Financial toxicity of cancer treatment in India: towards closing the cancer care gap

Abstract

BackgroundThe rising economic burden of cancer on patients is an important determinant of access to treatment initiation and adherence in India. Several publicly financed health insurance (PFHI) schemes have been launched in India, with treatment for cancer as an explicit inclusion in the health benefit packages (HBPs). Although, financial toxicity is widely acknowledged to be a potential consequence of costly cancer treatment, little is known about its prevalence and determinants among the Indian population. There is a need to determine the optimal strategy for clinicians and cancer care centers to address the issue of high costs of care in order to minimize the financial toxicity, promote access to high value care and reduce health disparities.MethodsA total of 12,148 cancer patients were recruited at seven purposively selected cancer centres in India, to assess the out-of-pocket expenditure (OOPE) and financial toxicity among cancer patients. Mean OOPE incurred for outpatient treatment and hospitalization, was estimated by cancer site, stage, type of treatment and socio-demographic characteristics. Economic impact of cancer care on household financial risk protection was assessed using standard indicators of catastrophic health expenditures (CHE) and impoverishment, along with the determinants using logistic regression.ResultsMean direct OOPE per outpatient consultation and per episode of hospitalization was estimated as ₹8,053 (US$ 101) and ₹39,085 (US$ 492) respectively. Per patient annual direct OOPE incurred on cancer treatment was estimated as ₹331,177 (US$ 4,171). Diagnostics (36.4%) and medicines (45%) are major contributors of OOPE for outpatient treatment and hospitalization, respectively. The overall prevalence of CHE and impoverishment was higher among patients seeking outpatient treatment (80.4% and 67%, respectively) than hospitalization (29.8% and 17.2%, respectively). The odds of incurring CHE was 7.4 times higher among poorer patients [Adjusted Odds Ratio (AOR): 7.414] than richest. Enrolment in PM-JAY (CHE AOR = 0.426, and impoverishment AOR = 0.395) or a state sponsored scheme (CHE AOR = 0.304 and impoverishment AOR = 0.371) resulted in a significant reduction in CHE and impoverishment for an episode of hospitalization. The prevalence of CHE and impoverishment was significantly higher with hospitalization in private hospitals and longer duration of hospital stay (p < 0.001). The extent of CHE and impoverishment due to direct costs incurred on outpatient treatment increased from 83% to 99.7% and, 63.9% to 97.1% after considering both direct and indirect costs borne by the patient and caregivers, respectively. In case of hospitalization, the extent of CHE increased from 23.6% (direct cost) to 59.4% (direct+ indirect costs) and impoverishment increased from 14.1% (direct cost) to 27% due to both direct and indirect cost of cancer treatment.ConclusionThere is high economic burden on patients and their families due to cancer treatment. The increase in population and cancer services coverage of PFHI schemes, creating prepayment mechanisms like E-RUPI for outpatient diagnostic and staging services, and strengthening public hospitals can potentially reduce the financial burden among cancer patients in India. The disaggregated OOPE estimates could be useful input for future health technology analyses to determine cost-effective treatment strategies.

Exploring the Influence of Decisionmaking Style and Financial Status of Cancer Patients on Varied Cultural Aspects of Decision Process

“…Previous literature suggests that as shared decision-making acknowledges patients' autonomy (Guadalajara et al, 2022;Lantos, 2021), it fosters greater trust in doctors for both patients and caregivers (Entwistle, 2004;Lincoln et al, 2023) and elicits higher patient satisfaction (Oprea et al, 2023;Pollard et al, 2015). Financial toxicity is also found to be linked to higher emotional distress (Abrams et al, 2021;Carrera et al, 2018), lower agency in decision process (Boby et al, 2021;Prinja et al, 2023) and higher trust in doctors (Abrams et al, 2021;Boby et al, 2021;Zafar & Peppercorn, 2023). Studies examining cultural beliefs in the face of illness also suggest that patients often attribute the cause of their illness to metaphysical factors, such as god, fate or karma (Agrawal & Dalal, 1993;Dalal & Misra, 2006;Kohli & Dalal, 2016).…”

“…Financial toxicity remains a nascent area of investigation within the literature, with most studies primarily focusing on its prevalence (Abrams et al, 2021;Boby et al, 2021;Prinja et al, 2023), identifying high-risk groups (Boby et al, 2021;Lentz et al, 2019;Prinja et al, 2023), and establishing its connections with quality of life, well-being and physical health (Abrams et al, 2021;Carrera et al, 2018;Zafar & Peppercorn, 2023). However, its impact on decision-making in cancer treatment remains an understudied area.…”

Assessment of Financial Toxicity and Coping Strategies Associated With Cancer Treatment Among Caregivers of Patients With Cancer From a Lower-Middle–Income Country

“…There is significant complete/partial out-of-pocket (OOP) expenditure for direct costs, whereas the patients or their families completely bear the indirect costs. 6 In India, cancer is a significant public health issue; nearly 0.85 million deaths and 1.3 million newly diagnosed patients of cancer were reported in the year 2020, with 1.1 million patients being reported each year, indicating a larger burden of cancer incidence, which continues to grow exponentially. 7,8 The economic burden related to cancer has also increased in the past few years; a report on oncology trends showed a rise in cancer-related medication expenses from $96 billion (2016) to $164 billion US dollars in 2020.…”