September 2018 President’s Message

A modern medical condition: fiscal toxicity

by Jed Delmore, MD

Risks and complications of treatment: infection, bleeding, kidney injury, death and bankruptcy.

As medical students we are taught early on about informed consent related a medical intervention or treatment. As care providers we relay all the pertinent information regarding the pros and cons of a proposed therapy, and answer questions, so that the patient may make an informed decision to accept the proposed treatment or not.

Until relatively recently the toxicities were physical or emotional. The rapid and expensive impact of medical innovation and technology now places financial toxicity on par with the remaining adverse effects of therapy. Although this is true for all aspects of medicine, my personal interest is the oncology patient.

Innovations in surgery and radiation therapy have resulted in a progressive increase in cost to patients, though in a relatively predictable and linear manner. The medical treatment of cancer patients has progressively moved from broad-acting cytotoxic drugs to targeted therapies against specific proteins or molecular markers.

I will present two examples of the financial impact of newer cancer therapies. Prior to 2014, most previously healthy patients diagnosed with chronic lymphocytic leukemia (CLL) were treated with a three-drug combination for six months, with a cost range of $60,000 to $100,000. In 2014, ibrutinib and idelalisib were approved by the Federal Drug Administration for primary and recurrent CLL. Both drugs were recommended for primary therapy and recurrent disease until disease progression or significant toxicities develop. Both drugs are priced at about $130,000 per year. On average those costs would apply annually over the four to five years of extended survival.

Last month, I met with a patient and her husband to discuss maintenance therapy following her second course of chemotherapy for recurrent ovarian cancer. A new class of drug called poly-ADP ribose polymerase (PARP) inhibitors has been approved for this indication. One of the drugs we discussed was priced at $13,740 per month and could bring an additional five to 11 months of life. The manufacturer and her insurance company agreed to cover $11,000 per month, leaving her with $2,740 a month as a co-payment. According to the National Cancer Institute website, cancer patients and survivors report higher out-of-pocket medical expenses (greater than 20 percent of annual income) than individuals without cancer.

That brings us to the discussion of toxicity. As I discuss the physical, emotional and financial toxicity to a patient and her family, a new dynamic has developed. Previously, all the toxicity to be considered was borne by the patient. Now, as we discuss therapy options, the decision to leave one’s family with tens of thousands of dollars in debt adds a new layer of decision-making for the patient and her family. What spouse would deny their partner the possibility of six more months of life? What woman would ask her children or spouse to risk bankruptcy for those six months?

Medical bankruptcy accounts for 67 percent of all U.S. family bankruptcy filings. Patients and families with cancer are 2.7 times more likely to file bankruptcy than families without cancer. The current cost of medical care, specifically cancer-related care, cannot continue this trend without fracturing families and moving financial toxicity ahead of the most feared physical toxicity for cancer patients and their families. We have become victims of our own scientific progress.