As health care costs in the United States continue to rise, financial responsibility is increasingly being shifted to patients and their families in the form of high deductible insurance plans, higher copays and premiums, secondary insurance, and uncovered medications, devices and services. In addition to burdensome out-of-pocket costs, patients often face indirect costs of medical care such as time off from work, physical limitations, early retirement and the need for informal caregivers to make financial sacrifices during recovery. Financial toxicity is a term that encompasses the harm associated with these direct and indirect costs and is gaining increasing interest as a patient-centered outcome.

The majority of research exploring financial toxicity has centered on cancer care, which represents one of the most expensive medical conditions in the United States. The development of novel systemic agents, increased use of multiple treatment modalities and gains in overall survival have all contributed to the rise in cancer treatment costs in a patient's lifetime. Launch prices of new cancer drugs increase over 10% annually and continue to rise after release into the market. The impact of these rising costs is reflected in a recent study that found 42.4% of newly diagnosed cancer patients had depleted their entire life's assets within 2 years of diagnosis. ¹

Just as potential toxicities (eg neuropathy, kidney injury and anemia) are considered when prescribing treatments, the American Society of Clinical Oncology now recommends transparent discussion of treatment costs in shared decision-making processes ( www.asco.org/research-guidelines). While generalized data assessing financial toxicity in cancer care are growing, further research is needed to describe the unique facets of this toxicity among different types of cancer. Indeed, very little data exist assessing financial toxicity in urological oncology.

A recent review of financial toxicity in localized prostate cancer from Memorial Sloan Kettering Cancer Center highlights the paucity of data and need for further investigation in this area. The authors propose a framework to assess cancer related economic burden (fig. 1) and provide a thoughtful review of current strategies to evaluate financial toxicity (fig. 2). According to their review it appears patients undergoing radical prostatectomy are at greater risk for financial toxicity early on in the disease course, whereas those undergoing radiation may experience delayed and longer lasting effects. Interestingly, when compared to nonurological malignancies such as colon and breast cancers, localized prostate cancer may carry a lower overall risk of financial toxicity. ² These findings were supported by recently published data from the Comparative Effectiveness Analysis of Surgery and Radiation study where only 15% of patients reported large or very large burden of treatment costs at 6 months. This prevalence declined even further to 3% at 5-year followup. ³

Figure 1. Proposed financial toxicity framework for clinicians to assess patient-level cancer related economic burden. Framework considers 5 domains and can be used in a bottom-up approach by analyzing individual patient-specific drivers or a top-down approach by considering overall patient-reported financial distress. (Reprinted with permission.) ²

Assessments of financial toxicity in other urological malignancies are not as encouraging. In an evaluation of 138 bladder cancer patients at the University of North Carolina financial toxicity was present in 24% of patients. ⁴ Those individuals with nonmuscle invasive disease were more likely to report financial toxicity, which was associated with worse physical and mental health. Soon-to-be published data from a cross-sectional survey of the Bladder Cancer Advocacy Network Patient Survey Network using the validated, 11-item Comprehensive Score for Financial Toxicity (COST) questionnaire, which assesses direct and indirect costs, found a high prevalence of financial toxicity among bladder cancer patients and identified younger age, annual household income of less than $50,000, not retired and nonMedicare or employer-paid insurance as risk factors for greater financial burden. ⁵ The Comparison of Intravesical Therapy and Surgery as Treatment Options for Bladder Cancer (CISTO) trial plans to assess financial toxicity using the COST questionnaire through 2 years after bladder cancer diagnosis and may offer further clarity on the extent and severity of financial toxicity in this population.

Perhaps the most extensive expansions in expensive treatments have occurred in advanced disease settings where multiple systemic agents with similar survival benefits and no clear consensus on which agent should be employed first are often available. A recent assessment of financial toxicity in renal cell carcinoma found significantly lower COST scores (greater financial toxicity) in patients with metastatic disease. Interestingly, patients taking systemic oral agents with the highest copays reported the lowest financial hardship. These seemingly contradictory findings stress the importance of gaining a deeper understanding of the financial implications of each treatment in order to help guide decision-making and provide better value care. Additionally, this study highlighted the potential exacerbation of financial toxicity secondary to the financial pressures created by the COVID-19 pandemic, further stressing the urgency of addressing this issue. ⁶

Figure 2. (Reprinted with permission.) ²

Clearly, efforts to limit financial toxicity in urology lag behind the work being done in nonurological care. However, even among disease states where literature is more robust, large gaps in data exist. For instance, many potential risk factors for financial toxicity such as preexisting debt, comorbidity burden, types of employment and asset levels remain unstudied. While one would expect knowledge of financial toxicity to influence treatment decision-making, this has not been evaluated in the literature to date. Clear expectations of financial toxicity may sway patients to pursue end of life care less aggressively or conversely empower them to access multiple subsequent treatments through use of lower-cost options up front. Finally, evaluations of interventions designed to alleviate financial toxicity are lacking. Reducing financial toxicity may improve quality of life for patients and caregivers, decrease cancer symptoms and treatment side effects, increase treatment adherence, reduce treatment regret and increase overall survival.

As the cost of cancer treatment continues to rise, clinicians have a growing responsibility to understand how the financial implications of management decisions impact patient well-being. Just as functional outcomes are weighed against oncologic benefit in choosing comparable management strategies, financial toxicity and its quality of life implications must be included in shared decision-making processes. In order to effectively achieve this, more work is needed to better describe this patient-centered outcome in urological care. Through these efforts we can strive to achieve the same goal of the expensive treatments we prescribe–to improve our patients' quality and quantity of life.