Financial toxicity and the economic cost of breast cancer therapy

Breast cancer impacts millions of lives globally. While the physical and emotional toll of cancer is widely recognized,the financial burden it imposes on patients and national healthcare systems is often overlooked, yet equally significant.

The economic burden can be as detrimental as the physical side effects of the disease and its treatment. As a reflection, the term “financial toxicity” was coined in 2013 by Doctors Yousuf Zafar and Amy Abernethy at Duke Cancer Institute. It describes the severe financial hardship that patients and their families experience due to high out-of-pocket expenses associated with cancer treatment.

What is financial toxicity in breast cancer?

Financial toxicity refers to the objective economic impact and subjective financial distress of cancer treatment experienced by patientsand their families, before, during, and after treatment. Financial toxicity includes:

• ‍Direct costs account for directly related expenses to medical treatment and care.These include hospital stays, surgeries, chemotherapy, radiation therapy, prescription drugs, and diagnostic tests.
•  Indirect costs comprise lost income due to the inability to work during the treatment associated with job loss and career impact, traveling to and from treatment centers, costs for informal caregivers, physical therapy…

Breast cancer diagnosis normally comes at a time of life of great impact on women, either at a professional or personal level, which increases the impact on indirect costs. In 2022, half of all estimated breast cancer cases in women in Europe occurred in the age group45-69. Being female, having low income, young age, and receiving prolonged adjuvant therapies are factors associated with financial toxicity.

 he impact of financial toxicity largely depends on the country's healthcare system. Patients in countries with private health services, such as the United States, are affected by gaps in insurance coverage, co-pays, and deductibles. This can lead to difficult decisions where patients must choose between paying for a potentially life-saving treatment or facing severe financial hardship.

Nevertheless, financial toxicity influences all health system structures and income levels. It even exists in countries with universal healthcare, such as the United Kingdom, Canada, Italy, and Japan, where the state typically covers the direct costs of cancer treatments. However,patients still face significant financial burdens from indirect costs, such as lost income and travel expenses for treatment, especially in rural areas.  

How much does breast cancer treatment cost? 

The efficacy of cancer treatment has significantly improved over the past few decades, thanks to advances in targeted therapies, immunotherapy, and precision oncology. These innovations have led to better survival rates, more effective management of various cancer types, and improved quality of life for patients. However, these advancements have also come with a substantial increase in costs as more treatment combinations have become available and as newer therapies have resulted in extended survival.

The average cost of breast cancer treatment around the world can vary significantly depending on the country and the type of treatment received. Globally, the cost per person over a year ranges from$128 to $196.226. In Italy, a country with a public healthcare system these numbers drop from $1157 to $9089, while in the USA the range is $505 to$196.226.

HER2+ breast cancer is a particularly aggressive form of cancer that requires costly and prolonged treatments, such as targeted therapies with trastuzumab and pertuzumab. These treatments, while effective, pose a significant financial challenge for both patients and national healthcare systems.

A study conducted in Denmark estimates that the average annual cost for a patient with HER2+ breast cancer treated with trastuzumab is approximately €58.217 during the first year after diagnosis.

Treatment optimization can help save costs and reduce financial toxicity. The duration of trastuzumab treatment significantly influences costs. The PERSEPHONE trial revealed that a six-month course of adjuvant trastuzumab can be as effective as the standard twelve-month course. This saves on average nearly £10.000 (€11.300) per patient with no evidence of detriment to quality of life.  Although, not every patient requires the same treatment duration or intensity. Some individuals may be correctly managed with a six months’ duration treatment instead of twelve.Others might need twelve months, correct selection and precision medicine is key. This approach can improve the financial burden for national health systems.

Treatment optimization for every individual case is key to reducing financial toxicity.

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Precision oncology has the potential to reduce financial toxicity in breast cancer

Precision oncology allows delivering the right cancer treatment to the right patient at the right dose and time.

Precision oncology has the potential to improve patient's quality of life and reduce costs associated with avoidable,often expensive treatments, as well as hospitalizations for adverse effects,without influencing treatment outcomes. It ultimately allows for a more effective use of healthcare resources.

In the case of HER2+ breast cancer, its heterogeneity generates diverse responses to the same treatment in diverse patients, allowing for the possibility to tailor therapy to each clinical case. Some patients may experience recurrence despite current therapies,while others may be cured with less intensive chemotherapy or no systemic treatment at all.

The administration of anti-HER2 agents and chemotherapy can result in various acute side effects such as reduced hematologic cell counts, alopecia, infections, nausea, vomiting, fatigue, hepatic inflammation, diarrhea, and cardiac dysfunction. These side effects can significantly impact the patient's quality of life, limiting their ability to work or take care of their families during the neo/adjuvant period and can persist long after treatment, resulting in long-term sequelae, which in turn increase direct and indirect costs contributing to financial toxicity.

HER2DX® is a precision oncology tool to guide HER2-positive breast cancer treatment,improving patients' quality of life without compromising its results.  

The DEFINITIVE project will assess the financial impact of an optimized treatment regime

HER2DX® is a genomic tool developed by REVEAL GENOMICS. This minimally invasive diagnostic assay uses a tumor sample previously obtained to analyze 27 genes involved in 4 key biological processes that lead to tumor development. It combines this information with 2 clinically used parameters: tumor size and the involvement of lymph nodes. This information is integrated into an artificial intelligence algorithm that provides scores to predict disease evolution and guide treatment choices.

HER2DX® guides healthcare professionals in selecting the optimal treatment for each patient, allowing them to reduce treatment intensity or reinforce it regarding the test results.

HER2DX® will be validated in the DEFINITIVE project,a prospective clinical trial , funded by the European Union. It is conducted to demonstrate that a personalized treatment guided by HER2DX® improves patients’ quality of life without affecting the outcome and survival rates. Besides evaluating health-related quality-of-life outcomes and measuring physicians' confidence in therapeutic decisions, the study will also focus on the financial aspect.  

The DEFINITIVE project will explore the financial impact of an optimized treatment regime guided by HER2DX®. It will include both direct and indirect costs, for hospitals and public health systems. Additionally, the study will explore the impact on work productivity through potential treatment de-escalation based on HER2DX®.