Mixed-Methods Evaluation of a Social Work Intervention to Reduce the Financial Burden of Cancer Treatment

Background: Cancer patients with low household incomes are at a high risk of financial hardship and poverty exposure. Cancer-related financial hardship has been associated with increased rates of anxiety, depression, treatment non-adherence, food and housing insecurity. While financial navigation programs are present in some medical settings, standardized interventions remain limited. The purpose of this sequential explanatory mixed-methods study was to evaluate the preliminary efficacy of a novel financial treatment program (FTP) on financial toxicity, health-related quality of life, anxiety, depression, and treatment non-adherence in cancer patients with low incomes. The social work delivered FTP intervention consisted of individualized resource navigation, financial education services, and a $1000 patient assistance grant that was used towards any non-treatment related expenses of the patient’s choice.

Methods: 152 cancer patients undergoing active treatment, with household incomes under the 400% poverty line, were recruited from two urban, NCI-designated cancer centers. In the quantitative phase, participants completed a pre-test survey prior to receiving the intervention and a follow-up survey two months after that included the following measures: Comprehensive Score for Financial Toxicity (COST), Hospital Anxiety and Depression Scale (HADS), 36-Item Short Form Health Survey (SF-36), food and housing insecurity, and treatment non-adherence. Paired samples t-tests were used to identify changes in primary outcomes from pre- to post- test. In the qualitative phase, we used financial toxicity (COST) gain scores to select 10 “high responders” and 10 “low responders” to participate in semi-structure narrative interviews about the intervention and their financial wellbeing during cancer treatment. Transcripts were analyzed thematically to elucidate psychosocial processes underlying differential response to the intervention.

Results: Participants were 69% female; roughly half (51%) were African American/Black, 34% were white, 4% were of mixed race, 3% were Asian and 8% reported ‘other’ or preferred not to answer and 52% were Hispanic or Latino. COST score at baseline (M=10.5, SD=6.4) significantly increased after 2 months (M=12.9, SD=7.9), t(176.2)= -2.3, p<.05. HADS-Anxiety score at baseline (M=11.1, SD=4.7) significantly decreased after 2 months (M=9.2, SD=4.4), t(186.0)= 2.88, p<.01. SF-36 Physical functioning score at baseline (M=34.0, SD=27.2) significantly increased after 2 months (M=43.9, SD=31.0), t(170.3)= -2.26, p<.05. No changes were observed in depression or treatment adherence. Qualitative themes suggested that social support, pre-diagnosis financial preparation, quality of government benefits, physical health, and coping processes influenced benefits received from the intervention.

Conclusions: Early evidence of this FTP indicates promising results to increase financial and physical well-being, and in reducing anxiety among lower income cancer patients. This program demonstrated improvements in COST scores and reduced non-medical cost concerns. However, average COST and anxiety scores only shifted from severe to moderate, suggesting that more intensive interventions are needed. Qualitative themes aid in understanding these findings and in shaping a more comprehensive response to cancer-related financial hardship in lower SES patients. A planned future study involving monthly guaranteed income payments of $1000/month will be carried out shortly to examine if sustained financial well-being and treatment adherence can be achieved.