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Janet is a 67-year-old woman with metastatic breast cancer. Despite having insurance, Janet has been saddled with lifealtering out-of-pocket expenses from her cancer treatment. In Part I of this two-part series, we described how Janets struggle with out-of-pocket expenses was not unique; a growing body of evidence has detailed the negative impact of costs on insured patients receiving cancer treatment.[l] The cost of cancer care, overall, is increasing. Innovations in therapy are more expensive now than ever before. [2] These innovations are less toxic than older drugs, so the elderly and frailer patients are more likely to get treated. And our population is aging- thus, more patients are being treated with more expensive drugs for longer periods. Due to the exorbitant price tag on cancer treatment, thirdparty payers have shifted a portion of costs to patients in the form of rising premiums, coinsurance, higher prescription drug copayments, and tiered drug formularies.
Don't get us wrong; we, too, celebrate the innovations that have made cancer treatments more effective, less toxic, and less physically burdensome. But now a new burden from these treatments is emerging- personal and societal "financial toxicity."
The manifestations of cost sharing for cancer treatments are not intangible expenses borne by society. Rather, the story of the palpable impact of cost sharing in cancer is voiced through patients like Janet. In order to defray cancer-related out-of-pocket costs, patients are altering their lives and their care: they are nonadherent with their medications; they are opting out of expensive treatment; they are spending less on basics like food; and they are spending down their retirement savings. [3] Patients are experiencing "financial toxicity" as a direct result of their cancer treatment. As Janet explained, she felt "caught between a rock and a hard spot" when it came to paying for cancer care. Mounting evidence has described the negative implications of cost sharing from the patients perspective; we know that many patients receiving cancer treatment experience both an objective financial burden and subjective financial distress. However, little is known about whether or how patients want costs included in treatment-related decision making. For instance, do patients want to talk about costs with their doctors? Can we identify patients at greatest risk for experiencing financial toxicity? If we can...