Skip to main content

Advertisement

SpringerLink
Log in

Multilevel determinants of financial toxicity in breast cancer care: perspectives of healthcare professionals and Latina survivors

  • Original Article
  • Published:
Supportive Care in Cancer Aims and scope Submit manuscript

Abstract

Purpose

Financial toxicity is a multidimensional side effect of cancer treatment. Yet, most relevant research has focused on individual-level determinants of financial toxicity and characterized only patient perspectives. This study examined the multilevel determinants of financial toxicity from the perspectives of Latina breast cancer survivors and healthcare professionals.

Methods

We analyzed qualitative data from focus groups with 19 Latina breast cancer survivors and interviews with 10 healthcare professionals recruited through community partners and venues in Chicago.

Results

At the individual-level, the lack of knowledge and prioritization regarding financial aspects of care (e.g., costs of treatment, insurance coverage) was identified as important determinants of financial toxicity. However, healthcare professionals emphasized the need for early financial planning, while survivors prioritized survival over financial concerns immediately after diagnosis. At the interpersonal-level, social networks were identified as important platforms for disseminating information on financial resources. At the community-level, community norms and dynamics were identified as important barriers to seeking financial assistance. Access to culturally astute community-based organizations was considered one potential solution to eliminate these barriers. At the organizational/healthcare policy-level, financial assistance programs’ restrictive eligibility criteria, lack of coverage post-treatment, limited availability, and instability were identified as major determinants of financial toxicity.

Conclusion

Our findings suggest that multilevel interventions at the individual-, interpersonal-, community-, and organizational/healthcare policy-levels are needed to adequately address financial toxicity among Latina and other survivors from disadvantaged communities.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Ashing K, Rosales M, Lai L, Hurria A (2014) Occurrence of comorbidities among African-American and Latina breast cancer survivors. J Cancer Surviv 8:312–318. https://doi.org/10.1007/s11764-014-0342-x

    Article  PubMed  Google Scholar 

  2. Fu OS, Crew KD, Jacobson JS et al (2009) Ethnicity and persistent symptom burden in breast cancer survivors. J Cancer Surviv 3:241–250. https://doi.org/10.1007/s11764-009-0100-7

    Article  PubMed  PubMed Central  Google Scholar 

  3. Luckett T, Goldstein D, Butow PN et al (2011) Psychological morbidity and quality of life of ethnic minority patients with cancer: a systematic review and meta-analysis. Lancet Oncol 12:1240–1248. https://doi.org/10.1016/S1470-2045(11)70212-1

    Article  PubMed  Google Scholar 

  4. Yanez B, Thompson EH, Stanton AL (2011) Quality of life among Latina breast cancer patients: a systematic review of the literature. J Cancer Surviv 5:191–207. https://doi.org/10.1007/s11764-011-0171-0

    Article  PubMed  PubMed Central  Google Scholar 

  5. Yanez B, McGinty HL, Buitrago D et al (2016) Cancer outcomes in Hispanics/Latinos in the United States: an integrative review and conceptual model of determinants of health. J Lat Psychol 4:114–129. https://doi.org/10.1037/lat0000055

    Article  PubMed  PubMed Central  Google Scholar 

  6. Advani PS, Ying J, Theriault R et al (2014) Ethnic disparities in adherence to breast cancer survivorship surveillance care. Cancer 120:894–900. https://doi.org/10.1002/cncr.28490

    Article  PubMed  Google Scholar 

  7. Breslau ES, Jeffery DD, Davis WW et al (2010) Cancer screening practices among racially and ethnically diverse breast cancer survivors: results from the 2001 and 2003 California Health Interview Survey. J Cancer Surviv 4:1–14. https://doi.org/10.1007/s11764-009-0102-5

    Article  PubMed  Google Scholar 

  8. Fedewa SA, Ward EM, Stewart AK, Edge SB (2010) Delays in adjuvant chemotherapy treatment among patients with breast cancer are more likely in African American and Hispanic populations: a national cohort study 2004-2006. J Clin Oncol 28:4135–4141. https://doi.org/10.1200/JCO.2009.27.2427

    Article  PubMed  Google Scholar 

  9. Palmer NRA, Kent EE, Forsythe LP et al (2014) Racial and ethnic disparities in patient-provider communication, quality-of-care ratings, and patient activation among long-term cancer survivors. J Clin Oncol 32:4087–4094. https://doi.org/10.1200/JCO.2014.55.5060

    Article  PubMed  PubMed Central  Google Scholar 

  10. White A, Pollack LA, Smith JL et al (2013) Racial and ethnic differences in health status and health behavior among breast cancer survivors—Behavioral Risk Factor Surveillance System, 2009. J Cancer Surviv 7:93–103. https://doi.org/10.1007/s11764-012-0248-4

    Article  PubMed  Google Scholar 

  11. Kale HP, Carroll NV (2016) Self-reported financial burden of cancer care and its effect on physical and mental health-related quality of life among US cancer survivors. Cancer 122:283–289. https://doi.org/10.1002/cncr.29808

    Article  PubMed  Google Scholar 

  12. Koskinen J-P, Färkkilä N, Sintonen H et al (2019) The association of financial difficulties and out-of-pocket payments with health-related quality of life among breast, prostate and colorectal cancer patients. Acta Oncol 0:1–7. https://doi.org/10.1080/0284186X.2019.1592218

    Article  Google Scholar 

  13. Lentz R, Benson AB, Kircher S Financial toxicity in cancer care: prevalence, causes, consequences, and reduction strategies. J Surg Oncol 0. https://doi.org/10.1002/jso.25374

    Article  PubMed  Google Scholar 

  14. Pearce A, Tomalin B, Kaambwa B et al (2019) Financial toxicity is more than costs of care: the relationship between employment and financial toxicity in long-term cancer survivors. J Cancer Surviv 13:10–20. https://doi.org/10.1007/s11764-018-0723-7

    Article  PubMed  Google Scholar 

  15. Timmons A, Gooberman-Hill R, Sharp L (2013) The multidimensional nature of the financial and economic burden of a cancer diagnosis on patients and their families: qualitative findings from a country with a mixed public–private healthcare system. Support Care Cancer 21:107–117. https://doi.org/10.1007/s00520-012-1498-4

    Article  PubMed  Google Scholar 

  16. Zafar SY, Peppercorn JM, Schrag D et al (2013) The financial toxicity of cancer treatment: a pilot study assessing out-of-pocket expenses and the insured cancer patient’s experience. Oncologist 18:381–390. https://doi.org/10.1634/theoncologist.2012-0279

    Article  PubMed  PubMed Central  Google Scholar 

  17. Blinder VS, Patil S, Thind A et al (2012) Return to work in low-income Latina and non-Latina white breast cancer survivors: a 3-year longitudinal study. Cancer 118:1664–1674. https://doi.org/10.1002/cncr.26478

    Article  PubMed  Google Scholar 

  18. Jagsi R, Pottow JAE, Griffith KA et al (2014) Long-term financial burden of breast cancer: experiences of a diverse cohort of survivors identified through population-based registries. J Clin Oncol 32:1269–1276. https://doi.org/10.1200/JCO.2013.53.0956

    Article  PubMed  PubMed Central  Google Scholar 

  19. Jagsi R, Ward KC, Abrahamse PH et al (2018) Unmet need for clinician engagement regarding financial toxicity after diagnosis of breast cancer. Cancer 124:3668–3676. https://doi.org/10.1002/cncr.31532

    Article  PubMed  Google Scholar 

  20. Lee M, Salloum RG (2016) Racial and ethnic disparities in cost-related medication non-adherence among cancer survivors. J Cancer Surviv 10:534–544. https://doi.org/10.1007/s11764-015-0499-y

    Article  PubMed  Google Scholar 

  21. Ashing-Giwa KT, Padilla GV, Bohorquez DE et al (2006) Understanding the breast cancer experience of Latina women. J Psychosoc Oncol 24:19–52. https://doi.org/10.1300/J077v24n03_02

    Article  PubMed  Google Scholar 

  22. Buki LP, Garcés DM, Hinestrosa MC et al (2008) Latina breast cancer survivors’ lived experiences: diagnosis, treatment, and beyond. Cultur Divers Ethnic Minor Psychol 14:163–167. https://doi.org/10.1037/1099-9809.14.2.163

    Article  PubMed  Google Scholar 

  23. Azzani M, Roslani AC, Su TT (2015) The perceived cancer-related financial hardship among patients and their families: a systematic review. Support Care Cancer 23:889–898. https://doi.org/10.1007/s00520-014-2474-y

    Article  PubMed  Google Scholar 

  24. Ashing‐Giwa KT, Padilla G, Tejero J et al (2004) Understanding the breast cancer experience of women: a qualitative study of African American, Asian American, Latina and Caucasian cancer survivors. Psychooncology 13:408–428. https://doi.org/10.1002/pon.750

    Article  PubMed  PubMed Central  Google Scholar 

  25. Zapka JG, Taplin SH, Solberg LI, Manos MM (2003) A framework for improving the quality of cancer care: the case of breast and cervical cancer screening. Cancer Epidemiol Biomarkers Prev 12:4–13

    PubMed  Google Scholar 

  26. Molina Y, Watson KS, San Miguel LG, et al. (2019) Integrating multiple community-based approaches in intervention development. Health Education Research. Health Educ Res

  27. Nevin PE, Blas M, Bayer A et al (2019) Positive cancer care in Peru: patient and provider perspectives. Health Care Women Int 0:1–14. https://doi.org/10.1080/07399332.2019.1608206

    Article  CAS  Google Scholar 

  28. Bernard HR, Wutich A, Ryan GW (2016) Analyzing qualitative data: systematic approaches. SAGE Publications, Content Analysis 11: 243–268

  29. Hsieh H-F, Shannon SE (2005) Three approaches to qualitative content analysis. Qual Health Res 15:1277–1288. https://doi.org/10.1177/1049732305276687

    Article  PubMed  Google Scholar 

  30. Lopez‐Class M, Gomez‐Duarte J, Graves K, Ashing‐Giwa K (2012) A contextual approach to understanding breast cancer survivorship among Latinas. Psychooncology 21:115–124. https://doi.org/10.1002/pon.1998

    Article  PubMed  Google Scholar 

  31. Warnecke RB, Oh A, Breen N et al (2008) Approaching health disparities from a population perspective: The National Institutes of Health Centers for Population Health and Health Disparities. Am J Public Health 98:1608–1615. https://doi.org/10.2105/AJPH.2006.102525

    Article  PubMed  PubMed Central  Google Scholar 

  32. Blackman DJ, Masi CM (2006) Racial and ethnic disparities in breast cancer mortality: are we doing enough to address the root causes? J Clin Oncol 24:2170–2178. https://doi.org/10.1200/JCO.2005.05.4734

    Article  PubMed  Google Scholar 

  33. Creswell JW, Miller DL (2000) Determining validity in qualitative inquiry. Theory Pract 39:124–130. https://doi.org/10.1207/s15430421tip3903_2

    Article  Google Scholar 

  34. Morse JM, Barrett M, Mayan M et al (2002) Verification strategies for establishing reliability and validity in qualitative research. Int J Qual Methods 1:13–22. https://doi.org/10.1177/160940690200100202

    Article  Google Scholar 

  35. Suri H (2011) Purposeful sampling in qualitative research synthesis. Qual Res J 11:63–75. https://doi.org/10.3316/QRJ1102063

    Article  Google Scholar 

  36. Sandelowski M (2001) Real qualitative researchers do not count: the use of numbers in qualitative research. Res Nurs Health 24:230–240. https://doi.org/10.1002/nur.1025

    Article  CAS  PubMed  Google Scholar 

  37. Sandelowski M, Barroso J (2003) Classifying the findings in qualitative studies. Qual Health Res 13:905–923. https://doi.org/10.1177/1049732303253488

    Article  PubMed  Google Scholar 

  38. Carrera PM, Kantarjian HM, Blinder VS (2018) 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 68:153–165. https://doi.org/10.3322/caac.21443

    Article  PubMed  PubMed Central  Google Scholar 

  39. Yousuf Zafar S (2016) Financial toxicity of cancer care: it’s time to intervene. J Natl Cancer Inst 108. https://doi.org/10.1093/jnci/djv370

    Article  PubMed  Google Scholar 

  40. Molina Y, Thompson B, Espinoza N, Ceballos R (2013) Breast cancer interventions serving US-Based Latinas: current approaches and directions. Womens Health (Lond) 9:335–350. https://doi.org/10.2217/WHE.13.30

    Article  CAS  Google Scholar 

  41. Galván N, Buki LP, Garcés DM (2009) Suddenly, a carriage appears: social support needs of Latina breast cancer survivors. J Psychosoc Oncol 27:361–382. https://doi.org/10.1080/07347330902979283

    Article  PubMed  Google Scholar 

  42. Moy B, Polite BN, Halpern MT et al (2011) American Society of Clinical Oncology Policy Statement: opportunities in the patient protection and affordable care act to reduce cancer care disparities. J Clin Oncol 29:3816–3824. https://doi.org/10.1200/JCO.2011.35.8903

    Article  PubMed  Google Scholar 

  43. Kent EE, Forsythe LP, Yabroff KR et al (2013) Are survivors who report cancer-related financial problems more likely to forgo or delay medical care? Cancer 119:3710–3717. https://doi.org/10.1002/cncr.28262

    Article  PubMed  Google Scholar 

  44. Pisu M, Kenzik KM, Oster RA et al (2015) Economic hardship of minority and non-minority cancer survivors 1 year after diagnosis: another long-term effect of cancer? Cancer 121:1257–1264. https://doi.org/10.1002/cncr.29206

    Article  PubMed  Google Scholar 

  45. Licqurish S, Phillipson L, Chiang P et al (2017) Cancer beliefs in ethnic minority populations: a review and meta-synthesis of qualitative studies. Eur J Cancer Care (Engl) 26:e12556. https://doi.org/10.1111/ecc.12556

    Article  Google Scholar 

Download references

Acknowledgments

The authors would like to thank study participants for their time, effort, and perspectives. They would also like to thank Mr. Hunter T. Norris for editorial support.

Funding

This work was supported by the University of Illinois at Chicago’s Institute for Race Research and Public Policy under a 2018–2019 Policy & Social Engagement Fellowship as well as by the National Cancer Institute under grant number K01CA154938. YM was also supported by the University of Illinois Cancer Center and Center for Research on Women and Gender.

Author information

Authors and Affiliations

  1. School of Public Health, University of Illinois at Chicago, 649 SPHPI MC923, Chicago, IL, USA

    Perla Chebli, Jocelyne Lemus, Corazón Avila, Kryztal Peña & Yamilé Molina

  2. ALAS-Wings, Chicago, IL, USA

    Bertha Mariscal, Sue Merlos & Judith Guitelman

Authors
  1. Perla Chebli
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jocelyne Lemus
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Corazón Avila
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Kryztal Peña
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Bertha Mariscal
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Sue Merlos
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Judith Guitelman
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Yamilé Molina
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Yamilé Molina.

Ethics declarations

Conflict of interest

The authors declare that they have no conflicts of interest.

Disclaimer

The opinions or assertions contained herein are the private ones of the authors and are not considered as official or reflecting the views of the National Institutes of Health.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Chebli, P., Lemus, J., Avila, C. et al. Multilevel determinants of financial toxicity in breast cancer care: perspectives of healthcare professionals and Latina survivors. Support Care Cancer 28, 3179–3188 (2020). https://doi.org/10.1007/s00520-019-05119-y

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00520-019-05119-y

Keywords

Search

Navigation