1. DiGiulio, Sarah

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"I suspect I ought to ask all patients about financial vulnerabilities. After all, shouldn't it be part of my full review of symptoms? Maybe it is not quite in the same league as shortness of breath, fevers, new neurologic symptoms, or fatigue. Or is it?"

Nandita Khera, MD, M... - Click to enlarge in new windowNandita Khera, MD, MPH. Nandita Khera, MD, MPH

Nandita Khera, MD, MPH, Assistant Professor of Medicine in Hematology/Oncology at Mayo Clinic, posed the question in a recent Journal of Clinical Oncology Art of Oncology article (JCO 2014;32:3337-3338). And in the article's 11 succinct paragraphs, Khera makes the argument that it might just be.


Khera defines "financial toxicity" as "adverse economic consequences resulting from medical treatment." She says that financial toxicity-similar to medical toxicity-can lead to treatment non-adherence and lifestyle changes for patients that impact quality of life and increase morbidity and mortality.


Others have suggested solutions could involve government playing a bigger role to rein in costs (OT 11/10/14 issue). But, Khera proposes that physicians themselves also need to play a bigger role in being aware of patients' financial vulnerabilities in order to be aware of how much financial toxicity is being caused by the patients' treatments.


In a phone interview, Khera elaborated on one solution-a standardized financial toxicity scoring system-and why it could be beneficial for patients and physicians.


1. Why do oncologists-and all physicians-need to be aware of the financial toxicities of treatments and how those toxicities affect the patients they treat?

"As physicians, we have to remember, especially as we continue from first-line treatment to second-line treatment to third-line treatment, that there are economic consequences. Especially if patients are underinsured or their coverage is not great, they may accumulate a lot of debt and financial burden that can impact their lifestyle-or even their ability to continue their treatment. Both the patient and the physician have to remember that even in the face of a life-threatening illness, you still have to think about those things.


"We're finding otherwise, that as treatment moves forward, patients will ultimately come and say, 'I will not take this treatment because I will have to sell my house or do something very catastrophic to be able to do that.'


"In order to not get to that point, I think it is important that we start talking about it. It's the elephant in the room, but somebody needs to talk about it."


2. You suggest a "Grading Criteria" or standardized scoring system could help-how does it work?

"It's a tool that makes it easier for the oncologist to think about financial toxicity and creates a language so we feel comfortable communicating with each other. It's a system to screen patients and identify who may be at risk for catastrophic financial outcomes as a result of their cancer diagnosis.


"Grade one is lifestyle changes-such as not being able to afford routine expenses. And if patients are struggling with grade one financial toxicities, unless something is done they will likely progress to grade three or grade four where we are going to be dealing with much more severe outcomes-and potentially progression of the patients' tumors if they cannot continue treatment.


"Once you identify that the patient is having financial difficulties due to the cost of their treatments, at that point the physician can refer them to social services or other resources, such as drug assistance programs.


"The grading system helps address potential financial toxicities as early as possible."


3. What are the barriers to implementing a system like this one?

"One barrier is attitudes. As physicians we need to see the broad perspective that we do have some responsibility toward patients' financial well-beings.


"Second is the knowledge barrier. When we order treatments and tests, a lot of physicians don't know or are not sure what it would cost or what the cost would be for the patient. That can be hard because there is a lot of variability, but even if physicians were more aware of some of the top costs that burden their patients-that would be important in helping overcome that barrier."


More from OT Associate Editor Sarah DiGiulio's "3 Questions on..." blog can be accessed at