Financial Toxicity Among Patients With Breast Cancer Worldwide: A Systematic Review and Meta-analysis

IMPORTANCE Financial toxicity (FT) is the negative impact of cost of care on financial well-being. Patients with breast cancer are at risk for incurring high out-of-pocket costs given the long-term need for multidisciplinary care and expensive treatments. OBJECTIVE To quantify the FT rate of patients with breast cancer and identify particularly vulnerable patient populations nationally and internationally. DATA SOURCES A systematic review and meta-analysis were conducted. Four databases-Embase, PubMed, Global Index Medicus, and Global Health (EBSCO)-were queried from inception to February 2021. Data analysis was performed from March to December 2022. STUDY SELECTION A comprehensive database search was performed for full-text, English-language articles reporting FT among patients with breast cancer. Two independent reviewers conducted study screening and selection; 462 articles underwent full-text review. DATA EXTRACTION AND SYNTHESIS A standardized data extraction tool was developed and validated by 2 independent authors; study quality was also assessed. Variables assessed included race, income, insurance status, education status, employment, urban or rural status, and cancer stage and treatment. Pooled estimates of FT rates and their 95% CIs were obtained using the random-effects model. MAIN OUTCOMES AND MEASURES FT was the primary outcome and was evaluated using quantitative FT measures, including rate of patients experiencing FT, and qualitative FT measures, including patient-reported outcome measures or patient-reported severity and interviews. The rates of patients in high-income, middle-income, and low-income countries who incurred FT according to out-of-pocket cost, income, or patient-reported impact of expenditures during breast cancer diagnosis and treatment were reported as a meta-analysis. RESULTS Of the 11 086 articles retrieved, 34 were included in the study. Most studies were from high-income countries (24 studies), and the rest were from low- and middle-income countries (10 studies). The sample size of included studies ranged from 5 to 2445 people. There was significant heterogeneity in the definition of FT. FT rate was pooled from 18 articles. The pooled FT rate was 35.3%(95% CI, 27.3%-44.4%) in high-income countries and 78.8% (95% CI, 60.4%-90.0%) in low- and middle-income countries. CONCLUSIONS AND RELEVANCE Substantial FT is associated with breast cancer treatment worldwide. Although the FT rate was higher in low- and middle-income countries, more than 30% of patients in high-income countries also incurred FT. Policies designed to offset the burden of direct medical and nonmedical costs are required to improve the financial health of vulnerable patients with breast cancer.

Automated summary

The study aimed to quantify the financial toxicity rate of patients with breast cancer and identify vulnerable populations. The analysis showed that breast cancer patients worldwide face high out-of-pocket costs and financial burden. Financial toxicity was more severe in low- and middle-income countries, but even in high-income countries, over 30% of patients experienced financial distress. Policies are needed to alleviate the financial burden and improve the financial well-being of breast cancer patients.