Financial Toxicity Among Patients with Multiple Myeloma Is a Dynamic Process

Background and Purpose: Financial toxicity, the perceived subjective financial distress resulting from objective financial burden, is estimated to occur in one-third to three-fourths of patients during their cancer journey. For patients with multiple myeloma, an incurable hematologic malignancy requiring indefinite, potentially costly treatment, financial toxicity may plausibly accumulate over the disease course. However, data in this area is extremely limited. In the one study reported, a cross-sectional study of 100 patients, there was no clear association between the number of treatment regimens received and financial toxicity. In this study, we longitudinally followed patients to assess how financial toxicity evolves.

Methods: This is a secondary data analysis of NCT03779555 which enrolled patients with multiple myeloma receiving lenalidomide-based therapy at a NCI Comprehensive Cancer Center. Patients completed the COmprehensive Score for financial Toxicity (COST) questionnaire at baseline and 3 months later (de Souza, Yap, Hlubocky, et al., 2014). Briefly, the COST is a measure of financial toxicity that predicts which patients are at risk of poorer outcomes. It is scored on a scale of 0 to 44, with lower scores indicating worse financial toxicity. A score ≤17 has been suggested as a clinical cut-off for financial toxicity.

Results: Ten patients completed the COST measure at both time points and were included in the analysis. The median age at enrollment was 74.5 (range 65-92); 7 of 10 were male. Nine identified as non-Hispanic Caucasian and 1 as African-American or Black. Six were married, 2 widowed, and 2 divorced. Nine were retired and 1 was working full time. Seven had a high school degree, 5 also had a college degree. Nine patients provided data on the estimated copay for their lenalidomide treatment. Seven reported receiving lenalidomide without a copay due to insurance or a copay assistance program. The two remaining patients reported copays of $100/month and $1150/month, respectively. There was no significant change in COST scores over the duration of the study. At baseline, the median COST score was 24.5 (range 10-40) and 3 patients were considered to have financial toxicity. Three months later, the median COST score was 24.5 (range 10-38) and 4 patients were considered to have financial toxicity. However, there was much fluctuation in COST scores, the median absolute change was 3.5 (range 0-17). The largest decline in COST was a patient whose COST score decreased from 40 to 26. The largest rise was an increase from 10 to 27. Two of the 3 patients with financial toxicity at baseline persisted 3 months later, one had resolution, and two patients developed it.

Conclusions and Implications: We found no clear signal that financial toxicity accumulates throughout treatment for multiple myeloma. To the contrary, the data suggests that financial toxicity is a dynamic process with patients experiencing both ebbs and flows. Therefore, clinicians should continuously monitor patients for signs of increasing financial toxicity. The COST is a simple measure that can be integrated into clinical workflows and electronic health records and allow for prospective monitoring of financial toxicity.