New study: Financial hardship common with metastatic colorectal cancer

photo of Veena Sharnkaran speaking at a podium in front of a large screen where the words: HICOR at Fred Hutch are visible — Dr. Veena Shankaran of Fred Hutch, who is co-director of the Hutchinson Institute for Cancer Outcomes Research, led the new SWOG Cancer Research Network study on the financial toxicity of a diagnosis with widely spread, or metastatic, colorectal cancer. Photo by Robert Hood / Fred Hutch News Service

This story was first published on Jan. 4 as a press release from the SWOG Cancer Research Network.

Despite having access to health insurance, nearly three out of four patients with metastatic colorectal cancer experienced major financial hardship during the first year after their diagnosis. These are the findings of a recent study of almost 400 patients by researchers at the SWOG Cancer Research Network, a cancer clinical trials group funded by the National Cancer Institute, part of the National Institutes of Health The work is just published in the Journal of the National Cancer Institute.

The study also found that major financial hardship was associated with a subsequent drop in patients’ social functioning and quality of life.

Financial toxicity — difficulties caused by the cost of treatment — is increasingly recognized as a problem among patients being treated for cancer. This is the first study to prospectively measure the financial impact of cancer treatment in a socioeconomically and geographically diverse nationwide group of patients newly diagnosed with advanced cancer. Previous smaller studies, most of which had asked patients to recall past experiences, had estimated that approximately one-quarter to one-half of cancer survivors face financial hardship.

The new study, known as S1417CD, was led by Dr. Veena Shankaran, a SWOG investigator with Fred Hutchinson Cancer Research Center and the University of Washington.

“Our findings suggest that cancer is a financial burden for most cancer patients, regardless of socioeconomic status or access to health insurance coverage,” Shankaran said, “and it gets worse with time. As a society, we need to really look at our healthcare system and social safety nets to understand why we are failing to protect patients with serious diseases from financial devastation.”

An editorial by Dr. K. Robin Yabroff and colleagues that accompanied publication of the findings suggested that “having health insurance may no longer be sufficient to protect patients and families from financial hardship and its adverse health sequelae.”

Noting that almost two-thirds of the patients who reported financial hardship at the end of a year had reported no hardship three months into the study, the editorial writers recommended that all cancer care providers conduct comprehensive financial hardship screening from diagnosis throughout treatment and connect patients to services when needed.

For the SWOG study, researchers at community oncology practices around the U.S. enrolled 380 adults who had been diagnosed within the previous four months with colorectal cancer that had spread to other parts of the body (metastatic cancer). All patients had recently begun or were about to begin treatment for their cancer. On joining the study, and then every three months for a year, patients completed questionnaires that asked about their financial, employment and insurance status. Other questions asked patients about their quality of life and whether they were experiencing physical, functional, cognitive, emotional or social problems.

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The researchers looked for changes in the questionnaire responses each quarter that would indicate the patient was facing major financial hardship, which was defined as the occurrence of at least one of the following situations: an increase in debt, taking on a new loan, selling or refinancing a home, or experiencing a decline in income of at least 20%.

They found that, although almost all of the patients were insured (98%), 71.3% of them experienced major financial hardship during the first year after their diagnosis. They also found that patients who reported major financial hardship three months after joining the study tended to report a decline in quality-of-life measures on their six-month questionnaires.

The study team further evaluated whether the percentage of patients facing hardship differed according to patients’ age, race, marital status, employment status or annual income. They found no statistically significant differences among these groups, suggesting that the risk of financial hardship was similar among key patient groups.

One overarching goal of the study was to determine whether it was even feasible to collect financial information in this way from patients with advanced cancer, or whether patient concerns about issues such as privacy and data security would keep many from joining the trial.

“Our experience shows that cancer patients are highly motivated and willing to share financial details and experiences,” Shankaran said, “particularly if it can help advance solutions to lessen the financial burden of cancer care.”

Building on the results of S1417CD, Shankaran and her SWOG colleagues recently launched a new nationwide study, S1912CD (NCT04960787), that is testing whether a financial counseling intervention can help ease financial hardship for patients with cancer.

SWOG is part of the NCI's National Clinical Trials Network and the NCI Community Oncology Research Program, or NCORP, and is part of the oldest and largest publicly funded cancer research network in the nation. SWOG has nearly 12,000 members in 47 states and nine foreign countries who design and conduct clinical trials to improve the lives of people with cancer. SWOG trials have led to the approval of 14 cancer drugs, changed more than 100 standards of cancer care, and saved more than 3 million years of human life.

Study S1417CD was sponsored by the NCI, led by SWOG, and conducted by the NIH-funded NCORP. It was supported by the ASCO Foundation Conquer Cancer Career Development Award 2013, by a SWOG Hope Foundation Charles A. Coltman, Jr., Award (2010) and by the NIH/NCI through grant CA189974.

In addition to Shankaran, the S1417CD study team included Dr. Joseph M. Unger and Amy K. Darke of SWOG Statistics and Data Management Center, which is co-located at Fred Hutch and Cancer Research and Biostatistics in Seattle, Dr. Jennifer Marie Suga of Kaiser Permanente-Vallejo/Kaiser Permanente NCORP, Dr. James L. Wade III of Cancer Care Specialists of Illinois/Heartland NCORP, Dr. Peter J. Kourlas of Columbus Oncology Associates/Columbus NCORP, Dr. Sreenivasa R. Chandana of Cancer and Hematology Centers of Western Michigan/Cancer Research Consortium of West Michigan NCORP, Dr. Mark A. O'Rourke of Prisma Health Cancer Institute/NCORP of the Carolinas, Dr. Suma Satti of Ochsner Cancer Institute, Diane Liggett of SWOG Data Operations Center/Cancer Research And Biostatistics, Dr. Dawn L. Hershman of Columbia University and Dr. Scott D. Ramsey of Fred Hutch.

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