Table 2.

Characteristics and quality assessment of eligible studies

Authors/year/country	Study design	Sample size and population	Time since diagnosis	Objectives	Financial toxicity outcome measures used	Main findings	Quality assessment
Albelda 2019 USA [17]	Cross-sectional	N = 171 Bone marrow transplant	6 months	Effects of access to paid leave on health, QOL, perceived stress, and reduction in financial burden of employed patients who underwent bone marrow transplantation	A 43-item survey developed after a structured literature review, focus group, consultations with researchers, and 7 in-depth interviews with patients	Paid leave affected health outcomes mostly through alleviating financial burden	8
Arndt 2019 Germany [18]	Cross-sectional, Population-based	N = 1.158 Mixed	Mean = 8.3 year	How many survivors return to work and when? How many make work changes (content, hours, quit) and is this related to financial toxicity? Does proportion of return to work vary according to certain characteristics?	EORTC QLQ-C30 financial difficulties item	Most survivors return to work. This was related to age at diagnosis, tumor stage, education and occupational class. Financial problems may arise due to reduced work hours	10
Banegas 2016 USA [38]	Cross-sectional	N = 4.719 Mixed	<1 yr; N = 940 1–4 yr, N = 1.845 5-9 yrs., N = 822 ≥10 yrs., N = 1026	To assess the proportion of working-age cancer survivors who reported that they or their families had gone into debt and the proportion who reported having filed for bankruptcy because of cancer, its treatment, or the lasting effects of that treatment	Amount borrowed and size of debt incurred, worry about paying bills, making financial sacrifices, types of OOP expenses	Younger, unemployed, and uninsured or publicly insured working-age survivors were at greater risk for debt (OR = 1.28, p < 0.05) and bankruptcy (OR = 1.74, p < 0.05)	9
Casilla-Lennon, 2018 USA [39]	Cross-sectional	N = 138 Bladder cancer	Median (IQR) = 0.4 (0.1, 1,2)	To define the prevalence of financial toxicity among bladder cancer patients and identify delays in care and its effect of HRQOL	Selecting “agree” or “strongly agree” on the following statement; “You have to pay more for medical care than you can afford”	Financial toxicity is a major concern, especially among younger bladder cancer patients. Whether the patient works for pay was not associated with financial toxicity. Patients reporting financial toxicity were more likely to delay care due to factors like inability to take time of work (p = 0.04)	10
Dean 2019 USA [19]	Retrospective Prospective	N = 129 Breast cancer	Mean = 12 year	Compare OOP costs for breast cancer survivors with and without lymphedema	Goosens’ cost diary, Breast Cancer Finances Survey	A significant greater percentage of women with lymphedema were in a lower income category. Breast cancer sometimes influenced work opportunities and long-term earning potential, and breast cancer-related lymphedema may further decrease productivity losses at work	10
Finkelstein 2009 USA [20]	Cross-sectional	N = 1940 Mixed	Not reported	To present nationally representative estimates of the effect of cancer care on OOP medical expenditures and lost productivity for the working-aged population	Medical Expenditure Panel Survey; total annual medical spending, including insurance and annual OOP spending	Cancer treatment increases the mean annual OOP medical expenditures by $1170. Those undergoing active cancer care were less likely to be employed full-time. Those employed undergoing cancer care missed 22.3 more workdays a year compared with those without cancer	5
Authors/year/country	Study design	Sample size and population	Time since diagnosis	Objectives	Financial toxicity outcome measures used	Main findings	Quality assessment
Ghasempour 2015 Iran [21]	Cross-sectional	N = 165 Mixed	Mean = 36.5 months	To determine the rate of return to work and its relation to financial distress among Iranian cancer survivors	Financial distress/financial well-being scale	Financial distress was significantly lower among survivors who had returned completely to work in comparison with patients who had quit working for cancer-related reasons or returned to work as part-time workers	10
Goodwin 2013 USA [22]	Cross-sectional	N = 762 Multiple myeloma	Mean = 5 years since treatment	To identify the personal financial effects of cancer among a cohort of multiple myeloma patients and its treatment in 5 areas including disability, employment, retirement, insurance (Health/medical and life), and OOP expenses	Self-designed questionnaire on employment, disability, health/medical and life insurance, retirement, and OOP expenses related to treatment	High OOP costs were reported among those with a reduced income from less worked hours; they also mention insurance coverage among unemployed individuals contributing to financial toxicity	9
Gordon 2017 Australia [23]	Cross-sectional	N = 289 Prostate cancer	N = 132 diagnosed < 3 years ago; N = 189 diagnosed < 5 years ago	To understand the extent, nature and variability of the current economic burden of prostate cancer among Australian men	Self-designed questionnaire covering, among others, the following domains; employment, household finances, OOP expenses of prostate cancer, and private health insurance status.	20% of men reported that the cost of treatment caused them “a great deal” of distress. Respondents in paid employment at diagnosis stated that they had retired 4–5 years earlier than planned	7
Gordon 2017 Australia [24]	Prospective POPULATION-based	N = 187 Colorectal cancer	6 and 12 months after diagnosis	To gain a better understanding of the work situation and the financial wellbeing of colorectal cancer survivors during the 12 months following diagnosis	3 financial toxicity measures: financial strain, ability to raise money, and perceived prosperity. “Increased work” and “reduced work” were defined as > 4 h difference per week	Middle-aged working cancer survivors were 66% more likely (p < 0.05) to report not being financially comfortable if they had ceased/decreased employment (21% or 33%) compared with those who maintained/increased employment participation (15% or 19%)	10
Gordon 2007 Australia [25]	Longitudinal Population-based	N = 287 Breast cancer	6, 9, 12, 15, 18 months	Identify and describe the direct and indirect economic losses to breast cancer survivors in Australia	Self-designed financial toxicity questionnaire on health service expenditure, physical and social support programs, use and cost of domestic services, care-giving support, OOP expenses, (un)paid work reductions and lost income	Economic costs related to breast cancer may continue to affect women 18 months post-diagnosis. Lost income, health services expenditures, and lost unpaid work were the greatest sources of economic burden	10
Authors/year/country	Study design	Sample size and population	Time since diagnosis	Objectives	Financial toxicity outcome measures used	Main findings	Quality assessment
Graeves-Otte 1990 Netherlands [26]	Cross-sectional	N = 849 Mixed	7–9 years ago	To what degree do impediments occur in everyday activities; what, if any, problems exist when a patient returns to a previous job or tries a new job; and what insurance problems are there?	Self-designed financial toxicity questionnaire	Compared with before diagnosis, the socioeconomic position had not changed in 62%. 28% of respondents employed at diagnosis were now housekeepers (99% female). Absence from work at survey did not differ from absence in the year before diagnosis. Cancer had a negative impact on promotional aspects, income and getting insurance	8
Guerin 2016 USA [27]	Retrospective follow-up study	N = 132 Lung cancer with brain metastasis	A median of 8.4 and 6.6 months in the pre- and post-diagnosis periods	To investigate healthcare utilization, direct and indirect costs of care among lung cancer patients with brain metastasis	A large administrative-claims database (Optum health reporting and insights database), productivity loss data, salary information	Development of brain metastasis in lung cancer patients is associated with a substantial economic burden to payers, patients and employers	10
Guy 2015 USA [8]	Cross-sectional	N = 4.960 Mixed	N = 348 ≤ 1 years after diagnosis; N = 1.993 > 1 year after diagnosis	To present nationally representative estimates of the impact of cancer survivorship on medical expenditures and lost productivity among US adults	MEPS, direct medical costs were estimated using total annual medical expenditures, by source of payment and service type	Cancer survivors aged 18 to 64 years were more likely to report employment disability, an higher number of missed workdays because of health, and higher number of additional days spent in bed because of health than individuals without a history of cancer	6
Honda 2019 Japan [40]	Cross-sectional	N = 156 Mixed solid tumors	Time to first chemotherapy = median 12 months (2–138 months)	To describe the burden and characteristics of financial toxicity among Japanese patients with cancer	The COST score, OOP medical costs, total family income, and total family savings	Older age and higher household savings were negatively associated with financial toxicity; non-regular employment, retirement because of cancer, and use of strategies to cope with the cost of cancer care were negatively associated with COST score	10
Huntington 2015 USA [45]	Cross-sectional	N = 100 Multiple myeloma	31 months median	To measure financial toxicity and its effects on patients undergoing treatment for multiple myeloma	COST measure.	71% reported at least minor financial burden, 36% reported applying for financial assistance. Use of savings for treatment was common (46%) and 21% borrowed money for medication. Stopping with work since diagnosis lead to more financial toxicity	10
Jagsi 2014 USA [44]	Longitudinal prospective	N = 1.502 Breast cancer	Mean of 9 months after diagnosis and 4 years later	To evaluate the financial experiences of a group of racially and ethnically diverse cohort of long-term breast cancer survivors	Several measures for financial impact, Perception of financial decline, OOP costs, employment and insurance	33% reported financial decline since diagnosis. Among others, younger than 65, household income < $50,000 at diagnosis, part-time employment at diagnosis, and reduction in work hours attributed to financial decline	10
Joo Ho 2018 Singapore [28]	Cross-sectional	N = 327 Breast cancer	Employed = 4 years median, Unemployed = 5 years median	To explore the determinants of employment and suboptimal workability and evaluate the association between workability and patient-reported physical, psychological, and social outcomes	Workability index, EORTC QLC-C30	Lower employment and reduced workability in breast cancer survivors is common, and reduced workability is associated with higher levels of depression, financial difficulty, physical fatigue, more breast symptoms, and poorer global health status	10
Authors/year/country	Study design	Sample size and population	Time since diagnosis	Objectives	Financial toxicity outcome measures used	Main findings	Quality assessment
Khera 2014 USA [29]	Cross-sectional, retrospective	N = 268 Allogeneic HCT patients	2.3 years median	To describe the impact of financial burden on health behaviors and evaluate the risk factors for objective financial burden and treatment non-adherence	Self-designed questionnaire on subjective and objective financial burden along with OOP expenses, medication copayments, insurance, and income	Forty-seven percent experienced financial burden. Younger age and poor current mental and physical functioning increased the likelihood of financial burden. Thirty-five percent reported deleterious health behaviors because of financial constraints. Being employed decreased the likelihood of experiencing financial burden and treatment non-adherence due to concern about costs	9
Lauzier 2013 Canada [42]	Longitudinal prospective	N = 829 Breast cancer	1, 6 and 12 months after start of treatment	To assess OOP costs and wage losses during the first year after diagnosis	All OOP costs including costs associated with surgeries, adjuvant treatments, complications, follow-up visits, transportation costs, parking costs, and meal costs	Higher OOP costs were associated with higher education, working at diagnosis, living > 50 km from the hospital, and having multiple types of adjuvant treatment. When considered simultaneously with wage losses, OOP costs were not associated with perceived deterioration in the family’s financial situation; rather, wage losses were the driving factor	11
Massa 2019 USA [30]	Cross-sectional	N = 16.771 Mixed	Not reported	To assess the financial burdens of patients with head and neck cancer compared with other cancers	MEPS database using household and condition survey files	Medical expenses and relative OOP costs were higher for head and neck cancer patients than for patients with other cancers. Higher OOP expenses were associated with unemployment, public insurance, poverty, and lower health status	9
Nekhlyudov 2016 USA [31]	Cross-sectional	N = 615 Mixed	5–6 years, N = 240 7–8 years, N = 213 9–10 years, N = 162	To examine how insurance coverage, financial status, and employment vary for survivors of different cancer types	Medical Expenditures Panel Survey (MEPS)—Experiences with Cancer Survivorship Survey	Fifteen percent experienced financial hardship due to cancer. Twenty-five percent of those employed reported that they or their spouses remained at their jobs due to concerns about losing medical insurance. Sixty-three percent reported making changes in their jobs due to cancer, and 42% reported that cancer interfered with their tasks at work or reduced productivity. Negative employment and financial implications were most common among those with colorectal, lung, and breast cancer, and those diagnosed before age 65	9
Paul 2016 Australia [32]	Cross-sectional	N = 255 Mixed	≤ 12 months, N = 113 > 12 months, N = 139	Quantify effects on income and employment; describe how cost-related factors influence treatment decision-making and need for financial assistance; identify patient factors associated with treatment decision-making, use of financial assistance	Self-designed questionnaire on employment, income, financial assistance, and treatment decision-making	Sixty-seven percent indicated a change in employment and 63% of those reported reduced household income since diagnosis. Unemployment status had higher odds of patients reporting reduced income (23.1%, 95%CI: 14.8–31.3). Travel (15%), loss of income (14%), and cost of treatments (11%) were factors influencing treatment decision-making	10
Authors/year/country	Study design	Sample size and population	Time since diagnosis	Objectives	Financial toxicity outcome measures used	Main findings	Quality assessment
Pearce 2019 Australia [33]	Cross-sectional	N = 2.931 Mixed	Mean 3.7 year (SD = 3.4), median 3 year	To examine the relationship between employment and financial toxicity by examining the prevalence of, and factors associated with, financial toxicity among cancer survivors	A question from the EORTC QLQ-C30 “Has your physical condition or medical treatment caused you financial difficulties in the past week?”	Forty-nine percent of survivors were employed, and 22% reported financial toxicity. Those not employed were at greater risk of financial toxicity (27% vs 16%). The odds of reporting financial toxicity were greater for those who were male, younger, unmarried, with low education, low socioeconomic status, or without paid employment	9
Rogers 2012 UK [34]	Cross-sectional	N = 447 Head and neck cancer	Months since treatment; < 12; N = 169 12–23; N = 155 24–59; N = 244 60+, N = 184	To study the financial burden of having head and neck cancer, and to explore its relation with health-related quality of life	The Social Difficulties Inventory (SDI) EORTC QLQ-C30, Cost of head and neck cancer questionnaire	The most notable costs of cancer that were a burden to patients were petrol (25%), home heating (24%), change in the type of food (21%), and loss of earnings (20%). During the previous week 15% had lost a moderate or large amount of income because of their medical condition. In terms of taking care of their financial needs, 10% were moderately dissatisfied and 15% very dissatisfied	8
Shankaran 2012 USA [46]	Cross-sectional	N = 284 Colon cancer (stage III)	19.7 months	To investigate factors associated with financial hardship in patients receiving adjuvant chemotherapy	Employment or income changes, insurance status and denials for specific services, copayments, deductibles, and monthly expenses, perceived financial burden	Thirty-eight percent of patients reported one or more financial hardships as a result of treatment. The factors most closely associated with treatment-related financial hardship were younger age and lower annual household income. Younger age, lower income, and unemployment or disability were most closely associated with treatment non-adherence	7
Sharp 2016 Ireland [41]	Cross-sectional	N = 740 Mixed	3–24 months	To identify factors associated with cancer-related financial stress and strain in breast and prostate cancer survivors in Ireland	Self-designed financial toxicity questionnaire including cancer-related OOP costs, objective and subjective financial difficulties.	Forty-eight percent reported cancer-related financial stress and 32% cancer-related financial strain and was more prominent among working individuals. Compared with those employed at diagnosis, risk of cancer-related financial stress was significantly lower in those not working (RR = 0.71, 95% CI 0.58–0.86) or retired (RR = 0.48, 95% CI 0.34–0.68).	8
Wheeler 2018 USA [35]	population-based prospective	N = 2.494 Breast cancer	5 and 25 months post diagnosis	To describe racial differences with regard to the financial impact of breast cancer	Self-designed financial toxicity questionnaire including job loss, income loss, financial and/or transportation barriers due to costs, refusal or delay in cancer treatment due to costs, loss of insurance	Since diagnosis, 58% of black women reported any adverse financial impact of cancer vs. 39% of white women (p < 0.001). In models adjusted for age, stage, and treatment, black women were more likely to report adverse financial impact due to cancer, including income loss, healthcare–related financial barriers, health care–related transportation barriers, and loss of health insurance	9
Authors/year/country	Study design	Sample size and population	Time since diagnosis	Objectives	Financial toxicity outcome measures used	Main findings	Quality assessment
Whitney 2016 USA [36]	Cross-sectional	N = 1.209 Mixed	Active treatment N = 166; <5 years after treatment N = 300; ≥ 5 years after treatment N = 487	To examine predictors of cancer-related financial difficulties and work modifications in a national sample of cancer survivors	Medical Expenditure Panel Survey Household Component and Experiences with Cancer Survivorship Supplement	Thirty-three percent reported any financial concern, 18% reporting financial difficulties like debt or bankruptcy. Forty-four made work modifications and 15% made long-term work modifications. Among survivors under age 65 years, predictors of long-term work modifications included good/fair/poor self-rated health, being married, uninsured, or publicly insured	7
Yabroff 2016 USA [43]	Cross-sectional population-based	N = 1.202 Mixed	Years since treatment; 1, N = 129 1- < 5, N = 137 ≥ 5, N = 214	To estimate the prevalence of financial hardship associated with cancer in the USA and identify characteristics associated with financial hardship	Medical Expenditure Panel Survey Experiences with Cancer questionnaire	Material financial hardship was more common in cancer survivors aged 18–64 years than in those ≥ 65 years (28.4% vs. 13.8%; p < 0.001). Survivors aged 18–64 years who were younger, female, nonwhite, and treated more recently and who had changed employment because of cancer were significantly more likely to report material financial hardship	8
Zheng 2016 USA [37]	Cross-sectional	N = 3.278 Mixed	Not reported	To provide nationally representative estimates of annual total economic burden among colorectal, female breast, and prostate cancer survivors by age group and cancer site	Medical Expenditure Panel Survey Household component	Compared with those without cancer, cancer survivors experienced annual excess medical expenditures. Nonelderly colorectal and breast cancer survivors experienced statistically significant annual excess employment disability (13.6% and 4.8%) and productivity loss at work (7.2 days and 3.3 days) and at home (4.5 days and 3.3 days). In contrast, elderly survivors had comparable productivity losses as those without cancer	7

EORTC QLQ-C30, European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30; HCT, hematopoietic cell transplantation; HRQOL, health-related quality of life; OOP, out of pocket costs; QoL, Quality of life; USA, United States of America; AUS, Australia; C.I., confidence interval; FT, financial toxicity; OR, odds ratio; p, probability; RR, relative risk