Cancer treatment-related financial toxicity experienced by patients in low- and middle-income countries: a scoping review

Financial Toxicity Among Breast Cancer Patients: A Scoping Review of Risk Factors and Outcomes

BACKGROUND

Breast cancer has become the leading cause of global cancer incidence. With the improvement of treatment methods, financial toxicity among breast cancer patients has been widely studied.

OBJECTIVES

The aims of this study were to summarize the risk factors for and outcomes of financial toxicity among breast cancer patients, to identify populations at risk for financial toxicity, to identify the consequent health impacts, and to provide evidence for subsequent intervention programs.

METHODS

We searched the PubMed/MEDLINE, Web of Science, MEDLINE (Ovid), CINAHL (EBSCO), EMBASE (Ovid), ProQuest, and China National Knowledge Infrastructure databases from inception to July 21, 2022. We followed the updated framework for scoping reviews proposed by the Joanna Briggs Institute.

RESULTS

A total of 31 studies were included. Risk factors and outcomes of financial toxicity among breast cancer patients were identified and extracted. The risk factors included socioeconomic, demographic, disease and treatment, and psychological and cognitive factors, whereas financial toxicity affected the physical, behavioral, and psychological domains of breast cancer patients, resulting in material loss, coping behaviors, and impaired health-related quality of life.

CONCLUSION

Financial toxicity among breast cancer patients depends on multiple factors and has profound effects. The findings will be helpful for identifying breast cancer patients at a high risk of financial toxicity and developing intervention programs to reduce financial toxicity and outcomes.

IMPLICATIONS FOR PRACTICE

More high-quality prospective, multicenter studies should be conducted in the future to better understand the trajectory of and risk factors for financial toxicity. Further studies should merge symptom management and psychosocial support into intervention programs.

Barriers and contributions of rural community health workers in enabling cancer early detection and subsequent care in India: a qualitative study

BACKGROUND

The cancer burden in India is escalating, with rural regions facing the greatest challenges in access to early detection and treatment. Community Health Workers (CHWs), such as Accredited Social Health Activists (ASHAs), Village Health Nurses (VHNs), and Auxiliary Nurse Midwives (ANMs), play a critical role in bridging these healthcare gaps. This study explores the barriers and contributions of CHWs while facilitating early detection and subsequent care in selected rural areas of India.

METHODS

This qualitative study is part of the Access Cancer Care India (ACCI) implementation research project, conducted in three states: Rajasthan, Kerala, and Tamil Nadu. We conducted six focus group discussions (FGDs) with 47 CHWs, representing various health cadres, to investigate their experiences and the barriers they face in delivering cervical, breast and oral cancer care. The discussions were analyzed using Charmaz's Grounded Theory approach, with axial coding and constant comparative analysis until data saturation was reached.

RESULTS

CHWs identified multiple barriers to cancer early detection and subsequent care delivery, organized into six overarching themes: (1) Program focus and awareness, (2) Treatment and referral challenges, (3) Acceptability and accessibility, (4) Rigid social customs and beliefs, (5) Lack of support at higher centers, and (6) Financial constraints. A lack of formal training, poor infrastructure, negative communication, fear of diagnosis, and financial burdens were among the major barriers highlighted. CHWs from Tamil Nadu and Kerala, where sporadic screening initiatives exist, reported better preparedness compared to their counterparts in Rajasthan. Additionally, the CHWs outlined the vital role of positive word-of-mouth and community engagement in improving cancer screening participation.

CONCLUSIONS

CHWs in rural India face significant personal, community, and health system barriers while facilitating cancer early detection services and subsequent follow up. Addressing these barriers through tailored training, enhanced health infrastructure, and community-based interventions can improve cancer care access and outcomes in rural settings. Future policies should focus on strengthening CHW-led approaches and addressing the systemic barriers in cancer care delivery.

Associations between financial toxicity, health-related quality of life, and well-being in Indonesian patients with breast cancer

OBJECTIVES

Financial toxicity (FT) is the impairment of financial well-being experienced by patients with cancer, categorized into subjective (SFT) and objective (OFT) forms. This study aimed to investigate the associations between FT, health-related quality of life, and overall well-being in patients with breast cancer.

METHODS

We analyzed baseline data from a single-center longitudinal study in Indonesia. Patients completed the EQ-5D-5L, EQ Health and Wellbeing (EQ-HWB), COST: A FACIT Measure of Financial Toxicity (FACIT-COST, for measuring SFT), and OFT-related questions. Ordinal logistic regression was used to examine the associations between FT and selected EQ-5D-5L and EQ-HWB items. Multivariable linear regression was used to assess the associations of FT and EQ-5D-5L and EQ-HWB-S index values. The main regression models were adjusted for socio-demographic and clinical factors such as age, income, metastasis status, and symptoms.

RESULTS

The survey included 300 female patients with breast cancer undergoing treatment (mean age = 51). Overall, 21% experienced high SFT (FACIT-COST ≤ 17.5) and 51% reported any OFT (e.g., incurring debt). Adjusted for covariates, higher SFT was associated with more problems in EQ-5D-5L pain/discomfort and anxiety/depression, and in EQ-HWB exhaustion, anxiety, sadness/depression, frustration, pain, and discomfort. OFT was associated with more problems in exhaustion. Higher SFT was associated with lower EQ-5D-5L and EQ-HWB-S index values, with explained variances of 46.3% for EQ-HWB-S and 31.2% for EQ-5D-5L.

CONCLUSIONS

This study is the first to explore the associations between financial toxicity, EQ-5D-5L, and EQ-HWB outcomes in breast cancer. Our findings provide insight into the cancer burden and its link to health and well-being.

Strategies for Mitigating Cancer-Related Financial Toxicity in China: A Multiperspective Qualitative Study Based on the Socioecological Framework

PURPOSE

To explore strategies related to cancer-related financial toxicity (FT) from the perspectives of cancer survivors and stakeholders in China and to evaluate their views within the context of the social ecological model (SEM).

METHODS

Between March and July 2022, we conducted a descriptive qualitative study with semistructured interviews of 23 cancer survivors and 14 stakeholders. Qualitative content analysis on the basis of the SEM was used to analyze the data with NVivo 12.

RESULTS

Guided by the SEM, we identified 12 subthemes that described how to mitigate FT. Individual-level strategies included increasing cost-related health literacy, strengthening adherence to standardized treatments, and improving resilience to cancer and financial changes. Interpersonal-level strategies included strengthening family support and social networks. Organizational-level strategies included using evidence-based treatments, effective communication of costs, and providing financial information support. Community-level strategies included improving symptom management throughout survivorship and providing psychosocial support. Policy-level strategies included optimizing health insurance policies and promoting collaboration among medical institutions.

CONCLUSION

Our findings provide a comprehensive understanding of strategies pertaining to FT, offering insights that could support the development of future interventions. This research suggests that interventions that encompass multiple levels-individual, interpersonal, organizational, community, and policy-rather than focusing on only one level might be the most beneficial for managing FT.

Depression, anxiety and associated factors among cancer patients in Africa; a systematic review and meta-analysis study

BACKGROUND

Depression and anxiety are the most common types of mental disorders among cancer patients. Many research studies carried out in African countries indicate that anxiety and depression are highly prevalent, but the results vary across regions. Thus, this study aimed to estimate the pooled prevalence and associated factors of depression and anxiety among cancer patients in Africa.

METHODS

The databases EMBASE, PubMed, African Journals Online, and Google Scholar were used to identify articles. This systematic review and meta-analysis included 32 (31 for depression and 25 for anxiety) original articles from 11 African countries. To detect publication bias, Egger regression tests and funnel plot analysis were employed. A sensitivity analysis and a subgroup analysis were carried out.

RESULTS

The pooled prevalence of depression and anxiety among cancer patients was found to be 53.21% (95% CI: 47.47-58.94) and 53.32% (95% CI: 46.85, 59.80) respectively. Across regions, the prevalence of depression among cancer patients was 60.03 (95% CI: 55.85-64.21), 53.59 (95% CI: 45.31-61.87), and 43.92 (95% CI: 36.17-51.67) in North, East, and West Africa, respectively. The pooled prevalence of anxiety among cancer patients was 64.85 (95% CI: 54.81-74.88) in North Africa, 49.53 (95% CI: 40.72-58.33) in East Africa, and 46.23 (95% CI: 38.98-53.48) in West Africa. Advanced stages of cancer (AOR = 3.8; 95% CI: 1.73, 8.42), less educated (AOR = 2.57; 95% CI: 1.28-5.14), and having no financial support (AOR = 2.03; 95% CI: 1.12, 3.67) were factors associated with depression. Advanced stages of cancer (AOR = 5.44; 95% CI: 1.95, 15.18) and no financial assistance (AOR = 2.88; 95% CI: 1.79, 4.63) were factors associated with anxiety.

CONCLUSION

Depression and anxiety among cancer patients are highly prevalent in Africa. Being at an advanced stage of cancer, low educational attainment, and not having financial support were all associated with depression symptoms; in addition, having advanced cancer and not having financial support were also associated with anxiety symptoms. Therefore, it is critical to screen cancer patients for anxiety and depression and provide them with appropriate interventions when these conditions arise.

Financial Toxicity in Cancer Supportive Care: An International Survey

PURPOSE

The study aims to explore unmet social needs and sources of financial toxicities in patients as noted by health care professionals and researchers in cancer supportive care, shedding light on potential health disparities.

METHODS

In this cross-sectional survey, we anonymously surveyed active members of the Multinational Association of Supportive Care in Cancer (MASCC). The survey, structured in three sections, included questions regarding the routine assessment of social needs during patient consultations, sociodemographic aspects, factors influencing financial toxicity (FT), perceived support for managing FT, and available/desirable resources.

RESULTS

A total of 218 MASCC members were included, predominantly from high-income countries (HIC, 73.4%), with many age 41-60 years (56.5%) and female (56.9%). Drug/treatment cost and insurance coverage were the main sources for FT among the HIC, whereas participants from low-middle-income countries (LMIC) considered transportation cost, loss of employment because of cancer diagnosis, and unavailability of return-to-work services as the top three sources of FT. Respondents from LMIC (adjusted odds ratio [aOR], 3.01 [95% CI, 1.15 to 7.93]) and physicians (aOR, 2.67 [95% CI, 1.15 to 6.21]) were more likely to routinely assess financial coverages. Socioeconomic status was consistently ranked as one of the top three sources of financial toxicities by participants from LMIC (34%), HIC excluding the United States (38%), those who do not self-identify as racial/ethnic minority (36%), and physicians (40%).

CONCLUSION

This global survey of health care professionals and researchers in HIC and LMIC revealed varying approaches to assessing financial coverage and social needs. Socioeconomic status emerged as a consistent concern across countries, affecting financial toxicities. The study highlights the need for tailored approaches and improved resource visibility while emphasizing clinicians' pivotal role in addressing financial aspects of cancer care.

Guiding Principles for Community Building in Global Oncology

With the escalating incidence and prevalence of cancer worldwide disproportionately affecting low- and middle-income countries, there is an urgent need for the global oncology community to foster bidirectional partnerships and an equitable exchange of knowledge, resources, and expertise. A dedicated Global Oncology Community of Practice (CoP) can serve as a self-organizing, grassroots approach for members, with common goals and values, to coordinate efforts, maximize impact, and ensure sustainable outcomes. It is imperative, however, when outlining goals and priorities to adhere to an ethical and appropriate framework during community building efforts to avoid perpetuating inequities and power imbalances. This article reviews the core guiding principles for ASCO's Global Oncology CoP which includes responsibility, amplification, accessibility, sustainability, and decolonization.

ESMO expert consensus statements on the screening and management of financial toxicity in patients with cancer

BACKGROUND

Financial toxicity, defined as both the objective financial burden and subjective financial distress from a cancer diagnosis and its treatment, is a topic of interest in the assessment of the quality of life of patients with cancer and their families. Current evidence implicates financial toxicity in psychosocial, economic and other harms, leading to suboptimal cancer outcomes along the entire trajectory of diagnosis, treatment, supportive care, survivorship and palliation. This paper presents the results of a virtual consensus, based on the evidence base to date, on the screening and management of financial toxicity in patients with and beyond cancer organized by the European Society for Medical Oncology (ESMO) in 2022.

METHODS

A Delphi panel of 19 experts from 11 countries was convened taking into account multidisciplinarity, diversity in health system contexts and research relevance. The international panel of experts was divided into four working groups (WGs) to address questions relating to distinct thematic areas: patients with cancer at risk of financial toxicity; management of financial toxicity during the initial phase of treatment at the hospital/ambulatory settings; financial toxicity during the continuing phase and at end of life; and financial risk protection for survivors of cancer, and in cancer recurrence. After comprehensively reviewing the literature, statements were developed by the WGs and then presented to the entire panel for further discussion and amendment, and voting.

RESULTS AND DISCUSSION

A total of 25 evidence-informed consensus statements were developed, which answer 13 questions on financial toxicity. They cover evidence summaries, practice recommendations/guiding statements and policy recommendations relevant across health systems. These consensus statements aim to provide a more comprehensive understanding of financial toxicity and guide clinicians globally in mitigating its impact, emphasizing the importance of further research, best practices and guidelines.

Pan-Canadian Survey of Radiation Oncology Professional Involvement in Global Oncology Initiatives in Low- and Middle-Income Countries

PURPOSE

Canadian radiation oncology professionals have a strong history of involvement in global oncology initiatives worldwide. This pan-Canadian survey-based study was conducted to determine the current level of engagement of Canadian radiation oncologists (ROs) and medical physicists (MPs) in global oncology initiatives and broaden the development of these activities.

MATERIALS AND METHODS

This was a cross-sectional study. The survey was designed to characterize current levels of engagement of Canadian ROs and MPs in global oncology initiatives. The survey was open from March 2019 to April 2020. It was disseminated to all Canadian Association of Radiation Oncology and Canadian Organization of Medical Physicists members with two subsequent email reminders.

RESULTS

Survey responses were received from 40 (93%) of the 43 Canadian cancer treatment centers that offer radiotherapy. At least one RO responded at 34 centers (79%) and one MP from 34 centers (79%) with some overlap. A response was received from a total of 93 participants, 47 ROs and 46 MPs. Of all survey participants, 58% reported some experience with global oncology. Nineteen percent of the participants surveyed were currently directly involved in short- or long-term projects, more than half of which have opportunity for additional staff involvement. The projects spanned 26 countries in South America, Africa, and Asia. Quality improvement and capacity building accounted for 27% and 20% of initiatives, respectively. The most common area of engagement was in direct treatment care, accounting for 56% of the projects.

CONCLUSION

This study demonstrates the landscape of involvement of Canadian ROs and MPs in global oncology initiatives. The study also highlights areas of opportunity for broadening international participation and collaboration as it relates to global oncology for Canadian radiation oncology professionals.

Interventions to Mitigate Financial Toxicity in Adult Patients with Cancer in the United States: A Scoping Review

Financial toxicity adversely affects quality of life and treatment outcomes for patients with cancer. This scoping review examined interventions aimed at mitigating financial toxicity in adult patients with cancer and their effectiveness. We utilized five bibliographical databases to identify studies that met our inclusion criteria. The review included studies conducted among adult patients with cancer in the United States and published in English between January 2011 to March 2023. The review identified eight studies that met the inclusion criteria. Each of the studies discussed the implementation of interventions at the patient/provider and/or health system level. Collectively, the findings from this scoping review highlight both the limited number of published studies that are aimed at mitigating financial toxicity and the need to create and assess interventions that directly impact financial toxicity in demographically diverse populations of adult patients with cancer.

Disparities of health expenditure associated with the experience of admission in long-term care hospital among patients with colorectal cancer in South Korea: A generalized estimating equation

With rising concerns about the functional role of long-term care hospitals in the Korean medical system, this study aimed to observe the experience of admission in the long-term care hospitals and their association with medical expenditures among patients with colorectal cancer, and to investigate disparities among vulnerable populations. Data were obtained from the National Health Insurance Senior Cohort Database in South Korea for the period 2008-2019. With 6,305 patients newly diagnosed with colorectal cancer between 2008 and 2015, we conducted a regression analysis using the Generalized Estimating Equation model with gamma distribution to investigate the association between health expenditure and the experience of long-term care hospitals. We also explored the interaction effect of disability or income, followed by subgroup analysis. Among patients who received care at long-term care hospitals, the health expenditure within one year and five years after the incidence of colorectal cancer was found to be higher than in those who did not receive such care. It was observed that the low-income and disabled groups experienced higher disparities in health expenditure. The rise in health expenditure highlights importance for functional improvement, aligning with these initial purpose of long-term care hospitals to address the growing healthcare needs of the elderly population and ensure efficient healthcare spending, of long-term care hospitals. To achieve this original intent, it is imperative for government initiatives to focus on reducing quality gaps in long-term care hospital services and addressing cost disparities among individuals with cancer, including those with disabilities or low-income.

Interventions for financial toxicity among cancer survivors: A scoping review

INTRODUCTION

Financial toxicity impairs cancer survivors' material condition, psychological wellbeing and quality of life. This scoping review aimed to identify interventions for reducing cancer-related financial toxicity (FT), and to summarize their main findings.

METHODS

A systematic search was performed in PubMed, Web of Science, EMBASE, CINAHL, Clinical Trials, China National Knowledge Internet, Wanfang and SinoMed from January 2010 to September 2022 following the PRISMA-ScR checklist.

RESULTS

From 2842 identified articles, a total of 15 were included in this review. Existing interventions can be classified into four types: financial navigation, financial counseling, insurance education and others. Previous interventions preliminarily affirmed the feasibility, satisfaction, and improvement in financial worries and knowledge. However, the effectiveness on FT was controversial.

CONCLUSIONS

Previous interventions affirmed the feasibility and primary effect of these interventions. Studies with more rigorous design are needed to evaluate the effectiveness and generalizability of interventions on FT across diverse healthcare systems.

Cost Drivers and Financial Burden for Cancer-Affected Families in China: A Systematic Review

This systematic review examined cancer care costs, the financial burden for patients, and their economic coping strategies in mainland China. We included 38 quantitative studies that reported out-of-pocket payment for cancer care and patients' coping strategies in English or Chinese (PROSPERO: CRD42021273989). We searched PubMed, Embase, Ovid, Web of Science, Cochrane, CNKI, and Wanfang Data from 1 January 2009 to 10 August 2022. We referred to the standards for reporting observational studies to assess the methodological quality and transparent reporting of the included studies and reported the costs narratively. Annual mean medical costs (including inpatient and outpatient costs and fees for self-purchasing drugs) ranged from USD 7421 to USD 10,297 per patient. One study investigated medical costs for 5 years and indicated that inpatient costs accounted for 51.6% of the total medical costs, followed by self-purchasing drugs (43.9%). Annual medical costs as a percentage of annual household income ranged from 36.0% to 63.1% with a metaproportion of 51.0%. The common coping strategies included borrowing money and reduction of household expenses and expenses from basic health services. Costs of inpatient care and self-purchasing drugs are major drivers of medical costs for cancer care, and many affected households shoulder a very heavy financial burden.

Cancer treatment-related financial toxicity in Japan: a scoping review

Financial toxicity during cancer survival has been studied mainly in the United States; 47-49% of cancer survivors reported financial hardships and 12-63% reported debt owing to treatment costs. Financial toxicity is influenced by each country's economic status and healthcare system. We aimed to review the evidence on financial toxicity in Japan. A systematic search was performed using PubMed and Ichushi databases. We included English or Japanese peer-reviewed articles that (1) explored the experiences of cancer patients facing financial toxicity due to cancer diagnosis and treatment, (2) were specific to Japan, and (3) focused on the experiences of financial toxicities among cancer patients. Data were extracted focusing on the experiences of patients, families, and healthcare providers. The main themes were synthesized based on a previous study. The search yielded 632 citations from PubMed and 21 from Ichushi, and non-duplicates were identified. Of these, 31 articles were selected for full-text review. Literature was divided into studies describing the following elements: (a) risk factors for financial toxicity, (b) description of financial toxicity, (c) psychological reactions, (d) coping strategies for financial toxicity, and (e) impact on treatment outcomes. Only three studies reported comprehensive financial toxicity scores. Furthermore, treatment costs influenced physicians' treatment decisions, and patients and their families adopted various strategies to cope with treatment costs. Two studies showed that low current income and younger age were high-risk factors. As for utilization of the support system, approximately 70% of the patients used the high-cost medical expense system, 20% used the sickness benefit system, and 40% used the medical expense deduction system. Many cancer patients in Japan suffer from financial toxicity during cancer survival. One reason for this is that the awareness of the system supporting financial toxicity is insufficient and actual utilization is low. It is necessary to actively encourage patients to ask healthcare providers questions, improve the link between patients and the support system, reconstruct the support system design, and improve the method of publicizing the system.

A qualitative study of lived experiences and needs of advanced cancer patients in Malaysia: Gaps and steps forward

PURPOSE

Due to the high burden of cancer-related suffering, it is paramount to understand the gaps in cancer care that lead to suffering. Advanced cancer patients have unmet needs and challenges that differ from those with early-stage cancer due to the rapid disease progression. By exploring advanced cancer patients' lived experiences and needs from the physical, psychological, social, and spiritual aspects, this study aims to identify gaps in the Malaysian health system and propose contextualised measures to improve cancer care.

METHODS

Semi-structured, in-depth interviews were conducted to explore advanced cancer patients' lived experiences and needs from the physical, psychological, social, and spiritual aspects. The interviews were then transcribed and coded. Themes were developed from the codes using iterative thematic approach.

RESULTS

The lived experiences and needs of nineteen patients converged into four major themes: disruption to daily lives, psychosocial and spiritual support system, information needs, and financial needs. This study described predominantly how cancer impacted patients' lives and livelihood, how patients coped with their psychological conditions after diagnosis, the need for effective communication and trust in a multicultural society, and how finance affected access to and experience of cancer care.

CONCLUSION

Advanced cancer patients had different needs beyond receiving medical treatments. A concerted effort is required from clinicians, allied health professionals, social workers, support groups, and family members to understand and fulfil these needs.