Nearly 50% of Women with Gynecologic Cancer are Affected by Financial Toxicity; Young Non-White Patients Disproportionately Impacted by Financial Distress


Nearly half of patients with gynecologic cancer reported financial distress, or financial toxicity, new study says.

Nearly 50% of Women with Gynecologic Cancer are Affected by Financial Toxicity

Nearly 50% of Women with Gynecologic Cancer are Affected by Financial Toxicity

An analysis of 2 previously collected surveys showed that nearly half of respondents in a geographically diverse cohort of patients with gynecologic cancer reported financial distress, with a Comprehensive Score for Financial Toxicity (COST) of <26.

A third of respondents (14.9%) reported that their financial toxicity was severe (COST<14). Respondents who reported moderate to severe financial toxicity were increasingly more likely to adopt economic cost-coping strategies, such as borrowing money or adjusting their normal spending habits. Medication non-compliance, a behavioral cost-coping strategy that patients with severe financial distress are more likely to adopt, has the potential to result in worse health outcomes for the patient.

The American Cancer Society estimates that the cost of cancer care in the United States was approximately $183 billion in 2015. Experts project that the cost will rise by 30% by 2030.

While some patients are able to offset some of the burden with the aid of private and government insurance, even insured patients may struggle financially with visit co-payments, prescription medications, and other cancer-related costs.

Using COST, this analysis considered the responses from 240 patients at Beth Israel Deaconess Medical Center (BIDMC) and 121 patients at University of Alabama at Birmingham (UAB) for a total of 308 participants.

Among the respondents, 32.1% reported moderate financial toxicity, with 14.9% reporting severe and 52.9% reporting no or mild financial toxicity. Factors such as young age, non-white race, lower education, unemployment, lower income, use of systematic therapy, and shorter time since diagnosis proved to be linked to worse levels of financial toxicity.Certain coping strategies such as changes in spending habits and borrowing money were reported across moderate to severe respondents. Those with severe financial toxicity were significantly more likely to engage in behavioral cost-coping by medication non-compliance (adjusted RR 4.6; 95% CI, 1.2-18.1).

“We sought to understand financial toxicity in a more diverse population by combining data from 2 very geographically distinct institutions to provide a more comprehensive understanding of how patients with gynecologic cancer are affected by financial distress,” explainedcorresponding author, Katharine M. Esselen, MD, MBA, a physician-researcher in the Division of Gynecologic Oncology in the Department of Obstetrics and Gynecology at BIDMC.

There were many different demographic characteristics amongst the surveyed patients at the 2 institutions, including variations in race, income, education, employment status, and insurance status. “Despite these differences as well as lower median COST score at UAB compared with BIDMC, the distribution of financial toxicity levels was not significantly different at the 2 institutions,” said Esselen. This suggests that “the COST score is a useful tool that can be broadly applied to identify gynecological cancer patients with financial needs.”

The research team measured financial toxicity according to an 11-item COST tool in which lower scores indicate more severe financial toxicity. The surveys identified economic cost-coping strategies by asking participants questions such as, “Due to your cancer diagnosis, have you had to change your spending habits?” or “Have you borrowed money from friends, or family, or the bank?” Behavioral cost-coping strategies, or medical non-compliance, were measured by asking respondents to answer, “Have you delayed or avoided buying medication” and “Have you not taken medications as instructed or not refilled meds?”

According to the findings from the study, cost-coping strategies can vary greatly depending on the patient’s level of financial toxicity; however, the findings can be used in clinical practice to proactively offer patients the financial resources they need to mitigate their financial distress.

The analysis also determined that younger age is a risk factor for significant financial toxicity for a variety of reasons: younger patients with cancer are not eligible for Medicare, are likely to be more impacted by their inability to work, and have not had as much time to save enough money to form a financial safety net. According to the analysis, decreasing median age increased the likelihood of financial distress.

One possible limitation to the study is that it is a retrospective review of previously collected data with different inclusion criteria. UAB patients were actively undergoing systematic treatment while BIDMC patients were surveyed regardless of treatment type. Furthermore, although the respondents were geographically diverse, the study was based out of 2 large academic centers and, therefore, may not accurately represent other health systems or regions in the country.

Moving forward, research should seek to understand how COST scores affect compliance with recommended care (dose intensity, treatment delays, etc.) and clinical cancer outcomes. Future studies should also assess whether practice efforts to provide resources and counseling can help decrease the risk of developing more severe financial toxicity and therefore worse cost-coping behaviors.


Esselen KMck, Gompers A, Hacker MR, et al. Evaluating meaningful levels of financial toxicity in gynecological cancers. Int J Gynecol Cancer. 2021; 31:801-806. doi:10.1136/ ijgc-2021-002701.

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