Assessing Financial Toxicity in Cancer: A Global Systematic Review and Meta-Analysis Using an Asset Framework

Financial toxicity (FT), encompassing objective and subjective impacts of cancer care costs, is linked to poorer quality of life, reduced treatment adherence, and higher mortality. While patient-level risk factors have been examined, a system-level perspective incorporating socioeconomic context is needed to understand global variation in FT.

MEDLINE, CINAHL, Embase, and Web of Science were searched from inception to 06/27/2025 for peer-reviewed, English-language studies describing self-reported FT outcomes among adults with cancer. Reviewers extracted study characteristics, FT prevalence, predictors, and measurement tools. Financial, physical, and social asset measures from the World Bank were merged with FT data by study country and year of data collection. Focusing on studies reporting Comprehensive Score for Financial Toxicity (COST) scores, multilevel random effects meta-analysis was performed. Univariate and multivariate multilevel meta-regression evaluated relationships between country-level assets and COST.

One hundred thirty-two studies from 22 countries were included, with FT prevalence ranging from 4.0% to 100.0%. Three-level meta-analysis of 75 COST-based studies (15 countries; 83,623 patients) yielded a pooled mean COST score of 21.2 (95% CI: 19.1-23.3; 95% prediction interval: 13.3-32.4), though substantial heterogeneity (I² = 99.2%) and a predominance of studies from the US (55%) limited its standalone interpretability. Variance decomposition showed that 46% of heterogeneity was attributable to between-country differences. Higher log GDP per capita was associated with higher COST (β = 4.44, 95% CI: 2.90-5.98), explaining 43.1% of between-country variance. Higher out-of-pocket health expenditure, population-level financial hardship, and vulnerable employment were associated with worse FT. GDP associations were robust to sensitivity analyses excluding US-based studies.

FT among cancer patients is linked to structural conditions governing access to education, employment, and financial systems, although expanded research in low-resource settings is needed. These findings highlight the roles of economic development strategies and investment in human capital in helping to safeguard against population-level FT.