Prostate cancer treatment costs are high and increasing. It is estimated that $22.3 billion was spent on prostate cancer in the United States in 2020, an increase from $19.4 billion in 2015.¹ “Financial toxicity” (FT) describes the excess burden caused by unaffordable cancer care, including both mental and emotional stress.² Large out-of-pocket payments can have devastating consequences to patients: high levels of psychological stress, decreased spending on food and other essential goods and services, altered medication use, lower adherence, poor health outcomes, and worse survival.^2-5 Thus, addressing FT in prostate cancer care is paramount for obtaining optimal health outcomes.

Addressing FT can seem daunting. However, even small reductions in out-of-pocket payments can result in better health outcomes.⁶ Awareness, communication, routine screening, and proactive referral to financial counseling are 4 steps that can be taken towards decreasing FT and improving health outcomes.

1. Maintain an appreciation of how treatment recommendations impact direct and indirect out-of-pocket payments.

Prior work demonstrates that clinician awareness of direct and indirect costs and FT results in lower patient out-of-pocket payments.^7,8 Direct costs are those that are directly attributable to patient care (eg clinic visits, lab tests). Indirect costs are costs that are associated with obtaining cancer care, but not directly part of the care itself (eg lost time from work, parking). Appreciating the costs of cancer care include reducing low-value tests or interventions, not duplicating studies that have already been performed, and considering how differing treatment options are associated with variations in both direct and indirect costs.⁹

2. Actively engage patients in communications about the costs of cancer care.

In 2009, the American Society of Clinical Oncology issued a statement encouraging physician-patient cost-of-care discussions as these conversations are critical for high-value cancer care.¹⁰ However, cost communication is rare in clinical oncology.¹¹ Potential barriers for cost-of-care discussions include significant time constraints, concerns about providing or receiving lower-quality treatment, inexperience, and inadequate training in cost communication.¹² Absence of price transparency data and an inability to obtain patient-specific out-of-pocket payment information further contribute to poor cost communication.¹³ However, patients desire cost communication and these conversations can result in cost reductions and lower FT.⁷ It is therefore critical to embark upon and normalize these financial discussions.

Clinicians should treat cost as a side effect of treatment and cost discussions should be incorporated into patient-clinician joint decision making. Clinicians and clinic staff members should receive education on how to conduct cost conversations.¹⁴ Even if patient-specific costs are unknown, potential direct and indirect costs of treatment can be discussed (eg visit frequency, required followup imaging, and labs for each treatment option). In fact, many current cost conversations do not entail direct out-of-pocket payment estimates, but rather emphasize insurance, job responsibilities, and duties that may or may not be able to be performed during cancer treatment.^15,16 These cost discussions allow patients to better understand the nonclinical aspects of cancer care, resulting in an improved patient experience.¹⁷

3. Routinely screen for the risk of development and degree of financial toxicity.

Just as with treatment side effects, patients have varying degrees of risk for developing FT.¹⁸ The level of toxicity can change as treatment progresses, so it should be reassessed regularly. Risk factors for FT include socio-demographic factors (ie younger age, lower income, female gender, and race/ethnicity), health care access (ie, health insurance status and type, change in employment), and clinical characteristics (ie advanced cancers, treatment with chemotherapy and/or radiation, and multiple co-morbidities).¹⁹ Ideally, financial screening would be standardized, incorporate patient-reported outcome measures, and be included in measures of cancer care quality.^8,20 Until that time, however, a variety of methods are currently used to measure FT, with varying degrees of accuracy.^16,21–23 In addition, screening questions, such as “Do you feel financially stressed because of your health care needs?” and “Are you worried about how your health care bills will be paid?” or other simple questions that can assess for concerns related to the costs of cancer care can be asked by a clinician or other clinic staff member.¹⁴ Screening for FT should be included on intake forms, and staff ought to be trained to investigate financial concerns. When inquiring about FT, it is important to emphasize that these questions are routine and asked of all patients.¹⁴ If a patient screens positive for FT, a management plan needs to be available and executed.

4. Proactively refer to financial counseling.

Financial navigation can decrease patient out-of-pocket payments, lower patient anxiety and depression, and reduce financial losses to health care practices.^16,24–26 Services provided during financial navigation are wide-ranging and may include financial education and assistance, referrals to resources, payment estimation, and health insurance improvement.¹⁶ Depending upon the organization, financial counseling can be performed by trained financial counselors, social workers, nurse navigators, or other clinical staff.⁸ The entire clinical team should support the efforts for maximal effectiveness.¹⁶ If no financial navigation programs are available at a clinical practice, then clinicians should refer to outside organizations, such as those recommended by the National Cancer Institute, that can assist with support services.²⁷

In conclusion, many patients with prostate cancer experience FT, which leads to poor health outcomes. Addressing FT can be daunting. However, even small steps can lead to reductions in FT, smaller out-of-pocket payments, and lower stress and anxiety. Awareness, communication, routine screening, and proactive referral to financial counseling are critical steps for reducing FT for patients with prostate cancer.

This work was supported in part by the 2021 Urology Care Foundation (UCF) Research Scholar Award Program, the Society of Urologic Oncology (SUO), and the National Cancer Institute of the National Institutes of Health (NIH) (1-K08CA267062-01A1). The content is solely the responsibility of the author and does not necessarily represent the official views of the UCF, SUO, and/or NIH.