Joanna Fawzy Doran

The National Cancer Institute (NCI) awarded administrative supplements to 11 NCI-designated cancer centers to build capacity for financial navigation services and collect preliminary data to implement and evaluate financial navigation programs. Preliminary findings from the projects were shared during a virtual conference in October 2022. This paper reflects major themes from the conference, the now completed projects, and findings from scientific literature to propose a set of recommendations for addressing financial hardship as part of cancer care delivery. Recommendations include the following principles. Healthcare systems should implement financial hardship screening using validated, culturally appropriate tools, considering patient literacy and language needs. Screening programs should be universal with assessments repeated over time. Financial navigation services should be available to help patients manage direct and indirect costs of care, access financial assistance and navigate employment-related challenges. Financial navigators should receive specialized training to build their knowledge of healthcare billing, insurance, financial assistance, and patient advocacy while also preparing them to support patients and leverage local and regional resources. A multidisciplinary care team approach should be applied to developing and implementing financial hardship screening and navigation services. Finally, health systems should harmonize information technology and workflows across departments involved in screening and financial navigation service delivery and automate screening, referral, and care team notification processes. Future research should address outstanding knowledge gaps, including the optimal interval for screening, how to identify patient needs early to mitigate downstream financial hardship, and the ideal components and timing of financial navigation for different settings and populations.

Few evidence-based trainings exist on how to equip healthcare providers, particularly nurses, with the skills to engage in cost of care conversations with patients/caregivers to mitigate the impact of cancer-related financial toxicity. This study evaluated a pilot training developed in collaboration with Triage Cancer® to prepare oncology nurses to identify and assist patients/caregivers facing financial and/or legal barriers to care. Ten pediatric oncology nurses completed the training and pre/post-surveys on behaviors related to financial and legal need screening, frequency and comfort level of answering questions, knowledge, and behavior changes, along with training evaluation questions. At baseline, six nurses reported never screening for financial needs and nine for legal needs. Following the training, seven nurses stated they were likely to screen for financial/legal needs. At six months post-training, nurses had referred 85 patients/caregivers to financial/legal navigation services. Comfort levels in answering financial/legal questions increased by 6.5 points and knowledge scores increased by 1.7 points post-training. Most nurses recommended this training to other healthcare providers who work with patients with cancer and their caregivers. This study highlights the importance of providing oncology nurses with resources to engage in cost of care conversations and oncology financial legal navigation programs to mitigate the impact of cancer-related financial toxicity.

Adverse financial burden and its effect on patients resulting from the costs associated with cancer care, both direct and indirect, is known as financial toxicity. This review explores the interplay between financial toxicity and key social and legal needs in cancer care. Drawing from the WHO's framework and the ASCO's policy statement on social determinants of health, we propose a conceptual model that discusses five key needs—housing insecurity, food insecurity, transportation and access barriers, employment disruptions, and psychosocial needs—which interact with, and are affected by financial toxicity, and adversely influence patients' well-being and adherence to treatment. We review literature addressing the scope of each of these key needs, their effect on patients with cancer, and how each increases the overall burden of cancer treatment. There is an emphasis on both the patient and the caregiver as one unit navigating through cancer treatment together. The aim is to guide interventions at the patient-provider, institutional, and policy levels that alleviate financial toxicity and improve overall care delivery for patients and caregivers by addressing underappreciated social and legal needs.

This study describes the conception, development, and growth of the Triage Cancer Conference hosted by Triage Cancer, a national nonprofit organization providing free legal and financial education to the cancer community. We conducted a retrospective analysis of post-conference participant surveys. Descriptive statistics were calculated for participant demographics, and acceptability, feasibility, and appropriateness were evaluated. From 2016–2021, 1239 participants attended the conference and completed post-conference surveys. Participants included social workers (33%), nurses (30%), and cancer patients/survivors (21%), with representation from over 48 states. Among those who reported race, 16% were Black, and 7% were Hispanic. For acceptability, more than 90% of participants felt that the conference content, instructors, and format were suitable and useful. For feasibility, more than 90% of participants felt that the material was useful, with 93–96% reporting that they were likely to share the information and 98% reporting that they would attend another triage cancer event. Appropriateness was also high, with >80–90% reporting that the sessions met the pre-defined objectives. Triage Cancer fills an important gap in mitigating financial toxicity, and formal evaluation of these programs allows us to build evidence of the role and impact of these existing resources. Future research should focus on adding validated patient-reported outcomes, longer-term follow-up, and ensuring inclusion and evaluation of outcome metrics among vulnerable populations.