Financial Toxicity Among Patients with Multiple Myeloma
Authors: Silberstein Alice , Fiala Mark A. , Kelley Sarah , Schroeder Mark A. , Stockerl-Goldstein Keith E. , Vij Ravi 
Published: November 2021

Abstract
Background: Treatment-related financial burden, or financial toxicity, can detract from mental health and quality of life and can lead patients to alter their care to offset treatment costs. In doing so, these patients compromise adherence which can contribute to disparities (Zafar Oncologist 2013). Among cancers, multiple myeloma treatment is particularly costly due to use of expensive, novel agents, often in combination, and for extended durations. One study found that patients with myeloma frequently reported financial toxicity and used coping strategies, including borrowing money or prematurely stopping treatment (Huntington Lancet Haematology 2015). In this study, we aim to measure financial toxicity in a cohort of patients with myeloma and examine relationships between financial toxicity and demographic, socioeconomic, and clinical factors. We further aim to follow this cohort longitudinally to examine the course of financial toxicity.
Methods: We contacted individuals with multiple myeloma who had participated in our institutional banking study between 2018 and 2021. Patients who agreed to participate were sent a questionnaire which included the 11-item Comprehensive Score for financial Toxicity (COST). Scores range from 0-44 with lower scores indicating higher financial toxicity. Follow-up surveys will be completed after 3 and 6 months. This analysis included data from the initial survey only; follow-up survey data will be available at time of presentation.
Results: At time of analysis, 234 patients were contacted and 122 (52%) had returned the survey. Ninety-four completed the COST at least 6 months following myeloma diagnosis and were included in the analysis. The median age at time of survey was 68 (range 37-88). The majority were Caucasian (95%), male (70%), college-educated (62%), and had left the workforce (70%). Seventy-two percent of patients were receiving first-line treatment for MM while 28% had relapsed or refractory disease. The median time from myeloma diagnosis to survey completion was 29 months (range 7-159 months).
The median COST score was 28 (range 7-44); those below the median were considered to have higher financial toxicity. Patient characteristics are detailed in Table 1. Notably, 4 of the 5 African-American participants were in the higher financial toxicity group. The mean COST score for African-Americans was 18.4 (SD 8.0) compared to 27.7 (SD 9.2) for Caucasians (p = 0.03). In addition, those in the higher financial toxicity group were less likely to be college educated (52% versus 72%; p &lt;0.05) and the mean COST score for college educated patients was 28.9 (SD 9.3) compared to 24.1 (SD 8.7) for those without (p = 0.02). Interestingly, patients off treatment (n =11) had lower COST scores than patients receiving treatment (mean 21.5 [SD 9.6] compared to 27.9 [SD 9.1]; p = 0.03).
Eighty-four patients had complete data and were included in the outcome analysis. Many trends were observed although none were statistically significant. Those with private insurance were more likely to be in the higher financial toxicity group. Those with college degrees or with higher socioeconomic status, approximated using the median household income from each patient's home census tract from the 2019 American Community Survey, were less likely to be in the higher financial toxicity group. Those receiving intravenous myeloma treatment were less likely to be in the higher financial toxicity group compared to those on oral only regimens or no treatment. Results from the analysis are detailed in Table 2.
Conclusion: In this study, we observed relationships between demographics, socioeconomic status, and myeloma clinical characteristics with scores on the COST. However, none were independently associated with having a score below the median. Our findings are limited by sample composition, which was skewed toward patients who were Caucasian, college educated, and retired. In addition, because there is no established threshold for financial toxicity on the COST measure, we used our sample's median score; however, our median was higher than that of prior studies and this may have impacted the results. Nevertheless, these preliminary results show financial toxicity is a complex outcome that is difficult to predict. Our longitudinal data, which will be available at time of presentation, will build on these findings to assess the trajectory of financial toxicity over time.
Figure 1 Figure 1.

Disclosures
Vij: BMS: Research Funding; Takeda: Honoraria, Research Funding; Sanofi: Honoraria, Research Funding; BMS: Honoraria; GSK: Honoraria; Oncopeptides: Honoraria; Karyopharm: Honoraria; CareDx: Honoraria; Legend: Honoraria; Biegene: Honoraria; Adaptive: Honoraria; Harpoon: Honoraria.