Understanding financial toxicity in cancer care through a social-ecological lens

Financial toxicity, defined as the material hardship and psychological distress associated with the costs of cancer care, has become a central concern in oncology as treatment complexity and patient cost-sharing increase. This review uses the Social-Ecological Model to conceptualize financial toxicity across multiple levels of influence, shifting focus from individual behaviors to the broader interpersonal, organizational, community, and societal systems that shape financial risk.

Financial toxicity arises through interconnected drivers across the Social-Ecological Model. At the individual level, direct and indirect treatment costs contribute to material and psychological burden. Interpersonally, limited cost communication and negative insurance interactions exacerbate distress. Organizational factors, including billing practices, ancillary expenses, and inflexible workflows, shape time and financial demands. Community-level inequities such as transportation barriers and area deprivation further compound hardship. Promising interventions include essential-needs programs, patient navigation, food support, financial counseling, structured cost conversations, universal screening, reduced ancillary fees, consolidated appointments, and partnerships with community groups. Societal drivers - including insurance design, cost sharing, and rising out-of-pocket expenses - require policy reforms that expand coverage generosity, address drug pricing, improve utilization-management transparency, and strengthen protections against medical debt.

Conceptualizing financial toxicity through a social-ecological lens underscores that meaningful progress requires multilevel interventions and coordinated efforts across patients, clinicians, institutions, communities, and policymakers.