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Financial Hardship in Cancer Care-The Need to Define and Intervene on Actionable Metrics.

Financial hardship associated with cancer care in the US is complex in its definition and quantification and is even more complex in its mitigation. Elements of financial hardship include (1) material consequences of treatment, such as out-of-pocket expenses, debt, and decreased income; (2) psychological distress because of costs; and (3) deleterious coping mechanisms, such as delaying or skipping medications or care. Despite evolving definitions and imperfect measurement tools, we know that financial hardship from cancer treatment is a common adverse event for patients; the prevalence of financial hardship varies across sociodemographic groups, but adverse implications can be seen in at least half of patients.1 Financial burdens associated with cancer are associated with increased financial strain,2 decreased willingness to pay for care,3 and increased mortality.4 We have a growing understanding of populations who are most at risk for financial hardship: those who are underinsured or uninsured; those who are minoritized and/or made vulnerable by structural racism, geographic barriers to care, language differences, ageism, sexism, undocumented immigration status, and health literacy, among other means; and those who lack financial reserves. We ought to be beyond simply describing the problem; future research can and must be geared toward designing and testing interventions. In the survey study by Khera et al5 involving more than 400 patients with cancer, the prevalence of financial hardship was high (48%-68%). Increased health insurance literacy was associated with lower risk of financial hardship. When adjusted for both health insurance literacy and financial literacy, however, the association did not hold. Khera et al5 interpreted these findings as suggesting that improving both health insurance literacy and financial literacy may mitigate the downstream consequences of financial hardship, such as poor treatment adherence and decreased emotional well-being. Given the multifactorial nature of financial hardship, the development of objective and validated measures to describe, quantify, and qualify financial hardship continues to be challenging. It is critical to ask and define what financial toxicity, financial hardship, and financial distress (which are interlinked but not identical concepts) truly mean for patients. The current health insurance structure in the US relies on the patient responsibly asking, essentially begging, the difficult question of what is an acceptable level of financial sacrifice for cancer care. Khera et al5 used the COST–FACIT (Comprehensive Score for Financial Toxicity–Functional Assessment of Chronic Illness Therapy), a validated survey of subjective financial concerns associated with quality-of-life decreases. There is no established cutoff for financial toxicity screening with the COST–FACIT score; for example, Khera et al5 used a median score, whereas other studies have used 20 or 26 (out of 44) points as the positive screen for financial toxicity. Newer studies are exploring more objective measures, such as credit record–based financial events (eg, delinquent mortgage payments, foreclosures, and thirdparty collections)2 and changes in credit score. Quality-of-life questionnaires, such as the EORTC QLQ-C30 (European Organisation for Research and Treatment of Cancer Core Quality of Life Questionnaire), have also included items that attempt to measure financial hardship; some studies have used question 28 as a single-item measure of financial hardship.6 Similarly, better tools are also needed to measure health insurance literacy and financial literacy. Khera et al5 used the validated 21-item Health Insurance Literacy Measure and 5 questions from the National Financial Capability + Related article