Though it would seem logical, cancer patients don’t always choose therapies with the best chance for survival – cost and side effects are also major considerations. Little has been known about the extent to which cost and side effects influence a patient’s treatment decision. Now, new findings by Fox Chase Cancer Center researchers reveals that a patient’s socioeconomic status, more than any other characteristic – such as age or disease site – is predictive of whether he or she will favor high efficacy, low cost or low toxicity when choosing a treatment. Yu-Ning Wong, M.D., Fox Chase medical oncologist and lead author on the study, will present her findings at the 2012 American Society of Clinical Oncology Annual Meeting on Tuesday, June 5.
“I’m really interested in how patients make healthcare decisions regarding cost,” says Wong. “We found that patients’ socioeconomic statuses can tell us a lot about what’s important to them when considering treatment options.”
The researchers presented a heterogeneous group of 400 patients with hypothetical scenarios and asked them to choose between two treatments of varying levels of efficacy, toxicity and cost. The scenarios covered both highly effective and moderately effective adjuvant therapies as well as palliative therapies.
In all three of the categories, patients who had an income over $60,000 were more likely to choose the most effective therapy, while those with an income under $60,000 were more likely to choose the most affordable therapy, regardless of whether the alternative treatment offered improved survival or lower toxicity. Conversely, patients with higher income were more likely to choose treatments that offered higher survival even if the alternatives were less expensive or more toxic. Education and employment status also affected treatment choice.
“It is possible that patients of higher socioeconomic status were more likely to have greater resources to focus on survival and tolerate more side effects, such as the ability to miss work. On the other hand patients of lower socioeconomic status are likely much more cost sensitive,” Wong explained.
The study’s findings have concerning implications for disparities in cancer care. Health plans with higher deductibles and co-pays may exacerbate disparities because patients of lower socioeconomic status and those with greater cost concerns may be more likely to avoid costly treatment.
“Policy makers should be aware of patients’ sensitivity to cost as this may influence their decision to proceed with high-value care,” Wong says.
“Clinicians need to become more comfortable with the fact that cost affects patients’ decisions,” Wong adds. “As greater focus is placed on ‘patient-centered’ care and ‘preference-sensitive’ decisions, patient sensitivity to costs should be integrated into decision making.”
Although the study found socioeconomic status to be predictive of patients’ preferences about efficacy, toxicity and cost for both adjuvant and palliative treatments, Wong reinforced that the scenarios were hypothetical However, although these were hypothetical and did not require patients to spend their own money, those who reported cost concerns were less likely to choose the more expensive treatment. This suggests that patients answered these questions consistent with their true preferences.
In addition, preferences may change. “We don’t know if patients’ preferences will change as they go through their disease trajectory,” she says.
The research was supported by the National Cancer Institute grant #K07 CA 136995, an American Recovery and Reinvestment Act supplement, and a 2008 ASCO Career Development Award.
Dr. Wong’s co-authors include Brian Egleston, Kush Sachdeva, Olivia Hamilton, Naa Eghan, Melanie Pirollo, Tammy K Stump, J. Robert Beck, and Neal J. Meropol. Patients were recruited from both Fox Chase Cancer Center and South Jersey Hospital in Vineland, NJ.
Fox Chase Cancer Center