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Nov 21, 2019

ASCO Daily News: Welcome to the ASCO Daily News podcast. I'm Lauren Davis, and joining me today is Dr. Fumiko Chino, a radiation oncologist who specializes in the treatment of gynecologic breast cancers at Memorial Sloan Kettering Cancer Center. Dr. Chino had a circuitous way to oncology and is here to talk about how financial toxicity led to a new career for her and how it still affects her today. Dr. Chino, welcome to the podcast.

Dr. Fumiko Chino: Thank you so much, Lauren. I appreciate the opportunity to talk to the ASCO Daily News about this very important topic.

ASCO Daily News: We're glad you're here. Although your first career was as an art director, you come from a family with a medical background. Can you tell me about that?

Dr. Fumiko Chino: Sure. So I would say you can't fight city hall. My mother is an oncologist. My brother's an oncologist, and my sister is also an oncologist. So it certainly was, I guess, to say, in the bloodline. But I had originally started a very fulfilling career in art and entertainment, and I was never really supposed to be a doctor. That wasn't in my grand plans.

Dr. Fumiko Chino: Unfortunately, as we all know, cancer doesn't follow signposts. It does whatever it wants to do. And whenever I faced the treatment or diagnosis and ultimate death of my husband, I knew that I needed to do more. I needed to do more to improve the lives of others. I needed to make a bigger impact. What I normally say is that my husband was brilliant. He was going to change the world. And after he died, I had to be the one to change the world.

ASCO Daily News: Mm, wow. I'm so sorry for your loss. So how did that lead to your decision to go to medical school for radiation oncology?

Dr. Fumiko Chino: Yeah, so when I was in the hospital with my husband-- he was diagnosed in 2000. Well, he started having symptoms in 2005. He was diagnosed in early 2006. And that process was long and complicated. We were given a number of different diagnoses that weren't cancer, immediately. Because, again, if you have a healthy twenty-something man in your clinic, the first one through five of your differential diagnosis isn't cancer.

Dr. Fumiko Chino: So like many young people, he went through a number of kind of false calls before ultimately getting his diagnosis of a high grade neuroendocrine carcinoma. And through the process of his cure, I realized that the people that you see in cancer care, each interaction is important. I originally actually thought I was going to go to nursing school. But coming from a family of oncologists, my sister said, you know what? You're not going to be happy as a nurse because eventually there's going to be some intern trying to tell you what to do, and you're going to know more than they will. And it's going to be frustrating for you.


Dr. Fumiko Chino: Which is accurate. I have the utmost respect for nurses. So she just said that I seriously consider medical school. And after my husband died, I thought about it for a long time. I went back to school, did some post-bac classes and ultimately decide to go to medical school.

Dr. Fumiko Chino: I'm so grateful that I came to that path, but it was a hard path because I really struggled for a while after he died to kind of give my life purpose. But like what I said earlier, we were a team before. My plan was to continue working in arts, do arts nonprofit management. And he was going to be the one to make meaningful change in the world. But we're still a team. So anything I do now is still under our banner.

ASCO Daily News: Absolutely. The sad fact of cancer care, we know, is that it's very expensive. And I know that your passion is around addressing issues around financial toxicity. I'm curious, what about the way insurance works surprised you when your husband was undergoing treatment?

Dr. Fumiko Chino: Yeah, so all of the research that I've done is really rooted in and around personal experience. And so, I guess, in that way, I'm very selfish. Because when my husband was diagnosed, he had graduate student health insurance, and at the time we didn't really think of it. We said, well, he has health insurance. There will be costs, and we know that. We know cancer care isn't free, but it'll be manageable.

Dr. Fumiko Chino: And what we didn't realize at that time-- and this is before the Affordable Care Act-- is that there wasn't the protections that were put in place. So for example, there were caps on how much the insurance company would pay. Those caps have been eliminated under the Affordable Care Act. But unfortunately, our part of what is being currently eroded in the-- I will say political environment that we are in now-- so the idea that you can now introduce a health insurance plan that does have a lifetime payment cap has been reintroduced.

Dr. Fumiko Chino: So the coverage gap that we had is now potentially something that people could face today, when it had been eliminated in the last decade. I'm sorry, in the last five years. So what we found is that his insurance just stopped paying after a certain dollar amount. Which, with a cancer diagnosis, with any ongoing treatment, you understand that that's going to be continuing to be expensive. There's chemotherapy. There's scans. There's office visits. There's, unfortunately, hospitalizations for my husband, and there's need for supportive services.

Dr. Fumiko Chino: And so those are all added to essentially the dollar amount. And after a certain point, his health insurance said, you're done. There's no more money that we will pay for his cancer care. And that was a huge shock to me, and is, unfortunately, is, again, what people are at threat for today, that at some point their insurance, if they have one of these, what I call sham insurance plans, that they have a serious diagnosis like cancer, that they will meet their max, meaning that the insurance company won't pay anymore.

Dr. Fumiko Chino: The other thing that was surprising to me is that there was no cap on what we would pay. So the protections that were placed under the Affordable Care Act are that there is an out-of-pocket max, meaning that once you reach that level, that the insurance company will pay 100%. Those caps are high under the current marketplace plans for 2020. For a family plan they're $6,400. Sorry, $16,400. So that's incredibly high for a family to pay for a single person with a cancer diagnosis.

Dr. Fumiko Chino: But at least it's a cap, whereas when my husband was diagnosed, it was literally a bottomless hole that we could throw money into. And it never seemed to make the difference in terms of what our balance was going to be. When he died, I owed hundreds of thousands-- I'm sorry, he owed hundreds of thousand dollars in medical bills. And I was really hounded by collectors for a decade afterwards.

Dr. Fumiko Chino: It was actually only recently that I found out I wasn't responsible for that debt. And it really was the huge weight that lifted off of me. Because in my mind, I'd always been like, well, this is going to get me some time. And the whole life I was building now, the new career I have as a physician, I kept thinking, well, they're going to find me eventually.

ASCO Daily News: Wow. What do you think clinicians need to know about financial toxicity in terms of how it affects patients and their families in the long term?

Dr. Fumiko Chino: I think that physicians really need to think of this as being an insidious process. And the person who walks through their door with a new cancer diagnosis may not have problems with their finances, with their insurance, with their bills. And they may not realize that this is a problem that can work in the shadows. And you can be months or even maybe years into your cancer diagnosis before being faced with problems.

Dr. Fumiko Chino: But what we know and what we have excellent evidence for is that it's financial toxicity can affect quality of life. It can affect the satisfaction you have with your cancer care, and ultimately can compromise the quality of the cancer care that you receive. So people will be cutting corners because of their costs. They'll be taking less of their medication. They'll be skipping scans.

Dr. Fumiko Chino: We know that cancer survivors, of which there's a growing population in the United States, are missing out on, for example, mental health care or getting their glasses replaced. Young survivors are facing job lock, which is when they basically can't fulfill their maximum career potential because they're scared of changing jobs because of their health insurance.

Dr. Fumiko Chino: Ultimately, we know that there's these huge family and personal burdens. We have medical bankruptcies. We have people who are literally losing their homes because of the financial burden of their cancer treatment. And the outcomes outside of just the personal and family effects can increase your risk of death. So this problem isn't something that will necessarily walk into your clinic and say, here I am. I have this problem. It can erode slowly over time.

Dr. Fumiko Chino: It's just like any toxicity. Someone comes in with peripheral neuropathy, they say, it's a little numbness and tingling in my fingers, but it's OK. I can still do my activities of daily living. And then that can get worse and worse and eventually it can be disabling. And the same thing with financial toxicity is that it's a process. And my goal is to stem the tide of that process. Like any side effect in cancer cure, though, it's going to be hard to eliminate completely.

ASCO Daily News: Absolutely. Thank you so much for continuing to spread the word about financial toxicity and sharing your personal story. It's been a pleasure speaking with you. Thanks so much for being on our podcast today.

Dr. Fumiko Chino: Absolutely. Thank you so much for having me.

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