Mapping the Landscape of Financial Toxicity Assessment in Cancer: A Scoping Review

Mapping the Landscape of Financial Toxicity Assessment in Cancer: A Scoping Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Mapping the Landscape of Financial Toxicity Assessment in Cancer: A Scoping Review Manraj Singh Sra, Parth Sharma, Varun Raj Passi, Larry Prokop, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6772539/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction Financial toxicity from cancer treatment is a significant barrier to equitable care and an important clinical and public health concern. This scoping review systematically review the financial toxicity assessment pattern in cancer care across global settings and generate an inventory of domains and sub-domains of questions used to assess financial toxicity. Methods A comprehensive search of six databases was conducted, without language or date restrictions. Eligible studies reported on the development, validation, or application of financial toxicity assessment tools, with ≥50% inclusion of patients with cancer or caregivers. Questions evaluating financial toxicity were extracted and classified into three domains: material, behavioral, and psychosocial, with further categorization into subdomains. Results Of the 3,343 records screened, 454 studies met the inclusion criteria. The majority were conducted in high-income countries (81.7%, n = 371), and 93.8% focused on adults. Across 438 quantitative studies, 164 unique financial toxicity questionnaires containing 1,104 questions were identified. The COmprehensive Score for financial Toxicity (COST) was the most used (40.4%). Only 48.2% of questionnaires had been validated among patients with cancer. Most questions assessed material domains (51.3%), followed by behavioral (29.9%) and psychosocial (18.8%). Themes from 32 qualitative studies echoed these distributions, highlighting healthcare expenditure and job loss as prominent concerns. Conclusions Most studies of financial toxicity in cancer care are conducted among adults in high-income countries, and measure material domains. There is a need to increase financial toxicity research in low- and middle-income countries, and among pediatric and adolescent patients and caregivers of people with cancer. Oncology Health Economics & Outcomes Research Health Policy Financial Toxicity Financial Burden COST Global Oncology Disparities Figures Figure 1 Figure 2 Introduction Financial toxicity (FT) refers to the financial burden and distress experienced by patients and their families due to the costs associated with the treatment of cancer. 1 FT extends beyond direct out-of-pocket expenditures (OOPE) to encompass broader financial consequences, including income loss, debt accumulation, and inability to fulfill essential non-medical expenses. 2 FT has significant psychosocial implications, leading to increased stress, anxiety, and reduced quality of life for patients undergoing treatment and their caregivers. 3 – 5 Although FT is observed globally, its impact varies between high-income countries (HICs) and low- and middle-income countries (LMICs). In HICs, despite the availability of universal coverage, health insurance and/or financial assistance programs, many patients experience FT due to copayments, limited coverage, loss of income, and non-medical costs such as transportation and caregiving. In LMICs, where many healthcare expenditures are OOPE and financial protection mechanisms are limited, FT is often more severe, leading to catastrophic health expenditures, impoverishment, and poor access and adherence to treatment. 6 – 8 FT is commonly assessed using two main approaches: (i) objective measures, such as the quantification of OOPE, catastrophic health expenditures, and impoverishment, and (ii) subjective assessments using patient-reported outcomes, which capture perceived financial distress. However, commonly used instruments such as the Comprehensive Score for Financial Toxicity (COST) may not be universally applicable due to differences in healthcare systems, economic and social structures, and cultural norms influencing financial decision-making. 9 While previous studies have analyzed the content of FT measurement tools, they have largely been limited to classifying the contents of FT assessment tools into broad categories of material, behavioral, and psychosocial FT without a detailed thematic analysis. 10 Additionally, some reviews have included studies conducted in a limited number of countries. 6 , 11 Researchers from LMICs have also identified a growing need for local sociocultural context-specific FT assessment tools. 9 Given the increasing recognition of FT as a major barrier to equitable cancer care, a comprehensive global comparison of FT assessment tools is warranted. This review aims to systematically examine existing tools used to assess FT across settings and identify global disparities in the generation of evidence and tools for cancer-related FT assessment. Additionally, it aims to highlight neglected themes and populations in existing FT assessment tools. Finally, we have generated an inventory of questions used for FT assessment globally in order to create a knowledge base for the development of locally relevant tools across various resource settings. Methods Overview This study followed a scoping review methodology, which allows the examination of broad topics and the identification of key characteristics related to a concept. Given the inconsistencies in the measurement of FT, we chose this methodology to understand and collate the various ways FT is measured in different resource settings and populations worldwide. This study adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines for scoping reviews. 12 (Supplementary Material) The detailed pre-registered protocol with the search strategy and all analyses included in this review is available from the Open Science Framework Registries. 13 Ethical approval was not required as this is a review article that does not involve any patient data. Data Sources and Search Strategy A comprehensive search of six databases from each database’s inception to July 24th, 2024, in any language, without any date restrictions, was conducted. The databases were Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, and Daily, Ovid EMBASE, Ovid Cochrane Database of Systematic Reviews, Ovid PsycINFO, Scopus, and Web of Science. The search strategy was designed and conducted by an experienced librarian (LP) with input from the study’s principal investigators (MSS and PS). The search terms and combinations used are available in the Supplementary Material. Eligibility Criteria Studies were included if at least 50% of the patient population comprised patients with cancer, cancer survivors, or their caregivers and if FT was assessed. The study population included participants of any age, cancer type, and geographic location. Both quantitative and qualitative studies were considered. The study designs included cross-sectional studies, cohort studies, tool development studies, randomized control trials, and tool validation studies. Perspectives, commentaries, correspondence articles, modeling studies, forecasting studies, and health technology assessment studies were excluded. We also examined the studies included in previous systematic reviews on similar topics to identify any articles that our search strategy may have missed. 6 – 8 , 10 , 11 Studies that only assessed costs associated with disease or socioeconomic inequality in cancer care were excluded. Lastly, studies for which the full text was unavailable were also excluded from this review. Study selection Duplicates were automatically removed by the Covidence software from the records identified in the databases, followed by two levels of screening. Titles and abstracts retrieved by the search were screened for relevance against the inclusion criteria by two independent reviewers at Level 1 screening. In cases of conflict between the reviewers, the final decision was taken by the investigators, MSS, or PS. The full texts of the studies included in Level 1 screening were reassessed for eligibility at Level 2 screening using the same methodology used for Level 1 screening. Studies that passed the Level 2 screening were included in this review. Data Extraction and Definitions An electronic data extraction form was developed to collect information on study characteristics, study populations, and FT assessment methods. Study characteristics included the study’s aim, design, start and end year, funding sources, and conflict of interest disclosures. Study population details captured the country of the study population, participant type ( individuals with cancer or caregivers), sample size, gender distribution, median age, and cancer type(s). The income group of the country where the study was conducted was based on the World Bank classification. 14 Caregivers of patients with cancer included any family members or friends who assisted the patient but did not receive any monetary compensation. Patients with cancer aged ≥ 18 years were classified as adults, 10–17 years as adolescents, and less than 10 years as children. Malignancies were classified as hematological (including leukemias, lymphomas, and multiple myeloma) or solid. For quantitative studies, FT assessment methods were documented by extracting the exact wording of questions assessing FT, question format (e.g., scales, dichotomous, multiple-choice, or other), psychometric validation status (within the study or in prior research), and the inclusion of FT sub-domains. For qualitative studies, identified themes were extracted verbatim. Data Analysis and Reporting The characteristics of each included study and its population were summarized using counts and percentages for categorical variables. The country-wise distribution of studies assessing FT was illustrated using a choropleth map. Each question from the FT assessment methods in the final set of quantitative studies was initially categorized into material, behavioral, or psychosocial FT domains. The material domain comprised material conditions resulting from increased OOPE and reduced income due to an inability to work during or after cancer treatment. The psychosocial domain addressed the mental and emotional responses to increased expenses and reduced income. The behavioral domain focused on coping strategies that patients and caregivers adopted to manage medical care in the face of heightened expenses. These definitions are similar to those used in previous studies. 10 , 15 Two investigators (MSS and PS) independently classified each question into one of the three domains and identified common themes within each domain. The themes were then compared and discussed to refine the categorization. Any conflicts were resolved through consensus. An iterative, inductive approach was used for content analysis, allowing themes to be updated as new concepts emerged. The themes extracted from qualitative studies were summarized similarly. Results Our search yielded 5,368 records, and by examining the reference lists of previously published systematic reviews, we identified ten additional studies relevant to this review. After removing 2,035 duplicates, the titles and abstracts of 3,343 studies were screened. Following Level 1 screening, 611 studies were selected for full-text retrieval, of which nine full texts could not be obtained. Thus, the full text of 602 studies were assessed, and 454 studies were ultimately included in this review (Supplementary Fig. 1). Of these, 422 were quantitative studies, while 16 were mixed-methods and 16 were qualitative studies. The full list of all studies included in this review is available in the Supplementary Material. Characteristics of included studies Most included studies were conducted in HICs (81.7%, n = 371), with the United States accounting for the largest share (59.3%, n = 269). (Table 1 ; Fig. 1 ) The number of studies included for each country is provided in Supplementary Table 1. Most studies were published between 2011 and 2020 (72.5%, n = 259). Studies were primarily conducted among adults ≥ 18 years of age (93.8%, n = 426) and focused on patients with solid organ malignancies (92.9%, n = 379). Most studies involved only patients with cancer (87.4%, n = 397), while a smaller proportion included caregivers (12.6%, n = 57). Additionally, 41.9% (n = 179) of studies reported a higher proportion of female participants compared to male participants. Financial Toxicity Assessment Questionnaires A total of 164 questionnaires comprising 1,104 individual questions were identified across 438 quantitative studies. The most commonly used questionnaire was the COST tool (40.4%, n = 177), followed by the Medical Expenditure Panel Survey (MEPS) (9.1%, n = 40), the European Organisation for Research and Treatment of Cancer (EORTC) instruments (7.7%, n = 34), the National Health Interview Survey (NHIS) (6.24%, n = 28), and the Financial Well-Being Scale (3.2%, n = 14). Other tools were each used in less than ten studies. The geographical distribution of the use of these questionnaires is shown in Fig. 2 . Only 79 questionnaires (48.2%) had been validated in patients with cancer prior to their use in the included studies. Domains and sub-domains from quantitative studies Most questions were related to the material domain (51.3%, n = 566), followed by the behavioral (29.9%, n = 330) and psychosocial domains (18.8%, n = 208) (Table 2 ). The most commonly used questions within the material, behavioral, and psychosocial domains were related to health expenditure (9.6%, n = 106), delaying or skipping healthcare services (12.6%, n = 139), and the financial burden of healthcare costs (12.8%, n = 141), respectively. Domains and sub-domains from qualitative studies A total of 236 themes related to FT were identified from the results of 32 qualitative studies. Consistent with findings from quantitative studies, the material domain was the most represented (n = 105, 32.2%), followed by the behavioral (n = 80, 24.5%) and psychosocial domains (n = 51, 15.6%) (Table 3 ). The most commonly reported sub-domains within the material, behavioral, and psychosocial domains were healthcare expenditure (8.6%, n = 28), reduced productivity at work or job loss (8.6%, n = 28), and the financial burden of healthcare costs (8.0%, n = 26), respectively. Discussion This systematic review highlights significant disparities in the assessment of cancer-related FT across countries, income levels, and populations. While LMICs and LICs account for most cancer cases worldwide, over 80% of the 441 included studies were conducted in HICs. 16 Our results highlight the need to develop tools to accurately measure FT in LMICs in order to inform context-specific policies to mitigate its impact. Relying solely on evidence from HICs may lead to the adoption of inappropriate interventions for the healthcare and socioeconomic contexts of LMICs. For instance, many strategies developed in HICs, such as reducing co-payments through insurance reforms and expanding access to financial navigators, are less applicable in LMICs, where OOPE are high and insurance coverage is limited or nonexistent. 17 Instead, interventions tailored to LMICs, such as expanding access to cancer centers in remote areas, raising clinician awareness of FT, and promoting pooled procurement of essential cancer medications, among many others, are likely to yield a greater impact. 18 We found that most research on FT has focused on adults with cancer, while the impact of FT on caregivers of children and adolescents remains underexplored. It is increasingly recognized that the FT of pediatric cancer care differs from that of adults. 19 The material and psychosocial burden of FT from pediatric cancer can have a deep and long-lasting impact on children and their families. While the impact of FT on adult survivors of childhood cancer is receiving growing attention in HICs, evidence from LMICs is sparse. 20 Our review also highlights the limited representation of caregiver perspectives in studies on FT. Among the few studies that included caregivers, the majority focused on pediatric cancer settings. Caregivers often face significant financial challenges, including the need to take on additional work or alter their lifestyle due to treatment-related expenses, compounding the emotional burden of a cancer diagnosis within the family. 21 , 22 To develop interventions that holistically address FT, it is essential to incorporate the experiences and needs of caregivers. Our findings align with previous reviews that have identified COST as the most frequently used questionnaire to assess FT. 6 , 10 , 11 Developed by researchers at the University of Chicago, COST is widely adopted due to its ease of administration and psychometric validity. 23 More recently, abbreviated versions of the COST questionnaire have been proposed to facilitate faster screening for FT. 24 The tool has also been translated into multiple languages and validated in diverse settings beyond the United States. 25 – 27 Nonetheless, as noted by the original developers of COST in a recent editorial, there remains a need for further advancement in FT measurement tools, particularly those that capture a broader range of domains and reflect the experiences of diverse populations. 28 Importantly almost half of the tools used in the studies included in this review had not undergone any psychometric validation before their application. This underscores the need for maintaining methodological rigor as interest in accurately measuring and addressing FT grows. We observed a wide variety of concepts and themes used to define FT. On one hand, this reflects the diverse ways in which the financial burden of cancer care can affect patients and their caregivers. On the other hand, it raises concerns about the accuracy and usefulness of many of these themes in identifying FT across diverse populations, especially given the limited validation of these measures. Our results show a predominance of material and behavioral domains, with comparatively limited attention to psychosocial dimensions. The most common subdomains under the material domain included healthcare expenses, applying for loans or credit, and limitations in insurance coverage. These findings are consistent with prior studies that have highlighted that the costs of cancer care, even in insured populations, often lead to catastrophic health expenditure and distress financing. 29 , 30 Patients with significant needs may even resort to online medical crowdfunding, which is often insufficient to meet these additional financial needs. 31 In the behavioral domain, we identified themes of delaying or foregoing medical care by skipping medications, seeking alternative therapies, or altering treatment plans without medical consultation. It is well documented that financial strain leads to poor compliance with cancer treatment in both HICs and LMICs. 7 , 32 Modifications in leisure activities and basic needs are often changes that might not be obvious in the clinical setting but do significantly impact the quality of life of patients. The scarcity of psychosocial content is concerning, given the evidence that FT contributes significantly to psychological distress, including depression and anxiety, among patients and caregivers. 30 , 33 The strengths of this review include its broad inclusion criteria encompassing both quantitative and qualitative studies and its mapping of FT items across material, behavioral, and psychosocial domains. By cataloging 164 unique questionnaires and categorizing 1,104 FT-related questions, this review provides a comprehensive inventory for future tool development. Including studies from multiple databases and settings enhances the robustness of the findings. Our search strategy was limited by the exclusion of conference proceedings or dissertations, resulting in an underrepresentation of studies that have not yet been published in indexed journals. Conclusion The current landscape of FT research primarily focuses on adult patients with cancer and the material impacts of financial toxicity. However, these findings may not adequately capture the lived experiences of children with cancer, their caregivers, or patients in LMICs. Future research should prioritize developing and validating culturally and contextually appropriate FT tools, particularly for use among underserved populations, including those living in LMICs, children, adolescents, and caregivers. Cross-cultural adaptation and rigorous psychometric testing are essential to ensure that FT assessments are globally relevant and locally meaningful, and that they lead to clinical and policy interventions designed to improve patient-centered care, and to mitigate the financial burden of cancer. Declarations Conflict of Interest: None Funding: No funding was received for this study. During the time of this work Dr. Pragati B. Hebbar was supported by the DBT/Wellcome Trust India Alliance Intermediate Fellowship (Grant number: IA/CPHI/22/1/506537). Data Availability statement: This scoping review is based on publicly available literature. The full list of included studies and the search strategies are provided in the supplementary material. All data analyzed in this study are available from the corresponding author upon reasonable request. References Hussaini SMQ, Gupta A, Dusetzina SB (2022) Financial toxicity of cancer treatment. JAMA Oncol 8(5):788. 10.1001/jamaoncol.2021.7987 Smith GL, Banegas MP, Acquati C et al (2022) Navigating financial toxicity in patients with cancer: A multidisciplinary management approach. CA Cancer J Clin 72(5):437–453. 10.3322/caac.21730 Ghazal LV, Abrahamse P, Ward KC, Morris AM, Hawley ST, Veenstra CM (2023) Financial Toxicity and Its Association With Health-Related Quality of Life Among Partners of Colorectal Cancer Survivors. 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Characteristic Number of studies (%) Income Group of Study Country* High income 371 (81.7) Upper middle income 52 (11.5) Lower middle income 32 (7.0) Low income 7 (1.5) Study Start Year (n = 357) Before 2000 6 (1.7) 2000–2010 41 (11.5) 2011–2020 259 (72.5) 2021–2024 51 (14.3) Study Type Quantitative 422 (93) Mixed-Methods 16 (3.5) Qualitative 16 (3.5) Patient Age Group* Adults (≥ 18 years) 426 (93.8) Adolescents (10–17 years) 18 (4.0) Children (< 10 years) 12 (2.6) Participant Type Only patients with cancer 397 (87.4) Only caregivers of patients with cancer 30 (6.6) Patients with cancer and their caregivers 27 (6) Tumor Type (n = 408)* Solid Malignancy 379 (92.9) Hematological Malignancy 144 (35.3) Participant sex distribution (n = 427) Female participants more than Male participants 179 (41.9) Male participants more than female participants 157 (36.8) Only female participants 75 (17.6) Only male participants 14 (3.3) Equal proportion of male and female participants 2 (0.5) * Categories are not mutually exclusive. The sum may exceed the total number of studies. Table 2 Domains and subdomains of questions assessing the financial toxicity of cancer care Domains Subdomains Number of questions (%) Material Healthcare expenditure 106 (9.6) Applying for loans or credit 83 (7.5) Extent of health insurance coverage 64 (5.8) Requesting financial aid 57 (5.2) Struggling to pay bills 55 (5.0) Reduced financial resources 48 (4.3) Utilizing personal savings 45 (4.1) Evaluating the adequacy of financial resources 37 (3.4) Selling valuable belongings 33 (3.0) Non-healthcare expenditure 17 (1.5) Inability to settle outstanding debts 9 (0.8) Filing for bankruptcy 9 (0.8) Seeking material aid 3 (0.3) Behavioral Delaying or skipping healthcare services 139 (12.6) Delaying or skipping basic needs 72 (6.5) Switching to affordable or alternative medication sources 23 (2.1) Reduced productivity at work or job loss 23 (2.1) Delaying or skipping leisure activities 21 (1.9) Seeking advice from financial planners 11 (1.0) Changes in general spending habits 11 (1.0) Postponing significant purchases 6 (0.5) Calculating treatment costs before seeking medical care 5 (0.5) Changing treatment plans without medical advice due to financial burden 5 (0.5) Increased need for family members to work to cope with healthcare costs 4 (0.4) Cutting back on family healthcare expenses 3 (0.3) Appealing against health insurance denials 3 (0.3) Increasing working hours to cope with healthcare expenses 2 (0.2) Efforts to preserve employment-linked health insurance 2 (0.2) Psychosocial The financial burden of healthcare costs 141 (12.8) Overall satisfaction with financial status 28 (2.5) Concern about non-healthcare-related expenditures 20 (1.8) Concern about health insurance 7 (0.6) Concern about reduced productivity at work or job loss 5 (0.5) Family members' concern about healthcare spending 4 (0.4) Considered filing for bankruptcy 2 (0.2) Importance of financial aid 1 (0.1) Table 3 Domains and subdomains of qualitative themes assessing financial toxicity of cancer care Domains Subdomains Number of questions (%) Material Healthcare expenditure 28 (11.9) Evaluating the adequacy of financial resources 16 (6.8) Non-healthcare expenditure 16 (6.8) Requesting financial aid 14 (5.9) Applying for loans or credit 9 (3.8) Utilizing personal savings 8 (3.4) Extent of health insurance coverage 7 (3) Struggling to pay bills 3 (1.3) Selling valuable belongings 3 (1.3) Reduced financial resources 1 (0.4) Behavioral Reduced productivity at work or job loss 28 (11.9) Delaying or skipping basic needs 13 (5.5) Changes in general spending habits 11 (4.7) Increased need for family members to work to cope with healthcare costs 6 (2.5) Delaying or skipping leisure activities 5 (2.1) Delaying or skipping healthcare services 4 (1.7) Increased non-financial support by family 4 (1.7) Seeking advice from financial planners 3 (1.3) Switching to affordable or alternative medication sources 1 (0.4) Changing treatment plans without medical advice due to financial burden 1 (0.4) Concern about reduced productivity at work or job loss 1 (0.4) Struggling to pay bills 1 (0.4) Increasing working hours to cope with healthcare expenses 1 (0.4) The financial burden of healthcare costs 1 (0.4) Psychosocial The financial burden of healthcare costs 26 (11) Overall satisfaction with financial status 11 (4.7) Family members' concern about healthcare spending 8 (3.4) Concern about non-healthcare-related expenditures 3 (1.3) Concern about health insurance 2 (0.8) Importance of financial aid 1 (0.4) Additional Declarations The authors declare no competing interests. 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Sharma","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBElEQVRIiWNgGAWjYJACZiBOALM+/rEBkoyNBwjoYGyGaWGc2ZAGohqI18LM23AYLIRXizn72eePCxjq8vhnn078wLvjvN3a9sNAW2psonFpsexJN2yewXC4WOJc7mYJyTO3k7edSQRqOZaW24BDi8GBNMZmHoYDiQ1neDdIGLDdTjYDsg8wNhzGreX8M5CWusT5Z3g3/0hgO5dsdv4hAS03wLYwJ244w7tN4mDbATuzGwRssZzxjHE2j8HhxI1ALZYNZ5ITzG4AbUnA4xdz/jSGzzwVdYnzgA67/afCzt7sfPrDBx9qbHA7DIkEg0SwygQcytEUQ4A9HsWjYBSMglEwQgEApCtm/U0IrZUAAAAASUVORK5CYII=","orcid":"","institution":"","correspondingAuthor":true,"prefix":"","firstName":"Parth","middleName":"","lastName":"Sharma","suffix":""},{"id":463390146,"identity":"885952dd-5f97-40a3-9577-6d994f047e15","order_by":2,"name":"Varun Raj Passi","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Varun","middleName":"Raj","lastName":"Passi","suffix":""},{"id":463390147,"identity":"c3091627-ed33-4b5d-ab0d-422a7ea25a4a","order_by":3,"name":"Larry 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Blanchard","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Charmaine","middleName":"","lastName":"Blanchard","suffix":""},{"id":463390154,"identity":"cfabf3a1-e930-4bfc-81e1-641664b53ee0","order_by":10,"name":"Enrique Soto-Perez-de-Celis","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Enrique","middleName":"","lastName":"Soto-Perez-de-Celis","suffix":""},{"id":463390155,"identity":"9dbd1f1c-6b5b-4d17-b347-ba657d74e122","order_by":11,"name":"Pragati B Hebbar","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Pragati","middleName":"B","lastName":"Hebbar","suffix":""},{"id":463390156,"identity":"767004fd-d3f2-4819-92a6-7b381e39b37d","order_by":12,"name":"Arun Ghoshal","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Arun","middleName":"","lastName":"Ghoshal","suffix":""}],"badges":[],"createdAt":"2025-05-29 04:18:10","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-6772539/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6772539/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":83812957,"identity":"24b8fdde-e955-49fb-994c-80dbb36d14bc","added_by":"auto","created_at":"2025-06-03 07:16:22","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":524994,"visible":true,"origin":"","legend":"\u003cp\u003eGeographical distribution of studies assessing the financial toxicity of cancer care\u003c/p\u003e","description":"","filename":"Figure11.png","url":"https://assets-eu.researchsquare.com/files/rs-6772539/v1/7bd70fe45d79af5249d9b95e.png"},{"id":83814088,"identity":"d20fab72-fa32-42f5-94e7-5753319ade08","added_by":"auto","created_at":"2025-06-03 07:24:22","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":57647,"visible":true,"origin":"","legend":"\u003cp\u003eStacked bar chart showing the distribution of financial-toxicity assessment questionnaires across country income groups. Studies conducted in more than one income group were classified according to the highest income group represented among the study sites. [COST (Comprehensive Score for Financial Toxicity), EORTC-QoL (European Organisation for Research and Treatment of Cancer), NHIS (National Health Interview Survey), MEPS (Medical Expenditure Panel Survey), HIC (high-income countries), UMIC (upper-middle-income countries), LMIC (lower-middle-income countries), and LIC (low-income countries)]\u003c/p\u003e","description":"","filename":"Figure21.png","url":"https://assets-eu.researchsquare.com/files/rs-6772539/v1/e498d222d0ed15f7a2773805.png"},{"id":83814852,"identity":"36fd609c-f04d-4106-83bf-c2aec331149a","added_by":"auto","created_at":"2025-06-03 07:32:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1324118,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6772539/v1/e8748a0b-633a-4eb9-933f-3812b9bd14c5.pdf"},{"id":83814089,"identity":"876df528-6e79-492e-958b-00079ba628e4","added_by":"auto","created_at":"2025-06-03 07:24:22","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":120532,"visible":true,"origin":"","legend":"\u003cp\u003eSupplementary Material\u003c/p\u003e","description":"","filename":"FinToxSupplement.docx","url":"https://assets-eu.researchsquare.com/files/rs-6772539/v1/f720537116527dc322af1960.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eMapping the Landscape of Financial Toxicity Assessment in Cancer: A Scoping Review\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eFinancial toxicity (FT) refers to the financial burden and distress experienced by patients and their families due to the costs associated with the treatment of cancer. \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e FT extends beyond direct out-of-pocket expenditures (OOPE) to encompass broader financial consequences, including income loss, debt accumulation, and inability to fulfill essential non-medical expenses. \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e FT has significant psychosocial implications, leading to increased stress, anxiety, and reduced quality of life for patients undergoing treatment and their caregivers. \u003csup\u003e\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAlthough FT is observed globally, its impact varies between high-income countries (HICs) and low- and middle-income countries (LMICs). In HICs, despite the availability of universal coverage, health insurance and/or financial assistance programs, many patients experience FT due to copayments, limited coverage, loss of income, and non-medical costs such as transportation and caregiving. In LMICs, where many healthcare expenditures are OOPE and financial protection mechanisms are limited, FT is often more severe, leading to catastrophic health expenditures, impoverishment, and poor access and adherence to treatment. \u003csup\u003e\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eFT is commonly assessed using two main approaches: (i) objective measures, such as the quantification of OOPE, catastrophic health expenditures, and impoverishment, and (ii) subjective assessments using patient-reported outcomes, which capture perceived financial distress. However, commonly used instruments such as the Comprehensive Score for Financial Toxicity (COST) may not be universally applicable due to differences in healthcare systems, economic and social structures, and cultural norms influencing financial decision-making. \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e While previous studies have analyzed the content of FT measurement tools, they have largely been limited to classifying the contents of FT assessment tools into broad categories of material, behavioral, and psychosocial FT without a detailed thematic analysis. \u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Additionally, some reviews have included studies conducted in a limited number of countries. \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e Researchers from LMICs have also identified a growing need for local sociocultural context-specific FT assessment tools. \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eGiven the increasing recognition of FT as a major barrier to equitable cancer care, a comprehensive global comparison of FT assessment tools is warranted. This review aims to systematically examine existing tools used to assess FT across settings and identify global disparities in the generation of evidence and tools for cancer-related FT assessment. Additionally, it aims to highlight neglected themes and populations in existing FT assessment tools. Finally, we have generated an inventory of questions used for FT assessment globally in order to create a knowledge base for the development of locally relevant tools across various resource settings.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eOverview\u003c/h2\u003e \u003cp\u003eThis study followed a scoping review methodology, which allows the examination of broad topics and the identification of key characteristics related to a concept. Given the inconsistencies in the measurement of FT, we chose this methodology to understand and collate the various ways FT is measured in different resource settings and populations worldwide. This study adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines for scoping reviews. \u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e (Supplementary Material) The detailed pre-registered protocol with the search strategy and all analyses included in this review is available from the Open Science Framework Registries.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Ethical approval was not required as this is a review article that does not involve any patient data.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData Sources and Search Strategy\u003c/h3\u003e\n\u003cp\u003eA comprehensive search of six databases from each database\u0026rsquo;s inception to July 24th, 2024, in any language, without any date restrictions, was conducted. The databases were Ovid MEDLINE(R) and Epub Ahead of Print, In-Process \u0026amp; Other Non-Indexed Citations, and Daily, Ovid EMBASE, Ovid Cochrane Database of Systematic Reviews, Ovid PsycINFO, Scopus, and Web of Science. The search strategy was designed and conducted by an experienced librarian (LP) with input from the study\u0026rsquo;s principal investigators (MSS and PS). The search terms and combinations used are available in the Supplementary Material.\u003c/p\u003e\n\u003ch3\u003eEligibility Criteria\u003c/h3\u003e\n\u003cp\u003eStudies were included if at least 50% of the patient population comprised patients with cancer, cancer survivors, or their caregivers and if FT was assessed. The study population included participants of any age, cancer type, and geographic location. Both quantitative and qualitative studies were considered. The study designs included cross-sectional studies, cohort studies, tool development studies, randomized control trials, and tool validation studies. Perspectives, commentaries, correspondence articles, modeling studies, forecasting studies, and health technology assessment studies were excluded. We also examined the studies included in previous systematic reviews on similar topics to identify any articles that our search strategy may have missed.\u003csup\u003e\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e Studies that only assessed costs associated with disease or socioeconomic inequality in cancer care were excluded. Lastly, studies for which the full text was unavailable were also excluded from this review.\u003c/p\u003e\n\u003ch3\u003eStudy selection\u003c/h3\u003e\n\u003cp\u003eDuplicates were automatically removed by the Covidence software from the records identified in the databases, followed by two levels of screening. Titles and abstracts retrieved by the search were screened for relevance against the inclusion criteria by two independent reviewers at Level 1 screening. In cases of conflict between the reviewers, the final decision was taken by the investigators, MSS, or PS. The full texts of the studies included in Level 1 screening were reassessed for eligibility at Level 2 screening using the same methodology used for Level 1 screening. Studies that passed the Level 2 screening were included in this review.\u003c/p\u003e\n\u003ch3\u003eData Extraction and Definitions\u003c/h3\u003e\n\u003cp\u003eAn electronic data extraction form was developed to collect information on study characteristics, study populations, and FT assessment methods. Study characteristics included the study\u0026rsquo;s aim, design, start and end year, funding sources, and conflict of interest disclosures. Study population details captured the country of the study population, participant type ( individuals with cancer or caregivers), sample size, gender distribution, median age, and cancer type(s). The income group of the country where the study was conducted was based on the World Bank classification.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e Caregivers of patients with cancer included any family members or friends who assisted the patient but did not receive any monetary compensation. Patients with cancer aged\u0026thinsp;\u0026ge;\u0026thinsp;18 years were classified as adults, 10\u0026ndash;17 years as adolescents, and less than 10 years as children. Malignancies were classified as hematological (including leukemias, lymphomas, and multiple myeloma) or solid.\u003c/p\u003e \u003cp\u003eFor quantitative studies, FT assessment methods were documented by extracting the exact wording of questions assessing FT, question format (e.g., scales, dichotomous, multiple-choice, or other), psychometric validation status (within the study or in prior research), and the inclusion of FT sub-domains. For qualitative studies, identified themes were extracted verbatim.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis and Reporting\u003c/h2\u003e \u003cp\u003eThe characteristics of each included study and its population were summarized using counts and percentages for categorical variables. The country-wise distribution of studies assessing FT was illustrated using a choropleth map.\u003c/p\u003e \u003cp\u003eEach question from the FT assessment methods in the final set of quantitative studies was initially categorized into material, behavioral, or psychosocial FT domains. The material domain comprised material conditions resulting from increased OOPE and reduced income due to an inability to work during or after cancer treatment. The psychosocial domain addressed the mental and emotional responses to increased expenses and reduced income. The behavioral domain focused on coping strategies that patients and caregivers adopted to manage medical care in the face of heightened expenses. These definitions are similar to those used in previous studies. \u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e Two investigators (MSS and PS) independently classified each question into one of the three domains and identified common themes within each domain. The themes were then compared and discussed to refine the categorization. Any conflicts were resolved through consensus. An iterative, inductive approach was used for content analysis, allowing themes to be updated as new concepts emerged. The themes extracted from qualitative studies were summarized similarly.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eOur search yielded 5,368 records, and by examining the reference lists of previously published systematic reviews, we identified ten additional studies relevant to this review. After removing 2,035 duplicates, the titles and abstracts of 3,343 studies were screened. Following Level 1 screening, 611 studies were selected for full-text retrieval, of which nine full texts could not be obtained. Thus, the full text of 602 studies were assessed, and 454 studies were ultimately included in this review \u003cb\u003e(Supplementary Fig.\u0026nbsp;1).\u003c/b\u003e Of these, 422 were quantitative studies, while 16 were mixed-methods and 16 were qualitative studies. The full list of all studies included in this review is available in the Supplementary Material.\u003c/p\u003e\n\u003ch3\u003eCharacteristics of included studies\u003c/h3\u003e\n\u003cp\u003eMost included studies were conducted in HICs (81.7%, n\u0026thinsp;=\u0026thinsp;371), with the United States accounting for the largest share (59.3%, n\u0026thinsp;=\u0026thinsp;269). (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e; Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) The number of studies included for each country is provided in Supplementary Table\u0026nbsp;1. Most studies were published between 2011 and 2020 (72.5%, n\u0026thinsp;=\u0026thinsp;259). Studies were primarily conducted among adults\u0026thinsp;\u0026ge;\u0026thinsp;18 years of age (93.8%, n\u0026thinsp;=\u0026thinsp;426) and focused on patients with solid organ malignancies (92.9%, n\u0026thinsp;=\u0026thinsp;379). Most studies involved only patients with cancer (87.4%, n\u0026thinsp;=\u0026thinsp;397), while a smaller proportion included caregivers (12.6%, n\u0026thinsp;=\u0026thinsp;57). Additionally, 41.9% (n\u0026thinsp;=\u0026thinsp;179) of studies reported a higher proportion of female participants compared to male participants.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eFinancial Toxicity Assessment Questionnaires\u003c/h2\u003e \u003cp\u003eA total of 164 questionnaires comprising 1,104 individual questions were identified across 438 quantitative studies. The most commonly used questionnaire was the COST tool (40.4%, n\u0026thinsp;=\u0026thinsp;177), followed by the Medical Expenditure Panel Survey (MEPS) (9.1%, n\u0026thinsp;=\u0026thinsp;40), the European Organisation for Research and Treatment of Cancer (EORTC) instruments (7.7%, n\u0026thinsp;=\u0026thinsp;34), the National Health Interview Survey (NHIS) (6.24%, n\u0026thinsp;=\u0026thinsp;28), and the Financial Well-Being Scale (3.2%, n\u0026thinsp;=\u0026thinsp;14). Other tools were each used in less than ten studies. The geographical distribution of the use of these questionnaires is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Only 79 questionnaires (48.2%) had been validated in patients with cancer prior to their use in the included studies.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eDomains and sub-domains from quantitative studies\u003c/h2\u003e \u003cp\u003eMost questions were related to the material domain (51.3%, n\u0026thinsp;=\u0026thinsp;566), followed by the behavioral (29.9%, n\u0026thinsp;=\u0026thinsp;330) and psychosocial domains (18.8%, n\u0026thinsp;=\u0026thinsp;208) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The most commonly used questions within the material, behavioral, and psychosocial domains were related to health expenditure (9.6%, n\u0026thinsp;=\u0026thinsp;106), delaying or skipping healthcare services (12.6%, n\u0026thinsp;=\u0026thinsp;139), and the financial burden of healthcare costs (12.8%, n\u0026thinsp;=\u0026thinsp;141), respectively.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eDomains and sub-domains from qualitative studies\u003c/h2\u003e \u003cp\u003eA total of 236 themes related to FT were identified from the results of 32 qualitative studies. Consistent with findings from quantitative studies, the material domain was the most represented (n\u0026thinsp;=\u0026thinsp;105, 32.2%), followed by the behavioral (n\u0026thinsp;=\u0026thinsp;80, 24.5%) and psychosocial domains (n\u0026thinsp;=\u0026thinsp;51, 15.6%) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The most commonly reported sub-domains within the material, behavioral, and psychosocial domains were healthcare expenditure (8.6%, n\u0026thinsp;=\u0026thinsp;28), reduced productivity at work or job loss (8.6%, n\u0026thinsp;=\u0026thinsp;28), and the financial burden of healthcare costs (8.0%, n\u0026thinsp;=\u0026thinsp;26), respectively.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis systematic review highlights significant disparities in the assessment of cancer-related FT across countries, income levels, and populations. While LMICs and LICs account for most cancer cases worldwide, over 80% of the 441 included studies were conducted in HICs.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e Our results highlight the need to develop tools to accurately measure FT in LMICs in order to inform context-specific policies to mitigate its impact. Relying solely on evidence from HICs may lead to the adoption of inappropriate interventions for the healthcare and socioeconomic contexts of LMICs. For instance, many strategies developed in HICs, such as reducing co-payments through insurance reforms and expanding access to financial navigators, are less applicable in LMICs, where OOPE are high and insurance coverage is limited or nonexistent. \u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Instead, interventions tailored to LMICs, such as expanding access to cancer centers in remote areas, raising clinician awareness of FT, and promoting pooled procurement of essential cancer medications, among many others, are likely to yield a greater impact. \u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eWe found that most research on FT has focused on adults with cancer, while the impact of FT on caregivers of children and adolescents remains underexplored. It is increasingly recognized that the FT of pediatric cancer care differs from that of adults. \u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e The material and psychosocial burden of FT from pediatric cancer can have a deep and long-lasting impact on children and their families. While the impact of FT on adult survivors of childhood cancer is receiving growing attention in HICs, evidence from LMICs is sparse. \u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eOur review also highlights the limited representation of caregiver perspectives in studies on FT. Among the few studies that included caregivers, the majority focused on pediatric cancer settings. Caregivers often face significant financial challenges, including the need to take on additional work or alter their lifestyle due to treatment-related expenses, compounding the emotional burden of a cancer diagnosis within the family. \u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e To develop interventions that holistically address FT, it is essential to incorporate the experiences and needs of caregivers.\u003c/p\u003e \u003cp\u003eOur findings align with previous reviews that have identified COST as the most frequently used questionnaire to assess FT.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e Developed by researchers at the University of Chicago, COST is widely adopted due to its ease of administration and psychometric validity. \u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e More recently, abbreviated versions of the COST questionnaire have been proposed to facilitate faster screening for FT. \u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e The tool has also been translated into multiple languages and validated in diverse settings beyond the United States. \u003csup\u003e\u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e Nonetheless, as noted by the original developers of COST in a recent editorial, there remains a need for further advancement in FT measurement tools, particularly those that capture a broader range of domains and reflect the experiences of diverse populations. \u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e Importantly almost half of the tools used in the studies included in this review had not undergone any psychometric validation before their application. This underscores the need for maintaining methodological rigor as interest in accurately measuring and addressing FT grows.\u003c/p\u003e \u003cp\u003eWe observed a wide variety of concepts and themes used to define FT. On one hand, this reflects the diverse ways in which the financial burden of cancer care can affect patients and their caregivers. On the other hand, it raises concerns about the accuracy and usefulness of many of these themes in identifying FT across diverse populations, especially given the limited validation of these measures. Our results show a predominance of material and behavioral domains, with comparatively limited attention to psychosocial dimensions. The most common subdomains under the material domain included healthcare expenses, applying for loans or credit, and limitations in insurance coverage. These findings are consistent with prior studies that have highlighted that the costs of cancer care, even in insured populations, often lead to catastrophic health expenditure and distress financing. \u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e,\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e Patients with significant needs may even resort to online medical crowdfunding, which is often insufficient to meet these additional financial needs.\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e In the behavioral domain, we identified themes of delaying or foregoing medical care by skipping medications, seeking alternative therapies, or altering treatment plans without medical consultation. It is well documented that financial strain leads to poor compliance with cancer treatment in both HICs and LMICs. \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e Modifications in leisure activities and basic needs are often changes that might not be obvious in the clinical setting but do significantly impact the quality of life of patients. The scarcity of psychosocial content is concerning, given the evidence that FT contributes significantly to psychological distress, including depression and anxiety, among patients and caregivers. \u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e,\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe strengths of this review include its broad inclusion criteria encompassing both quantitative and qualitative studies and its mapping of FT items across material, behavioral, and psychosocial domains. By cataloging 164 unique questionnaires and categorizing 1,104 FT-related questions, this review provides a comprehensive inventory for future tool development. Including studies from multiple databases and settings enhances the robustness of the findings. Our search strategy was limited by the exclusion of conference proceedings or dissertations, resulting in an underrepresentation of studies that have not yet been published in indexed journals.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe current landscape of FT research primarily focuses on adult patients with cancer and the material impacts of financial toxicity. However, these findings may not adequately capture the lived experiences of children with cancer, their caregivers, or patients in LMICs. Future research should prioritize developing and validating culturally and contextually appropriate FT tools, particularly for use among underserved populations, including those living in LMICs, children, adolescents, and caregivers. Cross-cultural adaptation and rigorous psychometric testing are essential to ensure that FT assessments are globally relevant and locally meaningful, and that they lead to clinical and policy interventions designed to improve patient-centered care, and to mitigate the financial burden of cancer.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of Interest:\u0026nbsp;\u003c/strong\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eNo funding was received for this study. During the time of this work Dr. Pragati B. Hebbar was supported by the DBT/Wellcome Trust India Alliance Intermediate Fellowship (Grant number: IA/CPHI/22/1/506537).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability statement:\u0026nbsp;\u003c/strong\u003eThis scoping review is based on publicly available literature. The full list of included studies and the search strategies are provided in the supplementary material. All data analyzed in this study are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHussaini SMQ, Gupta A, Dusetzina SB (2022) Financial toxicity of cancer treatment. JAMA Oncol 8(5):788. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/jamaoncol.2021.7987\u003c/span\u003e\u003cspan address=\"10.1001/jamaoncol.2021.7987\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmith GL, Banegas MP, Acquati C et al (2022) Navigating financial toxicity in patients with cancer: A multidisciplinary management approach. 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Int J Equity Health 23(1):145. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12939-024-02215-2\u003c/span\u003e\u003cspan address=\"10.1186/s12939-024-02215-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarrera PM, Kantarjian HM, Blinder VS (2018) The financial burden and distress of patients with cancer: Understanding and stepping-up action on the financial toxicity of cancer treatment. CA Cancer J Clin 68(2):153\u0026ndash;165. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3322/caac.21443\u003c/span\u003e\u003cspan address=\"10.3322/caac.21443\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSra MS (2025) Patterns of online medical crowdfunding in india. JAMA Netw Open 8(1):e2454855. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/jamanetworkopen.2024.54855\u003c/span\u003e\u003cspan address=\"10.1001/jamanetworkopen.2024.54855\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKnight TG, Deal AM, Dusetzina SB et al (2018) Financial toxicity in adults with cancer: adverse outcomes and noncompliance. J Oncol Pract Oct 24:JOP1800120. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1200/JOP.18.00120\u003c/span\u003e\u003cspan address=\"10.1200/JOP.18.00120\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKale HP, Carroll NV (2016) Self-reported financial burden of cancer care and its effect on physical and mental health-related quality of life among US cancer survivors. Cancer 122(8):283\u0026ndash;289. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/cncr.29808\u003c/span\u003e\u003cspan address=\"10.1002/cncr.29808\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003c/p\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eCharacteristics of included studies (n\u0026thinsp;=\u0026thinsp;454).\u003c/div\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eCharacteristic\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eNumber of studies (%)\u003c/div\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eIncome Group of Study Country*\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eHigh income\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e371 (81.7)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eUpper middle income\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e52 (11.5)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eLower middle income\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e32 (7.0)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eLow income\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e7 (1.5)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eStudy Start Year (n\u0026thinsp;=\u0026thinsp;357)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eBefore 2000\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e6 (1.7)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2000\u0026ndash;2010\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e41 (11.5)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2011\u0026ndash;2020\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e259 (72.5)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2021\u0026ndash;2024\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e51 (14.3)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eStudy Type\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eQuantitative\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e422 (93)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMixed-Methods\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e16 (3.5)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eQualitative\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e16 (3.5)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePatient Age Group*\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eAdults (\u0026ge;\u0026thinsp;18 years)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e426 (93.8)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eAdolescents (10\u0026ndash;17 years)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e18 (4.0)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eChildren (\u0026lt;\u0026thinsp;10 years)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e12 (2.6)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eParticipant Type\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eOnly patients with cancer\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e397 (87.4)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eOnly caregivers of patients with cancer\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e30 (6.6)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePatients with cancer and their caregivers\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e27 (6)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eTumor Type (n\u0026thinsp;=\u0026thinsp;408)*\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSolid Malignancy\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e379 (92.9)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eHematological Malignancy\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e144 (35.3)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eParticipant sex distribution (n\u0026thinsp;=\u0026thinsp;427)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eFemale participants more than Male participants\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e179 (41.9)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMale participants more than female participants\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e157 (36.8)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eOnly female participants\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e75 (17.6)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eOnly male participants\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e14 (3.3)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eEqual proportion of male and female participants\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2 (0.5)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e* Categories are not mutually exclusive. The sum may exceed the total number of studies.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eDomains and subdomains of questions assessing the financial toxicity of cancer care\u003c/div\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eDomains\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSubdomains\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eNumber of questions (%)\u003c/div\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"13\" align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eMaterial\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eHealthcare expenditure\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e106 (9.6)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eApplying for loans or credit\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e83 (7.5)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eExtent of health insurance coverage\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e64 (5.8)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eRequesting financial aid\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e57 (5.2)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eStruggling to pay bills\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e55 (5.0)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eReduced financial resources\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e48 (4.3)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eUtilizing personal savings\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e45 (4.1)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eEvaluating the adequacy of financial resources\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e37 (3.4)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSelling valuable belongings\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e33 (3.0)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eNon-healthcare expenditure\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e17 (1.5)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eInability to settle outstanding debts\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e9 (0.8)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eFiling for bankruptcy\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e9 (0.8)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSeeking material aid\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3 (0.3)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"15\" align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eBehavioral\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eDelaying or skipping healthcare services\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e139 (12.6)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eDelaying or skipping basic needs\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e72 (6.5)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSwitching to affordable or alternative medication sources\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e23 (2.1)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eReduced productivity at work or job loss\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e23 (2.1)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eDelaying or skipping leisure activities\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e21 (1.9)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSeeking advice from financial planners\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e11 (1.0)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eChanges in general spending habits\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e11 (1.0)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePostponing significant purchases\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e6 (0.5)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eCalculating treatment costs before seeking medical care\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e5 (0.5)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eChanging treatment plans without medical advice due to financial burden\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e5 (0.5)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eIncreased need for family members to work to cope with healthcare costs\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e4 (0.4)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eCutting back on family healthcare expenses\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3 (0.3)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eAppealing against health insurance denials\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3 (0.3)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eIncreasing working hours to cope with healthcare expenses\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2 (0.2)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eEfforts to preserve employment-linked health insurance\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2 (0.2)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"8\" align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003ePsychosocial\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eThe financial burden of healthcare costs\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e141 (12.8)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eOverall satisfaction with financial status\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e28 (2.5)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eConcern about non-healthcare-related expenditures\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e20 (1.8)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eConcern about health insurance\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e7 (0.6)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eConcern about reduced productivity at work or job loss\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e5 (0.5)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eFamily members\u0026apos; concern about healthcare spending\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e4 (0.4)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eConsidered filing for bankruptcy\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2 (0.2)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eImportance of financial aid\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1 (0.1)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eDomains and subdomains of qualitative themes assessing financial toxicity of cancer care\u003c/div\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eDomains\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSubdomains\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eNumber of questions (%)\u003c/div\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"10\" align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eMaterial\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eHealthcare expenditure\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e28 (11.9)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eEvaluating the adequacy of financial resources\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e16 (6.8)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eNon-healthcare expenditure\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e16 (6.8)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eRequesting financial aid\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e14 (5.9)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eApplying for loans or credit\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e9 (3.8)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eUtilizing personal savings\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e8 (3.4)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eExtent of health insurance coverage\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e7 (3)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eStruggling to pay bills\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3 (1.3)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSelling valuable belongings\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3 (1.3)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eReduced financial resources\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1 (0.4)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"14\" align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eBehavioral\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eReduced productivity at work or job loss\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e28 (11.9)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eDelaying or skipping basic needs\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e13 (5.5)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eChanges in general spending habits\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e11 (4.7)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eIncreased need for family members to work to cope with healthcare costs\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e6 (2.5)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eDelaying or skipping leisure activities\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e5 (2.1)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eDelaying or skipping healthcare services\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e4 (1.7)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eIncreased non-financial support by family\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e4 (1.7)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSeeking advice from financial planners\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3 (1.3)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSwitching to affordable or alternative medication sources\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1 (0.4)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eChanging treatment plans without medical advice due to financial burden\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1 (0.4)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eConcern about reduced productivity at work or job loss\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1 (0.4)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eStruggling to pay bills\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1 (0.4)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eIncreasing working hours to cope with healthcare expenses\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1 (0.4)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eThe financial burden of healthcare costs\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1 (0.4)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"6\" align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003ePsychosocial\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eThe financial burden of healthcare costs\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e26 (11)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eOverall satisfaction with financial status\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e11 (4.7)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eFamily members\u0026apos; concern about healthcare spending\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e8 (3.4)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eConcern about non-healthcare-related expenditures\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3 (1.3)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eConcern about health insurance\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2 (0.8)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eImportance of financial aid\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1 (0.4)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Association for Socially Applicable Research","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Financial Toxicity; Financial Burden; COST; Global Oncology; Disparities","lastPublishedDoi":"10.21203/rs.3.rs-6772539/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6772539/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFinancial toxicity from cancer treatment is a significant barrier to equitable care and an important clinical and public health concern. This scoping review systematically review the financial toxicity assessment pattern in cancer care across global settings and generate an inventory of domains and sub-domains of questions used to assess financial toxicity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA comprehensive search of six databases was conducted, without language or date restrictions. Eligible studies reported on the development, validation, or application of financial toxicity assessment tools, with ≥50% inclusion of patients with cancer or caregivers. Questions evaluating financial toxicity were extracted and classified into three domains: material, behavioral, and psychosocial, with further categorization into subdomains.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOf the 3,343 records screened, 454 studies met the inclusion criteria. The majority were conducted in high-income countries (81.7%, n = 371), and 93.8% focused on adults. Across 438 quantitative studies, 164 unique financial toxicity questionnaires containing 1,104 questions were identified. The COmprehensive Score for financial Toxicity (COST) was the most used (40.4%). Only 48.2% of questionnaires had been validated among patients with cancer. Most questions assessed material domains (51.3%), followed by behavioral (29.9%) and psychosocial (18.8%). Themes from 32 qualitative studies echoed these distributions, highlighting healthcare expenditure and job loss as prominent concerns.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost studies of financial toxicity in cancer care are conducted among adults in high-income countries, and measure material domains. There is a need to increase financial toxicity research in low- and middle-income countries, and among pediatric and adolescent patients and caregivers of people with cancer.\u003c/p\u003e","manuscriptTitle":"Mapping the Landscape of Financial Toxicity Assessment in Cancer: A Scoping Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-03 07:16:17","doi":"10.21203/rs.3.rs-6772539/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6f438355-7b0e-46b4-91b5-dccf2d1c996d","owner":[],"postedDate":"June 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":49204342,"name":"Oncology"},{"id":49204343,"name":"Health Economics \u0026 Outcomes Research"},{"id":49204344,"name":"Health Policy"}],"tags":[],"updatedAt":"2025-06-03T07:16:18+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-03 07:16:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6772539","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6772539","identity":"rs-6772539","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}