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  • Review Article
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Financial toxicity associated with treatment of localized prostate cancer

Nature Reviews Urology volume 17, pages 28–40 (2020)Cite this article

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Abstract

Financial toxicity is a broad term to describe the economic consequences and subjective burden resulting from a cancer diagnosis and treatment. As financial toxicity is associated with poor disease outcomes, recognition of this problem and calls for strategies to identify and support those most at risk are increasing. Men with localized prostate cancer face treatment choices including active surveillance, prostatectomy or radiotherapy. The fact that potential patient out-of-pocket costs might influence decision making has rarely been acknowledged and, overall, the risk of financial toxicity for men with localized prostate cancer remains poorly studied. This shortfall requires a work-up in the context of prostate cancer and a multidimensional framework for considering a patient’s risk of financial toxicity. The major elements of this framework are direct and indirect costs, patient-specific values, expectations of possible financial burdens, and individual economic circumstances. Current data indicate that total cost patterns probably differ by treatment modality: surgery might have an increased short-term effect, whereas radiotherapy might have an increased long-term risk of financial toxicity. Specific thresholds of patient income levels or out-of-pocket costs that predict risk of financial toxicity are difficult to identify. Compared with other malignancies, prostate cancer might have a lower overall risk of financial toxicity, but persistent post-treatment urinary, bowel or sexual adverse effects are likely to increase this risk.

Key points

  • The term financial toxicity broadly reflects the financial consequences and subjective burden resulting from a cancer diagnosis and treatment.

  • Financial toxicity is increasingly recognized in oncology but has been poorly studied in the context of prostate cancer.

  • A high risk of developing financial distress might influence a patient’s treatment decisions; however, no guidelines recommend explicit discussion of this topic.

  • A patient’s risk of developing financial toxicity is multifactorial and is likely to be influenced by direct costs, indirect costs, patient-specific values and expectations of possible financial burdens, as well as individual economic circumstances.

  • The risk of developing financial toxicity probably differs depending on the treatment approach: surgery might particularly influence short-term risk and radiotherapy might influence long-term risk.

  • The overall risk of financial toxicity might be lower for men with prostate cancer than for men with other cancers; however, men with persistent treatment-related adverse effects are likely to be at higher risk.

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Fig. 1: Proposed financial toxicity framework.
Fig. 2: Instruments and outcomes to study financial toxicity.

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Acknowledgements

The authors thank J. Goldberg, MSLIS, for graciously assisting with our research database queries and for providing suggestions on literature review best practices. B.S.I. received a Resident Seed Grant from the American College of Radiation Oncology (ACRO) to perform the literature research for this Review. The Review was also funded in part through the NIH/NCI Cancer Center Support Grant P30 CA008748.

Review criteria

Electronic searches of several research databases, including PubMed and the Cochrane Library, were conducted. A search strategy was developed in collaboration with an experienced medical librarian. The search string was initially developed for PubMed and later adapted for other databases. It was restricted to English language publications but not by date of publication. The research goal was to clarify the prevalence and potential drivers of patient-level financial strain for men diagnosed with non-metastatic prostate cancer. The search string was purposely broad given our experience that heterogeneous descriptors are often used in the literature. No restrictions were made regarding non-empirical studies, such as literature reviews or conference abstracts. Titles of identified studies were then manually screened followed by a secondary abstract review to ensure relevance to our research objective. Finally, following full-text review of selected sources, the references were cross-referenced with the database results to identify additional potentially relevant resources.

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Authors and Affiliations

  1. Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA

    Brandon S. Imber, Melissa Varghese & Daniel Gorovets

  2. Department of Urology, Memorial Sloan Kettering Cancer Center, New York, NY, USA

    Behfar Ehdaie

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Contributions

B.S.I. and M.V. researched data for the article. B.S.I., M.V., B.E. and D.G. made substantial contributions to the discussion of the article content. B.S.I., B.E. and D.G. wrote the manuscript. B.S.I., M.V., B.E. and D.G. reviewed and/or edited the manuscript before submission.

Corresponding author

Correspondence to Daniel Gorovets.

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Competing interests

B.E. is a speaker to the Myriad Genetics Inc Medical Advisory Board and is the Principal Investigator of a phase 2 trial of MR-guided high-intensity focused ultrasound in patients with intermediate-risk prostate cancer. B.S.I., M.V. and D.G. declare no competing interests.

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Nature Reviews Urology thanks E. Onukwugha and the other, anonymous, reviewer(s) for their contribution to the peer review of this work.

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Glossary

Financial toxicity

A comprehensive term for the patient harm caused by the direct and indirect costs of cancer treatment.

Payor

The private or public entities that pay for health-care services. Examples include private insurance companies or a government-supported single public system (for example, the National Health Service in the UK).

Deductibles

The total out-of-pocket annual health-care expenses that patients must accrue before the insurance coverage activates and the payor begins to pay some (or all) of the remaining costs for that calendar year (usually a fixed annual monetary amount; for example $1,000).

Co-payments

Fixed, out-of-pocket monetary amounts that patients are required to pay by their insurer for a particular health-care service such as a physician visit or a prescription drug.

Co-insurance

The amount of a total health-care cost that patients are responsible for paying after they have met their deductible (usually a fixed percentage; for example, 20%); the payor will pay the remaining portion of the cost.

Opportunity costs

The financial or other benefits a person misses out on by choosing one alternative over another (in the context of working, opportunity costs could reflect the lost wages from days not worked owing to illness).

Member cost-sharing

Features of insurance plans that are designed to distribute some of the fees billed for health care to beneficiaries (for example, deductibles, co-payments and co-insurance models).

Supplemental insurance

Extra or additional insurance that a person can obtain to cover some of the out-of-pocket health-care expenses not covered by the primary insurance plan.

Likert scale

A psychometric tool frequently used in surveys that ask respondents to state their level of agreement or frequency using predefined criteria (for example, agree, strongly agree, etc.).

Affordable Care Act

Also known as the ACA, PPACA or Obamacare. A comprehensive US health-care reform law passed in 2010 that contained several provisions, including the requirement that US citizens obtain health insurance or face a tax (known as the individual mandate).

Medical Expenditure Panel Survey

A set of US-wide surveys of individuals and families, their medical providers, and employers, providing one of the most complete data sources for the cost and use of health care and health insurance coverage in the USA.

Premium

The annual amount to be paid for an insurance policy.

Human capital approach

A commonly used labour economic strategy to estimate indirect costs that assumes that lost earnings are a proxy for lost output and generally multiplies incremental time lost from employment by wage per unit time.

Bundled payment

A financial reimbursement model in which a physician or health-care system is paid a single sum for an entire episode of care, not individual sums for each specific service provided.

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Imber, B.S., Varghese, M., Ehdaie, B. et al. Financial toxicity associated with treatment of localized prostate cancer. Nat Rev Urol 17, 28–40 (2020). https://doi.org/10.1038/s41585-019-0258-3

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