Tackling Financial Toxicity: One Institution’s Roadmap Forward

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Hanna K. Sanoff, MD, MPH

Hanna K. Sanoff, MD, MPH

ALTHOUGH FINANCIAL toxicity has become an important issue in the oncology community, evidence suggests the subject is rarely addressed by oncologists, exacerbating its grave effects on patients with cancer and their families.1 “But I don’t think it’s because health-care providers don’t want to talk about it. I think it’s because they feel they can’t do anything about the situation,” said Hanna K. Sanoff, MD, MPH, as she began her presentation titled, “Challenges and Triumphs of Addressing Financial Toxicity in Clinical Care” at the 2018 ASCO Quality Care Symposium.2

According to Dr. Sanoff, who is Clinical Medical Director of the University of North Carolina (UNC) Lineberger’s North Carolina Cancer Hospital, even the most financially educated health-care providers cannot solve this complex problem by addressing it with individual patients. “Only systemic change in how we address financial toxicities at an institutional level is going to have a substantive effect on the financial well-being of our patients with cancer,” said Dr. Sanoff.

Case Study

USING A CASE STUDY from her own institution’s program to refine financial navigation, she commented, “This effort should provide a practical look at the challenges faced when trying to implement financial navigation in clinical care.”

The case study was a 25-year-old man with testicular cancer who had been referred for stem cell transplant. At the time of diagnosis, he had no health-care coverage. He did, however, have a “catastrophic plan,” which is not uncommon among people in his age bracket. The plan had a large out-of-pocket responsibility.

“Only systemic change in how we address financial toxicities at an institutional level is going to have a substantive effect on the financial well-being of our patients with cancer.”
— Hanna K. Sanoff, MD, MPH

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“We have an outstanding financial counseling team built into our clinical program. When this man sat down with our stem cell transplant team, they discovered that he had an outstanding balance of more than $100,000, which was very disturbing, especially since he had been seen solely by doctors at UNC for his 6 months of care,” said Dr. Sanoff. Moreover, the young man had been a hospital inpatient and he’d worked with social workers, yet he had never been referred to a financial counselor. At this time, Dr. Sanoff polled the audience asking whether their institution would have had mechanisms in place to prevent this young man from accruing such a steep balance. The response was mixed, about 50-50, yes and no.

Key Challenges

DR. SANOFF examined some of the underlying challenges at UNC that created this financial toxicity scenario. Not surprisingly, the first issue was a lack of recognition of the problem. “We began with a backdrop of the rising national awareness about the importance of financial toxicity and the dissatisfaction among our clinical team and patients about how we were addressing the problem,” she said.

To that end, Dr. Sanoff and her colleagues met with the clinical leadership of the Hematology/Oncology Division and selected financial navigation as their primary concern for the operational group at UNC. They also agreed to meet with noted health-care financial consultant Dan Sherman.

“After the meeting, I naively thought we were on our way to a solution, one that money alone could provide. But the idea was dead in the water because we hadn’t done our legwork to bring all the UNC stakeholders involved with the problem to the table in a collaborative way,” said Dr. Sanoff.

She illustrated part of the implementation challenge with a slide that parodied the UNC dilemma of breaking down a siloed system in which the patient-centered team and the business team compete for limited resources. “Even though we had ‘boots on the ground’—nurse navigators, social workers, and financial navigators—there were really no touch points at the vice president level or below to look at quality concerns on a regular basis,” noted Dr. Sanoff.

Point by point, she examined the various implementation hurdles they faced at UNC, from deploying new hires, training financial navigators, triaging patients if understaffed, providing accurate care costs to patients, and proving value of the program to leadership.

Early Success and Program Implementation

ACCORDING TO Dr. Sanoff, an early success at the North Carolina Cancer Hospital was in establishing a yearly meeting as a quality care program to vote on and select a number of projects that would be central to improvement goals moving forward.

“In the past year, enhancing financial navigation received the most votes as something we needed to address in the next fiscal year. I think it was really important that we brought together the business team, the clinical team, and members of our Patient and Family Advisory Council all in the same room,” she said.

As a primary strategy, UNC hired additional members to the financial navigation team to be deployed to cancer services. “The financial navigation team can be accessed largely through the clinical group, where nurses, social workers, or patients themselves recognize a need and ask to be referred to the financial counselors,” she noted.

The UNC team also provides clinical orientation, workshops on communication, didactics on financial toxicity, and oncology-specific resources, both at the university and through assorted foundations. “And each of our new hires is taking the Association of Community Cancer Center’s Financial Advocacy Boot Camp class,” said Dr. Sanoff.

She concluded, “The implementation hurdles I’ve mentioned are not unique to the University of North Carolina, because true financial navigation is a new field. Most important, you need to take time to meet with the stakeholders from business and patient-centered perspectives. The more we can do as a quality community, the less activation energy will be required to foster nationwide change in how we address financial toxicity.” ■

DISCLOSURE: Dr. Sanoff has received institutional research funding from Bayer and Merck.


1. Greenup RA, Rushing C, Fish L, et al: The costs of breast cancer care: Patient-reported experiences and preferences for transparency. 2018 ASCO Quality Care Symposium. Abstract 207. Presented September 29, 2018.

2. Sanoff HK: Challenges and triumphs of addressing financial toxicity in clinical care. 2018 ASCO Quality Care Symposium. Presented September 28, 2018.