The validation of the Italian version of the COmprehensive Score for financial Toxicity (COST)

  • Carla Ida Ripamonti
  • Francesca ChiesiEmail author
  • Patricia Di Pede
  • Mauro Guglielmo
  • Luisa Toffolatti
  • Laura Gangeri
  • Elena Allocca
Original Article



Financial toxicity (FT) is the unintended, potential economic harm or damage of oncologic treatments that has become a medical problem with political implications. To assess FT, the COmprehensive Score for financial Toxicity (COST) questionnaire was developed. Since an Italian version is not available yet, we aimed to validate the Italian version of the COST questionnaire in a population of cancer patients during oncologic treatments or follow-up.


A sample of Italian native outpatients were asked to fill the Italian version of the COST and five other self-administered questionnaires to assess quality of life, treatment-related symptoms, hope, distress, and unmet needs. Additionally, a subsample of patients was asked to retake the COST after 2–6 weeks.


A single factor better represents the scale structure. Internal consistency and test–retest reliability were good. Evidence of convergent and discriminant validity was provided and criterion validity was established, showing that financial toxicity predicts the patient’s distress. Finally, known-groups validity was confirmed, testing the differences related to treatment-related expenses, sociodemographic characteristics, stage of the disease, and performance status.


The current findings suggest the Italian version of the COST is a psychometrically sound scale that potentially offers an added value in assessing FT in patients with cancer.


Toxicity Financial burden Oncologic treatments Cancer patients Distress Psychometric validation 



We would like to thank Barbara Bachtiary, MD, MSc, Paul Scherrer Institute Center for Proton Therapy, Switzerland; and Emily Parks-Vernizzi, MFA; Jason Bredle, MFA; and Benjamin J. Arnold, MA,, Ponte Vedra, FL, for their contribution in producing the Italian version of the COST.

Authors’ contributions

All authors contributed to the study conception and design. Patients’ recruitment, material preparation, and data collection were performed by Carla Ida Ripamonti, Patricia Di Pede, Mauro Guglielmo, Luisa Toffolatti, and Laura Gangeri. Data analysis and interpretation of results were performed by Francesca Chiesi. The first draft of the manuscript was written by Carla Ida Ripamonti, Francesca Chiesi, and Elena Allocca, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Compliance with ethical standards

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee (Ethic Committee of Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy, protocol number: INT 41/19) and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.

Supplementary material

520_2019_5286_MOESM1_ESM.pdf (94 kb)
ESM 1 (PDF 93 kb)
520_2019_5286_MOESM2_ESM.pdf (103 kb)
ESM2 (PDF 102 kb)


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2020

Authors and Affiliations

  1. 1.Oncology Supportive Care in Cancer UnitFondazione IRCCS Istituto Nazionale dei TumoriMilanItaly
  2. 2.Department of Neurosciences, Psychology, Drug, and Child’s Health (NEUROFARBA), Section of PsychologyUniversity of FlorenceFlorenceItaly
  3. 3.Clinical Psychology UnitFondazione IRCCS Istituto Nazionale dei TumoriMilanItaly

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