March 2020 Edition Vol.11, Issue 3

Getting Real on Financial Toxicity at GU 2020

By Christina Bennett, MS

The grim reality of patients dealing with financial toxicity and how that affects their quality of life was on the forefront of minds at the ASCO GU 2020 meeting, given that the entire keynote was dedicated to this problem. 

“This is a huge concept and something that we don’t think about much as GU oncologists,” said keynote speaker David Penson, MD, MPH, Vanderbilt University Medical Center.MD, MPH, Vanderbilt University Medical Center. “This is a real problem regardless if you have insurance or not,” he said. 

According to a 2013 study of the general population, 30% to 47% of patients younger than 65 and 12% to 24% of patients older than 65 face financial burden due to health care costs.1 

While financial burden profoundly affects the general population, the problem is worse in cancer, said Dr. Penson. A 2019 study found that cancer survivors younger than 49 years of age had more financial toxicity than patients without a history of cancer.2 Dr. Penson predicted that this problem will only get worse as high-deductible health plans become more common—a survey found that the proportion of covered workers with high-deductible health plans steadily rose from 4% in 2006 to 29% in 2016.2 

Studies have quantified financial burden, with one reporting that the median monthly out-of-pocket costs for cancer was $456 per month, or nearly $5500 per year.3 Dr. Penson put this into context, saying, “The median household income in the United States is $63,000 a year, so nearly 10% of the annual household income is being spent on cancer care.”

Not only are cancer patients financially strained but this can also lead to bankruptcy. A study estimated that within 2 years after a diagnosis, 42% of cancer patients deplete their total net worth.4 A different study found that 38% of prostate cancer survivors declared bankruptcy within 5 years of a diagnosis.5

Financial toxicity has also been found to be associated with worse survival. Among patients with prostate cancer, bankruptcy doubled the risk of death from any cause (HR=2.07; P<0.001), and this observation held true for patients without metastatic disease (HR=1.98; P=0.004).5

Although the studies evaluated patients in the United States, Dr. Penson said, “This is not a uniquely American problem.” A study among Canadian prostate cancer survivors found that 27% reported that cancer costs create a lot of stress, 21% reported that cancer costs were most stressful than other things, and 12% had trouble paying for their cancer costs.

To cope with financial burden, some cancer patients may alter their behavior in several ways, such as reducing spending on basics like food and clothing, delay in filling a prescription, borrowing money, and working more hours.3 The only study to look at financial toxicity in bladder cancer to date found that 39% of surveyed respondents with financial toxicity reported delaying care.6

“While perhaps it’s not completely unavoidable, financial toxicity and its effects on our patients can be minimized,” he said. He encouraged oncologists to discuss financial toxicity upfront with patients, create an environment where it’s acceptable to talk about it, and treat it like another possible side effect. “Think about the financial impact on the patient before you order discretionary testing and before you initiate therapies.”


  1. Ubel PA, Abernethy AP, and Zafar SY. Full disclosure–out-of-pocket costs as side effects. N Engl J Med. 2013;369(16):1484-1486.
  2. Zheng Z, Jemal A1, Han X, et al. Medical financial hardship among cancer survivors in the United States. Cancer. 2019;125(10):1737-1747.
  3. Zafar SY, Peppercorn JM, Schrag D, et al. The financial toxicity of cancer treatment: a pilot study assessing out-of-pocket expenses and the insured cancer patient’s experience. Oncologist. 2013;18(4):381-390.
  4. Gilligan AM, Alberts DS, Roe DJ, and Skrepnek GH. Death or debt? National estimates of financial toxicity in persons with newly-diagnosed cancer. Am J Med. 2018;131(10):1187-1199.
  5. Ramsey SD, Bansal A, Fedorenko CR, et al. Financial insolvency as a risk factor for early mortality among patients with cancer. J Clin Oncol. 2016;34(9):980-986.
  6. Casilla-Lennon MM, Choi SK, Deal AM, et al. Financial toxicity among patients with bladder cancer: Reasons for delay in care and effect on quality of life. J Urol. 2018;199(5):1166-1173.


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