title: Cancer patients' trade-offs among efficacy, toxicity, and out-of-pocket cost in the curative and noncurative setting.
abstract: BACKGROUND
  When making treatment decisions, cancer patients must make trade-offs among efficacy, toxicity, and cost. However, little is known about what patient characteristics may influence these trade-offs.
  
  
  METHODS
  A total of 400 cancer patients reviewed 2 of 3 stylized curative and noncurative scenarios that asked them to choose between 2 treatments of varying levels of efficacy, toxicity, and cost. Each scenario included 9 choice sets. Demographics, cost concerns, numeracy, and optimism were assessed. Within each scenario, we used latent class methods to distinguish groups with discrete preferences. We then used regressions with group membership probabilities as covariates to identify associations.
  
  
  RESULTS
  The median age of the patients was 61 years (range, 27-90 y). Of the total number of patients included, 25% were enrolled at a community hospital, and 99% were insured. Three latent classes were identified that demonstrated (1) preference for survival, (2) aversion to high cost, and (3) aversion to toxicity. Across all scenarios, patients with higher income were more likely to be in the class that favored survival. Lower income patients were more likely to be in the class that was averse to high cost (P<0.05). Similar associations were found between education, employment status, numeracy, cost concerns, and latent class.
  
  
  CONCLUSIONS
  Even in these stylized scenarios, socioeconomic status predicted the treatment choice. Higher income patients may be more likely to focus on survival, whereas those of lower socioeconomic status may be more likely to avoid expensive treatment, regardless of survival or toxicity. This raises the possibility that insurance plans with greater cost-sharing may have the unintended consequence of increasing disparities in cancer care.
authors.affiliation: Fox Chase Cancer Center, Temple Health System, Philadelphia,PA 19111, USA. yu-ning.wong@fccc.edu
authors.forename: Yu-Ning
authors.initials: YN
authors.lastname: Wong
authors.forename: Brian L
authors.initials: BL
authors.lastname: Egleston
authors.forename: Kush
authors.initials: K
authors.lastname: Sachdeva
authors.forename: Naa
authors.initials: N
authors.lastname: Eghan
authors.forename: Melanie
authors.initials: M
authors.lastname: Pirollo
authors.forename: Tammy K
authors.initials: TK
authors.lastname: Stump
authors.forename: John Robert
authors.initials: JR
authors.lastname: Beck
authors.forename: Katrina
authors.initials: K
authors.lastname: Armstrong
authors.forename: Jerome Sanford
authors.initials: JS
authors.lastname: Schwartz
authors.forename: Neal J
authors.initials: NJ
authors.lastname: Meropol
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003362:Cost-Benefit Analysis; D003657:Decision Making; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000628:therapy*; D057240:Patient Preference / Q000191:economics / Q000523:psychology / Q000706:statistics & numerical data*; D011788:Quality of Life; D012959:Socioeconomic Factors