Food Insecurity

Reduced spending on food is among the consequences of financial toxicity, and it can lead to adverse clinical outcomes. In a 2022 article in the Journal of the National Cancer Institute, researchers wrote about the importance of nutrition during cancer treatment.11 They addressed the impact of food insecurity, which may be a result of cancer treatment and its impact on household finances, with data showing that it is associated with worse clinical outcomes.

“Maintaining adequate nutrition is critical to cancer therapy success,” they wrote. “Food insecurity during and after cancer treatment may undermine therapy goals and treatment success and may also add a layer of difficulty to mitigating the side effects of many cancer treatments.”

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Loss of appetite, changes in olfaction and taste, and difficulty chewing and swallowing are among the adverse side effects of common cancer treatments, according to the authors. “Adapting to these changes in taste and symptoms requires flexibility in food purchasing and preparation, which is difficult while experiencing food insecurity,” the authors wrote.

Awareness of the need for patients with cancer to maintain adequate nutrition has prompted some institutions to address the issue. For example, the University of Chicago Medical Center launched Feed1st in 2010 to operate food pantries at various locations around Chicago.11 Feed1st is designed to eliminate widely known barriers to access, including stigma and burden resulting from having to show proof of need and inconvenient hours of operation. Feed1st pantries distribute shelf-stable foods in various locations, such as inpatient pediatric oncology and outpatient adult oncology units and waiting areas.

A Financial Toxicity Tumor Board

To deal with financial toxicity, the Levine Cancer Institute in Charlotte, North Carolina, in 2019 created what it calls the Financial Toxicity Tumor Board. The board is linked to a patient assistance program (PAP) for oncologic pharmaceutical agents. As reported in a 2021 article, the PAP served 1749 and 1819 patients in 2019 and 2020, respectively, saving patients approximately $55.4 million and $60.7 million in those years, respectively.12

Board members include physicians, nurses, nursing and medical administrators, the institute’s chief financial officer, financial counselors, social workers, nurse navigators, and oncology pharmacy personnel. The board meets monthly to address complex fiscal issues, identify frequent or repeated problems that require changes in standard operating procedures, and discuss in detail cases that were not handled effectively by standard patient and financial support operations.

To illustrate how the tumor board functions, the authors of the article described a case involving a 64-year-old patient undergoing adjuvant chemotherapy after surgery for a pancreatic tumor. Months after treatment began, the patient received notice that their insurer denied the chemotherapy claims, noting a required precertification was never obtained.

A review of the denied claim showed that one of the drugs in the treatment regimen required precertification through the patient’s pharmacy benefits rather than the medical plan, “which was outside the norm for outpatient chemotherapy.” The insurer billed the patient $42,000 for the denied medication.

The tumor board took up the case after the patient asked for assistance from the institute’s financial counseling team. A financial counselor was able to secure a retroactive and ongoing precertification for the entire course of treatment, effectively eliminating the patient’s financial responsibility.

The institute also implemented a program in which pharmacy technicians are embedded in physician office practices “to track and coordinate expensive oral medication needs for patients.” These technicians handle prior authorizations, copay assistance, free drug procurement, and directing to appropriate specialty pharmacies based on a patient’s insurance.

Calls to Action

Comments in the medical literature reflect concern about the financial consequences of health care costs to patients and the need for health care provider involvement. In the report detailing the findings of the survey of breast cancer patients and their physicians, the authors observed, “Efforts must now turn to confront the financial devastation that many patients face, particularly as they progress into survivorship. The first steps for clinical practice and policy are clear: all physicians must assess patients for financial toxicity and learn how to communicate effectively about it.”2

“As the price tags associated with cancer continue to rise and patients assume more responsibility for their treatment, it will become increasingly important for us to be able to discuss with our patients the trade-offs associated with more or less costly therapeutic options,” Matthew J. Resnick, MD, wrote in a 2019 editorial in The Journal of Urology. “Doing so will increase the likelihood that we are able to align patient preferences with treatment decision making.”13

In the same journal, Matthew Mossanen, MD, of Dana-Farber Cancer Institute in Boston, and Angela B. Smith, MD, of the University of North Carolina at Chapel Hill, wrote in a 2018 commentary, “By recognizing the importance of patient-level cost in decision making, we are in a position to take practical steps to address the common and corrosive consequences of financial toxicity of cancer treatment.”14

“In the context of patient-centered cancer care, the clinician plays a central role not just in the delivery of high-quality medical treatments but also in helping contain the financial burden and distress to an individual patient with cancer in the short term, and for all patients with cancer in the long term,” Pricivel M. Carrera, PhD, and coauthors wrote in a 2018 article in CA: A Cancer Journal for Clinicians. “More than anyone in the multidisciplinary team of care, the oncologist may be the professional most able to integrate the diverse components of patient care.”15

Despite their possible discomfort about bringing up treatment costs with patients, physicians should make the effort because it is in the best interest of their patients, according to Dr Hollowell.

“Although physicians are often ill-prepared for patient-provider communication about the financial costs and burdens of treatment, patients experiencing financial toxicity report significantly worse outcomes,” he said. “As a result, discussing out-of-pocket costs related to treatment can affect not just our patients’ emotional well-being but how they respond to treatment, compliance, quality of life, and survival.”

Moreover, as Dr Joyce pointed out, financial toxicity “is a valuable patient-reported outcome that places the cost of treatments in a context that clinicians are familiar and comfortable with.”


  1. Chan K, Sepassi A, Saunders IM, Goodman A, Watanabe JH. Effects of financial toxicity on prescription drug use and mental well-being in cancer patients. Explor Res Clin Soc Pharm. 2022;14;6:100136. doi:10.1016/j.rcsop.2022.100136
  2. Jagsi R, Ward KC, Abrahamse PH, et al. Unmet need for clinician engagement regarding financial toxicity after diagnosis of breast cancer. Cancer. 2018;124:3668-3676. doi:10.1002/cncr.31532
  3. Rae M, Claxton G, Amin K, Wager E, Ortaliza J, Cox C. The burden of medical debt in the United States. Kaiser Family Foundation website. Published online March 10, 2022.
  4. Gilligan AM, Alberts DS, Roe DJ, Skrepnek GH. Death or debt? National estimates of  financial toxicity in persons with newly diagnosis cancer. Am J Med. 2018;131(10):1187-1199.e5. doi:10.1016/j.amjmed.2018.05.020
  5. Becker NV, Scott JW, Moniz MH, Carlton EF, Ayanian JZ. Association of chronic disease with patient financial outcomes among commercially insured adults. JAMA Intern Med. 182(10):1044-1051. doi:10.1001/jamainternmed.2022.3687
  6. Joyce DD, Sharma V, Jiang DH, et al. Out-of-pocket cost burden associated with contemporary management of advanced prostate cancer among commercially insured patients. J Urol. 2022;208(5):987-996. doi:10.1097/JU.0000000000002856
  7. Yousuf Zafar S, Abernethy AP. Financial toxicity, part I: A new name for a growing problem. Oncology. 2013;27(2):80-81.
  8. de Souza JA, Yap BJ, Hlubocky FJ, et al. The development of a financial toxicity patient-reported outcome in cancer: The COST measure. Cancer. 2014;120(20):3245-3253. doi:10.1002/cncr.28814
  9. de Souza JA, Yap BJ, Wroblewski K, et al. Measuring financial toxicity as a clinically relevant patient-reported outcome: The validation of the Comprehensive Score for financial Toxicity (COST). Cancer. 2017;123(3):476-484. doi:10.1002/CNCR.30369
  10. Alexander GC, Casalino LP, Meltzer DO. Patient-physician communication about out-of-pocket costs. JAMA. 2003;290(7):953-958. doi:10.1001/jama.290.7.953
  11. Raber M, Jackson A, Basen-Engquist K, et al. Food insecurity among people with cancer: Nutritional needs as an essential component of care. J Natl Cancer Inst. Published online September 21, 2022. doi:10.1093/jnci/djac135
  12. Raghavan D, Keith NA, Warden HR, et al. Levin Cancer Institute Financial Toxicity Tumor Board: A potential solution to an emerging problem. JCO Oncol Pract. 2021;17(10):e1433-e1439. doi:10.1200/OP.21.00124
  13. Resnick MJ. Editorial comment. J Urol. 2019;201(6):1045. doi:10.1097/01.JU.0000554799.88126.46
  14. Mossanen M, Smith AB. Addressing financial toxicity: The role of the urologist. J Urol. 2018;200:43-45. doi:10.1016/j.juro.2017.10.039
  15. Carrera PM, Kantarjian HM, Blinder VS. The financial burden and distress  of patients with cancer: Understanding and stepping-up action on the financial  toxicity of cancer treatment. CA Cancer J Clin. 2018;68(2):153-165. doi:10.3322/caac.21443.

This article originally appeared on Renal and Urology News