Economic recovery: A measure of the quality of cancer treatment and survivorship?

Successful cancer treatment is measured in terms of mortality, progression-free survival, disease-free survival, and tumor reduction and through other biologic markers. By these measures, progress in cancer treatment is undeniable, with steadily declining cancer mortality rates over the past 3 decades. Thus, as longer term survival is achieved, providers, patients, and researchers turn their attention to the survivorship period, when former patients and their families are expected to go on with their lives in a manner resembling their prediagnosis state. The number of cancer survivors is substantial and growing—approximately 14 million with overall 5-year survival rates of 68%, comprising a significant portion of the general population. A likely and important predictor of the quality of cancer survivorship is the quality of cancer treatment. To date, the quality of cancer treatment has been conceptualized as following treatment guidelines and avoiding unnecessary treatments. Measures such as symptom control, improved quality of life, and treatment tolerability have also been considered as relevant endpoints in clinical trials. The Institute of Medicine (IOM) report Delivering High-Quality Cancer Care: Charting a Course for a System in Crisis suggests that much more can be done to improve cancer care and specifically calls for broader data collection that includes information on patients’ functional and cognitive status, socioeconomic status, social supports, family capacity, and psychological status in addition to other factors that can tell us more about patients’ experiences with care. Outcomes along these dimensions can be critical indicators of how well patients will function after treatment and perhaps whether treatment protocols should be adjusted, depending on patient responses. In addition to these data suggested by the IOM committee, information is needed on patients’ employment and financial outcomes. Without specific data collection with regard to employment, work capacity, and the financial impact of treatment, critical sequelae of cancer and its treatment will be overlooked. Economic consequences stemming from cancer treatment have received considerable attention in the scientific literature and have been termed by some as financial toxicity to bring them within the nomenclature of the clinical side effects—many of which can be long term—of treatment. Financial toxicity occurs from the depletion of financial resources to an extent that it causes a burden on patients and families. In addition, financial toxicity, in the extreme case, is characterized as a condition from which some families cannot recover after treatment has ended. Financial resources become depleted during and after treatment for at least 3 reasons. First, the cost of cancer care has steadily risen, and a substantial portion of these costs is shifted to patients and their families. Few private or social safety-net options exist to reduce the burden of out-of-pocket costs. Second, the expenses associated with treatment make health insurance and employment and earnings all the more necessary during and after treatment, but many patients are unable to work during the acute treatment phase. Fortunately, with passage of the Affordable Care Act, options outside of the employer-based system are now available for health insurance for patients aged 64 years and younger, but income loss remains a problem. Third, the long-term prospects for continued employment and earned income also may be diminished by cancer and its treatment, resulting in the loss of income and possibly reduced retiree benefits for qualified patients. Together, these conditions make it difficult for some patients and families to overcome the financial impacts associated with cancer treatment. Cancer and its treatment can affect an individual’s work capacity by directly reducing the ability of patients to perform at work because of longer term treatment consequences, such as fatigue and compromised mental functioning