BACKGROUNDCancer and its treatment lead to increased financial distress for patients. To the authors' knowledge, to date, no standardized patient‐reported outcome measure has been validated to assess this distress.METHODSPatients with AJCC Stage IV solid tumors receiving chemotherapy for at least 2 months were recruited. Financial toxicity was measured by the COmprehensive Score for financial Toxicity (COST) measure. The authors collected data regarding patient characteristics, clinical trial participation, health care use, willingness to discuss costs, psychological distress (Brief Profile of Mood States [POMS]), and health‐related quality of life (HRQOL) as measured by the Functional Assessment of Cancer Therapy: General (FACT‐G) and the European Organization for Research and Treatment of Cancer (EORTC) QOL questionnaires. Test‐retest reliability, internal consistency, and validity of the COST measure were assessed using standard‐scale construction techniques. Associations between the resulting factors and other variables were assessed using multivariable analyses.RESULTSA total of 375 patients with advanced cancer were approached, 233 of whom (62.1%) agreed to participate. The COST measure demonstrated high internal consistency and test‐retest reliability. Factor analyses revealed a coherent, single, latent variable (financial toxicity). COST values were found to be correlated with income (correlation coefficient [r] = 0.28; P<.001), psychosocial distress (r = ‐0.26; P<.001), and HRQOL, as measured by the FACT‐G (r = 0.42; P<.001) and by the EORTC QOL instruments (r = 0.33; P<.001). Independent factors found to be associated with financial toxicity were race (P = .04), employment status (P<.001), income (P = .003), number of inpatient admissions (P = .01), and psychological distress (P = .003). Willingness to discuss costs was not found to be associated with the degree of financial distress (P = .49).CONCLUSIONSThe COST measure demonstrated reliability and validity in measuring financial toxicity. Its correlation with HRQOL indicates that financial toxicity is a clinically relevant patient‐centered outcome. Cancer 2017;123:476–484. © 2016 American Cancer Society.

Context Evidence is mixed regarding the impact of advance directives on end-of-life expenditures and treatments. Objective To examine regional variation in the associations between treatment-limiting advance directive use, end-of-life (EOL) Medicare expenditures and use of palliative and intensive treatments. Design, Setting, and Patients Prospectively collected survey data from the Health and Retirement Study for 3,302 Medicare beneficiaries who died between 1998 and 2007 linked to Medicare claims and the National Death Index. Multivariable regression models examined associations between advance directives, EOL Medicare expenditures and treatments by level of Medicare spending in the decedent’s Hospital Referral Region (HRR). Main Outcome Measures Medicare expenditures, life-sustaining treatments, hospice care and in-hospital death over the last six months of life. Results Advance directives specifying limits in care were associated with lower spending in HRRs with high average levels of EOL expenditures (−$5,585 per decedent, 95% CI −$10903 to −$267), but there was no difference in spending in HRRs with low or medium average levels of EOL expenditures. Directives were associated with lower adjusted probabilities of in-hospital death in high- and medium-spending regions (−9.8%, 95% CI −16 – −3 in high-spending; −5.3%, 95% CI −10% to −0.4%). Advance directives were associated with higher adjusted probabilities of hospice use in high- and medium-spending regions (17%, 95% CI 11% − 23% in high-spending regions, 11%, 95% CI 6% to 16% in medium-spending), but not in low-spending regions. Conclusions Advance directives specifying limitations in end-of-life care were associated with significantly lower levels of Medicare spending, lower likelihood of in-hospital death, and higher utilization of hospice care in regions characterized by higher levels of EOL spending.

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Do sudden, large wealth losses affect mental health? We use exogenous variation in the interview dates of the 2008 Health and Retirement Study to assess the impact of large wealth losses on mental health among older U.S. adults. We compare cross-wave changes in wealth and mental health for respondents interviewed before and after the October 2008 stock market crash. We find that the crash reduced wealth and increased feelings of depression and use of antidepressant drugs, and that these effects were largest among respondents with high levels of stock holdings prior to the crash. These results suggest that sudden wealth losses cause immediate declines in subjective measures of mental health. However, we find no evidence that wealth losses lead to increases in clinically-validated measures of depressive symptoms or indicators of depression.

Importance Medicare beneficiaries with cancer are at risk for financial hardship given increasingly expensive cancer care and significant beneficiary cost-sharing. Objective To measure out-of-pocket (OOP) costs incurred by Medicare beneficiaries with cancer and to identify which factors and services contribute to high OOP costs. Design Prospectively collected survey data from the 2002-12 waves of the Health and Retirement Study (HRS). Setting A nationally representative panel study of U.S. residents over age 50. Participants We studied 18,166 community-dwelling Medicare beneficiaries who participated in HRS, including 1,409 participants who were diagnosed with cancer over the study period. Main Outcome and Measures OOP medical spending and financial burden (OOP expenditures/household income). Results Type of supplementary insurance was significantly associated with mean annual OOP costs incurred following a cancer diagnosis (Medicaid: $2,116; VA: $2,367; Medicare HMO: $5,976; employer-sponsored: $5,492; Medigap: $5,670; none: $8,115). Beneficiaries with a new cancer diagnosis and Medicare alone incurred OOP expenditures that on average were 24% of their household income; 10% of these beneficiaries incurred OOP expenditures that were at least 63% of their household income. Among the 10% of beneficiaries with cancer who incurred the highest OOP costs, hospitalization contributed to 42% of total OOP costs. Conclusions and Relevance Medicare beneficiaries without supplemental insurance incur significant OOP costs following a diagnosis of cancer. Costs related to hospitalization may be a primary contributor to high OOP costs. Medicare reform proposals that restructure the benefit design for hospital-based services and that incorporate an OOP maximum may help alleviate financial burden, as can interventions that reduce hospitalization in this population.