There were 147 patients who met eligibility criteria for participation, and 140 patients completed both PFW and COST-FACIT. Of those completing both surveys, 116 participants had previously completed radiation therapy and were included in this analysis of patients in the survivorship phase of care. Patient demographic and clinical characteristics are presented in Table 1. The median age was 66 years (range 28–88 years), and 52.6% were male. The median time from radiotherapy to survey completion was 9 months (IQR 3–24 months). A majority of participants were Caucasian (81%) or African American (14.7%). All patients had health insurance, primarily through Medicare (50%) or private insurance (44%). A bachelor’s degree or higher education was achieved by 46.5% of patients, while 20.7% completed high school or less. The most common primary diagnoses included head and neck cancer (27.6%), prostate cancer (18.1%), and lung cancer (15.5%). Radiotherapy techniques included intensity modulated radiotherapy (47.4%), stereotactic radiotherapy (29.3%), three-dimensional conformal radiotherapy (19.0%), and brachytherapy (4.3%). In addition to radiotherapy, 51.7% of patients received systemic therapy and 30.2% had surgical treatment by the time of survey completion.
Table 1
Patient Characteristics Associated with COST-FACIT or PFW Scores.
| Total N (%) | | COST-FACIT mean, SD | pa | | PFW mean, SD | pa |
Age | | | | | | | |
< 65 years | 53 (45.7) | | 25.8, 11.3 | ref | | 5.9, 2.3 | ref |
≥ 65 years | 63 (54.3) | | 34.0, 11.9 | 0.0001 | | 7.3, 2.5 | 0.002 |
Mean, SD | 64.6, 11.7 | | | | | | |
Sex | | | | | | | |
Male | 61 (52.6) | | 29.6, 12.2 | ref | | 6.8, 2.5 | ref |
Female | 55 (47.4) | | 31.0, 12.3 | 0.6 | | 6.5, 2.6 | 0.4 |
Race | | | | | | | |
White | 94 (81.0) | | 31.7, 11.9 | ref | | 7.0, 2.4 | ref |
African American | 17 (14.7) | | 24.2, 13.9 | 0.02 | | 5.3, 2.7 | 0.008 |
Other | 5 (4.3) | | 24.0, 13.9 | 0.2 | | 5.8, 2.3 | 0.3 |
Marital status | | | | | | | |
Never married | 12 (10.3) | | 27.0, 11.2 | ref | | 6.2, 2.5 | ref |
Married/domestic partnership | 84 (72.4) | | 31.0, 12.6 | 0.3 | | 6.8, 2.5 | 0.4 |
Divorced/widowed | 20 (17.2) | | 29.1, 11.3 | 0.6 | | 6.2, 2.5 | 1.0 |
Education level | | | | | | | |
High school (some or graduate) | 24 (20.7) | | 25.6, 11.7 | ref | | 5.3, 2.4 | ref |
Some college | 20 (17.2) | | 31.2, 11.8 | 0.1 | | 6.8, 2.2 | 0.03 |
Technical training/Associate degree | 17 (14.7) | | 24.8, 11.7 | 0.8 | | 5.3, 2.4 | 0.9 |
Bachelor’s degree | 26 (22.4) | | 29.9, 10.6 | 0.2 | | 7.1, 2.3 | 0.006 |
Graduate degree | 28 (24.1) | | 36.6, 12.1 | 0.0005 | | 8.0, 2.2 | < 0.0001 |
Missing | 1 | | | | | | |
Household income | | | | | | | |
<$20,000 | 10 (9.3) | | 17.8, 10.4 | ref | | 4.1, 2.4 | ref |
$20,000 to $49,999 | 31 (28.7) | | 25.8, 11.4 | 0.04 | | 5.4, 2.1 | 0.09 |
$50,000 to $100,000 | 40 (37.0) | | 31.6, 10.3 | 0.0002 | | 7.2, 2.1 | < 0.0001 |
$100,000+ | 27 (25.0) | | 36.2, 11.1 | < 0.0001 | | 8.0, 2.3 | < 0.0001 |
Missing | 8 | | | | | | |
Savings balance | | | | | | | |
<$1,000 | 33 (32.0) | | 20.2, 10.4 | ref | | 4.3, 1.8 | ref |
$1,000 to $4,999 | 17 (16.5) | | 30.1, 11.1 | 0.0005 | | 6.7, 2.3 | < 0.0001 |
$5,000 to $9,999 | 11 (10.7) | | 31.2, 10.5 | 0.0009 | | 6.6, 2.3 | 0.0002 |
$10,000 to $49,999 | 17 (16.5) | | 28.5, 10.1 | 0.003 | | 6.8, 1.8 | < 0.0001 |
$50,000+ | 25 (24.3) | | 40.2, 6.7 | < 0.0001 | | 9.0, 1.3 | < 0.0001 |
Missing | 13 | | | | | | |
Insurance status | | | | | | | |
Private | 51 (44.0) | | 29.1, 10.4 | ref | | 6.5, 2.2 | ref |
Medicaid/Marketplace/Other | 7 (6.0) | | 17.9, 14.7 | 0.02 | | 4.7, 3.1 | 0.08 |
Medicare | 58 (50.0) | | 32.8, 12.6 | 0.09 | | 7.0, 2.6 | 0.2 |
Household size | | | | | | | |
1 | 17 (14.8) | | 26.8, 11.1 | ref | | 6.2, 2.4 | ref |
2 | 64 (55.7) | | 33.6, 11.6 | 0.03 | | 7.2, 2.5 | 0.1 |
3+ | 34 (29.6) | | 26.0, 12.6 | 0.8 | | 5.9, 2.4 | 0.7 |
Missing | 1 | | | | | | |
House ownership | | | | | | | |
Own | 98 (84.5) | | 31.2, 12.0 | ref | | 6.8, 2.5 | ref |
Rent / Other | 18 (15.5) | | 25.3, 12.5 | 0.05 | | 5.8, 2.6 | 0.1 |
Cancer treatment support from family/friends | | | | | | | |
Not at all / A little | 29 (25.7) | | 23.2, 11.1 | ref | | 5.4, 2.3 | ref |
Somewhat / Quite a bit | 32 (28.3) | | 28.5, 10.9 | 0.05 | | 6.3, 2.1 | 0.1 |
Very much | 52 (46.0) | | 35.8, 10.6 | < 0.0001 | | 7.7, 2.4 | < 0.0001 |
Missing | 3 | | | | | | |
Distance traveled for care | | | | | | | |
< 5 miles | 13 (11.2) | | 34.6, 12.7 | ref | | 7.6, 2.4 | ref |
5–10 miles | 24 (20.7) | | 31.1, 12.1 | 0.4 | | 6.8, 2.6 | 0.2 |
10–30 miles | 40 (34.5) | | 30.7, 12.1 | 0.3 | | 6.7, 2.6 | 0.08 |
30 + miles | 39 (33.6) | | 27.8, 12.3 | 0.08 | | 6.2, 2.4 | 0.3 |
Transport mode | | | | | | | |
Drive self | 69 (59.5) | | 30.6, 11.8 | ref | | 6.9, 2.4 | ref |
Friends/family drive | 38 (32.8) | | 29.4, 12.7 | 0.6 | | 6.3, 2.7 | 0.2 |
Both (self and others drive) | 9 (7.8) | | 31.6, 14.6 | 0.8 | | 6.3, 2.7 | 0.5 |
Additional therapy: surgery | | | | | | | |
No | 81 (69.8) | | 29.2, 13.8 | ref | | 6.8, 2.5 | ref |
Yes | 35 (30.2) | | 30.7, 11.6 | 0.5 | | 6.2, 2.6 | 0.2 |
Additional therapy: systemic | | | | | | | |
No | 56 (48.3) | | 29.1, 12.4 | ref | | 6.4, 2.6 | ref |
Yes | 60 (51.7) | | 31.3, 12.2 | 0.3 | | 6.9, 2.5 | 0.2 |
Radiation technique | | | | | | | |
IMRT | 55 (47.4) | | 30.1, 12.5 | ref | | 6.6, 2.8 | ref |
SBRT/SRS | 34 (29.3) | | 29.6, 11.3 | 0.8 | | 6.7, 2.3 | 1.0 |
Brachytherapy | 5 (4.3) | | 36.4, 13.4 | 0.3 | | 8.0, 2.9 | 0.3 |
3DCRT | 22 (19.0) | | 30.3, 13.2 | 1.0 | | 6.3, 2.2 | 0.6 |
Abbreviations: 3DCRT, three-dimensional conformal radiotherapy; COST-FACIT, Comprehensive Score for Financial Toxicity - Functional Assessment of Chronic Illness Therapy; IMRT, intensity-modulated radiotherapy; PFW, Personal Financial Wellness scale; Ref, reference; SBRT, stereotactic body radiotherapy; SD, standard deviation; SRS, stereotactic radiosurgery. |
ap-value obtained from univariate linear regression models |
The mean COST-FACIT score ± standard deviation for this population was 30.3 ± 12.2 (range 1–48, median 32), and the mean PFW score was 6.7 ± 2.5 (range 1.0–10.0, median 6.8). Patient COST-FACIT scores correlated very strongly with PFW scores (r = 0.90, p < 0.0001, Fig. 1). The Cronbach’s alpha, a measure of the reliability of all items within each survey, was high for both the COST-FACIT (α = 0.92) and PFW (α = 0.97) surveys. Overall both the COST-FACIT and PFW scores exhibited a left skew towards higher scores in this study population, though COST-FACIT scores were more uniformly distributed (Supplemental Fig. 1). The distribution of patient scores for both surveys are arranged by score quartiles in Table 2. A total of eleven patients (9.5%) produced COST-FACIT scores in the lowest quartile of possible scores, indicating high levels of financial toxicity. Similarly, eleven patients (9.5%) scored in the lowest quartile of possible PFW scores. A composite score of 4.0 on the PFW corresponds to high financial distress/poor financial well-being, and 15.5% of participants indicated scores of 4.0 or lower.
Table 2
Patient Distribution of COST-FACIT vs. PFW Scores by Quartile, N(%).
| | COST-FACIT Scores |
| | 0–11 | 12–23 | 24–35 | 36–48 |
PFW Scores | 1.00-3.24 | 7 (6.0) | 4 (3.4) | 0 | 0 |
3.25–5.49 | 4 (3.4) | 18 (15.5) | 7 (6.0) | 0 |
5.50–7.74 | 0 | 5 (4.3) | 15 (12.9) | 6 (5.2) |
7.75-10.00 | 0 | 0 | 12 (10.3) | 38 (32.8) |
Abbreviations: COST-FACIT, Comprehensive Score for Financial Toxicity - Functional Assessment of Chronic Illness Therapy; PFW, Personal Financial Wellness scale. |
On univariate analysis, the same factors were associated with financial distress and financial toxicity (Table 1). Older age, Caucasian race, higher educational attainment, higher household income, higher savings balance, insurance (non-Medicaid) status, and support from family/friends were associated with higher scores (less financial distress or financial toxicity) on both the COST-FACIT and PFW surveys. Gender, marital status, additional other treatments such as surgery or chemotherapy and radiation technique did correlate with scores on either scale.
Patient factors with significant associations (p < 0.05) were considered in multivariable linear regression models, as no a priori factors for adjustment were specified. Results for the fully adjusted multivariable models including all significant factors in the univariate analysis are shown in Supplemental Table 1. The final multivariable models included only covariates that significantly improved model fit and demonstrated strong associations with financial toxicity (Table 3). In the final regression analysis, higher monetary savings and greater perceived support from family or friends during treatment were strongly associated with increased COST-FACIT and increased PFW scores. Age ≥ 65 years was significantly associated with higher COST-FACIT scores and approached significance with PFW scores, while higher household income was also associated with increased PFW score.
Table 3
Final Multivariable Linear Regression Models (best fit).
| COST-FACIT β (SE) | p | | PFW β (SE) | p |
Age | | | | | |
< 65 years | ref | | | ref | |
≥ 65 years | 4.05 (1.84) | 0.03 | | 0.66 (0.37) | 0.07 |
Savings balance | | | | | |
<$1,000 | ref | | | ref | |
$1,000 to $4,999 | 8.20 (2.61) | 0.002 | | 1.59 (0.54) | 0.003 |
$5,000 to $9,999 | 8.82 (3.09) | 0.004 | | 1.11 (0.66) | 0.09 |
$10,000 to $49,999 | 6.06 (2.75) | 0.03 | | 1.55 (0.59) | 0.008 |
$50,000+ | 14.01 (2.57) | < 0.0001 | | 2.93 (0.59) | < 0.0001 |
Cancer treatment support from family/friends | | | | | |
Not at all / A little | ref | | | ref | |
Somewhat / Quite a bit | 2.62 (2.46) | 0.3 | | 0.33 (0.48) | 0.5 |
Very much | 8.53 (2.22) | 0.0001 | | 0.99 (0.44) | 0.02 |
Household income | | | | | |
<$20,000 | - | - | | ref | |
$20,000 to $49,999 | - | - | | 0.84 (0.66) | 0.2 |
$50,000 to $100,000 | - | - | | 1.85 (0.70) | 0.008 |
$100,000+ | - | - | | 1.83 (0.77) | 0.02 |
Abbreviations: COST-FACIT, Comprehensive Score for Financial Toxicity - Functional Assessment of Chronic Illness Therapy; PFW, Personal Financial Wellness scale; Ref, reference; SE, standard error. |