3 oncologists discuss how they approach the question of cost

Three oncologists share how they talk to their patients about the cost of cancer care, which can often be prohibitive.

Editor's note: Responses have been edited for clarity and length and are presented alphabetically.

Question: What is your advice for having conversations with cancer patients about the cost of care? How do you approach these often difficult conversations?

Mark A. Lewis, MD, medical oncologist and director of gastrointestinal oncology at Intermountain Healthcare in Salt Lake City

Financial toxicity is increasingly recognized as an adverse effect of cancer care, as measurable and potentially damaging as some physical toxicities from chemotherapy. Before pursuing any given therapy, I run the cost through a financial authorization specialist and generate estimates for the patients. Although some chemotherapies are available in oral form, typically, their IV equivalents are more readily covered by insurance under infusional benefits, and that can affect the composition of the regimen.

Derek Raghavan, MD, PhD, president of the Levine Cancer Institute in Charlotte, N.C.

It is increasingly important to be transparent with patients about the costs of care and their component of those costs. With dramatically increased prices of the newer pharmaceutical agents, a copay of 10 percent can be $100,000 or more. Patients need to know what they are getting in return for these high costs and also whether reasonable alternatives are available.

When I approach these conversations, I introduce the topic of 'cost' and the concept of 'fiscal toxicity' as part of the decision process about choices of treatment. A patient needs to have the right information — if the patient is about to sacrifice a college education for their child or are considering mortgaging the house, he or she should know whether this will lead to cure or palliation and whether survival is likely to be short or long-term, and also what other options are available and their relative costs. This was not discussed in the past by many physicians, but that was an error of judgment.

Dale Shepard, MD, PhD, medical oncologists at the Cleveland Clinic

The financial impact of cancer care can be significant, and we need to consider all the patients' possible concerns. The cost of the treatment, appointments and tests are the aspects of care most often considered, but we also need to consider the effect of the disease or treatment on the patient's ability to work and the possible impact on their family. Most patients will have questions about cost of care, and this should be addressed as early in the process as possible. One should answer questions to the best of their ability with referral to the proper resource, including financial counselors, social workers or specialty pharmacy.

Discussing cost is important. Patients may be aware that a treatment may cost several thousand dollars a month based on the cost of the drug. It is crucial that patients don't decide to not pursue treatment for that reason alone. Insurance or patient assistance programs may reduce their financial responsibility. Much like the need for patients to understand the likely benefits, adverse effects and treatment schedule for a therapy, it is important any financial concerns they may have are addressed as well.

I let the patients know that the cost of care is an important part of their overall cancer treatment journey. These only seem like difficult conversations if there are barriers to the discussion or a lack of resources to guide the patients (and us). Some of the considerations related to cost of care may be associated with whether a therapy is an infusion, which is covered by medical insurance, or a pill, which is covered by prescription drug coverage. It's important that patients are aware of any alternatives if the cost of an initially discussed treatment option is a concern for them.

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