A Systematic Review of Financial Toxicity Among Cancer Survivors: We Can’t Pay the Co-Pay

  • Louisa G. Gordon
  • Katharina M. D. Merollini
  • Anthony Lowe
  • Raymond J. Chan
Systematic Review



To determine the extent of financial toxicity (FT) among cancer survivors, identify the determinants and how FT is measured.


A systematic review was performed in MEDLINE, CINAHL and PsycINFO, using relevant terminology and included articles published from 1 January, 2013 to 30 June, 2016. We included observational studies where the primary outcomes included FT and study samples were greater than 200. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed.


From 417 citations, a total of 25 studies were included in this review. Seventy outcomes of FT were reported with 47 covering monetary, objective and subjective indicators of FT. A total of 28–48% of patients reported FT using monetary measures and 16–73% using subjective measures. The most commonly reported factors associated with FT were: being female, younger age, low income at baseline, adjuvant therapies and more recent diagnosis. Relative to non-cancer comparison groups, cancer survivors experienced significantly higher FT. Most studies were cross-sectional and causal inferences between FT and determinants were not possible. Measures of FT were varied and most were not validated, while monetary values of out-of-pocket expenses included different cost components across studies.


A substantial proportion of cancer survivors experience financial hardship irrespective of how it is measured. Using standardised outcomes and longitudinal designs to measure FT would improve determination of the extent of FT. Further research is recommended on reduced work participation and income losses occurring concurrently with FT and on the impacts on treatment non-adherence.


Cancer Survivor MeSH Financial Burden Medical Tourism Financial Hardship 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Author contributions

LG and KM planned the search strategy, and performed searches and extracted the data into tables and Endnote. LG and KM drafted the paper with assistance from RC and AL. RC and AL provided consumer and clinical insights to the project and the written draft. LG synthesised the findings and produced summary information and results for Fig. 2. All authors contributed to the writing and editing of the final draft and have approved the submitted version.

Compliance with Ethical Standards


The authors received no funding assistance to conduct this study.

Conflict of interest

KM, AL and RC have no conflicts of interest to disclose. LG received consultancy fees for related work in 2013.


  1. 1.
    de Souza JA, Wong Y-N. Financial distress in cancer patients. J Med Person. 2013;11(2):73–7. doi: 10.1007/s12682-013-0152-3.CrossRefGoogle Scholar
  2. 2.
    Yabroff KR, Lawrence WF, Clauser S, et al. Burden of illness in cancer survivors: findings from a population-based national sample. J Natl Cancer Inst. 2004;96(17):1322–30.CrossRefPubMedGoogle Scholar
  3. 3.
    Laba TL, Essue BM, Jan S. Financing options to sustain Medicare: are we committed to universalism? Med J Aust. 2015;203(6):244.e1–245.e1.CrossRefGoogle Scholar
  4. 4.
    Tucker-Seeley RD, Yabroff KR. Minimizing the “financial toxicity” associated with cancer care: advancing the research agenda. J Natl Cancer Inst. 2016;108(5):djv410. doi: 10.1093/jnci/djv410.CrossRefPubMedGoogle Scholar
  5. 5.
    Zafar SY. Financial toxicity of cancer care: it’s time to intervene. J Natl Cancer Inst. 2016;108(5):djv370. doi: 10.1093/jnci/djv370.CrossRefPubMedGoogle Scholar
  6. 6.
    Jan S, Kimman M, Peters SA, Woodward M. Financial catastrophe, treatment discontinuation and death associated with surgically operable cancer in South-East Asia: results from the ACTION Study. Surgery. 2015;157(6):971–82. doi: 10.1016/j.surg.2015.02.012.CrossRefPubMedGoogle Scholar
  7. 7.
    Mahal A, Karan A, Fan VY, Engelgau M. The economic burden of cancers on Indian households. PloS One. 2013;8(8):e71853. doi: 10.1371/journal.pone.0071853.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol. 2009;62(10):e1–34. doi: 10.1016/j.jclinepi.2009.06.006.CrossRefPubMedGoogle Scholar
  9. 9.
    National Institutes of Health. Quality assessment tool for observational cohort and cross-sectional studies. 2014. Available from: Accessed 10 Aug 2016.
  10. 10.
    Bestvina CM, Zullig LL, Rushing C, et al. Patient-oncologist cost communication, financial distress, and medication adherence. J Oncol Pract. 2014;10(3):162–7. doi: 10.1200/jop.2014.001406.CrossRefPubMedGoogle Scholar
  11. 11.
    Davidoff AJ, Erten M, Shaffer T, et al. Out-of-pocket health care expenditure burden for Medicare beneficiaries with cancer. Cancer. 2013;119(6):1257–65. doi: 10.1002/cncr.27848.CrossRefPubMedGoogle Scholar
  12. 12.
    Fenn KM, Evans SB, McCorkle R, et al. Impact of financial burden of cancer on survivors’ quality of life. J Oncol Pract. 2014;10(5):332–8. doi: 10.1200/jop.2013.001322.CrossRefPubMedGoogle Scholar
  13. 13.
    Goodwin JA, Coleman EA, Sullivan E, et al. Personal financial effects of multiple myeloma and its treatment. Cancer Nurs. 2013;36(4):301–8. doi: 10.1097/NCC.0b013e3182693522.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Jagsi R, Pottow JA, Griffith KA, et al. Long-term financial burden of breast cancer: experiences of a diverse cohort of survivors identified through population-based registries. J Clin Oncol. 2014;32(12):1269–76. doi: 10.1200/jco.2013.53.0956.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Kaisaeng N, Harpe SE, Carroll NV. Out-of-pocket costs and oral cancer medication discontinuation in the elderly. J Manage Care Specialty Pharm. 2014;20(7):669–75. doi: 10.18553/jmcp.2014.20.7.669.Google Scholar
  16. 16.
    Kale HP, Carroll NV. Self-reported financial burden of cancer care and its effect on physical and mental health-related quality of life among US cancer survivors. Cancer. 2016;122(8):283–9. doi: 10.1002/cncr.29808.CrossRefPubMedGoogle Scholar
  17. 17.
    Kent EE, Forsythe LP, Yabroff KR, et al. Are survivors who report cancer-related financial problems more likely to forgo or delay medical care? Cancer. 2013;119(20):3710–7. doi: 10.1002/cncr.28262.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Khera N, Chang YH, Hashmi S, et al. Financial burden in recipients of allogeneic hematopoietic cell transplantation. Biol Blood Marrow Transpl. 2014;20(9):1375–81. doi: 10.1016/j.bbmt.2014.05.011.CrossRefGoogle Scholar
  19. 19.
    Pisu M, Kenzik KM, Oster RA, et al. Economic hardship of minority and non-minority cancer survivors 1 year after diagnosis: another long-term effect of cancer? Cancer. 2015;121(8):1257–64. doi: 10.1002/cncr.29206.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Ramsey S, Blough D, Kirchhoff A, et al. Washington State cancer patients found to be at greater risk for bankruptcy than people without a cancer diagnosis. Health Aff (Millwood). 2013;32(6):1143–52. doi: 10.1377/hlthaff.2012.1263.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Stump TK, Eghan N, Egleston BL, et al. Cost concerns of patients with cancer. J Oncol Pract. 2013;9(5):251–7. doi: 10.1200/jop.2013.000929.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Yabroff KR, Dowling EC, Guy GP Jr, et al. Financial hardship associated with cancer in the United States: findings from a population-based sample of adult cancer survivors. J Clin Oncol. 2016;34(3):259–67. doi: 10.1200/jco.2015.62.0468.CrossRefPubMedGoogle Scholar
  23. 23.
    Tucker-Seeley RD, Abel GA, Uno H, Prigerson H. Financial hardship and the intensity of medical care received near death. Psychooncology. 2015;24(5):572–8. doi: 10.1002/pon.3624.CrossRefPubMedGoogle Scholar
  24. 24.
    Chan A, Chiang YY, Low XH, et al. Affordability of cancer treatment for aging cancer patients in Singapore: an analysis of health, lifestyle, and financial burden. Support Care Cancer. 2013;21(12):3509–17. doi: 10.1007/s00520-013-1930-4.CrossRefPubMedGoogle Scholar
  25. 25.
    You CH, Kang S, Kwon YD, Choi JH. Time trend of out-of-pocket expenditure among cancer inpatients: evidence from Korean tertiary hospitals. Asian Pac J Cancer Prev. 2013;14(11):6985–9.CrossRefPubMedGoogle Scholar
  26. 26.
    Sharp L, Carsin AE, Timmons A. Associations between cancer-related financial stress and strain and psychological well-being among individuals living with cancer. Psychooncology. 2013;22(4):745–55. doi: 10.1002/pon.3055.CrossRefPubMedGoogle Scholar
  27. 27.
    Sharp L, Timmons A. Pre-diagnosis employment status and financial circumstances predict cancer-related financial stress and strain among breast and prostate cancer survivors. Support Care Cancer. 2016;24(2):699–709. doi: 10.1007/s00520-015-2832-4.CrossRefPubMedGoogle Scholar
  28. 28.
    Baili P, Di Salvo F, de Lorenzo F, et al. Out-of-pocket costs for cancer survivors between 5 and 10 years from diagnosis: an Italian population-based study. Support Care Cancer. 2016;24(5):2225–33. doi: 10.1007/s00520-015-3019-8.CrossRefPubMedGoogle Scholar
  29. 29.
    de Oliveira C, Bremner KE, Ni A, et al. Patient time and out-of-pocket costs for long-term prostate cancer survivors in Ontario, Canada. J Cancer Surviv. 2014;8(1):9–20. doi: 10.1007/s11764-013-0305-7.CrossRefPubMedGoogle Scholar
  30. 30.
    Lauzier S, Levesque P, Mondor M, et al. Out-of-pocket costs in the year after early breast cancer among Canadian women and spouses. J Natl Cancer Inst. 2013;105(4):280–92. doi: 10.1093/jnci/djs512.CrossRefPubMedGoogle Scholar
  31. 31.
    Gordon LG, Walker SM, Mervin MC, et al. Financial toxicity: a potential side effect of prostate cancer treatment among Australian men. Eur J Cancer Care (Engl). 2015. doi: 10.1111/ecc.12392 [Epub ahead of print].
  32. 32.
    Kimman M, Jan S, Yip CH, et al. Catastrophic health expenditure and 12-month mortality associated with cancer in Southeast Asia: results from a longitudinal study in eight countries. BMC Med. 2015;13:190. doi: 10.1186/s12916-015-0433-1.CrossRefPubMedGoogle Scholar
  33. 33.
    Azzani M, Roslani AC, Su TT. The perceived cancer-related financial hardship among patients and their families: a systematic review. Support Care Cancer. 2015;23(3):889–98. doi: 10.1007/s00520-014-2474-y.CrossRefPubMedGoogle Scholar
  34. 34.
    de Souza JA, Yap BJ, Hlubocky FJ, et al. The development of a financial toxicity patient-reported outcome in cancer: the COST measure. Cancer. 2014;120(20):3245–53. doi: 10.1002/cncr.28814.CrossRefPubMedGoogle Scholar
  35. 35.
    Bouwmans C, Krol M, Severens H, et al. The iMTA Productivity Cost Questionnaire: a standardized instrument for measuring and valuing health-related productivity losses. Value Health. 2015;18(6):753–8. doi: 10.1016/j.jval.2015.05.009.CrossRefPubMedGoogle Scholar
  36. 36.
    Johar M, Mu C, Van Gool K, Wong CY. Bleeding hearts, profiteers, or both: specialist physician fees in an unregulated market. Health Econ. 2016. doi: 10.1002/hec.3317 [Epub ahead of print].
  37. 37.
    O’Connor JM, Kircher SM, de Souza JA. Financial toxicity in cancer care. J Commun Support Oncol. 2016;14(3):101–6. doi: 10.12788/jcso.0239.CrossRefGoogle Scholar
  38. 38.
    Scott AM. Health technology assessment in Australia: a role for clinical registries? Aust Health Rev. 2016. doi: 10.1071/AH15109 [Epub ahead of print].
  39. 39.
    Wortley S, Tong A, Howard K. Community views and perspectives on public engagement in health technology assessment decision making. Aust Health Rev. 2016. doi: 10.1071/AH15221 [Epub ahead of print].
  40. 40.
    Greer JA, Amoyal N, Nisotel L, et al. A systematic review of adherence to oral antineoplastic therapies. Oncologist. 2016;21(3):354–76. doi: 10.1634/theoncologist.2015-0405.CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005;353(5):487–97.CrossRefPubMedGoogle Scholar
  42. 42.
    Tucker-Seeley RD, Abel GA, Uno H, Prigerson H. Financial hardship and the intensity of medical care received near death. Psychooncology. 2015;24(5):572–8. doi: 10.1002/pon.3624.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  • Louisa G. Gordon
    • 1
  • Katharina M. D. Merollini
    • 2
  • Anthony Lowe
    • 3
    • 4
  • Raymond J. Chan
    • 5
    • 6
  1. 1.Population HealthQIMR Berghofer Medical Research InstituteBrisbaneAustralia
  2. 2.Faculty of Science, Health, Education and EngineeringUniversity of the Sunshine CoastSunshine CoastAustralia
  3. 3.Prostate Cancer Foundation of AustraliaSydneyAustralia
  4. 4.Menzies Health Institute QueenslandGriffith UniversityGold CoastAustralia
  5. 5.School of NursingQueensland University of TechnologyBrisbaneAustralia
  6. 6.Cancer Care ServicesRoyal Brisbane and Women’s HospitalBrisbaneAustralia

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