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Table of Contents
Year : 2021  |  Volume : 4  |  Issue : 1  |  Page : 172-173

Digging deeper into cancer-associated financial toxicity in low- and middle-income countries

1 The Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
2 Division of Cancer Care and Epidemiology, Queen's University, Queen's University, Kingston, Ontario, Canada

Date of Submission10-Jan-2021
Date of Decision18-Jan-2021
Date of Acceptance18-Jan-2021
Date of Web Publication26-Mar-2021

Correspondence Address:
Bishal Gyawali
Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Queen's University, 10 Stuart Street, Level 2, Kingston, Ontario K7L 3N6
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/crst.crst_4_21

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How to cite this article:
Gupta A, Gyawali B. Digging deeper into cancer-associated financial toxicity in low- and middle-income countries. Cancer Res Stat Treat 2021;4:172-3

How to cite this URL:
Gupta A, Gyawali B. Digging deeper into cancer-associated financial toxicity in low- and middle-income countries. Cancer Res Stat Treat [serial online] 2021 [cited 2022 May 27];4:172-3. Available from: https://www.crstonline.com/text.asp?2021/4/1/172/312101

We read with great interest the work by Kalra et al. on the cross-sectional prevalence of financial toxicity (FT) among patients with brain tumors treated at a cancer center in India.[1] They reported that, of the 147 patients, more than half reported grade 2/3 FT based on the 12-item COmprehensive Score for FT (COST)-Functional Assessment of Chronic Illness Therapy instrument. Although FT is an important barrier to cancer care in low- and middle-income countries, most of the FT-related studies are reported from high-income countries. Addressing FT first requires proper measurement and documentation of the burden.[2] Therefore, this work by Kalra et al. from India is a welcome addition to the literature on FT in cancer.

Measuring the problem requires the employment of a valid tool. The COST tool has been developed and validated for patients with cancer in the United States of America. It is uncertain whether the same tool can be copy-pasted to measure FT in the Indian context. A previous study on cancer surgery-related FT in India defined FT as treatment expenses >10% of the annual household income.[3] Another study from Nepal defined FT as the prevalence of at least one of the three following parameters: selling property, borrowing money, or asking for charity.[4] FT research in the Indian context will first require the development and validation of a new tool for the Indian patients or validation of the COST tool in the Indian context before employing it in routine practice. For example, the COST tool has been validated in the Japanese context previously.[5]

Longitudinal assessment(s) of FT and changes in scores over the disease course could inform us about the “speed” at which FT proceeds, if left unimpeded. FT is expected to increase along the disease course, as is apparent from the findings of this study whereby patients with recurrent disease reported greater FT.[1] Furthermore, the participants in this study represent a unique population of young patients (median age: 38 years) with a guarded prognosis overall (two-thirds of the patients had grade 3/4 glioma). People in their 30s often have partners and young children. Therefore, the partners may have to bear more responsibilities on the social, occupational, and childcare fronts, while the patients receive treatment and recover. Thus, it would be meaningful to assess FT not only in the patients but also in their caregivers. FT and related distress to a caregiver can unfortunately continue even after the patients' demise, and longitudinal assessments of patient–caregiver dyads may provide unique insights into the evolution and a more global impact of FT.

In this study, the participants in the “general category” (who were required to pay nominal to no money for consultation and investigations) reported more FT than those in the “private category” (who paid full price). While this is expected (poorer patients have less savings), it would be important to understand the major treatment-related expenditures that patients in the general category experienced so as to plan appropriate policy interventions to address FT.

Finally, four patients in this cohort received bevacizumab, which is an expensive drug. This study does not allow for the assessment of the appropriateness of therapy. On the clinicians' part, not using ineffective or minimally effective drugs (especially the costly ones) is an important way to reduce FT.

We look forward to more work in this area.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Kalra D, Menon N, Singh GK, Dale O, Adak S, Das S, et al. Financial toxicities in patients receiving systemic therapy for brain tumors: A cross-sectional study. Cancer Res Stat Treat 2020;3:724-9.  Back to cited text no. 1
  [Full text]  
Desai A, Gyawali B. Financial toxicity of cancer treatment: Moving the discussion from acknowledgement of the problem to identifying solutions. EClinicalMedicine 2020;20:100269.  Back to cited text no. 2
Basavaiah G, Rent PD, Rent EG, Sullivan R, Towne M, Bak M, et al. Financial Impact of complex cancer surgery in India: A study of pancreatic cancer. J Glob Oncol 2018;4:1-9.  Back to cited text no. 3
Poudyal BS, Giri S, Tuladhar S, Neupane S, Gyawali B. A survey in Nepalese patients with acute leukaemia: A starting point for defining financial toxicity of cancer care in low-income and middle-income countries. Lancet Haematol 2020;7:e638-9.  Back to cited text no. 4
Honda K, Gyawali B, Ando M, Kumanishi R, Kato K, Sugiyama K, et al. Prospective survey of financial toxicity measured by the comprehensive score for financial toxicity in Japanese patients with cancer. J Glob Oncol 2019;5:1-8.  Back to cited text no. 5


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