Cost Conversations to Mitigate the Effects of Financial Toxicity in Oncology: Current State, Opportunities, and Barriers.

The direct and indirect financial burden of cancer care, from medication costs to lost wages, results in financial toxicity for patients. Despite the growing recognition of financial toxicity as a problem for patients, there are few solutions available at the point of care. Structured cost conversations between oncologists and patients to help identify financial toxicity and intervene early when it is recognized have been posited as a patient facing intervention. Cost conversations fit into a framework of shared decision making within cancer care. Although more than 90% of patients with cancer express a desire to discuss the costs of their care, <15% report that such conversations occurred. This contrasts with oncologists who self-report that they discuss costs with patients up to 60% of the time. Poor utilization of cost conversations may be due to both patient and oncologist reluctance of discussing money; this can be driven by fear that lower cost care is less effective and lack of training/guidance for oncologists on how to effectively conduct cost conversations. Currently, there is an abundance of small, pilot studies showing benefits of cost conversation or other decision aids in meaningfully reducing financial toxicity. However, no large randomized prospective study has assessed the role of structured conversations designed exclusively to address costs in cancer care. This review suggests a framework for cost conversations in oncology and outlines the steps necessary to develop a full cost conversation guide.