Oncology Unfiltered: If a Patient Can’t Afford to Fill the Prescription, Is It Really a Treatment Option

In this episode of Oncology Unfiltered, Melissa Cutrona, Co-Founder and General Manager of i3 Health and Oncology Data Advisor, and Dr. Matthew Hadfield, Oncology Data Advisor Editor in Chief, explore financial and geographic toxicities in oncology and how they are really clinical toxicities. If a patient can’t afford to fill the prescription, is it really a treatment option?

Understanding Financial Toxicity as a Clinical Toxicity

Financial toxicity encompasses far more than drug prices. Dr. Hadfield emphasizes that clinicians must consider the whole patient experience: "If patients can't afford a treatment, or it's a significant burden to them financially to undergo a treatment, is it really a treatment that's offering benefit beyond potential efficacy?" The implication is stark—efficacy alone is insufficient if the treatment remains inaccessible.

When Wallets Influence Treatment Decisions

Despite advancements in oncology, access remains uneven. Dr. Hadfield highlights that even in resource-rich New England, geography and cost frequently drive care decisions. For patients in Rhode Island seeking tumor-infiltrating lymphocyte (TIL) therapy, the barrier is formidable: "Patients might have two hours in the car, significant parking expenses, limited transportation options back and forth, and facing all of these things on frequent visits."

The result is sobering. Patients decline innovative options not because the therapies lack scientific merit, but because they lack accessibility. Clinical trials face identical challenges. As Dr. Hadfield notes, "If someone has an opportunity to go on a novel clinical trial in Boston but doesn't have the capabilities financially, there are limitations—and it does happen." 

Impact on Shared Decision Making

Financial toxicity fundamentally alters the physician-patient conversation. The increasing complexity of oncology—from next-generation sequencing to minimal residual disease testing—adds layers of cost and nuance that clinicians often fail to address directly. Dr. Hadfield raises a critical concern: "Are we adequately educating patients that they may incur a financial bill for those tests?" 

He goes further, challenging the profession's approach to testing: "Any money that a patient has to pay for a test that isn't needed is something where they need to understand the potential benefits of having that information or not." Oncologists may be ordering tests not out of clinical necessity but out of habit or the desire for additional information, unknowingly burdening patients financially.

The Intersection of Geographic and Financial Toxicity

The burdens of distance and cost are deeply intertwined, creating a system where geography becomes destiny. Dr. Hadfield draws from personal experience: "I grew up in northern New York, two hours north of Syracuse. The town I grew up in was 5,000 people, and the closest academic medical center was over two and a half hours away." He reflects on the human cost: "Two and a half hours in a car, in a town that has a low socioeconomic baseline, that's an incredible burden."

Research confirms this disparity. "The closer you live to an academic medical center, the more likely you are to participate in a randomized phase 3 clinical trial," Dr. Hadfield notes, citing work by colleagues at Brown. Geography, therefore, becomes a stratifying factor in who receives cutting-edge care.

Newer therapies exacerbate these inequities dramatically. "If you have metastatic melanoma and you're not near one of those centers, it's going to be very, very expensive and very, very hard for you to even consider TIL therapy," he says. The statement extends beyond melanoma: "Unfortunately, that's not true of just TIL. We are now using multiple T-cell–engaging therapies, which require monitoring, and those are really only being done in larger centers." 

Creating a Two-Tiered System of Care

The concentration of advanced therapies in select centers has created an unspoken but undeniable reality: "If you're not near one of these centers or have the means to make it to one of these centers, the therapies really aren't available to you." Dr. Hadfield acknowledges the gravity of this situation: "We have to think about how to expand these treatments because ultimately, having very cool and potentially efficacious novel treatments for cancer patients is a wonderful thing, but only if you can get them to patients everywhere."

The Role of Institutions, Policy, and Pharma

While no single solution exists, progress is emerging. Dr. Hadfield credits both academic centers and pharmaceutical companies for improving patient support. Notably, he defends an often-maligned sector: "When you work with people at pharma companies. they're all very, very passionate about treating cancer patients and trying to increase access to care. I would consider them an ally with trying to increase access to these therapies." 

Rethinking Clinical Trial Diversity and Representativeness

Trial populations often skew toward patients who can afford participation, fundamentally skewing our understanding of real-world efficacy. Dr. Hadfield articulates the problem plainly: "We have very homogenous clinical trial populations, and as a result, patients are being enrolled who have the means to enroll, who are from higher socioeconomic situations and support systems. Inherently, that's going to improve their outcomes because they have access to care."

This creates a vicious cycle: the therapies we develop are tested on populations that do not represent the broader patient base, yet we apply the results universally.

The Holistic Cost of Cancer Care

Financial toxicity does not only mean the direct costs of treatment. "It also very much includes time lost at work,” Dr. Hadfield explains. “We really should focus on the holistic aspect of the patient: how the treatment’s going to affect their lives, how missing work may affect their lives, how having to go to another center may lead to a significant increase in bills. Ultimately, it matters a lot.”

When discussing metastatic disease, he articulates a sobering reality: "You're using therapy to try and induce the least amount of toxicity possible while increasing someone's lifespan and preserving their quality of life. A therapy might have a high potential for toxicity with a low potential of efficacy, and someone has socioeconomic factors that will be exacerbated or pushed to the brink by pursuing this therapy. If we don’t consider how their personal lives may be affected and if we don’t adequately explain the risks and benefits and potential outcomes, we would be doing a disservice to our patients.” 

What Needs to Happen Next? 

Dr. Hadfield acknowledges that in light of significant issues with patient access, discussing and researching disparities in treatment access is a critical first step. “We're talking much more about disparities than we ever have, thankfully, and that is at least part of the solution."

Key Takeaways

•      Financial and geographic toxicities are true clinical toxicities—not administrative concerns—that materially impact outcomes.

•      A treatment that is unaffordable or inaccessible is not a viable option, regardless of efficacy.

•      Shared decision making must include transparent discussions about cost, travel, lost wages, and logistical burdens—not just drug side effects.

•      Limited access to novel therapies creates inequitable tiers of cancer care based on zip code and bank account.

•      Clinical trial diversity suffers when participation requires substantial travel or financial resources, compromising the representativeness of efficacy data.

•      Systemic changes—policy, infrastructure, and care delivery redesign—are necessary to meaningfully reduce these disparities.

•      Clinicians must ask harder questions about whether every test, procedure, and referral is truly necessary or simply done out of habit.

•      If oncology aims to offer equitable, high-quality care, addressing financial and geographic barriers is not optional—it is essential clinical work.

Thank you for watching Oncology Unfiltered. Check out our playlist and stay tuned for next month’s topic, Molecular Testing Chaos: Are We Over-Testing, Under-Testing, or Testing the Wrong Things at the Wrong Time?