Practices must redouble efforts to help patients cope with financial toxicity

The financial burden of cancer treatment can decrease a patient’s quality of life in many ways. Cancer patients face not only high direct costs, debt and decreased income, but also psychological suffering and treatment delays or even discontinuation.1 Physicians are uniquely positioned to help patients understand the financial ramifications of treatment.

However, it has been difficult to establish validated measures to describe, quantify and qualify the prevalence of financial difficulties associated with cancer treatment at all levels of care.two Assessments by the National Cancer Institute’s Community Oncology Research Program (NCORP) and the National Comprehensive Cancer Network (NCCN) have demonstrated that although nearly 75% of NCCN care centers nationwide have methodologies for assessing financial toxicity, Effective management protocols are not yet in place.3.4

Seventy-two percent of the 221 NCORP centers have instituted a financial screening process, but only 50% of them have a cancer financial navigator on staff.4 Despite these high screening rates, the most commonly used method of assessing financial hardship at NCORP centers was admission forms (68%), which investigators noted may only highlight insurance-related charges.3

Results of a recent survey of cancer patients receiving treatment at outpatient infusion centers (Mayo Clinic in Phoenix, Arizona and Mississippi Medical Center in Jackson) showed that 48% to 68% of them reported financial difficulties.5

The authors found that financial literacy may be essential for reducing adverse outcomes and that intervention programs are needed to increase financial literacy among cancer patients.

“Patient-reported financial hardship due to cancer treatment is a growing challenge,” Khera et al wrote in the study.5 “The field of financial hardship is now shifting to interventions. Understanding the association between health insurance literacy and financial hardship and how financial literacy can change this association is important because these factors are potentially modifiable.”

An important tool used to determine financial literacy is the FACIT-COST assessment (Financial Toxicity—Functional Assessment of Chronic Illness Therapy Comprehensive Score), whose scores range from 0 to 44, with lower scores indicating greater burden. Includes responses such as the following:

  • I know I have enough money in savings, retirement, or assets to cover the cost of my treatment.
  • My out of pocket medical expenses are more than I thought they would be.
  • I worry about the financial problems I will have in the future as a result of my illness or treatment.
  • I feel like I have no choice in how much money I spend on care.
  • My cancer or treatment has reduced my satisfaction with my current financial situation.
  • My illness has been a financial hardship for my family and me.6

Additional assessment tools include the National Health Interview Survey and the Health Insurance Literacy Measure, which reveal an individual’s ability to evaluate health plan information and select the plan that best fits their circumstances.5

Dealing with Financial Toxicity

Of the NCCN centers that reported financial assessments, only 56% reported having repeated assessments. Results from an additional study of NCORP websites showed that patients with metastatic colorectal cancer experienced “major financial distress” (defined as large debt, borrowing, refinancing, or loss of income of at least 20%) within 3 months of starting treatment. treatment.2.3

NCORP investigators proposed adapting the 5As (Ask, Advise, Evaluate, Help, and Organize) approach, which has been successful in smoking cessation programs, to address financial toxicity in the community setting.3 Among the 5As, assessing and supporting are the most important steps for an effective intervention. Financial navigators, nurses and physicians can assess whether changing treatment alleviates the financial burden and reduces non-adherence. They can then help by updating and monitoring results to ensure ongoing effective care.3

Findings from several studies presented at the American Society of Clinical Oncology’s 2022 Quality Care Symposium showed that investigators are researching integrative approaches to dealing with financial hardship.7.8

Ohio State University investigators implemented a study to identify patients with breast, lung, or blood cancer who were financially challenged and to optimize pathways to connect them to appropriate services.7 In 3 clinics – breast surgical oncology, hematology and thoracic medical oncology – no financial screening system had been previously implemented. The screening asked, “How hard is it for you to pay for basics like food, housing, medical care, and heat?” Responses ranged from “not at all difficult” to “very difficult” and included the option of not answering. Of the 4,732 respondents, 10% chose “a little difficult”, “difficult” or “very difficult”.7

The investigators proposed a workflow that would lead patients to the appropriate services; however, obstacles in terms of liability were identified. For example, once a patient has been identified as having financial difficulties, who should make the referral (e.g. nurse, advanced practice provider, physician), how the referral would be documented (e.g. phone call, email, consultation ) and who would be responsible for monitoring?7

A second, more complex and staggered workflow identified stakeholders. After the admitting nurse asked the triage questions, patients would be categorized as either in urgent need of assistance or not. Those categorized as in urgent need of help were assigned to a social worker, and those not categorized were placed on a weekly list and assigned to a patient navigator, who would either address the need or refer the individual to a social worker or financial adviser.7

These workflows are properly staffed for implementation and streamlined electronic health records for documenting information and transmitting it to the appropriate parties.

Another study from the O’Neal Comprehensive Cancer Center at the University of Alabama at Birmingham came to the same conclusion after examining the referral process in place for patients treated at their gynecological oncology clinic. In addition to admissions questions about ability to afford medication and financial hardship, investigators conducted an additional screening for financial hardship using the FACIT-COST.2.8

If difficulties were identified, patients were referred to social workers, lay navigators, financial counselors, and other appropriate services. In all, among 115 patients who had at least 1 financial need, 38 were assisted by a lay navigator and 98 were referred, the majority to social workers (86.7%). In addition to care, the investigators reported qualitative data from 43 patient interviews, with the majority of participants reporting that they “felt positively” about financial issues and considered them relevant to their care.8

Universal financial screening is feasible and patients are open to participation, the authors noted; however, a dedicated financial hardship tool is required. Fully integrating assessment into the workflow to ensure continuity of support for financially burdened patients remains an unmet need.8

In addition to large cancer centers, community cancer care facilities may be less able to handle financially difficult cases due to their size, resources and location.3 For example, in a recent study, investigators sought to identify gaps in care pathways based on stakeholder responses across 10 cancer care settings (5 rural practices and 5 non-rural practices).9

Researchers identified 6 financial assistance elements of the process across all sites: issue triage, referrals, resource connection points, and pharmaceutical, insurance, and community resources. Opportunities to effect change included more systemic, proactive and routine emergency triage, dedicated financial navigation staff, and the development of infrastructure to track the availability of external resources. The investigators also noted that expanding insurance and regulating pharmaceutical costs are also needed to address financial difficulties.9

As in other studies, facilitators were identified as essential: team members with institutional knowledge and relationships with external resources are needed to assess, process, and implement solutions for patients facing financial difficulties, note Biddell et al.9

“Financial hardship is more common among populations that have historically faced challenges in accessing cancer care, including [individuals] who are low-income, uninsured/underinsured, or racial/ethnic minorities, but financial hardship is becoming commonplace across the economic spectrum,” wrote Yabroff et al.two “Advances in expensive cancer treatments threaten to increase disparities in access to care based on ability to pay. It is therefore increasingly important to understand how institutions and providers identify patients with financial difficulties and the strategies used to mitigate difficulties and meet patients’ needs.”


  1. 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
  2. Yabroff KR, Bradley CJ, Shih YT. Improving the screening process for medical financial hardship in oncology practice. Previous Cancer Epidemiology Biomarkers. 2021;30(4):593-596. doi:10.1158/1055-9965.EPI-21-0111
  3. Khera N, Sugalski J, Krause D, et al. Current practices for screening and managing financial distress at NCCN member institutions. J Natl Compr Canc Netw. 2020;18(7):825-831. doi:10.6004/jnccn.2020.7538
  4. McLouth LE, Nightingale CL, Dressler EV, et al. Current practices for screening and treating financial hardship within the NCI Community Oncology Research Program. Previous Cancer Epidemiology Biomarkers. 2021;30(4):669-675. doi:10.1158/1055-9965.EPI-20-1157
  5. Khera N, Zhang N, Hilal T, et al. Association of literacy in health plans with financial difficulties in cancer patients. JAMA Netw Open. 2022;5(7):e2223141. doi:10.1001/jamanetworkopen.2022.23141
  6. FACIT-COST. Accessed October 8, 2022.
  7. Obeng-Gyasi S. Implementing financial hardship screening in a comprehensive cancer center: what worked and what failed. Presented at: 2022 American Society of Clinical Oncology Quality Care Symposium; September 30 to October 1, 2022; Washington DC.
  8. Pisu M. The added value of a dedicated screening tool to identify patients with financial difficulties. Presented at: 2022 American Society of Clinical Oncology Quality Care Symposium; September 30 to October 1, 2022; Washington DC.
  9. Biddell CB, Spees LP, Petermann V, et al. Financial assistance processes and mechanisms in rural and non-rural oncology care settings. JCO Oncol Practice. 2022;18(9):e1392-e1406. doi:10.1200/OP.21.00894
Practices must redouble efforts to help patients cope with financial toxicity

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