Financial toxicity in patients with leukemia undergoing hematopoietic stem cell transplantation: A systematic review

Although the physical toxicity of many cancer regimens has improved with the use of targeted therapies and advancements in supportive care, the impact of the financial burden arising from this care has increasingly been recognized as a driver of treatment-associated hardship for many cancer patients, especially in the era of greater patient cost sharing and the ongoing development of expensive cancer therapeutics [[1], [2], [3], [4]]. The term financial toxicity (FT) was created to describe the objective financial burden from cancer care including the associated psychological distress and coping behaviors utilized by patients and caregivers [5].

In the most direct and easily understood association, patients’ financial health and well-being are greatly impacted by the direct costs of their cancer treatment. Previous research has found that patients undergoing cancer treatment experience higher rates of personal bankruptcy [6], have a diminished ability to build savings and acquire assets due to financing unexpected medical costs [7], and experience long-term career implications including decreased productivity, unwanted changes in jobs and responsibilities, and a prolonged period of time away from work [8]. These effects culminate in cancer survivors having lower asset ownership, more debt, and lower net worth than the general public, especially among those who are middle-aged [9].

Perhaps more concerning is the impact that these financial concerns have on the delivery of care. Patients who report financial burdens have repeatedly been shown to be more likely to delay or forego all forms of medical care including office visits, prescription drugs and mental health [[10], [11], [12], [13], [14], [15], [16]]. Financial burdens are also being recognized as an important driver of the inequities in clinical trial participation, with younger, poorer, nonwhite patients with private insurance at highest risk of financial burdens and least likely to participate in trials [17,18]. The impact of financial toxicity on overall survival has also been shown, particularly among cancer patients who require bankruptcy protection [19,20].

Although it is easy to assume that financial toxicity is a unique problem in the USA due to the fragmented payer systems and lack of universal health coverage, there is mounting evidence that patients across multiple different health systems across the world are vulnerable to similar financial burdens [[21], [22], [23]]. This is important to keep in mind as the country continues to undergo healthcare reform, because even more progressive healthcare systems will inevitably have patients experiencing financial distress. As a result, even with possible future changes in payer structure, financial toxicity will unfortunately remain a relevant and important topic among cancer patients.

Hematologic malignancies comprise a set of diseases with a particularly devastating effect on patient finances [24,25]. These diseases frequently require high healthcare utilization involving intensive and debilitating inpatient treatments, frequent lengthy office and lab visits, and potentially hematopoietic stem cell transplant (HSCT) [[26], [27], [28], [29]]. This extensive time commitment, the costs of cancer directed and supportive care, and the physical toll of disease have a distinct and deleterious impact on patient and caregivers’ financial circumstances [[30], [31], [32], [33]]. However, the vast majority of research done on the financial toxicity of cancer care has focused on patients with solid tumors. Patients with hematologic malignancies face a different mix of direct and indirect costs related to their disease and treatment, due to the types of medications used, the degree of blood product/transfusion support, and their decreased income from time away from work. Specifically, patients with a diagnosis of acute leukemia undergoing HSCT specifically face an increased cost burden of disease due to the preparation involved, lengthy hospitalizations and high incidence of acute and chronic morbidity associated with such a treatment [34,35]. Thus, this review aims to identify risk factors, effects and outcomes of financial toxicity within the leukemia population who are eligible for or have already undergone hematopoietic stem cell transplant.

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