Financial toxicity correlated with worse psychological well-being among breast cancer surgical patients

Financial toxicity among breast cancer patients is independently associated with worse psychological well-being following a mastectomy or lumpectomy operation. However, even small improvements in financial pressure associated with treatment-related costs can lead to better mental well-being and higher patient satisfaction with breast reconstruction, according to an "article in press" published on the website of the Journal of the American College of Surgeons ahead of print.

Women undergoing breast cancer surgery are vulnerable to financial stress due to the expensive and extended duration of treatment. High out-of-pocket costs can take a major toll on a patient's health, leading to financial toxicity (the harm or stress a person experiences due to the unaffordability of his or her medical care).

"Breast cancer therapy is highly sensitive to patient preferences, so right from the start patients are expected to make a lot of decisions and each one has trade-offs," said lead study author Christopher J. Coroneos, MD, MSc, an assistant professor of plastic surgery at McMaster University in Ontario, Canada. "There is a unique set of decisions that a patient has to make--undergoing a lumpectomy versus mastectomy, undergoing chemotherapy, adjuvant therapy and radiation, and then breast reconstruction--that is why breast cancer is different from other cancers."

Even so, timely and in-depth discussions between providers and patients about the cost of cancer care are uncommon. This is the first study to examine the connection between financial distress and quality-of-life outcomes (overall and condition specific) in women who undergo surgery for breast cancer, according to the authors.

Researchers analyzed the results of three self-reported surveys and medical record data for 532 women who underwent lumpectomy or mastectomy at The University of Texas MD Anderson Cancer Center in Houston. Patients were aged 18 years and older and had completed the surveys within 18 months of their breast cancer operation. Most of the patients (64 percent) underwent breast reconstruction. The median annual household income was reported between $80,000 and $120,000, well above the national average.

Using the COST (COmprehensive Score for financial Toxicity) questionnaire, researchers identified patients in financial distress. In addition, participants responded to questions from the BREAST-Q and SF-12 surveys, designed to assess quality of life, mental well-being, and physical satisfaction after undergoing breast reconstruction; a lower score represents a worse outcome.

After adjusting for multiple confounding factors, the analysis showed that financial toxicity, as reflected in a lower COST score, was strongly associated with lower BREAST-Q and SF-12 scores, indicating worse outcomes. Further, COST had the largest impact on one particular outcome, psychological well-being, with a one unit increase in COST correlated with a 0.89 unit increase in the psychological well-being score.

"Even a small change in financial toxicity translates to an important change in psychosocial well-being," Dr. Coroneos said. The data also showed a positive relationship between patients' psychological well-being and their own perceived satisfaction with the outcome of their breast reconstruction.

The study builds on previous findings examining the link between financial toxicity and quality of life. However, this study is important because it uses validated patient reported outcome measures for the analysis.

In this world of patient-centered outcomes and value-based care, there are two takeaway points from our study. First, for populations at high risk for financial toxicity, deliberations around treatment costs are incredibly important. Second, early intervention in instances of self-reported financial toxicity will be a key element of maximizing patient-reported outcomes in breast cancer surgery. This is because financial toxicity really does dampen the high-quality, patient-centered outcomes we are capable of delivering."

Anaeze C. Offodile II, MD, MPH, Study Senior Author, Assistant Professor of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston

Currently, the authors are conducting a prospective multi-center trial, reproducing this work in a variety of settings. They hope to get a more in-depth understanding of how economic well-being impacts quality of life outcomes in breast cancer surgery (timing, triggers and duration), and ultimately, how interventions that improve the economic well-being of cancer patients could lead to improvements in care.

"What clinicians have to do with these study results is to consider the financial reserve patients have when discussing breast cancer management." Dr. Coroneos said. "From a research perspective, integrating the financial risk and patient reported outcomes can inform decision-making models, and is especially important in vulnerable populations."