Assessing Clinician Attitudes and Beliefs Around Financial Toxicity Screening in Medical Oncology Clinic

In cancer treatment, “financial toxicity” describes out-of-pocket (OOP) costs, such as copayments, deductibles, and coinsurance, that may cause financial problems for a patient.^1,2 A growing body of literature has documented the impact of financial hardship on cancer clinical outcomes.^3-5 Prior studies have shown that patients undergoing cancer treatment or survivorship experience higher OOP costs compared to nonelderly adults with or without chronic medical conditions; insured patients with a new cancer diagnosis may incur OOP expenditures totaling about a quarter of their household income.^6,7

In 2009, the American Society of Clinical Oncology released a guidance statement affirming the role of oncologists in communicating costs as a key component of high-quality care.⁸ Yet, Palmer et al reported in 2018 that 76% of physician survey respondents did not routinely screen for financial burden of cancer treatment.⁹ Diminished quality of communication about costs of treatment, or lack thereof, affects patients’ ability to make well-informed decisions regarding their care, leading to substantial OOP expenses.¹⁰ Prior research in the oncology setting has shown that most patients expressed that no health care professional had ever discussed cost with them, despite 80% of patients wanting cost information.¹¹ 

While the financial burden associated with cancer care is well-recognized, few studies have qualitatively explored defining a clinician’s role, if any, in identifying patients at higher risk for financial toxicity and how to standardize communication on cancer treatment costs. Qualitative research is increasingly used in health care to provide insights into a problem and understand the context or meaning that individuals give to their actions.¹² In many instances, qualitative research offers a unique opportunity to systematically learn the beliefs or values underlying behaviors.¹³ Compared to quantitative analyses, which aim to achieve breadth of understanding on the subject, a qualitative exploration is necessary to observe the depth in perspectives on cost communication between clinicians and patients. As such, the primary objective of this study is to evaluate the attitudes, motivation, and experiences of clinicians regarding screening for financial toxicity in a medical oncology clinical setting and identify potential opportunities for future clinician-led interventions to mitigate financial hardship.

 This qualitative study was conducted at a National Cancer Institute-designated Comprehensive Cancer Center in the United States. A phenomenological approach was employed to encourage participants to openly discuss their views and experiences of screening for financial toxicity. Phenomenology aims to reveal hidden dimensions of meaning in certain phenomenon through reflective analysis of an individual’s lived experiences.¹⁴ Data was collected through in-depth, in-person, semi-structured interviews with a purposive sample of study participants (physicians, n=5; social workers, n=2) from June 2019 to September 2019. 

Interviews were conducted in an outpatient clinic setting by an experienced qualitative researcher with doctoral training in clinical psychology. The interviewer utilized a guide containing seven open- and closed-ended questions focused on different aspects of screening for financial toxicity which served as starting points for the discussion (Table 1).The questions in the guide were chosen based on a preliminary literature review by the study team to adequately capture the subjective experience of participants while allowing for flexibility in the discussion. The interviewer asked follow-up questions to probe for details and further clarification when necessary. On average, each interview lasted approximately 30 minutes.

Semi-structured interviews were audio-recorded and transcribed verbatim using Rev.com.¹⁵ Interview data were organized and analyzed by researchers with formal training or experience in qualitative research upon conclusion of data collection using Atlas.ti version 8.4.4.¹⁶ 

A blended analytical method was utilized during the interpretive process, leveraging both deductive and inductive coding schemes.¹⁷ Deductive coding schemes apply a priori questions based on literature and inductive coding identifies themes that emerge through open-ended questions. To ensure the validity of emergent findings and increase intercoder reliability, all interview data were triple-coded, and discrepancies among the coders were reviewed and resolved. 

The characteristics of study participants are summarized in Table 2. 

All participants self-reported a moderate to high level of comfort with screening patients for financial toxicity (moderate, n=3; high, n=4). Three major themes emerged from discussions with participants on cost communication and screening for financial toxicity screening in cancer care: (1) barriers facing clinicians and health care professionals; (2) perceived benefits of screening for financial toxicity; and (3) impact on patient care (Figure 1). 

Barriers Facing Clinicians and Health Care Professionals

Study participants described notable challenges to screening for financial toxicity in the clinical setting, including time constraints and lack of preparedness or defined protocol to manage situations when a patient discloses financial hardship. Frequently, participants noted feeling “helpless” and “not trained to really understand [the patient’s] insurance or how to make recommendations with regard to the ‘black box’ [of treatment costs] without understanding the implications on patients and their families.” The hesitation voiced by some participants largely stemmed from the “limited number of solutions” and actionable items rather than initiating the conversation itself.

Importantly, the study participants who were physicians often stated they rely on referrals to social workers if a patient expresses financial distress without knowing the social workers’ capacity or what resources are available. However, one study participant who is a clinical social worker emphasized that, even though inherent to her role is providing concrete resources for patients with cancer, “it was initially a bit challenging to be honest because we didn’t have the tools or the knowledge related to the treatment that patients were receiving” and so it “took [her] a good year to feel comfortable having these conversations at all.” It was clear that a combination of clinical knowledge, awareness of available resources, and understanding of the patient population is necessary to provide effective financial navigation. 

According to participants, the decision to screen patients for financial toxicity was subjective and primarily based on verbal, social, and physical cues rather than objective measures. One participant stated: “I shouldn’t have made the assumption that the financial toxicity wasn’t stressful to [certain patients], and I think that was surprising and eye-opening to me, that just because somebody had a good job, or what seemed to be financial security, that didn’t necessarily mean that they weren’t stressed out about the financial toxicity of the things that we prescribed.” Additionally, when asked whether certain populations seem to face more financial toxicity than others, participants echoed previous sentiments, pointing out that insurance payer or subject matter of casual conversations unrelated to cancer provided insight into financial status of patients. 

Perceived Benefits of Financial Toxicity Screening

In response to the question, “Do you think there are some benefits to screening cancer patients for financial toxicity?” participants expressed similar views; screening is a proactive approach to guiding resource allocation and has potential to identify patients who are experiencing financial hardship at the beginning and throughout the course of cancer treatment. While participants provided different perspectives on how to best incorporate financial toxicity screening in the clinical setting, they noted that routine screening would help identify patients experiencing financial hardship who would stand to benefit from early interventions such as financial counseling or assistance programs. One social worker participant commented:

Most patients, or some patients, I feel already have a lot of anxiety around their treatment, and the unknown of whether the treatments going to work or not, or whatever happens with their care. And I think having concrete information and real information [about costs] is really beneficial, because then it makes patients feel they have control over some of their treatment and some of their care. 

Furthermore, clinicians and health care professionals acknowledged that, with increased transparency of costs, patients are better equipped to manage their financial situation or reach out directly for more information about available resources. According to one participant, although many of the resources that currently exist are “not obviously substantial, patients definitely appreciate having this information ahead of time and knowing there are a few resources that can alleviate some of their financial concerns.”

Impact on Patient Care

In general, participants expressed having neutral or positive experiences with patients when screening for financial toxicity. One participant stated that “most of the patients I screened were really grateful that I had brought up the topic,” and “patients felt I cared about multiple aspects of their care and not just their medical condition.” Another participant mentioned that, from her own experience, patients who are reticent to discuss costs associated with cancer treatment oftentimes felt a sense of relief or gratitude when the subject was introduced by the provider. Even for the “patients who had no concerns at all, most of the time [they] were appreciative of [the clinician] bringing it up.” Overall, participants expressed sentiments associated with intrinsic motivation—an internal drive to act and discuss cost with patients. For example, they find it “really important […] to make sure that the patient has appropriate financial means to receive the care that we think that they need” and that discussion of cost with patients “gives the provider a deeper appreciation for the patient experience.”

Notably however, one participant recalled a previous experience when initiating the discussion with a patient who “didn’t want [cost] to color the recommendations [of treatments] for him” and felt their responses to the screening questions were going to lead to discriminatory behavior on the part of the clinician. When asked whether that experience had changed the participant’s approach to screening, the participant responded that “targeting patients is more likely to elicit that kind of a response” and “asking everyone made it easier because I was less likely to make someone feel like I was targeting them.” 

We observed that clinicians are highly motivated to understand and address financial toxicity to deliver patient-centered care, yet they feel ill-equipped. Prior studies have quantitatively documented clinicians’ experiences on cost communication,¹⁸ however, to our knowledge, this is the first study to qualitatively examine the dyadic relationship between clinicians and patients. Additionally, this analysis deeply explored the clinician perspective and characterized intrinsic motivations expressed regarding screening for financial toxicity in the context of cancer treatment.

Our observations are consistent with prior literature detailing patients’ and oncologists’ preferences for communicating cancer treatment-related costs.^11,19 Henrikson et al¹⁹  and indicated that patients and medical oncologists alike lack access to pertinent cost information, which may explain variations in frequency of cost discussions.²⁰ Our findings, along with Henrikson’s observations, demonstrate the need to develop standardized training to promote clinician comfort in addressing financial hardship in the context of cancer treatment. Moreover Philip et al reiterated this notion, stating a dearth of training programs or interventions in Graduate Medical Education to prepare clinicians for conducting cost discussions in an effective manner.²¹ 

Prior research has shown that asking about financial toxicity is a patient-centered strategy to delivering cancer treatment. Slavova-Azmanova et al showed that patients who discussed treatment options and their associated costs with their physician felt empowered to make informed decisions about their health.¹⁰ The promise of novel therapeutics is coupled with the harsh reality of rising treatment costs²²; therefore, developing standardized strategies for identifying patients at financial risk is critical. Although several instruments have been developed to measure and quantify financial distress experienced by cancer patients,^23-25 few studies have discussed effective and appropriate strategies for their implementation in clinical practice. Further research is needed to develop successful models for systematic screening for financial toxicity in the clinical setting that maximizes benefit to the patient and minimizes the burden placed on clinicians or other health care professionals. To provide patient-centered care that is respectful of and responsive to the individual patient preferences, needs, and values,²⁶ clinicians and health care professionals will need to understand the financial context that may impact a patient’s clinical outcomes. 

One important finding of our study is that, in the current clinical environment, prompting discussion of cancer-related finances may lead to heightened anxiety or additional distress for patients. For instance, some patients may not feel comfortable disclosing their financial status with a physician in fear of receiving substandard care or that their finances may influence the clinician’s choice of treatment regimen. However, these observations reveal the importance of financial discussions becoming a routine part of clinical care and an entry point for shared decision-making. 

This exploratory study has limitations worth noting. The findings of this study derived their significance from having emerged out of a diversity of perspectives on cost communication. Study participants, which consisted of both physicians and social workers, were identified and interviewed using a purposive sample from outpatient medical oncology clinics at a single academic medical center. This technique sampled a small group of study participants of different backgrounds, trainings, and patient experiences. While the methods of qualitative research can produce a rich understanding of detailed experiences from a select number of participants, the results of this study must be generalized with caution. Additional studies are needed to examine the prevalence of these attitudes and beliefs toward financial toxicity screening, as well as the relationships between screening, clinical role, and years of experience. Furthermore, interpretation of the findings must be grounded in the setting in which the study took place. This study was conducted at a medical center located in a metropolitan area with median household income approximately 74% greater than that of the United States ($107,898 vs $62,937 in 2018).²⁷ As a result, the general patient population is periodically screened for financial toxicity and is not representative of the wider population. Therefore, in-depth interviews with clinicians and health care professionals in low-resource settings are necessary to understand the greater impact of screening for financial toxicity.

Despite these limitations, our study highlights a critical need for implementing routine methods for assessing financial risk among cancer patients. Future studies should examine methods for developing, integrating, and evaluating financial toxicity screening in health care delivery. Clinicians in this study recognize the need for objective screening for financial toxicity and that its benefits to the well-being of the patient outweigh the discomfort or uncertainty experienced by all. This recognition plays a role in intrinsically motivating clinicians to discuss costs with patients. With robust training on cost communication and education about insurance and available resources to ensure continuity of care, clinicians and health care professionals may serve as an important entry point for identifying and mitigating risks of financial toxicity in cancer care. 

Authors: Sylvia T Zhang, MS¹; Errol J Philip, PhD²; Nichole Legaspi³; Lucky Ding²; Tracy Kuo Lin, MSc, PhD⁴; Hala T Borno, MD^1,3

Affiliations: ¹University of California San Francisco, Helen Diller Family Comprehensive Cancer Center, San Francisco, CA
²School of Medicine, University of California San Francisco, San Francisco, CA
³Department of Medicine, Division of Hematology/Oncology, University of California San Francisco, San Francisco, CA
⁴Institute for Health & Aging, Department of Social and Behavioral Sciences, University of California San Francisco, San Francisco, CA

Correspondence: Sylvia Zhang, MS
Senior Clinical Research Coordinator
University of California San Francisco Helen Diller Family Comprehensive Cancer Center
Phone: (415) 514-3601
Email: sylvia.zhang@ucsf.edu

Disclosures: Unrelated to the development of this manuscript, Dr Borno receives support from the Prostate Cancer Foundation, and Ms Zhang and Dr Borno receive support from the Lazarex Cancer Foundation. All other authors report no relevant financial disclosures or conflicts of interest.