Cancer costs leaving patients in debt

LUGANO-SINGAPORE, 18 December, 2016 – Cancer patients are ending up in debt because they have to cover the costs of treatment as well as other care related expenses, researchers report at the ESMO Asia 2016 Congress in Singapore.

Previous studies have demonstrated that cancer patients face financial difficulties even in countries where the national public health system covers most of the expense. The economic hardship experienced by patients and survivors is often refered to as the "financial toxicity" of cancer (1). Research presented at ESMO Asia 2016 shows new aspects of the burden of cancer care on patients.

A study (2) from Malaysia has found that more than half of cancer survivors spend at least a third of their yearly household income on treatment, as well as on costs such as transport to hospital and childcare. They have to pay for cancer drugs because many are not funded by the government despite the availabilty of free healthcare.

Lead author Nirmala Bhoo Pathy, a clinical epidemiologist at the Faculty of Medicine, University Malaya Medical Center, Kuala Lumpur, Malaysia, said: "The scope of cancer care and drugs offered free through the public health services is limited in Malysia.

"The current system of funding for cancer healthcare needs to be reviewed. The government must increase financial risk protection especially for the poor. Early cancer detection must also be improved through policy changes."

The findings were based on 1,662 men and women who participated in the 2012-2014 ASEAN Costs in Oncology Study. More than half (51%) of those still alive (n=1,215) a year after diagnosis were suffering financial difficulties.

Low-income, a lack of health insurance and not having surgery were among the factors associated with patients having money issues. The risk was lower for those who did not undergo chemotherapy.

Commenting on the study, Professor Nathan Cherny, lead investigator for the ESMO International Consortium Study on the Availability of Anti-neoplastic Medicines, said: "Unfortunately this situation is not limited to Malaysia. Data from the soon-to-be published ESMO International Consortium Study on the Availability of Anti-neoplastic Medicines (3), indicates that the burden of out-of- pocket expenses for drugs that are not on the World Health Organisation (WHO) essential medicines list, is substantial in most upper-middle income countries like Malaysia.

"The problems are even more severe in low-middle and low income countries where patients often need to cover costs themselves, even for essential anticancer treatments."

Cancer patients report loss of jobs and income

The financial burden of cancer care is also highlighted in a separate pilot study (4) to be presented at the ESMO Asia 2016 Congress. It includes data from patients (n=14) aged 37 to 77 currently being treated at a hospital outpatient department in Australia.

All participants completed a questionnaire covering issues including income and employment history, as well as health insurance status.

Preliminary results found nearly three quarters (n=10) reported a reduction in household income after their cancer diagnosis. Of the twelve patients who did have a job, ten highlighted changes in employment conditions such as decreased hours (n=6), others were no longer working (n=3) and one had retired.

"The loss of work, a carer's income and early retirement can all contribute to the financial burden on the household," said lead author Anupriya Agarwal, research fellow, Concord Cancer Center, Concord Repatriation General Hospital, Sydney, Australia.

"Our study aims to provide insight into these costs and assist policymakers in finding ways of reducing this burden on patients."

Doctors favour expensive drugs if life-prolonging

Another study (5) included in the programme investigated why cancer doctors recommend costly cancer drugs.

Oncologists were asked to complete an online experiment. They were presented with several scenarios involving a fictional patient with advanced cancer, and then had to state the cancer drug (A or B) they would recommend.

The results based on 101 responses found that healthcare professionals were more likely to advise the use of drugs that allow patients to live longer and have a higher chance of improving their symptoms.

They were less likely to recommend drugs with an increased chance of side-effects and that cost patients more, because they are not subsidised by the government. However, doctors would favour expensive treatments if they increased a person's survival time by two months or more over the standard care available. They would take this approach even when the out-of-pocket cost could expose patients with advanced cancer to extreme financial difficulty or 'toxicity'.

Lead author Deme Karikios, PhD candidate, National Health and Medical Research Council (NHMRC) Clinical Trials Centre, University of Sydney, Sydney, Australia, said: "Australian oncologists are willing to expose their patients to financial toxicity when recommending expensive unfunded anticancer drugs. They will only do this though in cases where the survival benefit is above that of standard care.

"Cancer doctors need to help patients understand the potential benefits, harms and costs of drugs not subsidised by the government. Then patients can make an informed decision about these treatment options."

Commenting on the findings, Cherny said: "Tools like the ESMO Magnitude of Clinical Benefit Scale (ESMO-MCBS) (6) can help clinicians better inform patients on how extensive the potential benefit is from a treatment option being considered.

"Using a very objective tool such as the ESMO-MCBS helps put the evidence into perspective, mitigates against optimism bias and can lead to shared decision-making that is better informed."

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Thomas Balasso
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