Evaluating predictors of financial toxicity in head and neck cancer patients treated with transoral robotic surgery

Presentation: A101
Topic: Oropharynx / HPV Related Disease
Type: Poster
Authors: Austin C Cao, BA; Evan Cretney, MD; Leila J Mady, MD, PhD, MPH; Jason G Newman, MD; Ara C Chalian, MD; Karthik Rajasekaran, MD; Steven B Cannady, MD; Devraj Basu, MD, PhD; Gregory S Weinstein, MD; Robert M Brody, MD
Institution(s): University of Pennsylvania Department of Otorhinolaryngology- Head and Neck Surgery


Patients with HPV-associated (HPV+) oropharyngeal squamous cell carcinoma (OPSCC) are younger and have better prognosis, leading to an increased focus on adverse treatment effects. One underrecognized adverse effect is financial toxicity (FT), understood as the patient-level impact of the costs of cancer care.  


 To test our hypothesis that there are identifiable risk-factors for FT in HPV+ OPSCC we aimed to 1) examine the prevalence of FT in patients receiving primary transoral robotic surgery (TORS) and 2) identify patient and treatment-level predictors for worse FT.

Study Design: Single-site, cross-sectional cohort survey study.

Methods: Eligible patients were ≥18 years who received primary TORS for HPV+ OPSCC between March 2007-March 2021. A survey including financial and insurance status, swallowing function [MD Anderson Dysphagia Inventory (MDADI), 20 (extremely low functioning)–100 (high functioning); Functional Oral Intake Scale (FOIS), 1 (no oral intake)–7 (total oral diet)], and subjective financial toxicity [Comprehensive Score for Financial Toxicity (COST), 0 (worse toxicity)–44 (less toxicity)] was sent to participants. A retrospective chart review was conducted to collect demographics, treatment information, and survival outcomes. 

Results: A cohort of 120 cancer survivors were included [response rate 12.9%, male 89% (n = 107) median age 60 (IQR = 54-64)]. Median time between treatment and survey completion was 5.24 years (IQR = 3.46-7.27). There were no differences by sex, age, race, insurance class, or type of adjuvant treatment between the response and non-response cohorts. In the study cohort, 41% (n = 49) reported a COST score £ 25, representing high FT.  There were significant differences in COST scores by race and income. Reported FT was worse in non-white compared to white patients [10 (95% CI: 4-17) vs. 29 (27-31), p < 0.001] and for those with lower annual income at time of surgery [< $40,000, 20 (14-27) vs. $40,000-79,000, 23 (20-27) vs. $80,000-150,000, 31 (28-34) vs. > $150,000, 34 (31-37), p < 0.001]. These factors also demonstrated significant associations on multiple linear regression (p < 0.001). Treatment factors associated with worse FT included free flap reconstruction [25 (19-30) vs. 31 (28-34), p = 0.022], and adjuvant treatment modality [surgery only, 36 (32-39) vs. adjuvant radiation, 28 (25-32) vs. adjuvant chemoradiation, 27 (22-32), p = 0.015]. At time of survey completion, worse FT was also significantly associated with patient-reported swallowing outcomes, including impaired functional oral intake [26 (23-28) vs. 31 (28-33), p = 0.007], and moderate/severe dysphagia on composite MDADI [23 (19-27) vs. 30 (27-32), p = 0.002]. On multiple linear regression, composite MDADI but not impaired functional oral intake remained an independent predictor of FT when controlling for race, income, and time from surgery date. Factors not associated with COST included late tumor stage (pT3/4), time from surgery date, government-sponsored insurance, lack of full-time employment at surgery date, and loss of full-time employment following surgery.

Conclusions: Income, race, adjuvant treatment modality, and long-term patient-reported swallowing outcomes are associated with FT. There is an increasing need for healthcare providers to understand and develop strategies to identify and assist at-risk patients.