Discussion and Future Directions
Calls have been made to reduce survivor exposure to the virus by postponing adjuvant treatments or elective surgeries for “stable patients”17 and minimizing extended treatments whenever possible.64 These measures may not only limit exposure but also decrease potentially unnecessary treatment-related financial toxicity at this critical time. Additionally, there is a critical need – now more than ever before – to promote financial planning among patients and improve the frequency and content of patient-provider communication concerning expected OOP expenses.65 It is essential to adopt an approach of shared decision-making, involving patients not only in conversations regarding goals of care, but also discussions involving access to care, availability of caregiver support, and exposures to financial toxicity. This also raises the need for early palliative care intervention and incorporation within treatment plans. Although the capacity for palliative care may be limited at this time due to increased demand,66 experiences from other institutions do provide a framework to improve delivery of high-quality palliative care during the pandemic.67,68 These measures, however, do not specifically address patients with cancer, as of yet. The potential vulnerability of this patient population, both to the infection itself as well as the economic ripples of the pandemic, highlight an urgent need for future paradigms specifically addressing cancer survivors.
The pandemic and its economic repercussions have the potential to disproportionately affect cancer survivors’ financial status and, as a result, their HRQOL and mortality.2-8 Estimation of financial toxicity is a complex problem. The socioeconomic impacts due to COVID-19 are multi-layered and include 1) loss of household income due to unemployment and death of earning members; 2) temporary or permanent closure of small businesses; and 3) loss of productivity of a business. We have a variety of questions to address in order to fully examine these issues. For example, how should we conduct optimal survey designs for such studies? What are the suitable variables to investigate? How do we model these resulting data? Studies such as these may have a major impact on healthcare delivery systems, payors, providers, and consumers.
We may start to tackle these questions by heightening our sensitivity – developing a collective consciousness – to the increased vulnerability of our patients to financial toxicity in the context of the COVID-19 pandemic. There is a need to develop interventions and facilitate policy changes at local and national levels to mitigate the effects of the current pandemic as well as protect our patients from cyclic infectious outbreaks and recurrent recessions. Though telemedicine is a tool, it is not the solution. Despite the recent unprecedented adoption of such technology to manage patients remotely, the current health crisis has revealed widespread discrepancies in telehealth systems and regulations surrounding reimbursement. We must get creative and leverage multidisciplinary stakeholders, not only within tertiary practice centers, but also within our communities to balance the virtualization of care delivery with critical in-person visits. By doing so, we may strive to minimize treatment interruptions and non-adherence and help our patients attenuate the adverse outcomes of financial toxicity during and after the COVID-19 era.
Full author list
Khalil Baddour, MD Department of Otolaryngology – Head and Neck Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
Lauren D. Kudrick, MA, Med Department of Medicine, Division of Infectious Diseases; Department of Otolaryngology – Head and Neck Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
Aakriti Neopaney Department of Otolaryngology – Head and Neck Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
Lindsay M. Sabik, PhD Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health; University of Pittsburgh Health Policy Institute; UPMC Hillman Cancer Center; Pittsburgh, PA 
Shyamal D. Peddada, PhD Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
Marci L. Nilsen, PhD, RN Department of Acute and Tertiary Care, University of Pittsburgh School of Nursing;  Department of Otolaryngology – Head and Neck Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
Jonas T. Johnson, MD Department of Otolaryngology – Head and Neck Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
Robert L. Ferris, MD, PhD UPMC Hillman Cancer Center; Department of Otolaryngology – Head and Neck Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
Leila J. Mady, MD, PhD, MPH  Department of Otolaryngology – Head and Neck Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
  
Keywords: Coronavirus; COVID-19; Cancer; Financial Toxicity; Head and Neck
 
Disclosure Statement: The authors have no conflicts of interest to declare.
 
Acknowledgments: The authors would like to thank Aishat Okunade for her help and contributions to this article. 
 
Funding: This work was supported by American Academy of Otolaryngology – Head & Neck Surgery Foundation (AAO-HNSF) and the Centralized Otolaryngology Research Effort (CORE) Study Section - Health Services Research Grant (Mady, Johnson); and UPMC Hillman Cancer Center Specialized Programs of Research Excellence (Ferris, Mady)