Emeline Aviki
Memorial Sloan Kettering Cancer Center (MSK) gynecologic cancer surgeon Emeline Aviki was making final preparations to present her research during the opening plenary session at the Society of Gynecologic Oncology (SGO) Annual Meeting on Women’s Cancer in March.
Her study found that the dose-specific packaging of lenvatinib (Lenvima®), a drug recently approved for the treatment of people with some kinds of endometrial cancer, was projected to drive as much as $168 million in out-of-pocket spending for patients. Prior to the SGO meeting, Dr. Aviki and some colleagues had met with the pharmaceutical company that makes lenvatinib to discuss concerns about this and suggest constructive ways to limit the financial strain on patients.
Moments before taking the stage, she learned her work had made an impact: Representatives from lenvatinib’s manufacturer gave her a verbal commitment that they would change their existing dose exchange program to better meet patient needs by including more dose reductions. She shared this development during her presentation, and a surprised audience reacted with cheers and sustained applause in a video posted on Twitter by MSK clinical research fellow Eric Rios-Doria.
In the months following the meeting, the company confirmed the expansion of its lenvatinib dose exchange program. According to reporting in a May 10, 2022 story published by the media outlet Medscape, the program will cover all indicated dose reductions for women with endometrial cancer. The company will exchange up to 15 days of a patient’s current dosage for a lower dosage once per quarter at no cost.
In response to the company following through on making changes to the dose exchange program, Dr. Aviki told Medscape, “I am so grateful they did.” She added that moving forward, she hopes the company will consider allowing more than 15 doses of lenvatinib to be exchanged at a given time. This change would prevent additional out of pocket costs for some patients.
While Dr. Aviki’s study focused on one example, financial toxicity is a growing problem for many people with cancer. Dr. Aviki is one of the founders of MSK’s Affordability Working Group, a team of dedicated clinicians, researchers, and hospital administrators working to address the affordability and financial toxicity issues facing patients with cancer through innovating care delivery, improving interventions, and bridging the gap between patient care and research.
Research nationally and at MSK shows that medical debt is a hardship for many Americans — and particularly, medical debt related to complex cancer treatment. In 2019, the national patient economic burden associated with cancer care was $21.09 billion, with patient out-of-pocket costs totaling $16.22 billion. According to a recent study from the American Cancer Society Cancer Action Network, more than a quarter of patients with cancer depleted most or all of their savings to cover the costs of their care.
Dr. Aviki and her colleagues have found a similar situation within MSK’s patient population, estimating that a quarter of MSK patients experience financial hardship from their cancer care. Unfortunately, MSK providers sometimes do not learn a patient is suffering financially until they stop filling their prescriptions or begin missing appointments or treatments.
These findings came from a survey done by the Affordability Working Group in 2019 and published in November 2021 in Supportive Care in Cancer. Another survey, published on April 19, 2022, in JAMA Network Open, revealed that many physicians at MSK understand they play an important role in financial toxicity and want to be involved in addressing it.
“Knowing in advance how a recommended treatment will impact a patient’s life is so critical,” Dr. Aviki said. “Incorporating financial impact into treatment guidelines, such as those managed by the National Comprehensive Cancer Network, could help guide oncologists and patients as they decide on a personalized treatment path.”
While cancer treatment–related financial hardship affects many people, the impact is not felt equally. Black people are more likely to report having medical debt associated with their cancer care. A non-MSK study published in February in JCO Oncology Practice found that Black individuals are more than five times as likely as their white peers to be denied insurance and more than twice as likely to report being hurt financially because of their cancer care.
Dr. Aviki confirms that MSK’s Affordability Working Group has also found that race, ethnicity, age, and certain diagnoses and treatments put a patient at risk for financial toxicity. These findings were published in December 2021 in the American Journal of Obstetrics & Gynecology.
“Certain underserved populations, especially communities of color, are at high risk for significant financial burdens related to cancer treatment,” she said. “As we work to expand access to MSK and other NCI-designated cancer centers, it will be essential to ensure high-quality cancer care remains affordable and we have appropriate interventions in place to assist patients financially when they need help.”
Last year, MSK’s Affordability Working Group launched an order set for inpatients and outpatients that has proven successful so far. Any staff member who engages with a patient’s electronic medical record can refer that patient to Patient Financial Services for financial assistance. MSK has philanthropic funds and financial aid available for patients who need assistance with medical costs, such as co-pay assistance, or to cover costs not associated with treatment, such as transportation, utility bills, and groceries.
“This order set is making a difference and has been a success so far,” Dr. Aviki said. “We are seeing more patients being referred and in turn more who are receiving aid.
Just recently, the team received approval to pilot a screening tool that will proactively assess patients for financial toxicity. This survey is launching in the gynecology, breast, colorectal/gastrointestinal, and lung cancer services, as these services have a diverse population of patients, treatment modalities, and clinical trials. When the survey shows a patient needs assistance, they will be automatically referred to Patient Financial Services and can receive aid.
“Our approach to financial toxicity has been reactive for a long time, but that is no longer tenable,” said Dr. Aviki. “We want to be proactive and think about financial toxicity the same way we think about preventive screening for cancer: Identify it early so it can be addressed before it becomes a serious problem that impacts a person’s life, family, and future.”
She notes that the Affordability Working Group believes MSK will be the first hospital to proactively screen patients for financial toxicity, but their work is not close to being completed.
“Our goal is for this approach to become the standard of care throughout MSK, and eventually across the country at every cancer hospital,” she said. “No person diagnosed with cancer should have to experience the effects of financial toxicity.”
