-Fonseca P, Hernández R, et al. The role of financial difficulties as a mediator between physical symptoms and depression in advanced cancer patients. Curr Oncol. 2023;30(6):5719-5726. doi:10.3390/curroncol30060429
18. Bradley CJ, Yabroff KR, Zafar SY, Shih YCT. Time to add screening for financial hardship as a quality measure? CA Cancer J Clin. 2021;71(2):100-106. doi:10.3322/caac.21653
19. Jacobsen PB, Ransom S. Implementation of NCCN distress management guidelines by member institutions. J Natl Compr Cancer Netw JNCCN. 2007;5(1):99-103. doi:10.6004/jnccn.2007.0010
20. Dreismann L, Schoknecht K, Vogel A, Zimmermann T. Should I call psycho-oncology? Training nurses on psycho-oncological screening reduces uncertainties. J Cancer Res Clin Oncol. 2023;149(12):10585-10592. doi:10.1007/s00432-023-04936-3
21. Mitchell AJ, Hussain N, Grainger L, Symonds P. Identification of patient-reported distress by clinical nurse specialists in routine oncology practice: a multicentre UK study. Psychooncology. 2011;20(10):1076-1083. doi:10.1002/pon.1815
22. Werner A, Stenner C, Schüz J. Patient versus clinician symptom reporting: how accurate is the detection of distress in the oncologic after-care? Psychooncology. 2012;21(8):818-826. doi:10.1002/pon.1975
23. Donovan KA, Grassi L, Deshields TL, Corbett C, Riba MB. Advancing the science of distress screening and management in cancer care. Epidemiol Psychiatr Sci. 2020;29:e85. doi:10.1017/S2045796019000799
24. McLouth LE, Nightingale CL, Dressler EV, et al. Current practices for screening and addressing financial hardship within the NCI community oncology research program. Cancer Epidemiol Biomark Prev Publ Am Assoc Cancer Res Cosponsored Am Soc Prev Oncol. 2021;30(4):669-675. doi:10.1158/1055-9965.EPI-20-1157
25. Smith SK, Nicolla J, Zafar SY. Bridging the gap between financial distress and available resources for patients with cancer: a qualitative study. J Oncol Pract. 2014;10(5):e368-372. doi:10.1200/JOP.2013.001342
26. Corrigan KL, Fu S, Chen YS, et al. Financial toxicity impact on younger versus older adults with cancer in the setting of care delivery. Cancer. 2022;128(13):2455-2462. doi:10.1002/cncr.34220
27. Hastert TA, Young GS, Pennell ML, et al. Financial burden among older, long‐term cancer survivors: Results from the LILAC study. Cancer Med. 2018;7(9):4261-4272. doi:10.1002/cam4.1671
28. Imber BS, Varghese M, Ehdaie B, Gorovets D. Financial toxicity associated with treatment of localized prostate cancer. Nat Rev Urol. 2020;17(1):28-40. doi:10.1038/s41585-019-0258-3
29. Kent EE, Forsythe LP, Yabroff KR, et al. Are survivors who report cancer-related financial problems more likely to forgo or delay medical care? Cancer. 2013; 119(20):3710-3717. doi:10.1002/cncr.28262
30. Cheung CK, Nishimoto PW, Katerere-Virima T, Helbling LE, Thomas BN, Tucker-Seeley R. Capturing the financial hardship of cancer in military adolescent and young adult patients: A conceptual framework. J Psychosoc Oncol. 2022;40(4):473-490. doi:10.1080/07347332.2021.1937771
31. Tucker-Seeley RD, Thorpe RJ Jr. Material–psychosocial–behavioral aspects of financial hardship: A conceptual model for cancer prevention. The Gerontologist. 2019;59(Supplement_1):S88-S93. doi:10.1093/geront/gnz033
32. Freeman HP. The origin, evolution, and principles of patient navigation. Cancer Epidemiol Biomarkers Prev. 2012; 21(10):1614-1617. doi:10.1158/1055-9965.EPI-12-0982
33. Donabedian A. Evaluating the quality of medical care. Milbank Mem Fund Q. 1966;44(3):166-206. doi:10.2307/3348969
34. Donabedian A. The quality of care: How can it be assessed? JAMA. 1988;260(12): 1743-1748. doi:10.1001/jama.1988.03410120089033
35. Donabedian A. Evaluating the quality of medical care. Milbank Q. 2005;83(4):691-729. doi:10.1111/j.1468-0009.2005.00397.x
36. Peterson K, Anderson J, Bourne D, et al. Health care coordination theoretical frameworks: A systematic scoping review to increase their understanding and use in practice. J Gen Intern Med. 2019;34(1):90-98. doi:10.1007/s11606-019-04966-z
37. Tossaint-Schoenmakers R, Versluis A, Chavannes N, Talboom-Kamp E, Kasteleyn M. The challenge of integrating ehealth into health care: Systematic literature review of the Donabedian model of structure, process, and outcome. J Med Internet Res. 2021;23(5):e27180. doi:10.2196/27180
38. Creswell JW. Qualitative Inquiry and Research Design: Choosing among Five Approaches, 2nd Ed. Sage Publications, Inc; 2007:xvii, 395.
39. Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol. 2013;13:117. doi:10.1186/1471-2288-13-117
40. National Cancer Institute. Cancer Control Continuum. National Cancer Institute Division of Cancer Control and Population Sciences. Accessed August 31, 2023. https://cancercontrol.cancer.gov/about-dccps/about-cc/cancer-control-continuum
41. National Comprehensive Cancer Network. NCCN Guidelines Version 2.2023 Distress Management. Accessed August 31, 2023.
42. de Souza JA, Yap BJ, Hlubocky FJ, et al. The development of a financial toxicity patient-reported outcome in cancer: The COST measure. Cancer. 2014;120(20):3245-3253. doi:10.1002/cncr.28814
43. Pirl WF, Fann JR, Greer JA, et al. Recommendations for the implementation of distress screening programs in cancer centers: Report from the American Psychosocial Oncology Society (APOS), Association of Oncology Social Work (AOSW), and Oncology Nursing Society (ONS) joint task force. Cancer. 2014;120(19):2946-2954. doi:10.1002/cncr.28750
44. Pizarro DMP, Francia MBI, Ordinario MVC. Diagnostic accuracy of the NCCN distress thermometer for the assessment of psychosocial distress among Filipino patients with cancer. Acta Med Philipp. 2022;56(12). doi:10.47895/amp.vi0.3463
45. Alanazi AK, Lynch-Kelly D, Weaver M, Lyon DE. A scoping review of psychological distress instruments in women with early-stage breast cancer during chemotherapy. Cancer Rep. 2023;6(6):e1833. doi:10.1002/cnr2.1833
46. McElroy JA, Waindim F, Weston K, Wilson G. A systematic review of the translation and validation methods used for the national comprehensive cancer network distress thermometer in non-English speaking countries. Psychooncology. 2022;31(8):1267-1274. doi:10.1002/pon.5989
47. Pavela G, Fifolt M, Tison S, Allison M, Burton B, Ford E. Re-validation of the Comprehensive Score for financial Toxicity (COST): Assessing the scale’s utility in chronic disease populations. Health Serv Insights. 2021;14. doi:https://doi.org/10.1177/11786329211057352
48. D’Rummo KA, Nganga D, Chollet-Hinton L, Shen X. Comparison of two validated instruments to measure financial hardship in cancer survivors: comprehensive score for financial toxicity (COST) versus personal financial wellness (PFW) scale. Support Care Cancer. 2022;31(1):12.
49. Dee EC, Chino F. Financial hardship in cancer care—The need to define and intervene on actionable metrics. JAMA Netw Open. 2022;5(7):e2223149. doi:10.1001/jamanetworkopen.2022.23149
50. Ver Hoeve ES, Ali-Akbarian L, Price SN, Lothfi NM, Hamann HA. Patient-reported financial toxicity, quality of life, and health behaviors in insured US cancer survivors. Support Care Cancer Off J Multinatl Assoc Support Care Cancer. 2021;29(1):349-358. doi:10.1007/s00520-020-05468-z
51. Prasad RN, Patel TT, Keith SW, Eldredge-Hindy H, Fisher SA, Palmer JD. Development of a financial toxicity screening tool for radiation oncology: A secondary analysis of a pilot prospective patient-reported outcomes study. Adv Radiat Oncol. 2021;6(6):100782. doi:10.1016/j.adro.2021.100782
52. Patel MR, Zhang G, Heisler M, et al. Measurement and validation of the comprehensive score for financial toxicity (COST) in a population with diabetes. Diabetes Care. 2022;45(11):2535-2543. doi:10.2337/dc22-0494
53. Wang SY, Valero‐Elizondo J, Ali H, et al. Out‐of‐pocket annual health expenditures and financial toxicity from healthcare costs in patients with heart failure in the United States. J Am Heart Assoc. 2021;10(14):e022164. doi:10.1161/JAHA.121.022164
54. Shankaran V, Leahy T, Steelquist J, et al. Pilot feasibility study of an oncology financial navigation program. J Oncol Pract. 2018;14(2):e122-e129. doi:10.1200/JOP.2017.024927
55. Wheeler S, Rodriguez-O’Donnell J, Rogers C, et al. Reducing cancer-related financial toxicity through financial navigation: Results from a pilot intervention. Cancer Epidemiol Biomarkers Prev. 2020;29:694.2-694. doi:10.1158/1055-9965.EPI-20-0067
56. Khan HM, Ramsey S, Shankaran V. Financial toxicity in cancer care: Implications for clinical care and potential practice solutions. J Clin Oncol. 2023;41(16):3051-3058. doi:10.1200/JCO.22.01799
57. United States Census Bureau. QuickFacts Baltimore city, Maryland. Published 2021. Accessed August 9, 2023. https://www.census.gov/quickfacts/fact/table/baltimorecitymaryland/INC110221