Understanding and Addressing Patient and Provider Preferences Around Discussions of Cost of Breast Cancer Care

Newly diagnosed breast cancer patients over the age of 18 will be eligible for participation.
All stages of disease will be included. Eligible participants will be approached in clinic.
Those interested will provide written, informed consent at the time of their clinic visit.
All participants will be asked to complete baseline surveys consisting of the InCharge
Financial Distress/Financial Well Being scale (IFDFW),[24] the Maximizer-Minimizer Scale,[25]
and a three question, 5-point Likert scale survey about desire for cost information (1: How
concerned are you about the cost of your cancer care? 2: How interested are you in discussing
cost of care with your doctors? 3: How interested are you in meeting with a financial
counselor about the costs of your care?) Demographic information including age, race and
ethnicity, marital status, number of children, current employment status of self and spouse,
and education level will be included. To decrease participant burden and encourage study
participation, only the three question survey will be required to be completed prior to the
visit. The other survey components (IFDFW and Max-Min Scale) can be completed after the
visit, but prior to seeing a financial counselor. Participants will be offered a $10 giftcard
of their choice (grocery store, Starbucks, Amazon, or gas) at each survey timepoint ($20
total) for participation.

For this study, we will use a pre and post design with 100 total participants. All visits
will be audiorecorded, transcribed, and coded for whether cost was discussed in the control
group and whether the intervention was successfully implemented in the intervention group as
well as shared decision making using the observer-OPTION scale. The first 50 patients will
have usual care with providers conducting the visit in their typical manner.

From our past studies, study team discusses cost in 15% of visits, though these discussion
tend to be very superficial. The second group of 50 patients will be the intervention group
where the providers will have a discussion of cost emphasizing five points: 1) Cancer care is
expensive and it is normal to be concerned about cost. 2) We will recommend treatments for
your cancer based on what we think gives you the best chance of doing well, not based on the
cost of the treatment. 3) Because of how complex our healthcare system is, it is very hard
for your doctors to know what your costs will be, but we will do our best to give you some
general information. 4) We have resources available to help you get more specific information
so that you can plan appropriately. 5) Do you have any specific concerns about cost that
you'd like to share with me? We will encourage study team to have this discussion at the
beginning of the consult, but the exact timing will be according to study team judgment.

After the visit, all patients will complete a patient satisfaction survey and will be offered
a referral to a financial counselor at our institution. Financial counseling will take place
per our usual institutional protocols either in person or over the phone. Our financial
counselors are aware that they may see an increased volume of patients during the study
period and we will provide funding to cover the increased need. Volume will be tracked during
the study period and compared to the non-study period and between the groups.

At the first three to six-month follow-up visit with the surgeon, participants will again
complete the IFDFW, a validated patient satisfaction scale[26], and the Satisfaction with
Decision Scale.[27].

Data will have personal health identifiers removed from the data for the analysis portion of
the study. PHI will not be reused without first seeking IRB approval.

We will enroll 100 patients in two consecutive groups of 50. This gives us 80% power with a
two sided significance level of 0.05 for seeing a 27-30% improvement (0.27-0.3 higher score)
in our primary outcome of financial well-being as measured by the IFDFW in the intervention
group at 3-6 months after the initial visit; the average pre-score on the IFDFW is 5.52 in
past studies with improvements of 0.32-1.18 seen in past studies of education interventions
to improve financial well-being.[24] This level of difference may not be achievable with this
small study, but will provide data for powering a larger study.

Maximizer-Minimizer status, uptake of financial counseling, patient satisfaction, decision
satisfaction, and demographic variables will be evaluated for associations with financial
well-being using logistic regression methods.

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Inclusion Criteria:

- Age 18 or older

- All patients who present to Huntsman Cancer Hospital/University of Utah for a newly
diagnosed breast cancer surgical consultation.

Exclusion Criteria: