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Volume 32, 12 Issues, 2022
  Editorial     May 2022  

Financial Toxicity Tumor Board: A Multi-disciplinary Team Activity Required in Low and Middle-income Countries (LMIC)

By Ahmed Nadeem Abbasi1, Sohail Rasool2, Laraib Khan1

Affiliations

  1. Department of Radiation Oncology, The Aga Khan University, Karachi, Pakistan
  2. General Practice Clinic, Portlaoise, County Laoise, Republic of Ireland

In Low and Middle-Income Countries (LMIC) almost all cancer patients and their close relatives face some form of financial deprivation during the phases of diagnostic workup and treatment of cancer. The term financial toxicity (FT) refers to the detrimental effects of the excess financial burden caused by the diagnosis of cancer on the well-being of patients, their families, and society.1 In cancer management this phenomenon of financial constraint becomes extremely important for both patient and the healthcare provider. In LMIC, like in Pakistan, the affordability of patients plays a pivotal role in access to healthcare. Financial toxicity leads to multifaceted challenges for the patients. At each step, the patient and his or her family members face various forms of psychological distress.

Patients undergoing cancer treatment are likely to experience financial toxicity due to the longer timeframe between diagnosis and treatment. Multiple modalities are available for treatment, e.g. surgery, radiation therapy, chemotherapy, hormones, etc. Overall costs also include out-of-pocket costs like transportation, residence, childcare, loss of income etc. To address these issues effective patient screening, transparent pricing, and commitment to providing evidence-based high-quality care are important.2 Multidisciplinary approaches provided by a team of experts will be required to provide solutions to this perpetual problem which demands expert mature input from disciplines involved in the overall comprehensive care of the cancer patients. As the problem is multifaceted, therefore its solution will also require multipronged coping strategies. All the stakeholders have to play their roles in their domains. The list of stakeholders of the Financial Toxicity Tumor Board is healthcare providers, patients, policymakers, fund providers, and financial councillors.3
 

Exact measurement of financial toxicities for families seeking financial assistance in cancer care is performed via meticulous documentation of appropriate socioeconomic details of the household throughout treatment. It is imperative to identify strata of cancer patients who are relatively at the greatest risk of experiencing financial constraints. Financial councillors can assist in this. An open deliberation between multi-disciplinary clinical and finance team members to ensure costing as part of treatment plans is the desired process and objective of FTTB to practically reduce the burden of financial toxicity.1

In a study published in June 2021 in the Journal of Clinical Oncology, conducted at Levine Cancer Institute, North Carolina, it was reported that the establishment of the financial toxicity tumor board (FTTB) resulted in a net saving of more than 60 million dollars of 1819 cancer patients’ expenses.4 Like any other multidisciplinary tumor board, this tumor board also requires the maintenance of high-quality parameters. Clinical quality indicators can be introduced in the process to make sure that all board recommendations are being made in full compliance with evidence-based medicine.5An online survey conducted in 2017 reported that out of all cancer patients included in the survey, three-quarters experience some degree of financial toxicity after the diagnosis of cancer. The most common barrier was found to be lack of resources which represented fifty percent of all cases. Other factors were complex documentary work requirements for getting financial assistance and partial or total unawareness of available financial support and resources.6

In LMIC, this FT tumor board can prove itself as a useful entity and breaking point where financial status, disease status, and cost of treatment are discussed in one room leading to open debate and argument. In this tumor board, each stakeholder will represent his or her domain while addressing each patient’s case on clinical merit. The difference between strategies adopted in the scenarios of radical and palliative intents of treatment would be clarified to the non-medical team members of the board. A regular sitting of multidisciplinary stakeholders representing both clinical and financial experts will lead to a better cost-effective and realistic tumor board recommendation. Under no circumstances, clinicians would give any opinion in FTTB which does not lie inside the boundaries of evidence-based medicine. Multidisciplinary Tumor Boards do play an important role in the overall care and management of cancer patients treated in LMIC.7 We came across some examples of FTTB in contemporary published literature. Abbott et al. in their study published in the journal of surgical oncology highlighted the importance of financial toxicity concerning other significant factors originating from inherent disparities between various strata of socio-economic groups. The authors concluded that relevant utilization of telehealth can lead to lesser expenditure and it can potentially minimise the overall cost of cancer treatment. It would result in better patient compliance and a better clinical outcome.8

Financial toxicity is a significant issue that is quite relevant to Pakistani patients. The healthcare system has many areas which need improvement.9 We strongly recommend the establishment of multi-disciplinary tumor boards as a measure of the quality and safety of patients. In our opinion, for developing countries, this is a lifeline for our patients.10 An example of an independent non-institutional Tumor Board is the Karachi City Tumor Board.11 Financial Toxicity Tumor Board would be an innovative patient-centred initiative.

COMPETING INTEREST:
The authors declared no conflict of interest.

AUTHORS’ CONTRIBUTION:
All authors were involved in designing, drafting, and revising of the manuscript.
All authors approved the final version of the manuscript to be published.

REFERENCES

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  2. Schroeder SR, Agusala V, Sher DJ. Financial toxicity and cancer therapy: A primer for radiation oncologists. Haematol Oncol Clin 2019; 33(6):1117-28. doi: 10.1016/j. hoc.2019.08.013.
  3. Lentz R, Benson III AB, Kircher S. Financial toxicity in cancer care: Prevalence, causes, consequences, and reduction strategies. J Surg Oncol 2019; 120(1):85-92. doi: 10.1002/jso.25374.
  4. Raghavan D, Keith NA, Warden HR, Chai S, Turan WJ, Moroe J, Feild D, Knight TG. Levine cancer institute financial toxicity tumor board: A potential solution to an emerging problem. JCO Oncol Pract 2021; 17(10):e1433-9. doi: 10. 1200/OP.21.00124. 
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  7. Abbasi AN, Qureshi BM, Karim MU. Impact of multi-disciplinary team meetings and decision-making on cancer management in lower and middle-income countries. Chest 2021; 159(2):887-8. doi: 10.1016/j.chest.2020.08. 2097.
  8. Abbott DE, Voils CL, Fisher DA, Greenberg CC, Safdar N. Socioeconomic disparities, financial toxicity, and opportunities for enhanced system efficiencies for patients with cancer. J Sur Oncol 2017; 115(3):250-6. doi: 10.1002/jso.24528. 
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  11. Asghar AH, Abbasi AN, Rizvi S. City tumour board Karachi: An innovative step in multidisciplinary consensus meeting and its two years audit. J Pak Med Assoc 2013; 63(12): 1534.