In oncology, the term "financial toxicity" means the financial hardship or financial burden for patients and families that arise from cancer treatment and ongoing expenses. Individuals from any socioeconomic group may experience this, and it can occur in both low- and high-income countries. There are 2 key contributors: (1) high medical payments by individuals/households and (2) reduced income while being treated or recovering from cancer. The former is likely to affect more individuals in high-income countries, whereas the latter is more problematic in poor households although, clearly, individuals will be worse when faced with both high out-of-pocket medical expenses (outgoings) and concurrent loss of earnings (incomings). In some studies, financial hardship is defined as spending greater than 30% of household income on healthcare and is termed "catastrophic spending."1

What is the State of Science in Financial Toxicity?

Studies reporting on the personal financial burdens of cancer are not new. There are hundreds of published studies and several reviews on the topic. In our recent systematic review,2 we assessed the most recent evidence of financial toxicity and the ways in which researchers measured it. Because of the large number of possible measures of financial toxicity, we categorized them into 3 broad areas: (1) monetary measures: currency values of out-of-pocket expenses and ratio of out-of-pocket spending to income; (2) objective measures: question sets on tangible solutions to ease financial burden such as to increase debt levels, borrow money from family or friends, sell assets, withdraw money from retirement or savings funds, and file for bankruptcy; and (3) subjective measures: question sets on perceptions of cancer-related financial burden and which cover the psychological effects.2

These 3 areas each measure a different aspect of financial toxicity with currency values being absolute but not revealing much about the ways in which people coped (indicated by the objective measures) or what was the actual effect on distress levels (indicated by subjective measures). When monetary measures were used, the findings from our review indicated the frequency of financial toxicity among cancer survivors ranged from 28% to 48%.2 Using objective or subjective measures, the frequency ranged from 16% to 73%.2 Factors that were consistently associated with financial toxicity were being female, low income at baseline, younger age, adjuvant and antineoplastic therapies, advanced cancer, more recent diagnosis, and rural living. In 3 studies, there was a statistically significantly higher burden for individuals with cancer relative to noncancer control groups.2

Methodological Concerns and Research Priorities for Consideration

Several improvements could be made for future studies of financial toxicity to strengthen their rigor. If financial toxicity is to be comprehensively researched, collecting complementary measures from each of the 3 categories is advisable. Most measures used in the studies in our review were not validated or tested for reliability. Standardizing the measurement of financial toxicity in cancer is strongly advised because it means that research findings can be more comparable across samples. One tool, the Comprehensive Score for financial Toxicity (COST) measure, developed and validated by Souza et al,3 is an 11-item survey covering both objective and subjective questions and work-related issues.3,4 When collecting data on monetary costs, participant recall needs to be restricted to prospective, short, and frequent data collections using closed questions and a wide range of cost types. Longitudinal designs are needed with 72% of studies in our review using cross-sectional designs.2 Financial hardship could exist for individuals before a cancer diagnosis or from other concurrent diseases. The experience of cancer therefore worsens an existing problem in these situations. Collecting data at the time of cancer diagnosis will improve understanding of baseline financial situations.

Finally, each country and healthcare setting is unique, and there is a need to recognize the country-specific protections in place for health-related costs incurred by patients with cancer. Costs may include direct healthcare costs for treatment and care-related resources, other financial costs (supportive care, respite, aids, home modifications, transport, and accommodation), productivity costs (work time lost and carer costs), transfer costs (welfare and disability payments and taxation revenue to government forgone), nonfinancial costs or burden of disease (pain, suffering, and quality-of-life loss). Obviously, different cancer types will have different sorts of cost burdens,5 often dictated by cancer aggressiveness, survival expectations, and age at diagnosis. For example, a person on the old-age pension with colorectal cancer could be faced with AU$10 000 in out-of-pocket expenses on average whereas a working-age man with lung cancer could incur AU$203 600 in economic costs.6 Further research should investigate the role of oncology nurses, including nurse navigators and care coordinators, in assessing and addressing financial toxicity in patients across the cancer trajectory, from diagnosis to survivorship and ultimately end-of-life care.

- Louisa G. Gordon, PhD, MPH, BEcon

- Raymond Javan Chan, PhD, MAppSc (Research), RN, BN, FACN

QIMR Berghofer Medical Research Institute (Dr Gordon),

Brisbane, Australia; Cancer Nursing Professorial

Precinct, Royal Brisbane and Women's Hospital

(Dr Chan), Queensland, Australia;

and School of Nursing (Dr Gordon and Dr Chan)

and School of Public Health (Dr Gordon),

Queensland University of Technology,

Brisbane, Australia.

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