Table 1.

Characteristics of the included studies

Authors	Year	Aim	Study design/data collection	Country	Sample size	Cancer type	Cancer stage	Gender	Mean age (years)	Tools for measuring financial toxicity	Key results
a. Included quantitative studies
Ting et al. [38]	2020	To determine the prevalence and associated factors of objective and subjective financial toxicity among urologic cancer patients in Malaysia. Secondly, it investigated the association between financial toxicity and HRQoL	Prospective, cross-sectional/questionnaire	Malaysia	429	Prostate = 366, bladder = 31 and kidney = 32	I = 48, II = 179, III = 85 and IV = 117	M = 414 and F = 15	NR	Used the catastrophic health expenditure tool and Personal Financial Wellness Scale to measure financial toxicity	•Greater objective and subjective financial toxicities were associated with poor HRQoL •Patients attending a private tertiary hospital were more likely to face objective financial toxicity (OR = 258.14, 95% CI = 22.16–3007.58) •Female respondents were more likely to face average to high subjective financial toxicity (OR = 44.88, 95% CI = 4.58–440.12)
Su et al. [39]	2020	To estimate the proportion of Chinese cancer survivors experiencing financial hardship and then examine the relationship between material and behavioural financial hardship	Cross-sectional/questionnaire	China	964	Breast = 398, lung = 140, colorectal = 198 and stomach = 228	NR	M = 366 and F = 598	NR	Material financial problem questions: How much did you or your family borrow or how much debt did you incur because of your cancer, its treatment or the lasting effects of that treatment? Behavioural financial hardship questions: Have you ever forgone cancer treatments because of worrying about the costs? And if so, which cancer treatment is it?	•Almost half of survivors experienced material financial hardship •10% of cancer survivors reported experiencing behavioural financial hardship
Kasahun et al. [40]	2020	To examine the incidence of catastrophic health expenditure and identify associated factors and coping strategies among patients attending cancer treatment services in Addis Ababa, Ethiopia	Cross-sectional/questionnaire	Ethiopia	352	Breast = 130, cervical = 58, colorectal = 46, NPC = 13 and others = 105	NR	M = 94 and F = 258	48 ± 13.2	Structured questionnaire based on WHO Study of Global Ageing and Adult Health Household income and expenditure were measured based on respondents’ self-reported daily or monthly income and expenditure	•74.4% of patients experienced CHE with mean overall expenditure of $2366 per patient •Inpatient services accounted for 2-thirds of the total expenditure with a mean cost of $1584
Zhao et al. [41]	2019	To measure the comprehensive needs of cancer patients and explore the possible factors associated with their needs	Cross-sectional/questionnaires	China	200	General	NR	M = 96 and F = 104	54.87 ± 12.45	Used the comprehensive needs assessment tool (CNAT) in cancer for patients to measure financial burden	•84.5% of the patients had medical insurance •Patients who were younger, female, with low family monthly income, at their own expense, more than 3 years after diagnosis, and with highly educated caregivers had higher score of CNAT (49.13 ± 10.13) •Lowest score of CNAT was the need for physical symptoms (35.12 ± 16.68)
Tekin and Saygili [29]	2019	To determine the annual direct medical costs of all breast cancer patients in Turkey with top-down cost approach	Retrospective cohort/electronic records	Turkey	26,664	Breast	NR	M = 2432 and F = 24,232	NR	Hospital billing system	•Total medical cost of outpatients was $73,534,475.5 •Total medical cost of inpatients was $23,159,274.9 •Total cost of drugs and medical equipment was $14,805,009.2
Rozman et al. [42]	2019	To describe the resource utilisation and costs among cancer patients by cancer localisation and per month of treatment before death	Retrospective cohort/electronic records	Brazil	2985	Lung = 370; colon and rectal = 368; H&N = 353; stomach = 243; breast = 221; female genital tract = 176; oesophagus = 145; prostate = 139; bladder = 94; malignant melanoma = 92; haematological = 90; liver = 87; pancreas = 80; kidney = 71; malignant neoplasm, not otherwise = 65; other sites in the digestive tract = 62; male genital tract = 18; thyroid = 14; others = 146	NR	M = 1629 and F = 1356	64.4 ± 13.46	Hospital billing system	•Average cost per patient was $12,335, ranging from $8269 for patients with pancreatic cancer to $19,395 for patients with brain cancer
Piroozi et al. [43]	2019	To investigate the prevalence as well as the effective factors on facing CHE after the implementation of health transformation plan	Cross-sectional/questionnaire	Iran	161	Oesophageal = 36, stomach = 34, colon and rectum = 67 and others = 24	I = 26, II = 30, III = 37 and IV = 68	M = 152 and F = 9	NR	World Health Survey Questionnaire developed by the WHO	•Lack of supplementary health insurance and low socio-economic status were the significant factors affecting exposure to CHE •The rate of households facing CHE was 72.7%
Moghadam et al. [36]	2019	To investigate the economic burden of prostate cancer patients and their health-related quality of life	Retrospective cohort/questionnaire	Iran	499	Prostate cancer	NR	M = 449	72 ± 9.25	Self-developed questionnaire based on opinions of urology and oncology specialists and experts in the field of economics	•The mean score for HRQoL was 0.62 ± 0.16 for all patients •Chemotherapy patients suffered the worst scores in the physical well-being subscale (0.47 ± 0.24)
Leng et al. [44]	2019	To explore the prevalence, determinants and consequences of CHE among urban and rural end-of-life cancer patients in China	Retrospective cohort/questionnaires	China	792	Lung = 187, intestinal = 53, gastric = 126, liver = 135, oesophagus = 86 and others = 205	NR	M = 539 and F = 253	Urban dwellers = 64.75 Rural dwellers = 64.01	Unvalidated questionnaire that collected information such as demographic characteristics, health services utilisation and end-of-life out-of-pocket payments	•94.3% of urban households and 96.1% of rural households spent 40% or more of their monthly income as out-of-pocket cancer health care expenditure •The poorer the household, the higher the prevalence of catastrophic health expenditure •Health insurance did not adequately compensate for CHE
Bhoo-Pathy et al. [45]	2019	To examine the incidence, cost drivers and factors associated with financial toxicity after cancer in an upper–middle-income country with universal health coverage	Prospective longitudinal cohort/cost dairies and questionnaire	Malaysia	1294	GI = 345, respiratory = 62, breast = 424, female reproductive = 81, urogenital = 14, hematologic = 278 and other = 90	I = 59, II = 153, III = 103, IV = 170 and unknown = 531	M = 470 and F = 824	Median = 53	Unvalidated questionnaire that collected cost data on conventional medical care, traditional and complementary medical care and goods and services related to cancer care (transportation, meals, lodging, parking, childcare and personal items directly incurred by patients and not reimbursed by insurance	•Overall incidence of financial toxicity among the cancer survivors at 1 year was 51% (n = 665), ranging from 33% in MOH hospitals to 65% in the public university hospital and 72% in the private hospitals •Low-income status, type of hospital and lack of health insurance were strong predictors of financial toxicity •Payments for conventional medical care made up 39% of the total OOP costs borne by the affected households
Zheng et al. [46]	2018	To evaluate the medical economic burden, including total current curative expenditure and CHE on cancer in Liaoning Province, China	Retrospective cohort/medical records and questionnaire	China	1344	General	NR	M = 775 and F = 569	NR	Questionnaire surveys among cancer patients, which collected information of demographic characteristics, household income and expenditure, medical expenses and compensation	•Incidence of CHE was 42.78%. Influencing factors were length of stay, type of health insurance and location of household •Among the households, those with oesophageal cancer patients were most likely to experience CHE of which the incidence rates were 60.29%, 57.89% and 46.89%
Sun et al. [37]	2018	To examine the costs of the first course treatments in Chinese patients with stomach cancer and the associated trends	Retrospective cohort/medical records	China	14,692	Stomach	I = 2357, II = 2590, III = 3452, IV = 4838 and unknown = 1060	M = 10,092 and F = 4205	58.1 ± 12.6	Hospital information system that collected medical expenses for cancer treatments including payments (both of out-of-pocket payments and payments by insurance plans) of each patient for admissions and outpatients from the first admission date to the last discharge date	•Average medical expenses of the first course treatments were about $6851 •Contributing factors included long stay in hospital and an increased number of episodes of care
Saengow et al. [32]	2018	To determine the willingness to pay for faecal immunochemical test and colonoscopy and examine an effect of proposed co-payment on uptake rates	Cross-sectional/questionnaire	Thailand	437	Colorectal		M = 183 and F = 254	58.4 ± NR	Willingness to pay for colorectal cancer screening questionnaire	•Less than half of participants were willing to pay for colonoscopy •Presence of companion, female and family history of cancer were influential factors
Qiu et al. [34]	2018	To understand the medical expenditure for liver cancer during 2002–2011 in urban areas of China	Retrospective cohort/questionnaire	China	12,342	Liver	I = 905, II = 3089, III = 4683, IV = 2556 and unknown = 1109	M = 9638 and F = 2704	54.91 ± 12.29	Individual case–based medical care cost records, with data such as demographic, diagnostic information and detailed expenditure information relating to different types of service including registration, ward bed, diagnosis, examination, treatment, surgery, laboratory, nursing and drugs	•Pharmaceuticals accounted for the biggest part of the medical expenditure, and it rose from 48.01 to 52.96%
Perin et al. [24]	2018	To assess the hospital costs of diagnosing and treating patients with stage IIIB and IV non-small cell lung cancer	Retrospective cohort/electronic records	Serbia	187	Lung	IIIB = 69 and IV = 118	M = 137 and F = 50	NR	Extracted resources and procedures from the integrated hospital information system to estimate the cost for each patient	•The average hospital cost per patient was $3309.40 •37% of the hospital cost was due to medication
Owenga and Nyambedha [47]	2018	To assess the financial challenges and sources of financial assistance for cervical cancer patients	Cross-sectional/questionnaire	Kenya	334	Cervical	I = 52, II = 40, III = 63 and IV = 129	F = 334	NR	Self-designed questionnaire that collected information such as socio-demographics and health history, financial challenges of cervical cancer patients, patient care and information needs and spiritual needs	•Financial challenges were costs of medication 291 (87%), cost of travel 281 (84%) and cost of diagnostic tests 250 (75%) •13% of patients received assistance from charity organisation, 27% received assistance from friends, 9% received assistance from colleagues, 10% received assistance from relatives and 10% received assistance from church
Nguyen, et al. [48]	2018	To estimate the medical costs for the treatment of cervical cancer patients	Retrospective cohort/medical records and expert discussion	Vietnam	52 patients and 10 experts	Cervical	NR	F = 62	NR	Reviewed medical records of 52 patients with cervical cancers to document the medical procedures, types and quantity of resources needed for the service	•The unit costs for precancer services fluctuated from $18.26 to $33.31 •The main cost driver of radical hysterectomy and radiotherapy was the staff payments (59%)
Liao et al. [30]	2018	To assess the economic burden of breast cancer (BC) diagnosis and treatment in China through a multicentre cross-sectional study and to obtain a theoretical evidence for policy-making	Cross-sectional/questionnaire	China	2746	Breast	I = 546, II = 1236, III = 603, IV = 285 and unknown = 76	F = 2746	49.6 ± 10.0	Questionnaire comprising of demographic characteristics, clinical information and relative expenditure information (dates of diagnosis and treatment, all medical expenditure [self-pay and healthcare costs], non-medical expenditure [transportation, accommodation, meals, nutrition and employee escort fees])	•Overall average expenditure was $8450 (medical expenditure: $7527; non-medical expenditure: $922) •Average loss of time was $1529
Chen et al. [25]	2018	To examine the effect of financial burden, using objective and subjective indicators, on the HRQoL in lung cancer patients	Cross-sectional/medical records and questionnaires	China	227	Lung	I = 12, II = 28, III = 57 and IV = 130	M = 159 and F = 68	59.48 ± 9.42	Financial information was collected using 4 questions: How much did you pay for the medical expense last month? (direct medical costs) How much did you spend on the disease-related expenses other than medical expenses, such as buying health supplements, last month? (direct nonmedical costs) What proportion of your annual household income do you spend on healthcare annually? (healthcare cost-to-income ratio) Have your disease and treatment caused you and your family financial difficulty? (perceived financial difficulty)	•Financial difficulty was perceived in 83.7% of the participants •Mean direct medical costs was $2518.83 with a median of $1515.01 and a range from $60.60 to $18,180.17 •27.3% reported that the healthcare cost-to-income ratio was less than 40%
Atieno et al. [49]	2018	To evaluate the economic burden of treating cancer patients	Cross-sectional/questionnaire	Kenya	412	General	NR	M = 152 and F = 261	NR	The self-designed questionnaire collected information such as patient demographics, medicines prescribed and their costs, cost of radiologic tests, costs of laboratory tests, any surgery and associated costs and quantity and costs of any medical devices used	•Patients on chemotherapy alone cost an average of $1364.3, surgery cost $1265.6, radiotherapy $1175.1 and combination of all 3, $3291.8 per patient
Zhuyan et al. [35]	2017	To assess the association of financial status and QoL among Chinese women actively undergoing chemotherapy for recurrent ovarian cancer	Prospective, longitudinal cohort/medical records, questionnaires	China	123	Ovarian	NR	F = 123	53.4 ± 9.3	Reviewed medical records to document information such as demographic and clinical data (age, marital status, education, occupation, type of insurance, financial status and number of recurrences and intervals between recurrences) Financial status was based on self-reported annual family income minus expenses Quality of life was evaluated using the simplified Chinese version (3.0) of the European Organization for Research and Treatment of Cancer (EORCT) 30-Item Core Quality of Life Questionnaire (QLQ-C30) and the simplified Chinese version of the QLQ-OV28 questionnaire which is specific to ovarian cancer	•Patients with low financial status had a significantly higher risk of deteriorating HRQoL in physical functioning (p = 0.001), role functioning (p = 0.0140), emotional functioning (p = 0.021), pain (p = 0.010) and financial difficulties (p = 0.003)
Wenhui, Shenglan [50]	2017	To analyse the health services utilisation and financial burden of insured cancer patients and identify the gaps of financial protection provided by insurance in urban China	Retrospective cohort/medical records	China	Shanghai = 600 Beijing = 600 Fuzhou = 600 Chongqing = 608	General	NR	Shanghai M = 289 and F = 311 Beijing M = 325 and F = 275 Fuzhou M = 311 and F = 289 Chongqing M = 346 and F = 262	Shanghai = 63.5 ± 12.4 Beijing = 63.2 ± 13.5 Fuzhou = 67.1 ± 10.0 Chongqing = 67.4 ± 13.7	Hospital records of participants were extracted. Average total expense per visit, average out-of-pocket payments and average reimbursement rate were analysed	•The average OOP as the proportion of household’s capacity to pay was 87.3% (Chongqing), 66.0% (Fuzhou), 33.7% (Beijing) and 19.6% (Shanghai)
Thongprasert et al. [26]	2015	To evaluate the patient and public willingness to pay for a quality-adjusted life year for lung cancer treatments using Thailand as an example	Cross-sectional/questionnaire	Thailand	150	Lung	I–II = 5 and III–IV = 145	M = 78 and F = 72	60.9 ± 10.40	The questionnaire collected information such as socio-demographic data, respondents’ health status/utility and willingness to pay	•Patients’ willingness to pay was associated with quality of life, financial difficulties, health insurance, diarrhoea and wealth
The Action Study Group et al. [23]	2015	To determine, in this region, in patients with a first-time diagnosis of cancer and in whom surgery was specified in their initial treatment plans, the incidence of financial catastrophe owing to out-of-pocket payments for treatment, treatment discontinuation (as defined by whether such patients proceed to hospitalisation by 3 months), and mortality, as well as the factors associated with such outcomes	Prospective, longitudinal cohort/questionnaire	8-country (Malaysia, Thailand, Indonesia, Philippines, Vietnam, Laos, Cambodia and Myanmar)	4584	Breast = 1667; mouth and pharynx = 388; stomach = 227; colon and rectum = 622; trachea, bronchus and lung = 116; cervix = 341; uterus = 135; ovary = 179; and others = 779	I = 415, II = 1181, III = 944 and IV = 483	M = 1300 and F = 3284	51.3 ± 12.4	The questionnaire collected information such as participants’ age, sex, marital status, country of residence, highest level of education attained, employment status and recent experience of economic hardship whether in the previous 12 months they were unable to make any necessary household payments or needed assistance to do so, annual household income and health insurance status	•31% of participants incurred financial catastrophe. Women had greater odds of financial catastrophe than men (OR, 1.35; 95% CI, 1.05–1.74)
Lkhoyaali et al. [51]	2015	To assess the social, psychological, behavioural and economic impact on patient’s family caregivers	Prospective cohort/questionnaire	Morocco	150	Lung, breast and lymphoma	NR	M = 61 and F = 89	44.7	Participants’ demographics, disease characteristics and social, economic and psychological features were collected with a questionnaire. Psychological impact was assessed using Diagnostic and Statistical Manual of Mental Disorders	•Economic resources were exceeded in 78.7%. 56% used banking credits and sold properties. Work lay-off was recorded in 54%
Ak et al. [27]	2015	To evaluate the relationship between cost according to treatment type and prognosis in malignant PI	Retrospective cohort/medical records	Turkey	275	PM	I–II = 50, III–IV = 221 and unknown = 4	M = 146 and F = 129	63.2 ± 11.2	Medical records of participants were reviewed. Direct medical costs were estimated as the sum of hospital bills attributed to the disease. The phases of care were divided into 3 periods as diagnosis, treatment and terminal phase in chemotherapy and multimodality groups	•Factors affecting the cost were histology, treatment type, received second- and third-line chemotherapy and number of hospitalisations
Nguyen et al. [31]	2013	To estimate the direct medical cost of a 5-year treatment course for women with primary breast cancer in Central Vietnam	Retrospective cohort/medical records	Vietnam	129	Breast	I = 9, II = 73, III = 35 and V = 12	F = 129	51 ± 9.5	Medical records were reviewed to obtain personal information (e.g. name, age, home address), date of admission, diagnosis and stage, treatment regimes, itemized invoices and health insurance participation. Unit costs for treatments received over the study period were acquired from the hospital’s finance department	•Total direct medical cost for a 5-year treatment course was estimated at $975 per patient (range: $11.7–$3955)
Nazer et al. [52]	2013	To describe the drug utilisation pattern and drug cost in the treatment of cancer patients with severe sepsis and septic	Retrospective cohort/electronic records	Jordan	116	General	NR	M = 65 and F = 51	51.7 ± 14.8	Electronic medical records were reviewed to determine the total number of medications prescribed, the type of medications, and the cost of each medication	•Mean number of medications prescribed per patient were 11.7 (SD ± 4.7)
Chindaprasirt et al. [33]	2012	To identify admission rates and healthcare cost of colorectal cancer	Retrospective cohort/medical records	Thailand	45,692	Colorectal	NR	M = 24,068 and F = 21,624	NR	Medical records were reviewed to collect data such as age, gender, level of hospital, regions of hospital, admission rate and hospital costs	•Colorectal cancer contributed to 98.5 per 100,000 adult persons admission rates •Average hospital charge per admission were $1360.06
Edis and Karlikaya [28]	2007	To evaluate the individual and societal costs of lung cancer derived from our patient representative	Observational cohort/medical records	Turkey	103	Lung	NR	M = 98 and F = 5	64 ± 9.3	Hospital billing system were reviewed to obtained direct medical costs and additional medical costs associated with the diagnosis and treatment of lung cancer	•Average survival was 6.8 months •Average cost per patient was $5.480 ± 4.088 •Direct medical cost was $5.471 ± 4.091
b.Included qualitative studies
Moradian et al. [53]	2012	To explore, through qualitative semi-structured interviews, Iranian cancer patients’ needs	Qualitative, descriptive/semi-structured interviews	Iran	30	Breast = 7, GI = 5, bladder = 2; testis = 2, lung = 2, sarcoma = 2 and other = 10	I = 8, II = 15 and III-IV = 7	M = 11 and F = 19	42 years and ranged between 19 and 59 years	Semi-structured interviews with interview guide focused on the main theme: ‘patients need to express feelings about the disease, impact of cancer on their daily life and their experiences of existing services’	•Major themes: financial issues (cost of treatment and interference with their ability to work), psychosocial issues (social and significant others support, distress and fear from future) and care satisfaction (accessing information and nursing care)