Influence of Financial Burden on Withdrawal or Change of Cancer Treatment in Japan: Results of a Bereavement Survey

doi:10.21203/rs.3.rs-906189/v1

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Research Article

Influence of Financial Burden on Withdrawal or Change of Cancer Treatment in Japan: Results of a Bereavement Survey

https://doi.org/10.21203/rs.3.rs-906189/v1

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published 01 Mar, 2022

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Purpose: This study aimed to examine the effect of financial burden of cancer treatment from diagnosis to end-of-life on treatment withdrawal or change in Japan.

Methods: This study was part of a nationwide survey of bereaved family members of cancer patients in Japan (J-HOPE2016 study). We asked questions regarding withdrawal or change of cancer treatment (stratified according to whether the treatment was recommended by physicians or based on the patients’ request), experiences of financial difficulties in coping with cancer treatment expenses, and the participants’ socioeconomic background. We conducted descriptive analyses and used logistic regression to examine the factors related to withdrawal or change of cancer treatment.

Results: Approximately 7.5% of participants reported withdrawal or change of cancer treatment for financial reasons. The experiences of financial difficulties in coping with cancer treatment expenses such as using up all or a portion of one’s savings (OR=2.14, 95% CI=1.14-4.04, p=0.018 / OR=3.45, 95% CI=1.52-7.81, p=0.003) and subjective financial burden (OR=2.54, 95% CI=1.25-5.14, p=0.010 / OR=3.89, 95% CI=1.68-9.00, p=0.002) were significantly related to withdrawal or change of cancer treatment (recommended by physicians / based on patient request).

Conclusion: Fewer participants reported withdrawal or change of cancer treatment than in previous studies, which might reflect the characteristics of the Japanese health-care system. However, there are patients in Japan who withdraw or change cancer treatment for financial reasons. Medical staff should consider financial toxicity as a serious side effect and assist patients in their decision-making regarding treatment while considering their socioeconomic background.

Cancer Biology

Cancer

oncology

financial toxicity

financial burden

palliative care

family caregivers

Use of the term “financial toxicity” has spread recently in the field of oncology [1, 2]. Financial toxicity is a new concept regarding the side effects of cancer treatment, caused by the effects of high cancer treatment costs. According to this concept, the financial burden on the patient is likely to affect treatment choices and quality of life during treatment [3–5].

A previous study [3] reported that the financial burden on patients with cancer influences their withdrawal from or change of treatment. Specifically, Zafar and colleagues [3] reported that approximately 80% of patients with cancer receiving chemotherapy or hormone therapy experienced a financial burden, and hence, 7–9% did not receive the treatment recommended by their physician. According to other studies [6–9], 7–51% of patients experienced a financial burden or financial toxicity. Additionally, 68% of such patients cut back on their leisure activities, 46% reduced spending on basics such as food and clothing, and 46% had to draw on their savings [3]. However, most previous studies were conducted mainly in the United States. Therefore, a wider scope of research including a variety of medical and social systems might provide a better understanding regarding the factors associated with withdrawal from or change of cancer treatment.

Japan’s medical and social system can be considered unique in several ways. All citizens are part of a national long-term health insurance system in which they typically only have to pay 30% of medical costs themselves, and citizens aged ≥75 years only have to pay 10%. In addition, a unique “ceiling amount” system covers high-cost medical expenses. Although some age and income restrictions apply, the ceiling amount for out-of-pocket expenses ranges between 10,000 and 250,000 JPY per month (approximately 100–2,500 USD). This is the maximum amount that a patient has to pay, as the excess amount is covered by public subsidies. Under this system, approximately 80% of the population falls under the monthly medical cost bracket of between 57,600 and 80,100 JPY. In this study, we hypothesized that these systems reduce the out-of-pocket costs for patients with cancer in Japan so that only a small number of patients withdraw from or change treatment because of a financial burden. However, to our knowledge, no reports have been conducted in Japan to investigate this issue [10–12].

In addition, previous studies have examined only a certain period of cancer treatment, and not the entire period, including end-of-life. By investigating the entire period, including end-of-life, it might be possible to gain a more accurate understanding of the financial toxicity and burden that the patient experiences due to cancer treatment. However, it is difficult to ask the patient about end-of-life, so family members are typically the proxy for the patient.

Therefore, the aim of the present study was to examine the characteristics and impact of financial burden of cancer treatment from diagnosis to end-of-life, and its effect on withdrawal from or change of cancer treatment in Japan.

This study was part of a nationwide survey of bereaved family members of patients with cancer in Japan (the Japan HOspice and Palliative care Evaluation study 2016: J-HOPE study 2016). The J-HOPE 2016 study was a cross-sectional, anonymous, self-reporting questionnaire survey conducted between May and July 2016. We sent letters to 169 palliative care units that were members of Hospice Palliative Care Japan before September 1, 2015. Of these institutions, 71 participated in the study. To identify potential study subjects, we asked each institution to identify and list up to 80 bereaved family members of patients who had died prior to January 31, 2016. This study included a subpopulation of the main study. The inclusion criteria included: 1) the patient died of cancer; 2) the patient was aged ≥20 years (the age at which one is considered an adult in Japan); and 3) the bereaved family member was aged ≥20 years. The exclusion criteria were as follows: 1) the patient received palliative care for less than 3 days; 2) the bereaved family member was unavailable or could not be identified; 3) treatment-associated death or death in an intensive care unit; 4) study participation would cause the participant serious psychological distress, as determined by the primary physician and a nurse; and 5) the potential participant was incapable of completing the self-reported questionnaire because of health issues such as cognitive impairment or visual disability. Questionnaires were sent to the bereaved family members identified by each participating institution. A document explaining the aims and procedures of the J-HOPE2016 study was sent along with the questionnaire, and return of a completed questionnaire was considered to indicate consent to participate in the study. A ballpoint pen was included in the envelope as an incentive to participate. Participants were asked to return the completed questionnaire to the secretariat office (Tohoku University) within 1 month. We sent a reminder to non-responders 1 month after sending the questionnaire. If they did not wish to participate in the study, they were asked to check a “no participation” box and return the incomplete questionnaire. Ethical approval for the study was granted by the institutional review boards of Tohoku University (No. 2016-1-015) and all participating institutions.

Measurements

Withdrawal from or change of cancer treatment

We asked the following two questions regarding withdrawal from or a change of cancer treatment: “whether patients had withdrawn from or changed the cancer treatment recommended by their physician”, and “whether patients had withdrawn from or changed the cancer treatment that they wanted to receive”. We asked the participants to answer these questions on a five-point scale (never / not very often / some of the time / most of the time / not sure). If a withdrawal or change was noted, we also asked about the kind of treatment that was withdrawn or changed.

Experiences of financial difficulties in coping with the expenses of cancer treatment

We asked the participants whether they had ever had to do any of the following: 1) reduce spending on food, 2) reduce spending on clothing, 3) borrow money from relatives (e.g., parents, children, siblings), 4) move to a house where the rent was cheaper, 5) work more hours to increase income (e.g., overtime, side jobs), 6) reduce spending on leisure activities, such as vacations, 7) have disputes about money with family members, 8) sell possessions or property, 9) use all or a portion of their savings, 10) worry about their family’s living and school expenses, and 11) refrain from going to the hospital or purchasing prescription drugs. This list of items was created by the researchers based on a review of previous studies [3, 4].

In addition, we inquired about the participants’ sociodemographic data, including the deceased patient’s gender, age, and primary cancer site, duration of care received, period from cancer diagnosis to death, duration after bereavement, cost of care, employment status, and perceived social support, as factors that could potentially be associated with withdrawal from or change of cancer treatment.

Statistical analysis

We first conducted descriptive analyses of the patients’ socioeconomic background, whether they had withdrawn from or changed their cancer treatment, and their experience during treatment.

Since the distribution of answers was biased, we dichotomized the answers among the following questions for analysis. First, “whether the patient had financial concerns” was dichotomized as no/mild worries and moderate/severe worries. Second, “whether the patient had cut down on his/her living expenses to pay for cancer treatment” was dichotomized as never and not very often/some of the time/most of the time.

Bivariate analysis (logistic regression) was used to assess the correlation between the patients’ socioeconomic backgrounds and whether they had withdrawn from or changed cancer treatment.

A p value < 0.05 was considered statistically significant, and all tests were two-tailed. All statistical analyses were performed using SAS software (Japanese ver. 9.4; Cary, NC; BMDP, Los Angeles, CA).

A total of 510 (60%) questionnaires were returned. The characteristics of the participants and bereaved family members are described in Table 1, and the results regarding whether patients had withdrawn from or changed cancer treatment are described in Table 2. Not all the questions were responded to by all the participants. Consequently, the response rates of each question were different. For treatment that had been recommended by the physician, 1% (n = 5) reported that they had withdrawn/changed treatment most of the time, 4% (n = 20) said some of the time, 4% (n = 20) said not very often, and 85% (n = 412) said never. For treatment that the patients wanted to receive, 1% (n = 4) reported that they had withdrawn/changed treatment most of the time, 3% (n = 12) said some of the time, 2% (n = 11) stated not very often, and 86% (n = 401) said never. The patients’ experiences in relation to paying for treatment are described in Fig. 1. The highest percentage of patients used all or a portion of their savings (35%, n = 166) on treatment, 30% (n = 144) reported reduced spending on clothing, and 24% (n = 114) reported reduced spending on leisure activities such as vacations.

Table 1

Deceased cancer patients’ and participating family members’ characteristics
Patients
Patients		N		%
Gender
	Male		302	59
	Female		208	41
Age
	< 65 y		65	13
	65–74 y		161	32
	> 75 y		284	56
Primary tumor site
	Lung		112	22
	Stomach		77	15
	Colon		63	12
	Liver, bile duct, pancreas	109		21
	Other		149	29
Duration of care received
	< 2 weeks		144	28
	2 weeks to 1 month		155	30
	1–2 months		120	24
	> 2 months		91	18
Period from cancer diagnosis to death
	< 3 months		74	15
	3–6 months		59	12
	6 months to 1 y		80	16
	1–3 y		148	30
	> 3 y		133	27
Duration since death
	< 6 months		109	21
	6–8 months		113	22
	8–10 months		104	20
	10–12 months		94	18
	> 12 months		90	18
Cost of care
	< 1 million JPY	211		46
	1–2 million JPY	134		29
	> 2 million JPY	117		25
Employment status
	None		353	72
	Full-time		85	17
	Part-time	51		10
Whether the patient had financial concerns
	Yes		79	16
	No		409	84
Whether the patient had private cancer insurance
	Yes		162	33
	No		327	67
Whether the patient had used the high-cost medical care benefit system
	Yes		332	67
	No		110	22
	Not sure		50	10
Whether the patient had cut down on his/her living expenses to pay for cancer treatment
	Yes		120	26
	No		333	74
Whether the patient or family had consulted with medical staff about financial issues
	Yes		65	13
	No		418	87
Bereaved family members
Bereaved family members		N		%
Gender
	Male		141	28
	Female		366	72
Age
	< 65 y		259	51
	65–74 y		163	32
	> 75 y		84	17
Relationship
	Partner		218	43
	Child		186	37
	Child-in-law	29		6
	Parent		14	3
	Brother or sister	35		7
	Other		23	5
Educational background
	Elementary and junior high school	66		13
	High school	222		45
	Junior college or vocational school	113		23
	University	85		17
	Graduate school	6		1
	Other		5	1
Not all the questions were responded to by all the participants and do not add up to 510. Consequently, the response rates of each question were different.

Table 2

Results regarding whether patients had withdrawn from or changed cancer treatment
	N		%
Whether the patient had withdrawn from or changed the cancer treatment recommended by their doctor for financial reasons	N = 484
Never		412	85
Not very often	20		4
Some of the time	20		4
Most of the time	5		1
Not sure		27	6
Type of treatment	N = 45
Surgery		7	16
Chemotherapy (intravenous)	18		40
Chemotherapy (oral)	12		27
Oral medicine (other than anticancer medicine)	9		20
Radiation therapy (other than proton beam therapy, heavy ion therapy)	5		11
Molecular-targeted drugs (insured)	2		4
Proton beam therapy, heavy ion therapy	1		2
Unproven cancer treatments (e.g., vitamins, homeopathy, unproven immunotherapy)	3		7
Other		2	4
Whether the patient had withdrawn from or changed the cancer treatment they had wanted to receive for financial reasons	N = 467
Never		401	86
Not very often	11		2
Some of the time	12		3
Most of the time	4		1
Not sure		39	8
Type of treatment	N = 27
Surgery		2	7
Chemotherapy (intravenous)	3		11
Chemotherapy (oral)	1		4
Oral medicine (other than anticancer medicine)	1		4
Radiation therapy (other than proton beam therapy, heavy ion therapy)	3		11
Molecular-targeted drugs (insured)	1		4
Proton beam therapy, heavy ion therapy	7		26
Unproven cancer treatments (e.g., vitamins, homeopathy, unproven immunotherapy)	10		37
Other		1	4

The results of logistic regression analysis comparing subjects who reported never and most of the time/some of the time/not very often in response to the question regarding whether patients had withdrawn from or changed cancer treatment are described in Tables 3 and 4. Among all socioeconomic background variables described in Table 1, the items of “whether the patient had financial concerns” (odds ratio [OR] = 2.54, 95% confidence interval [CI] = 1.25–5.14, p = 0.010), “whether the patient had cut down on his/her living expenses to pay for cancer treatment” (OR = 2.80, 95% CI = 1.47–5.36, p = 0.002), and “whether the patient or family had consulted with medical staff about financial issues” (OR = 2.52, 95% CI = 1.22–5.18, p = 0.012) had a significant correlation with “whether patients had withdrawn from or changed the cancer treatment recommended by their physician”. “Cost of care” (OR = 3.62, 95% CI = 1.32–9.95, p = 0.030), “whether the patient had financial concerns” (OR = 3.89, 95% CI = 1.68–9.00, p = 0.002), “whether the patient had cut down on his/her living expenses to pay for cancer treatment” (OR = 6.54, 95% CI = 2.76–15.50, p < .0001), and “whether the patient or family had consulted with medical staff about financial issues” (OR = 3.51, 95% CI = 1.50–8.24, p = 0.004) were significantly related to “whether patients had withdrawn from or changed the cancer treatment they wanted to receive”. Regarding patients’ experiences in paying for treatment, there were significant correlations between all 11 questions and “whether patients had withdrawn from or changed the cancer treatment recommended by their physician”.

Table 3

Correlation between patient characteristics and whether patients had withdrawn from or changed cancer treatment
		Treatment recommended by physician				Treatment patients wanted to receive
		OR	95% CI		p	OR	95% CI		p
			Low	High			Low	High
Gender	(vs. Male)
	Female	0.80	0.42	1.52	0.50	0.70	0.31	1.60	0.40
Age	(vs. <65 y)
	65–74 y	0.60	0.23	1.56	0.35	1.00	0.34	2.98	0.36
	> 75 y	0.73	0.31	1.71	0.85	0.46	0.15	1.42	0.073
Primary tumor site	(vs. Lung)
	Stomach, colon	0.49	0.19	1.26	0.16	0.09	0.01	0.71	0.019
	Liver, bile duct, pancreas	0.54	0.20	1.46	0.33	1.03	0.36	2.89	0.077
	Other	1.17	0.53	2.59	0.062	0.83	0.30	2.28	0.21
Duration of care received	(vs. <2 weeks)
	2 weeks to 1 month	1.73	0.76	3.93	0.24	1.50	0.59	3.80	0.082
	1–2 months	0.96	0.37	2.52	0.32	0.44	0.11	1.70	0.15
	> 2 months	1.70	0.68	4.29	0.34	0.87	0.25	3.01	0.99
Cost of care	(vs. <1 million JPY)
	1–2 million JPY	1.82	0.83	3.96	0.37	2.18	0.74	6.46	0.76
	> 2 million JPY	1.78	0.80	4.00	0.43	3.62	1.32	9.95	0.030
Employment status	(vs. None)
	Full-time	0.83	0.33	2.07	0.32	0.67	0.19	2.32	0.23
	Part-time	1.79	0.74	4.35	0.15	2.08	0.73	5.89	0.10
Whether the patient had financial concerns
	Yes (vs. No)	2.54	1.25	5.14	0.010	3.89	1.68	9.00	0.002
Whether the patient had private cancer insurance
	Yes (vs. No)	0.93	0.49	1.76	0.82	0.94	0.41	2.17	0.89
Whether the patient had cut down on his/her living expenses to pay for cancer treatment
	Yes (vs. No)	2.80	1.47	5.36	0.002	6.54	2.76	15.50	< .001
Whether the patient or family had consulted with medical staff about financial issues
	Yes (vs. No)	2.52	1.22	5.18	0.012	3.51	1.50	8.24	0.004
OR: odds ratio, CI: confidence interval.

Table 4

Correlation between whether patients had withdrawn from or changed cancer treatment and changes in daily life
		Treatment recommended by doctor				Treatment patients wanted to receive
		OR	95% CI		p	OR	95% CI		p
			Low	High			Low	High
Used all or a portion of savings
	Yes (vs. No)	2.14	1.14	4.04	0.018	3.45	1.52	7.81	0.003
Reduced spending on clothing
	Yes (vs. No)	2.42	1.29	4.56	0.006	3.42	1.55	7.54	0.002
Reduced spending on leisure activities such as vacations
	Yes (vs. No)	3.89	2.03	7.47	< .001	2.03	0.87	4.71	0.10
Reduced spending on food
	Yes (vs. No)	2.51	1.29	4.89	0.007	3.82	1.70	8.61	0.001
Worried about family’s living and school expenses
	Yes (vs. No)	3.02	1.57	5.81	< .001	3.24	1.43	7.35	0.005
Borrowed money from relatives (e.g., parents, children, siblings)
	Yes (vs. No)	3.21	1.54	6.71	0.002	1.99	0.72	5.56	0.19
Had disputes about money with family members
	Yes (vs. No)	3.33	1.59	6.97	0.001	3.34	1.32	8.46	0.011
Refrained from going to the hospital or purchasing prescription drugs
	Yes (vs. No)	5.54	2.22	13.86	< .001	6.02	2.00	18.13	0.001
Worked more hours to increase income (e.g., overtime, side jobs)
	Yes (vs. No)	4.13	1.62	10.54	0.003	1.72	0.38	7.86	0.48
Moved to a house where the rent was cheaper
	Yes (vs. No)	4.59	1.66	12.66	0.003	2.25	0.48	10.45	0.30
Sold possessions or property
	Yes (vs. No)	3.62	1.24	10.59	0.019	2.24	0.48	10.42	0.30
OR: odds ratio, CI: confidence interval.

The results of this study revealed that only a few (approximately 6–9%) patients with cancer in Japan withdrew from or changed the cancer treatment that was recommended by their physicians or that they opted to receive for financial reasons. However, in patients with financial difficulties or concerns due to cancer treatment, there was a significant correlation between their concerns and withdrawing from or changing treatment. Furthermore, it became clear that the patients’ subjective indices might have a stronger influence on withdrawing from or changing treatment than their objective financial situation. The strength of our results is the fact that they reflect the entire experience from cancer diagnosis to end-of-life, and not only a particular phase of cancer treatment.

In this study, approximately 6–9% of patients with cancer withdrew or changed their cancer treatment to some degree for financial reasons during their entire treatment period. This result may reflect the strength of the Japanese health insurance system. A previous study [3] from the United States reported that 7–9% of patients had altered the care recommended by their physician, such as not having a test and/or procedure or missing a clinical or chemotherapy appointment. Considering that our results also included respondents who answered, “some of the time” and “not very often”, relatively fewer participants in this study withdrew from or changed cancer treatment compared with that study. However, it should be noted that the previous study was based on patient-reported outcomes, whereas the present study was based on responses from bereaved family members. In addition, the previous study was conducted in the United States, where the out-of-pocket costs for patients are substantial and not all patients with cancer are insured [13]. In addition, few studies have investigated the financial burden of end-of-life care [14, 15], whereas a systematic review reported greater financial toxicity among patients with early-stage disease and/or more severe cancers [16]. The present study did not ask about the specific period of cancer treatment, but rather the entire period. Our results suggest that not all patients’ financial burdens are well managed under the Japanese health-care system.

In our study, the treatments that patients had wanted to receive before withdrawing or changing treatment for financial reasons included unproven cancer treatments, such as vitamins, homeopathy, and unproven immunotherapy (n = 10, 37%), and advanced medical treatments, such as proton beam therapy and heavy ion therapy (26%), neither or which are covered by insurance in Japan at the time the present survey was conducted. On the other hand, the percentage of patients who had difficulty continuing treatment that is covered by insurance was small. Again, it is difficult to compare the results as there are few reports of treatment withdrawal or change in other countries; however, the results of our study reflect the characteristics of the Japanese health-care system. Although unproven treatments and some advanced medical treatments are not covered by insurance in Japan, patients can receive standard treatment under the universal health-care system. Previous studies from Japan reported that almost half of cancer patients used complementary and alternative medicine (CAM) regardless of whether they were of proven efficacy and safety [17, 18]. Hyodo et al. indicated that oncologists must keep CAM in mind due to the high prevalence of usage by cancer patients [17]. On the other hand, Suzuki and colleagues reported that these uninsured treatments are often expensive, and approximately 30% of patients and families considered them a financial burden [18]. Although patients’ wishes should be respected as much as possible in regard to uninsured treatments, it is important to ensure that patients receive the standard treatments recommended by their physician, and that they do not have to withdraw from or change treatment because of a financial burden.

Moreover, in this study, there were significant correlations between the patients’ experiences regarding financial difficulties and their having to withdraw/change treatment. In addition, our results indicated that patients with financial difficulties were more likely to withdraw or change their treatment when the treatment had been suggested by their physician rather than being chosen by them. Therefore, medical staff should consider the financial difficulties of patients in relation to treatment, i.e., financial toxicity, as a serious side effect and assist patients in their decision-making by taking their socioeconomic background into consideration [19]. It might also be advisable to refer patients to specialists, such as medical social workers, so that they can receive and continue the treatment they need.

Finally, the study results suggested that subjective items used to evaluate the financial status of the patients, such as “whether the patient had financial concerns”, “whether the patient had cut down on his/her living expenses to pay for cancer treatment”, and “whether the patient or family had consulted with medical staff about financial issues”, were significantly related to withdrawing from or changing cancer treatment, whereas objective items, such as the duration of care received and annual income, were not. This indicates that the reason a patient decides to withdraw from or change cancer treatment might often be difficult for the medical staff to notice. Hence, medical staff might need to talk to patients to understand their subjective financial situation and introduce available support systems. In addition, previous studies have indicated that there are often barriers in terms of employment of cancer survivors.

In Japan, the out-of-pocket costs for patients are lower because of the medical system, so it seems that withdrawing from or changing cancer treatment occurs less frequently than in other countries. A systematic review of the financial toxicity associated with a variety of cancer diagnoses in countries with publicly funded health care reported out-of-pocket costs of 273 USD per month, even in countries with the most inexpensive health care [16]. As mentioned previously, Japan has a unique system that includes a “ceiling amount” for high-cost medical expenses, which limits monthly out-of-pocket costs to approximately 100–2,500 USD. Although no reports from Japan were included in the previous review, Japan could be considered one of the countries with the lowest out-of-pocket cancer costs. However, a small number of patients still had to withdraw from or change the treatment recommended by their physician because of a financial burden. Therefore, it might be necessary to improve health-care policies in Japan so that fewer patients with cancer experience financial burdens/toxicity when undergoing treatment.

Limitations

This study had several limitations. First, the participants were limited to those who had lost their loved ones in palliative care units in Japan. Second, there was a potential bias due to missing data from non-responders (response rate: 60%). Third, we could not discuss causality because of the cross-sectional study design. Fourth, the financial background of the patients, such as employment status, might have changed depending on their duration of care and disease condition.

In this study, 6–9% of the patients with cancer withdrew from or changed their cancer treatment by their end-of-life for financial reasons. These results suggest the importance of considering financial aspects during treatment-related decision-making.

Funding

This work was supported by JSPS KAKENHI (Grant No. JP 18K17480).

Conflict of interest

This study was supported by Hospice Palliative Care Japan. The authors declare no conflicts of interests.

Data availability

The data that support the findings of this study are available from the corresponding author (M.A.) upon reasonable request.

Code availability

Not applicable.

Author’s contributions

The study was conceived by Taichi Sasaki and Maho Aoyama. The study was designed by Maho Aoyama and Mitsunori Miyashita. Data were collected by Naoko Igarashi. Data were analyzed by Taichi Sasaki and Maho Aoyama. All authors contributed to the data interpretation. The first draft of the manuscript was written by Taichi Sasaki and Maho Aoyama. All authors contributed to the revision of the manuscript and reviewed the final version for submission.

Ethics approval

Ethical approval for the study was granted by the institutional review boards of Tohoku University Hospital and all participating institutions (Approval No. 2016–1-015).

Consent to participate

A document explaining the aims and procedures of the study was sent along with the questionnaire, stating that return of a completed questionnaire would be considered to indicate consent to participate in the study.

Consent for publication

A document was sent along with the questionnaire, stating that return of a completed questionnaire would be considered to indicate full consent for publication.

Acknowledgments

We wish to thank all the participants and institutions that participated in the study. English language editing and grammar check was supported by FORTE Science Communications (https://www.fortescience.com/).

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published 01 Mar, 2022

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01 Nov, 2021
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28 Oct, 2021
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15 Sep, 2021
First submitted to journal
13 Sep, 2021

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Influence of Financial Burden on Withdrawal or Change of Cancer Treatment in Japan: Results of a Bereavement Survey

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Abstract

Figures

Introduction

Methods

Measurements

Withdrawal from or change of cancer treatment

Experiences of financial difficulties in coping with the expenses of cancer treatment

Statistical analysis

Results

Discussion

Limitations

Conclusions

Declarations

References

Status:

Journal Publication

Version 1