“Financial toxicity” affects poorer cancer patients in Australia

A recent report demonstrates that the great advances in modern cancer treatment are not equally affordable for all those who need them. Social inequality exacerbates the situation facing poorer cancer sufferers, curtailing their access to the treatment and drugs they must have to survive.

A paper released by the Cancer Council of Australia on February 3, Australians living with and beyond Cancer in 2040, shows that a greater proportion of cancer survivors in 2040 will be from those of a high socio-economic position (20 percent more than people of low socio-economic position).

This is most probably due to wealthier people having greater access to treatment, and benefitting from earlier detection, better prognosis or being diagnosed with cancers with better survival rates. Other factors are also involved, relating to the life pressures on working class people. That is, poorer prospects of survival from cancer can be directly related to socio-economic disadvantage.

Cancer Council CEO Professor Sanchia Aranda told the World Socialist Web Site: “The Australian Institute for Health and Welfare produces national data on cancer incidence and mortality. This shows that the age standardised mortality rate for the poorest quintile of Socio Economic Status (SES) is 30 percent higher than for the highest quintile.

“This equates to about 28,000 deaths in five years that would not occur if everyone had cancer outcomes as good as the highest SES quintile.”

Aranda said many factors contribute to this difference, and the Cancer Council commissioned work from the team at QIMR Berghofer Medical Research Institute to assess the outcomes further. She said the known factors included higher smoking rates in lower SES groups, contributing to poorer lung cancer outcomes, as well as lower participation in national screening programs and less access to general practitioner (GP) doctors by people with lower SES.

“We would hypothesise that people who are poor may also be less able to take time off work for tests, and this may contribute to later diagnosis. This will potentially be compounded by lower health literacy, and residence in areas with lower GP density. It will also be likely that people of lower SES are subject to delays in diagnosis, when they cannot bypass the public system by getting a diagnosis from a private specialist.

“There may also be issues of foregoing parts of treatment, e.g., follow up radiotherapy after surgery, because of the financial burden of out of pocket costs and things like ability to take time off work.”

Despite supposedly providing affordable and equal access to medical care, the Australian public health system, Medicare, imposes considerable “out of pocket” costs. Together with employment difficulties, these can have such an adverse effect on cancer patients that they suffer what has been termed “financial toxicity,” that is, financial distress or hardship experienced as a result of cancer treatment.

Aranda added: “We have very poor understanding of the true impact of financial toxicity on treatment choices. We know from our survey work with nurse coordinators and oncology social workers that treatment costs are part of patient concerns about treatment decisions.”

A QIMR Berghofer Medical Research Institute study published in 2017 outlined that “financial problems after cancer diagnosis are a major contributor to poorer quality of life, treatment non-adherence and delayed medical care.” (Cancer Forum 2016, “Financial Toxicity—what it is and how to measure it,” Louisa Gordon, et al.)

The authors found few Australian studies examining the economic burden on patients with cancer. One 2014 study observed changes in employment of 239 colorectal cancer patients and compared findings with a non-cancer control group in middle-aged working adults. The findings showed 27 percent had not returned to work 12 months after their diagnosis, compared with 8 percent leaving work in the matched general population group.

In another study, men recently diagnosed with prostate cancer (within 16 months of the survey), reported spending a median $8,000 for their cancer treatment, while 75 percent spent up to $17,000. Twenty percent found the cost of treating their prostate cancer caused them “a great deal” of distress.

The study authors said financial toxicity has two key contributors—high medical payments and reduced income while being treated or recovering from cancer. They said: “Healthcare professionals should understand that poorer health outcomes in their patients may arise, not only from the cancer, but also from the financial fallout from the cancer.” They concluded: “It can have a very negative impact on quality of life and cause distress.”

Another Cancer Forum study, “Unemployment after cancer—a hidden driver of financial toxicity,” (Bogdam Koczwara Flinders Medical Centre, Flinders Centre for Innovation in Cancer, South Australia) found that: “Loss of work after cancer disproportionally impacts on those already more vulnerable, such as low income employees and the very young, with impact persisting for some for many years.”

One Australian study of 255 oncology outpatients in two hospitals—metropolitan and rural—found that the financial impact of unemployment seemed to be the major driver of financial toxicity. Of these patients, 67 percent reported a change of employment, the most common being reduced hours, retirement or resignation/unemployment and 63 percent reported reduced household income.

A Breast Cancer Network of Australia study, “The financial impact of breast cancer,” surveyed 2,000 women about their out of pocket costs for the first five years after breast cancer diagnosis. It found that these costs were around $3,600 for a woman without private health insurance and around $7,000 for a woman with private health insurance. In other words, taking out increasingly expensive private insurance is no protection against medical costs.

While 12 percent of women reported no out of pocket costs, 25 percent reported costs of more than $17,000, and 25 percent of those with private health insurance reported costs of more than $21,000.

Further, the study noted that the necessity to take time off work could lead to further financial cost, especially for women who are part of the 38 percent of the Australian workforce who have no paid sick leave entitlements. The survey found that the total number of household hours worked dropped by 50 percent in the first year after a breast cancer diagnosis. In the second year, the number of hours worked remained 13 percent lower than before the breast cancer diagnosis.

The study noted: “Some women find that paying for cancer treatment and its associated costs pushes them to the brink.”

A diagnosis of cancer should not be a sentence of financial disaster. High quality, free public treatment and state of the art medication should be made available to all, on the basis of need, not private profit. This means a struggle against entrenched corporate interests for the basic social right to healthcare.

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