CHARACTERISTICS OF OUT-OF-POCKET PAYMENT FREQUENCY AMONG COLORECTAL CANCER PATIENTS UNDERGOING CHEMOTHERAPY DEPENDING ON CLINICAL AND ANTHROPOMETRIC INDICATORS

Abstract

Introduction. Despite improvements in the accessibility of medical services following the introduction of the current healthcare reform in 2017, the issue of out-of-pocket (OOP) payments remains relevant. Colorectal cancer (CRC) is among the three most common malignancies in Ukraine and ranks second in terms of mortality.

Aim. To investigate the frequency of out-of-pocket payments among patients undergoing chemotherapy for colorectal cancer and its association with clinical and anthropometric characteristics.

Materials and methods. In this cross-sectional study, 459 patients who underwent treatment for CRC in Ukraine from July 1, 2023, to June 30, 2024, under the chemotherapy package of the Medical Guarantee Program were surveyed. Patients were divided into two groups according to the presence or absence of OOP payments (121 and 338 patients, respectively). The questionnaire comprised four groups of questions covering general information, attitudes toward informal payments, CRC-related clinical data (including disease stage and TNM classification), chemotherapy-related characteristics, and anthropometric indicators, including weight and height. Comparisons between groups were performed using the chi-square (χ²) test or Fisher’s exact test when the expected frequency in any group was less than 5. The Cochran–Armitage test was used to assess linear trends. Statistical analysis was performed using the R programming language (version 4.3.1) with the EZR graphical user interface (version 1.64).

Results. A statistically significant difference between the OOP payment groups was found for the N component of the TNM classification (p=0.04). Statistically significant linear trends were also observed for disease stage and the T and N components of the TNM classification (χ²=4.5, p=0.03 and χ²=6.0, p=0.02, respectively), waiting time for treatment, and the number of completed chemotherapy cycles (χ²=4.3, p=0.04 and χ²=4.9, p=0.03, respectively). Higher values of these variables were associated with a higher frequency of OOP payments. Additionally, OOP payments were more frequent among patients receiving palliative chemotherapy (p=0.001), those with metastases (p<0.001) or disease progression (p=0.001), those with a lower BMI (p<0.001), a greater percentage of weight loss over 5 years (p=0.024), and a more pronounced decrease in BMI over 5 years (p<0.001). No significant differences were found between the patient groups according to the mode of chemotherapy delivery (outpatient vs. inpatient) (p>0.05).

Conclusions. The study results indicate that patients at higher risk of OOP payments are characterized by more advanced colorectal cancer and a longer waiting period before initiation of chemotherapy (more than 2 months). OOP payments were more frequently observed among patients with more advanced disease according to the TNM classification, metastases or disease progression, those receiving palliative chemotherapy, and those who had completed a greater number of chemotherapy cycles. Notably, OOP payments were associated with indicators of nutritional depletion, including lower BMI, BMI <18.5, substantial (≥10%) weight loss over 5 years, and a more pronounced decrease in BMI over the same period. Overall, these findings highlight the need to improve the entire cancer care pathway for patients with CRC. To reduce OOP payments among CRC patients receiving chemotherapy at healthcare facilities, measures should include the implementation of an electronic waiting list, increased attention to patients with disease progression, metastases, or nutritional depletion, and regular managerial monitoring of delays in the provision of medical services.