Many Doctors Silent on Cost of Cancer Care
WEDNESDAY, June 21, 2017 -- Cancer doctors are often mute when a patient asks about the cost of treatment, a new study shows.
Yet, such questions are critically important. Cancer patients are three times more likely to declare bankruptcy than people with other chronic ailments, and tight finances often lead patients to skip doses of medicine or drop out of treatment altogether, said lead researcher Dr. Rahma Warsame.
Of more than 500 recorded conversations between oncologists and their patients, just 28 percent contained any talk of treatment cost or finances, said Warsame, an assistant professor with the Mayo Clinic in Rochester, Minn.
In seven out of 10 cases, patients or caregivers raised the subject -- but the doctors didn't necessarily respond.
"Forty percent of the time there was silence," with the doctor not acknowledging patients' financial concerns, Warsame said.
Doctors' reluctance to talk about prices comes as the United States faces rising costs of cancer care. The nation spent $124 billion on direct cancer costs in 2010, and even in a best-case scenario costs are expected to rise to $157 billion by 2020, Warsame said.
"This is causing distress to our patients, so much so that a term has been coined -- 'financial toxicity,' " Warsame said. It's defined as the economic burden patients face after a cancer diagnosis.
To see how often doctors and patients discuss the costs of cancer care, Warsame and her colleagues reviewed 529 audio recordings of doctor-patient conversations at three sites in California and Minnesota. The conversations occurred between May 2012 and September 2014.
Fewer than one-third of the recordings contained any mention of cost or finances, the researchers found. When that occurred, patients brought up the topic 70 percent of the time.
Financial conversations lasted less than two minutes, on average, before talk turned to other topics, the researchers found.
People were more likely to bring up cost if they had publicly funded Medicaid insurance or no insurance, and less likely if they had private insurance, Warsame said.
The financial conversations largely revolved around four themes -- insurance coverage, drug costs, medical bills and lost income due to disability, researchers found.
Doctors acknowledged their patients' concerns 60 percent of the time. In those instances they took some action to help the patient only one-quarter of the time. The action could include a letter written to an insurance company or a change to a less expensive medication, Warsame said.
One discussion of medical bills went like this:
Doctor: "Your insurance did not cover anything?"
Patient: "I have never had insurance and I have to deal with that other hospital and I do not know what to do."
Doctor: "Oh gosh!"
Patient: "The surgeon really hurt my morale. He said I should go to another hospital. He wanted to throw me out of here. He said do you know how much are these rooms here? Like $2,500 per night. And I was like, 'I am here because of an emergency.' "
These results show a need to teach doctors how to talk money matters with patients, Warsame said.
"You don't go to medical school to understand the costs of care and how that impacts your patient, but it is becoming clearly important to learn," she said.
Doctors also could help patients by placing financial navigators or patient advocates in their clinics to help address cost issues, Warsame said.
Because the study relied on audio recordings, doctors may have come off as more heartless than they actually were, Warsame noted.
"There is so much that we say that's not verbal," she said. "There's no way to know that those silences weren't appropriate or kind."
Also, it's not known if financial considerations came up in any doctor appointments before or after these recorded visits, she said.
Nevertheless, the findings troubled Dr. Erin Aakhus, a cancer specialist with the University of Pennsylvania School of Medicine.
"What concerned me the most was that in response to patient concerns about cost, action was not routinely taken," Aakhus said.
"Talk is not enough," Aakhus said. "We have learned that the initiation of a cost discussion, while a very much desired outcome, may not lead to any action that benefits the patient.
She said oncologists and their practices may need "to boost resources and support to facilitate action in response to recognized financial toxicity."
The findings were presented recently at the American Society of Clinical Oncology annual meeting in Chicago. The results should be considered preliminary until published in a peer-reviewed medical journal.
For more about costs of cancer care, visit the U.S. National Cancer Institute.
Posted: June 2017