Modern oncology has significantly changed the outlook for people living with cancer. Advances in diagnosis, novel therapeutic agents, targeted therapies, and immunotherapy have made it possible to prolong survival in many malignancies and, in some cases, achieve long-term disease control. According to 2022 data, more than 12 million people in Europe are living with or beyond cancer.
However, this progress has another side—one that often remains invisible: financial toxicity.
What does a cancer diagnosis actually cost a person?
The issue is not limited to the cost of medications or medical procedures. From the moment of diagnosis, patients may face expenses related to diagnostic investigations, medications, transportation, and accommodation, as well as loss of working days, reduced income, the need for a family member to temporarily leave employment to provide care, depletion of savings, debt, and, in some cases, even the sale of assets.
Together, these circumstances can significantly increase the burden of living with cancer.
In modern oncology, this phenomenon is referred to as financial toxicity.
The 2024 ESMO Expert Consensus defines financial toxicity as the combination of objective financial burden and subjective financial distress resulting from cancer diagnosis and treatment.
The latter component is particularly important, both for individual patients and globally. Two patients may incur the same financial expense, yet experience completely different consequences. For one family, a particular expense may be manageable; for another, it may mean having to choose between cancer treatment and essential everyday household needs.
Therefore, financial toxicity cannot be measured solely by the amount of money spent.
One of the key messages of the ESMO consensus is precisely this: financial toxicity should not be regarded as a secondary social consequence of cancer treatment. It can affect quality of life, psychological well-being, access to treatment, and adherence to prescribed therapy.
In other words, a financial problem can ultimately become a medical problem.
Who is most vulnerable to financial toxicity?
The evidence analyzed by ESMO indicates that the risk is not equally distributed.
Groups particularly vulnerable to financial toxicity include people with low individual or household income, patients who lose their source of income during treatment, individuals with inadequate insurance coverage, and families with lower socioeconomic status.
Household structure also matters.
According to a meta-analysis of data from low- and middle-income countries, cancer patients living in households with more than four members had a 17% higher likelihood of experiencing objective financial toxicity. The situation may be particularly challenging when other family members are financially dependent on the patient.
However, the opposite situation can also create difficulties. A person living independently or alone may not have family members with whom to share the financial and practical burden associated with the disease.
Which treatment modalities or treatment regimens create the greatest financial burden?
Current evidence does not support considering any particular cancer site or malignancy as an automatic independent cause of financial toxicity.
Instead, the type and duration of treatment are important.
According to the ESMO consensus, systemic anticancer therapies—particularly chemotherapy and targeted therapy—are more frequently associated with financial toxicity than treatment consisting solely of surgery or radiotherapy.
The reason is not simply the price of the medication.
Prolonged treatment may involve repeated visits to healthcare facilities, additional diagnostic investigations, supportive medications, transportation costs, missed working days, and, in some cases, the continuous involvement of a family caregiver.
Geographical location is also important. For a patient living outside a major urban center, every visit to an oncology center may involve not only the cost of medical care, but also transportation, food, and sometimes temporary accommodation.
Therefore, the existence of universal healthcare coverage does not automatically eliminate financial toxicity. Even when the state or an insurance system covers part of the treatment costs, patients may still face substantial direct and indirect out-of-pocket expenses.
How can we determine how severe a patient’s financial situation is?
Assessment of financial well-being is one of the key—and practically important—issues addressed by the ESMO consensus.
Financial toxicity should not be assessed only after a patient has already experienced severe financial hardship or is considering refusing treatment because of cost.
ESMO recommends that an initial assessment of financial difficulties be performed at the time of diagnosis or before treatment begins, and repeated subsequently according to the patient’s needs.
The first step can be very simple.
One of the most widely used cancer-specific quality-of-life questionnaires worldwide, the EORTC QLQ-C30, includes a question assessing whether the patient’s physical condition or treatment has caused financial difficulties.
A single question may serve as the first warning signal.
If screening identifies a potential financial problem, more detailed assessment tools can be used. One of the best-known instruments is COST (Comprehensive Score for Financial Toxicity), which enables a more systematic assessment of financial well-being and the financial burden associated with cancer.
This principle is very similar to what we already do routinely in oncology: we assess pain, nutritional status, psychological distress, treatment-related adverse effects, and quality of life.
So the question arises: why should we not also ask patients about financial distress?
Financial toxicity can begin before the cancer diagnosis
Another important message of the ESMO consensus concerns the diagnostic phase.
A cancer diagnosis is rarely established in a single day. It is often preceded by imaging studies, laboratory investigations, biopsy, histopathological and, in some cases, molecular testing, as well as consultations with different specialists.
If a patient cannot afford the necessary investigations at this stage, a financial barrier may become a barrier to timely diagnosis, subsequently leading to delayed treatment and potentially poorer outcomes.
For this reason, ESMO experts emphasize that, when there is a substantial suspicion of cancer, the necessary diagnostic pathway should be as free as possible from financial barriers.
At the same time, more testing does not necessarily mean better care. The consensus also emphasizes the principles of Choosing Wisely: investigations that are unlikely to change the patient’s management should be avoided. This approach protects both the patient’s financial resources and the healthcare system’s budget.
What do we know about Georgia? How significant is the financial burden of cancer for Georgian patients?
According to evidence available through PubMed Central (PMC), cancer-related financial toxicity is a significant and documented problem in Georgia.
A study conducted in healthcare settings found that 74.5% of patients experienced moderate or severe financial burden when receiving cancer-related medical services.
Furthermore, 44.2% of patients reported taking out a loan, with the costs of diagnostic investigations being the most frequently reported reason for borrowing.
The study also found that only 31.5% of surveyed patients were stably employed, while 33.5% of employed or self-employed patients reported cancer-related difficulties affecting their ability to work or maintain employment.
Available evidence therefore indicates that financial protection for people living with cancer in Georgia remains insufficient.
How can we develop healthcare models for cancer survivors that also protect them from financial risks?
Healthcare organizations and relevant health-sector institutions should support the implementation of models that incorporate long-term follow-up and survivorship monitoring strategies.
Such models may include:
- rational and evidence-based use of surveillance investigations;
- implementation of remote monitoring systems;
- greater emphasis on rehabilitation services and their importance.
These approaches can help reduce financial risks for cancer survivors while improving clinical outcomes, including health-related quality of life (HRQoL), and ultimately contributing to improvements in the overall quality of cancer care.
Financial hardship mitigation strategies should also be integrated into long-term follow-up and survivorship care plans.
Such strategies may include the development of financial navigation programs and a centralized online platform providing patients with information about available financial assistance programs, rehabilitation services, psychological support, access to other essential healthcare and supportive services, and, in the longer term, programs designed to facilitate employment and return to work.
These approaches are consistent with the broader principles of the WHO Package of Interventions for Rehabilitation (PIR) and the WHO Rehabilitation 2030 initiative, which emphasize access to comprehensive rehabilitation across the continuum of care.
Author: Mariam Chirakadze
