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One of my primary care patients was diagnosed with cancer six months back. At the time, he was set to receive the best available regimen for his type of cancer. We were excited about the opportunity to help him battle the disease with a sophisticated weapon. However, a few months later on a follow up appointment he said he had stopped taking the medication. Chemotherapy had made him frail, and he was let go from his job as he could no longer stand for hours on end. Though he remained hopeful, his bank account dwindled from the drug payments, and the inability to pay for his daily expenses prompted the decision to stop treatment. Head clutched in his hands; he sat in the clinic overwhelmed.

This is an extremely unfortunate situation, however, in the United States, it is not a novel occurrence. Approximately a third of cancer patients drop out of treatment plans because of costs. Treatment for cancer is expensive, and, despite insurance coverage, deductibles remain high. Many patients are unable to continue working and subsequently also lose their employment-based health insurance. Without a job to pay bills, support a family or save for the future, receiving chemotherapy causes insurmountable emotional and financial distress. Even years after diagnosis, cancer survivors have higher medical costs compared to those who do not carry such a diagnosis. Therefore cancer patients are three times more likely to file for bankruptcy, and by stopping treatment, they risk the worsening of the disease. The term "financial toxicity" has been coined to encompass this dilemma.

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Cost of cancer treatment is comprised of hospital-based care and drug prices. Studies have revealed that Medicare patients who do not have supplemental insurance are at greater risk for financial toxicity. Even with supplemental insurance, fixed co-pay percentages can translate into thousands of dollars in out-of-pocket costs. With ever-increasing overall drug prices, insurance companies are also stretched and eventually may not be willing to cover as much of the cost for patients. So, despite Medicare coverage and the presence of supplemental insurance, bankruptcy is still a possibility. Not all patients are well versed with the inevitability of this toxic reality at the start of treatment.

According to the American Society of Clinical Oncology, patients should be clearly informed of costs and the options based on their finances. But recommendations and reality seem to be vastly different. Not all cancer specialists in clinics and hospitals are aware of the cost of medications they prescribe, nor do they engage in these discussions.

Physicians primarily make choices for each cancer patient based on therapies that are the best at decreasing cancer burden and increasing length and quality of life. They monitor medication side effects and extend emotional support during the ordeal. As all patients deserve nothing but the best; costs are not usually part of these judgments. Providing alternative options for cancer based on finances is less than ideal for physicians, but on the other hand drug prescriptions leading to thousands of dollars in debt is also contrary to our principle of "do not harm."

Therefore, from a provider's perspective, it is of critical importance to help evaluate patients ability to pay prior to starting treatment. This is done through validated screening questionnaires that have been developed to identify patients at risk of financial toxicity. It is also imperative for patients to ask to be educated on the total expected cost and the share that they will bear. This clarification will ensure development of a holistic plan for the entirety of their care and not just on drug doses and side effects.

Learning the nuances of each patient's goals and tying them with their social and financial conditions is the true essence of patient centered healing. Following the legacy of Dr. William Osler, one of the founders of Johns Hopkins Medicine, of knowing the person with the disease rather than the disease associated with a person, will help us curb financial toxicity and improve the lives of many people battling cancer.

Dr. Ali Thaver is an internal medicine resident physician at Johns Hopkins Bayview Medical Center; his email is minhalthaver1@gmail.com.

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