Financial toxicity of cancer care: Defining pathways of decline vs resilience.
Authors: Grace L. Smith, Lisa M Lowenstein, Susan K. Peterson, Alyssa G. Rieber, Nathan Goodwin, Pragati G Advani, Reshma Jagsi, Sharon Hermes Giordano, Robert Joseph Volk
Journal: Journal of Clinical Oncology (2018)

Article Tools Patient and Survivor Care Article Tools OPTIONS & TOOLS Export Citation Track Citation Add To Favorites Rights & Permissions COMPANION ARTICLES No companion articles ARTICLE CITATION DOI: 10.1200/JCO.2018.36.15_suppl.e22150 Journal of Clinical Oncology - published online before print June 1, 2018 Financial toxicity of cancer care: Defining pathways of decline vs resilience. Grace L. SmithxGrace L. SmithSearch for articles by this author, Lisa M LowensteinxLisa M LowensteinSearch for articles by this author, Susan K. PetersonxSusan K. PetersonSearch for articles by this author, Alyssa G. RieberxAlyssa G. RieberSearch for articles by this author, Nathan GoodwinxNathan GoodwinSearch for articles by this author, Pragati G AdvanixPragati G AdvaniSearch for articles by this author, Reshma JagsixReshma JagsiSearch for articles by this author, Sharon Hermes GiordanoxSharon Hermes GiordanoSearch for articles by this author, Robert Joseph VolkxRobert Joseph VolkSearch for articles by this author Show More The University of Texas MD Anderson Cancer Center, Houston, TX; The University of Texas MD Anderson Cancer Center, Houston, TX, US; NCI, Bethesda, MD; University of Michigan Health System, Ann Arbor, MIAbstract Disclosures https://doi.org/10.1200/JCO.2018.36.15_suppl.e22150 Abstract Abstracte22150Background: "Financial toxicity”, the patient experience of financial declines due to costs of treatment, occurs in about half of cancer patients. It is unknown why some cancer survivors persist in severe decline while others find financial resilience. We identified pathways differentiating trajectories of decline vs resilience in cancer survivors. Methods: We conducted semi-structured interviews in 62 cancer survivors from a comprehensive care center (n = 30), county safety-net clinic (n = 22), and community-based practice (n = 10). Purposive sampling captured a range of diagnoses and economic status. Grounded theory guided qualitative analysis. Results: There were 3 major thematic categories of responses: 1) There are “static” and “dynamic” sources of resilience. Key “static” sources of resilience are savings, credit, and assets, which patients deplete to face costs of care. "Static" sources are inherently defined by resources patients accumulate up until initiation of cancer care. These resources seldom grow during ongoing financial disruptions of continuing care. Key “dynamic” sources of resilience are employment rebound and the waxing/waning stream of household income. 2) When combined magnitude and multitude of static plus dynamic resources are high, patients follow three pathways of resilience: a) avoiding/delaying financial toxicity, b) having stamina to withstand ongoing toxicity, and c) regenerating to the baseline state of accumulated resources and experiencing some resolution, or “healing”, from toxicity. 3) However, when static and dynamic resources are deplete, patients instead experience severe decline into a phase of marked toxicity, characterized by living “paycheck to paycheck”, relying on social safety net resources, and experiencing debt (including reliance on predatory loans), lack of credit access, and basic needs insecurity. Beyond the threshold of severe decline, resilience sources rarely provide adequate leverage for patients to achieve resolution of financial toxicity, even after treatment completes. Conclusions: Novel understanding of pathways of decline vs resilience to financial toxicity is critical to develop risk assessment and intervention targets in cancer survivorship.© 2018 by American Society of Clinical Oncology