ASCO CEO Discusses New Studies on Patient Financial Toxicity and Opioid Use Risks

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Welcome to this ASCO In Action podcast. This is ASCO's podcast series where we explore policy and practice issues that may impact oncologists, the entire cancer care delivery team, and the quality of care they provide. But most importantly, of course, the patients we care for. My name is Clifford Hudis. And I'm the CEO of ASCO and the host of this ASCO In Action podcast series. For today's podcast, I'm going to share with you some highlights from the research that was featured at this year's recent Quality Care Symposium.

So ASCO is the host and sponsor of the Quality Care Symposium, an annual meeting that brings together oncology leaders, and all of the members of the cancer care team, to share strategies and methods for improving the measurement and the implementation of quality and safety activities in oncology. The recently held 2018 symposium presented a wide range of scientific abstracts, focused on initiatives that aim to improve the quality of care for patients with cancer, and, also, new research in this field.

Today, I want to highlight five of these abstracts from the Quality Care Symposium. These are abstracts that deal with issues I know are of particular concern to ASCO members, financial toxicity for the one and opioid use for the other.

Now, turning first to financial toxicity. As everybody knows, oncologists see the impact of high treatment costs on our patients, many of whom are not taking all of their prescribed medication because of cost. They are drawing down their savings, when they have savings. And they're often not paying their other household bills or taking other drastic measures because the cancer treatment that they have to receive has become so expensive. This distress is now broadly defined as financial toxicity.

Three different studies were presented at the Quality Care Symposium that put a spotlight on this issue. In the first study, by Wheeler, et al, we saw results of a national survey of more than 1,000 patients with metastatic breast cancer drawn from 41 states. What we saw here, was that in these individuals, especially those who are uninsured, there really was significant financial distress. A full third of these patients were uninsured and more often they reported refusing or delaying treatment because of the cost of care. They also reported that they were contacted by collection agencies because of unpaid bills, again, for their cancer care.

The study also found that insured respondents were not immune to financial toxicity. Those with health insurance reported having higher cost-related emotional distress, being stressed, themselves, because they weren't sure about the cost of their treatment, as well as spending a lot of time-- as well as having, I'm sorry, a lot of financial stress placed on their families because of cancer.

The second research study by Arastu, et al, related to the cost of care. And this showed that nearly one in five older patients-- and these patients were defined as age 70 and above-- who had advanced cancer, were experiencing financial difficulties, again, due to the costs of their treatment. They noted that these difficulties negatively affected their care, their quality of life, and mental health. In this study, patients experiencing financial toxicity had a prior higher

prevalence of severe anxiety and depression, poor measured quality of life, than patients who did not report financial hardship.

And finally, there was a third study by Greenup, et al, in which 600 women with a history of breast cancer were surveyed. The majority of them said that they would prefer to discuss the cost of care before beginning treatment, but few of them recalled having such conversations about treatment costs with their cancer care teams. In this survey, fully 79% of these women said that they preferred to have a full understanding of the costs of care prior to starting, but 78% of them said they never actually discussed costs with their cancer care team.

The findings of these three studies, I think, are important. They're a reminder that financial toxicity is real, that it represents a particularly harsh reality for many of our patients, and that we, as oncologists, are expected to initiate and guide conversations about the cost of care with our patients, although it doesn't happen very much yet.

A very good starting point for this seems to be to direct our patients to resources and help our patients prepare for these discussions. So ASCO offers an array of these materials on its patient information website. You can look that up at cancer.net.

Now, the other big area of focus, and, again, one that's been covered in the late news extensively in the last years, is, of course, the opioid crisis. At the Quality Care Symposium there were several aspects of the opioid issue that were addressed. I'll point out in background that although there's evidence clearly available that shows that patients with cancer may be at lower risk for abusing opioids than the general population, we also are aware of the fact that opioids are a controlled substance and they can be addictive. And patients with cancer are not immune to addiction either.

So understanding the size of the problem within the arena of cancer care, and then learning what the best practices are to help control the use of opioids to the most appropriate usages, especially after surgery, are very important matters for us. There were two studies presented during the symposium that provide some important insights on both of these matters.

The first by Chino, et al, was a retrospective study conducted over a 10-year period that comprehensively explored the risks associated with opioid use among cancer patients and compared that to the general population. They analyzed death certificates. And they found that deaths attributed to opioids, in cancer patients, were about 10 times less than in the general population. Although the incidence of opioid deaths had increased significantly in the general population, that increase, again, attributed to the opioids among patients with cancer was much, much smaller. Deaths from opioid use were highest in patients with lung, GI, head and neck, hematologic and GU cancers.

The second study by Stevenson, et al, looked at how oncology care team members could use a two-prong approach to achieve a reduction in opioid use-- in this case, it was 46%-- among cancer patients who underwent a variety of urologic surgical procedures. And they accomplished this without increasing pain or anxiety.

The first part of their strategy involved developing new processes for post-operative pain control that focused on non-opioid medications and therapies. These were interventions provided first line as pain management. Patients could still be prescribed opioids, but when they got these prescriptions, they were at lower doses and dose escalation was only performed if necessary.

The second prong of their two-pronged attack involved post-operative conversations with patients. Talking to them. Rather than having nurses routinely ask patients whether they wanted any pain medication or not-- and this was often a direct reference to opioid medications, specifically-- the nurses, instead, discussed current non-opioid medications that the patients were receiving for pain, along with their frequency and dosage, asked whether these medications were sufficient and discussed their potential side effects, along with the side effects of opioids. The opioids were never withheld, but they were no longer the reflexive standard, thanks in part to this two-pronged approach.

Now, from an ASCO point of view, we are really supportive of efforts to address opioid misuse and abuse. And we counsel our members to discuss the benefits and the risks of opioids with their patients. And then, of course, to prescribe pain treatment for patients responsibly and especially paying attention to those patients who have risk of addiction. At the same time, we keep our primary concern on adequate pain control for cancer patients. This has been a long-term issue for us. And it's an important one. So taking all this into account, we are working continuously with policymakers to ensure that both federal and state initiatives that are implemented do not impede cancer patients access to essential pain medication.

Now in closing, I want to say, again, thanks to all of you for spending some time with me today to learn about ASCO's Quality Care Symposium. The meeting provides a great forum for the entire cancer care delivery team to learn about evidence-based strategies and methods for evaluating and reporting on patient outcomes, provider efficiency, and quality and safety in cancer care. And the abstracts that we've highlighted today point that out nicely, I think.

In the end, all of this is about evaluating which approaches work best and how to continuously improve them so that we can do our best to ensure that every individual patient with cancer continues to receive the highest quality care that's possible. If you would like more information on the research that was presented at this year's Quality Care Symposium, please come to our website, abstracts.asco.org. And until next time, thanks again for listening to this ASCO In Action podcast.