QS138 - The Impact of Out-of-Pocket Medical Expenses on Patients’ Preferences in the Surgical Management of Low Rectal Cancer

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Purpose/Background: Financial hardships following surgical treatment of rectal cancer is associated with significant psychosocial distress and a deterioration in quality of life. However, financial considerations are rarely part of the discussion of surgical treatment options. In fact, little is known about how out-of-pocket expenses may impact patients’ medical decision making in the context of rectal cancer surgery. Thus, the objective of this study is to determine whether potential out-of-pocket expenses of rectal cancer treatment will influence the patient’s choice of surgery.

Methods/Interventions: This is an ex-ante prospective study investigating patient preferences. Ambulatory adult patients undergoing colorectal evaluation for benign disease at a tertiary colorectal centre were approached for participation. Participants were presented a hypothetical scenario in which they have been diagnosed with a cT2N0 low rectal cancer. Two surgical options were offered: abdominoperineal resection (APR) versus local excision. Sphincter preservation was omitted because its associated bowel dysfunctional in low rectal cancer generates additional complexity that may detract from the goal of evaluating the impact of cost alone. Furthermore, the practice at our institution is to encourage APR for low-lying rectal cancers requiring proctectomy due to the poor functional outcomes associated with sphincter preservation and coloanal anastomoses.

Key advantages and disadvantages of both options were presented, but associated out-of-pocket expenses were left out at first. A questionnaire was then used to elicit patient preferences. Participants were initially asked to choose between local excision with a 10% increased risk of local recurrence versus an APR with a permanent colostomy. Next, the out-of-pocket expenses of these respective surgeries were revealed to participants. For local excision, there are no expected out-of-pocket expenses. For APR, the out-of-pocket costs of stoma appliances in Quebec is approximately $2200 per year. Participants who would undergo APR were then asked whether the out-of-pocket expenses would influence them to change their decision to local excision instead and accept a higher local recurrence rate.

Results/Outcomes: A total of 31 patients have been recruited to complete the questionnaire so far. 29% of participants initially chose an APR and 71% chose a local excision. There were no differences in the baseline patient characteristics between the 2 groups, including health literacy. All patients who initially chose APR changed their treatment preference to local excision if the recurrence rate was lower (mean risk 6.1%, SD=2.2). Once presented with the out-of-pocket expenses associated with an APR, 11% of participants would change their decision to have a local excision and accept a higher local recurrence rate. Of those who initially chose local excision, 54.6% would never accept an APR, no matter the risk of local recurrence.

Conclusion/Discussion: These preliminary results suggest that the potential out-of-pocket expenses associated with a lifelong stoma may affect patients’ treatment preferences in rectal cancer. Financial information should be included as part of the informed consent discussion and shared decision-making process.