Preview Mode Links will not work in preview mode

Nov 26, 2018

Communicating with Patients about Financial Toxicity: Dr. Ryan Nipp

Welcome to the ASCO Daily News podcast. I'm Alex Carolan, and joining me today is Dr. Ryan Nipp, a gastrointestinal oncologist and health services researcher at the Massachusetts General Hospital Cancer Center. Dr. Nipp, welcome to the podcast.

Thank you. Thank you so much for the opportunity.

Of course. Financial toxicity is a big factor in how patients with cancer approach treatment. Dr. Nipp, how do you talk to your patients about this issue?

It's a great question. I think there are a number of ways to somewhat, you know, bring up this topic in clinic with patients. I don't know that there's one correct way. I think it somewhat depends on the person, depends on the patient and how well you know the patients, somewhat depends on when the topic may come up and how it comes up.

So, often, when we meet patients for the first time, we have a multidisciplinary discussion about the treatment plan, the options, and potential side effects, and side effects related to the cancer and the cancer therapies. And that's where I've started taking the opportunity to say, how are things going? Any issues with nausea, pain, bowel issues?

And at that point-- also, kind of bring up the thought of sometimes therapies can be expensive. Sometimes when people get sick, they have to take time away from work. Has any of this affected you up to this point-- and kind of just opening up the idea to are there any issues.

At other times, they'll be issues that come up throughout treatment where someone's having trouble with insurance covers or co-pays or getting to clinic on time or finding a ride. And so that will be another opportunity where people kind of offer you this opportunity to bring up the idea and at least start to discuss it and see if it's a problem. And, you know, for the most part, people welcome the question.

A lot of the time, people are like, no, I'm doing fine, but thank you for asking. But for those certain people where it is a problem, I find that it's a huge problem. And they're incredibly relieved to hear about it and have the opportunity to talk about it.

That's good to know. And with that in mind, how do you create treatment plans while taking financial toxicity into consideration?

Yeah. This is a little bit difficult. I don't know that there's any correct answer. I think that you have to be mindful. It's just like you would with any other toxicity that you're dealing with. If you know a therapy is going to cause nausea, you have nausea medicines.

If you know a therapy may have cardiac side effects, you think about discussing that with the patient, letting them know the risks, you know, what are the percentages and the potential that this could happen to them. And just so that people know that down the road it's not a surprise if and when something happens, you almost have that obligation to bring it up. And that's the way I've started to categorize financial toxicity in my mind as well.

It's another side effect that could come up at some point. If it hasn't come up yet, it may come up at some point. And you don't want to surprise patients with it. I think that's one of the big issues right now with financial burden that patients encounter throughout their care or that they're just worried about it.

It's just this unknown of you hear about the financial toxicity of cancer. And it's so scary when you've got a new diagnosis. There's so many things that you're dealing with as far as symptoms, and job, and family, and how are you going to handle this, and just coping with so many other things.

And this is another thing, just the uncertainty of what things may cost-- co-pays. Do they have insurance? Can you get time away from work to do this?

And so I think it is just something to bring up that it could happen down the road, that this does happen to some people. And then that kind of brings you to the point of what options are available for people if and when that does happen. Similar to where if you had nausea or diarrhea that people may be experiencing, you can say, if and when that happens, we've got resources available.
And here's what we have available at our institution. And, increasingly, there are more options available to help patients. And so I think that's something that clinicians, you know, throughout the clinic, you know different clinicians-- social work, financial navigation, MDs, nurse practitioners, physician assistants-- can help with, just kind of getting familiar with what the institution may have, may not have, what's out there in the country as far as other resources and things going on to help.

Right. How does financial toxicity affect patient quality of life and treatment outcomes?

Yeah. That's where I think a lot of the research has been growing in recent years is kind of describing that this is a huge problem for patients. I don't think it's all patients. But definitely, for those patients where a financial burden or financial toxicity is an issue, it is a major issue. It has shown in multiple studies now to negatively correlate with patients' quality of life.
And then interestingly, if you think about, you know, the financial toxicity and financial burden that patients may be experiencing, it would make sense that that might impact how patients may adhere to certain medications. Might patients, if they're experiencing financial burdens, not want to pay for their Zofran or pay for other medications that might help them with side-effects of treatment. And then that point, you know, if you're not adhering to certain medications that you may or may not have needed, then that's a barrier to getting adequate symptom control, supportive care, and then ultimately could affect outcomes related to cancer therapy if you're also not able to adhere to your chemotherapy regimen or schedule and having to, you know, miss trips or missed visits-- another way that it can impact patient outcomes. And there have been studies showing associations with financial burden and adherence to medications and, if you take it even further, to potentially affecting patient survival.
In what ways can oncologists ease patient burden through advocacy or financial navigation programs?
I think advocacy is a good way to put it, meaning that you are kind of their advocate at this point, where, as a clinician, you may or may not. That's one of the barriers right now within the world of oncology, that we may not actually even know that our patients are struggling with financial burden or we may not know how much their copay is. We don't understand what their insurance may or may not cover or what certain drugs might cost.
And so it's going to be somewhat of a learning curve with all of us as far as, you know, I've seen patients with this before. I have understood that this medication can be expensive. Or I understand that this medication is needing to be frequently refilled. And so this may, you know, add to the cost of your care.
So you're their advocate. Knowing that you've had experience with this before, it might actually, you know, behoove them to be thinking about this could become expensive and just to let them know about that, that it could be coming down the road. And then that gets into, well, what are we going to do about it if and when the financial burden, you know, hits or becomes a problem.
And that's where there's more and more research that's needed. I think there's a lot of research underway looking at financial navigation programs, financial counselors. Social work has been really helpful at our institution.
I often go to other clinicians, the nurse practitioners or mid-level practitioners, that are helping us in clinic that have done this more than, you know, others and have seen this before. And are there programs available as far as getting reimbursements or some way to help patients with their co-pays? We've done a little bit of research here at Mass General as far as helping with patients to stay enrolled on cancer clinical trials to, you know, somewhat as far as the travel and lodging that's related to the frequent visits associated with clinical trials.
Could you reimburse for some of the travel on lodging and help, you know, alleviate some of the financial burden? And that's one strategy. Again, how sustainable and how scalable that strategy is in question. But at least, you know, there's people out there thinking about it.
I understand there's, you know, a good number of start-ups. There's multiple advocacy groups, online communities, that are thinking very hard about this. And how can we do more research and better understand the problem in order to intervene upon the problem?

What role can research play to help patients and oncologists stand on the same page regarding the effects of financial toxicity on their treatment?

Yes. I think this is a very important point. I think getting patients and clinicians on the same page regarding the financial toxicity has been an issue in the recent years where more and more research is showing this is a problem. And I think it is now getting to the front lines as far as clinicians, oncologists, their staff, their faculty are understanding that we need to be thinking about this as a problem.
And that's one huge hurdle, at least identifying this as a problem and naming it. And, now, I think the next step for research is to start trying to intervene, trying to think of creative ways to do something about this. Are there apps?
Are there financial navigation programs as we've mentioned-- social work, implementing social work earlier in the course, or having ways of identifying, you know, what a drug or combination therapy is going to cost for a patient and letting them know up front? You know, these are the options available if there are options, if there's multiple chemotherapy strategies or multiple nausea medicines that are out there that could work equally effective. Is there a way to then discuss that with patients in a way that says this may cause this? This may cost this.

This is what this schedule looks like. You'll be coming in weekly versus bi-weekly. And this is what the drug costs and may affect your job or your work life and how your family might need to be helpful at certain times.

And similar to the way we deal with other toxicities where we trade off if somebody has renal issues or other blood problems where certain treatments may not be the best idea for them, we think creatively about ways to get people the best treatment possible for them. And I think that's going to be a lot of the research in the next few years is looking at how can we intervene upon the problem of financial toxicity. And it's actually really exciting that this movement has taken off.

We've now named the problem. It's become mainstream and gotten a lot more attention. And I think, now, the next step is for all of us in the research community and in the clinician community to start thinking about creative ways to help with the problem.

Again, my guest today has been Dr. Ryan Nipp. Thank you for joining us.

Thank you so much for the opportunity. It's always my pleasure.

And to our listeners, thank you for tuning into the ASCO Daily News podcast. If you're enjoying the content, we encourage you to rate and review us on Apple podcast.