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With Colorectal Cancer Treatment, Physical Toxicity Is Not the Only Concern.

One of us recently treated a patient (let’s call him Carl) with localized rectal cancer who was started on standard, neoadjuvant chemoradiation with capecitabine. He did very well with treatment in terms of his degree of physical toxicity, completing the treatment without any adverse effects at all. Unfortunately, after completion of this course of therapy, Carl’s cancer was found to have progressed. We discussed this finding with him and started describing options for combination firstline therapy, including capecitabine, oxaliplatin, and bevacizumab. In the midst of that discussion, Carl shook his head and said, “Doc, I don’t think I can take that regimen.” Carl stated he was not concerned about the physical toxicity of the treatment; rather, he was concerned about the financial toxicity. Despite having insurance, he revealed he had to pay fully out of pocket for the capecitabine because he did not have any prescription drug coverage. As a result, he had amassed thousands of dollars in medical debt over the course of a few weeks. Because he assumed he had no other option, Carl had never revealed his financial toxicity to his healthcare team, and, more importantly, we had not inquired about his ability to afford his care. Yet, he is not alone in experiencing this degree of treatment-related financial burden. Financial toxicity is increasingly recognized as a key determinant of quality of cancer care. Studies suggest that 42% of patients experience a catastrophic, subjective, financial burden as a result of their cancer diagnosis. In this issue of Diseases of the Colon & Rectum, Sharp et al add to this literature by highlighting the financial impact specifically related to colorectal cancer treatment and by evaluating both the subjective (financial strain) and objective (financial stress) impact of economic burden on cancer in association with health-related quality of life (HRQoL). Sharp et al showed that, among colorectal cancer survivors, 41% reported cancer-related financial stress, 39% reported financial strain, and 32% reported both stress and strain. These findings highlight how both tangible and intangible financial concerns play a significant role in our patients’ lives. Other studies have highlighted the objective (financial stress) or subjective (financial strain), although most have not examined both; this study highlights how both are important to consider. For instance, patients with cancer are 2.7 times more likely to declare personal bankruptcy (an example of financial stress) in Washington state than those without cancer. In addition, those patients with cancer who declared personal bankruptcy were at significantly higher risk of mortality compared with those who did not declare bankruptcy. In addition, in a crosssectional study, financial distress (example of financial strain) was more severe than physical stress, social stress, family stress, and emotional distress. Understanding the financial impact of cancer treatment is of utmost importance, because both financial strain and financial stress could harm outcomes in colorectal cancer survivors. Sharp et al show that the OR of reporting low HRQoL was significantly higher in patients who reported cancer-related financial stress and financial strain and who experienced both, suggesting that quality of life can be impacted by both of these factors. This is not the first study to examine outcomes in relation to cost of care for colorectal cancer survivors. For example, Shankaran et al found that, among patients diagnosed with stage III colon cancer, 38% reported treatment-related financial hardship. Veenstra et al found that ≈40% of patients with colorectal cancer receiving adjuvant therapy had to use their savings to make ends meet. One important limitation to the study, however, is difficulty in generalizability. Per the article, the healthcare system of Ireland is notable in that it includes both a complex public and private healthcare system. Interestingly, neither public or private insurance covers prescription medications. Instead, individuals electively join the Drug Payment Scheme with a ceiling of €120 per month for prescription drugs and certain aids. Thus, these results may be difficult to generalize in that prescription medications can be a significant burden of cost in other countries. In addition, although the authors point out that the With Colorectal Cancer Treatment, Physical Toxicity Is Not the Only Concern