Navigating the Halo and Horn Effect
By Molly MacDonald
As breast cancer patients journey through the maze of cancer, from diagnostic testing to diagnosis, to prescribed treatment, they encounter a dichotomy of perceptions held by healthcare providers, including oncology radiologists. These perceptions, known as the Halo and Horn effects, subtly influence decisions that may impact the financial feasibility of treatment options, treatment adherence and ultimately survivorship outcomes.
The Halo effect illuminates the tendency to perceive individuals who exhibit one positive trait as possessing numerous other positive qualities. In the context of cancer care, a patient's perceived financial stability or access to resources can often cast a radiant halo, leading healthcare professionals to assume the patient’s ability to afford treatment. However, this assumption fails to recognize the financial intricacies that can cause patients to skip treatment.
Conversely, the Horn effect accentuates negative traits, clouding perceptions and leading to judgments that may unfairly impede access to necessary treatments. Patients from marginalized communities, or with limited financial resources often find themselves ensnared in the horns of this bias. Radiation oncologists may unwittingly associate financial constraints with a lack of commitment to treatment, overlooking the resilience and determination that characterize many patients facing economic hardship.
These unconscious biases manifest in various ways including assumptions about patients’ socioeconomic status, insurance coverage, level of education and occupation.
Consider the case of Molly, a post-menopausal woman diagnosed with early-stage breast cancer. She is seen as financially secure due to how she presents; well-dressed and well-spoken.
Her radiation oncologist will overlook the hidden complexities of her financial situation because of what they don’t know about Molly.
No one has screened Molly for financial toxicity.
What they don’t know is that Molly was diagnosed during a time of job transition and has a costly COBRA health premium of $1,300 a month, equal to her monthly house payment.
What they don’t know is that Molly went through a financially devastating divorce and was left to raise five children on her own.
What they don’t know is that Molly has no savings, child support or alimony.
Despite her Halo effect, Molly’s home will fall into foreclosure within three months of starting treatment and every 58 days she will be threatened with vehicle repossession unless she makes a payment on her car note. If Molly’s car is repossessed, she will have no way to get to the six weeks of daily radiation as prescribed.
The Halo effect blinds healthcare providers to these financial realities, potentially compromising survivorship outcomes and annually costing the healthcare system billions in lost revenue when patients don’t show up for treatment.
Conversely, an elderly black woman living in the city of Detroit experiences the unconscious bias of the Horn effect which leads her physician to assume she cannot afford treatment and would be unwilling to seek financial assistance.
Study after study has shown that Black and Hispanic cancer patients are more likely to experience financial toxicity than their White counterparts.
In a 2018 study on financial toxicity, it was found that many patients report inadequate clinician engagement in the management of financial toxicity, even though many providers believe that they make services available. (Jagsi R, Ward KC, Abrahamse PH, Wallner LP, Kurian AW, Hamilton AS, Katz SJ, Hawley ST. Unmet need for clinician engagement regarding financial toxicity after diagnosis of breast cancer. Cancer. 2018 Sep 15).
Integrating financial screening at the time of diagnosis and before treatment begins is essential to treatment adherence and survivorship outcomes. Additionally, patients need to be screened for financial toxicity throughout the care continuum because treatment protocols and circumstances may change.
Financial counseling and support services can serve as a potent antidote to the insidious effects of bias. By equipping patients with the resources and information needed to navigate the financial maze, healthcare providers can empower individuals to make informed decisions about their treatment options. Additionally, fostering open communication and trust between clinicians and patients can dismantle barriers erected by the Halo and Horn effects, fostering a collaborative partnership grounded in mutual respect, understanding and shared decision-making.
Healthcare institutions can implement policies and practices aimed at reducing financial toxicity, such as transparent pricing information, financial counseling and connecting patients with resources for financial assistance.
It is important to recognize that financial toxicity is not limited to the patient, but to the provider as well, as missed diagnostic and treatment appointments cost the US Healthcare system $150 billion annually according to a 2017 study. (Chen AM. Socioeconomic and demographic factors predictive of missed appointments in outpatient radiation oncology: an evaluation of access. Front Health Serv. 2023 Nov 27). We can assume it will be significantly more in 2024.
In 2021, another study identified knowledge gaps in treatment expectations, provider conversations, identification of resources, and support-finding. This study surveyed breast cancer patients who were recipients of financial assistance provided by Pink Fund, a national breast cancer nonprofit.
Ultimately, navigating cancer treatment is fraught with challenges, both medical and financial. By recognizing and addressing the influence of biases such as the Halo and Horn effects, physicians can uphold the principles of equity and justice that lie at the heart of compassionate care. In doing so, they not only honor the inherent dignity of each patient but also contribute to a healthcare system that strives to serve all individuals.
This article was published in the October edition of GE Healthcare's Breast Care Magazine.