Addressing financial toxicity for sustainable oncology care in the UK

Abstract

Financial toxicity is increasingly acknowledged as a growing challenge in oncology. While it has been extensively researched internationally, the UK lags behind, hindering the adoption of patient-centred approaches. This contribution explores sustainable healthcare practices, targeted education and the need to address structural gaps through focused research efforts.

Comment

Financial toxicity (FT) is a concept gaining considerable recognition internationally. It has been especially studied in the United States [1], where the private healthcare system often exposes patients to significant out-of-pocket costs. Research interest has also grown in European countries such as Italy and Germany [2, 3], where scholars have developed or validated tools to assess FT within public healthcare systems.

FT refers to the financial distress or hardship experienced by patients as a result of cancer treatment. It includes both objective elements, such as out-of-pocket expenses and income loss and subjective elements, such as stress, anxiety, and worry about the financial burden [1]. Its impact extends beyond economic strain, affecting multiple domains of a patient’s life. According to the Altice framework [4], FT comprises three interrelated components: Material Hardship (e.g. out-of-pocket costs, lost income), Psychological Responses (e.g. anxiety, stress and reduced sense of control), and Health Behaviours (e.g. treatment delays, non-adherence, or care avoidance). These dimensions can significantly undermine quality of life, treatment outcomes and long-term survivorship, underscoring the urgency of addressing FT as a core component of oncology care.

However, in the United Kingdom, it remains significantly understudied and inadequately addressed within medical education and clinical research. This appears partially mitigated by efforts from the recent European Organisation for Research and Treatment of Cancer Quality of Life group, where several researchers, including those based in the UK, are working on the issue. Nevertheless, this remains an underestimated topic and is not part of recent research calls promoted by UK Research and Innovation. This oversight limits both the understanding of its implications and the development of effective interventions to mitigate its impact on patients and the healthcare system. Addressing FT is not only critical for patient care but also integral to achieving sustainability in oncology, ensuring that care delivery remains equitable, accessible and efficient over the long term.

In public healthcare systems such as the UK’s National Health Service (NHS), FT represents a growing concern, even in environments where core clinical treatments are funded by public budgets. This was explored, albeit through preliminary analysis, in our recent study, where we not only validated and conducted a cross-sectional translation of a tool to measure FT in the UK but also highlighted key challenges related to financial toxicity through patient interviews [5]. Unlike private healthcare settings, where financial strain primarily arises from direct treatment costs, public healthcare systems, like the NHS, experience financial toxicity through indirect expenses and gaps in coverage for essential services. These include transportation costs to treatment centres, non-covered integrative therapies (e.g. rehabilitative or complementary treatments), and out-of-pocket expenditures for extended care, such as psychological support, dental care, or physiotherapy.

Evidence from other universal healthcare systems further highlights the prevalence and complexity of FT. In Australia, Gordon and Chan emphasise two main contributors to financial hardship: direct out-of-pocket medical expenses and loss of income due to illness [6]. They point out that these challenges arise even in high-income countries with publicly funded healthcare systems, and that both objective and subjective dimensions—such as stress, coping mechanisms and psychological distress—must be captured for a comprehensive assessment. Similarly, in Canada, researchers have documented the financial strain experienced by cancer patients, noting the impact of both systemic gaps in service provision and the indirect costs associated with treatment, caregiving and travel [7]. These studies underscore the need for context-specific assessment tools and longitudinal research designs that reflect the lived experiences of patients within universal healthcare contexts. Additionally, indirect costs, such as lost income due to illness or caregiving responsibilities, exacerbate patients’ financial burdens and undermine the sustainability of care. However, longitudinal or controlled studies are needed to comprehensively examine this pressing issue.

Research in Europe, including our study utilising the Patient-Reported Outcome For Fighting Financial Toxicity (PROFFIT) questionnaire—a tool specifically adapted to measure FT in public healthcare settings—has highlighted the unique ways FT manifests within the public healthcare system [8]. These findings reveal disparities in how financial burdens are experienced in public versus private systems, emphasising the need for tailored solutions. Despite this evidence, FT remains poorly understood and largely overlooked in the UK, limiting its integration into broader healthcare sustainability strategies and reforms.

Sustainability in oncology relies on delivering high-quality care that reduces inequalities and addresses systemic inadequacies. Unaddressed FT jeopardises this goal by creating barriers to treatment adherence, increasing the risk of poorer outcomes and ultimately leading to higher costs for the healthcare system [9]. For example, patients facing financial stress may delay or forgo necessary care, resulting in advanced disease states that require more intensive and expensive interventions. Recognising and addressing FT is essential for ensuring long-term efficiency and resilience within oncology care [10].

At an academic level, medical and psychological courses in the UK often fail to integrate FT into their curricula, leaving future healthcare professionals (HCPs) ill-equipped to recognise or address this important issue. This omission perpetuates gaps in patient-centred care and fails to prepare the workforce to implement sustainable practices. Research from Australia has shown that, although HCPs recognise the importance of addressing FT, many feel ill-equipped to do so owing to a lack of formal training, limited resources and organisational constraints. A national study by McLoone et al. [11] found that financial concerns were frequently perceived as a ‘blind spot’ within the medical model, with many HCPs expressing discomfort when discussing costs due to uncertainty about how best to offer effective support or solutions. Social workers and nurses—often the first point of contact—were commonly expected to manage these issues, yet reported notable gaps in their training and knowledge, particularly in relation to complex financial and legal frameworks. Similarly, Canadian research [7] highlights the need for early screening, routine financial assessment and well-defined referral pathways, noting that FT is often overlooked by clinicians despite its considerable psychological impact. These findings underscore the pressing need to embed FT education within medical and allied health curricula, and to deliver targeted training that enhances HCPs’ capability and confidence in addressing this critical aspect of cancer care.

International examples, such as the implementation of tools like the COmprehensive Score for Financial Toxicity (COST) [12] and the PROFFIT [2], demonstrate the value of integrating FT into both education and clinical practice. These Patient-Reported Outcome Measures (PROMs) offer clinicians valuable insights into the financial burdens experienced by individuals living with cancer. Embedding such tools into routine care enables HCPs to identify those at risk at an earlier stage and to provide timely, targeted support. This approach aligns with growing evidence that PROMs not only improve clinical communication, but also enhance care planning and resource allocation. Moreover, the use of such measures could facilitate greater integration between clinical services and welfare or benefits systems, allowing for immediate support to be offered where necessary. To align with the NHS’s sustainability goals, addressing FT must become a priority. Incorporating FT into the NHS’s 10-year action plan would help ensure that even well-intentioned reforms are truly patient-centred and effective [13, 14]. Measures such as embedding financial navigation services into oncology or chronic care programmes could provide patients with essential guidance to access financial resources, reducing the stress associated with out-of-pocket expenses and improving overall care experiences [1]. Financial navigation services refer to structured support programmes designed to help patients manage the financial aspects of their care. These services typically involve trained professionals—often called financial navigators—who assist patients in understanding treatment costs, accessing entitlements (e.g. sick pay, travel support, benefits), applying for financial aid or charity grants, managing insurance or billing issues (where relevant) and connecting with community resources.

Furthermore, academic institutions must lead efforts to advance understanding of FT. By including FT in core curricula and research priorities, the next generation of HCPs will be equipped to address this critical issue and contribute to sustainable healthcare practices. Interdisciplinary collaboration between researchers, clinicians and policymakers can further integrate FT into broader strategies aimed at delivering equitable, sustainable and patient-focused oncology care.

The NHS’s mission to provide equitable and holistic care aligns with the principles of sustainability in oncology. Addressing FT is an essential step towards fulfilling this promise, ensuring that patients receive not only clinical treatment but also the financial support necessary to navigate the multifaceted challenges of their care. By doing so, the NHS can enhance its long-term viability, uphold its commitment to equitable care and set an international example for sustainable oncology practices.

Author contributions

SR conceived the manuscript, conducted the literature review, and wrote the manuscript. An AI-based tool was used to support grammar and punctuation correction. All intellectual content and interpretations are the author’s own.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability

No datasets were generated or analysed during the current study.

Competing interests

The author declares no competing interests.