Financial factors shaping treatment decisions in oncology: A systematic review

The rising cost of cancer care has made financial considerations increasingly prominent in oncology practice. Although patient financial toxicity is well studied, how cost-related factors influence physician treatment decision-making is less clearly understood. This systematic review evaluates how various financial factors shape prescribing and treatment decisions in oncology.

A comprehensive literature search was conducted in MEDLINE, Embase, and Web of Science databases. Eligible studies evaluated associations between financial exposures (e.g., drug pricing, reimbursement, promotional payments, formulary status, patient out-of-pocket costs) and physician treatment decisions in oncology. Quantitative, qualitative, and mixed-methods studies were included. Screening, data extraction, and risk-of-bias assessment (ROBINS-I) were performed by independent reviewers. Findings were synthesized descriptively due to study heterogeneity.

Of the 7206 unique articles identified, 60 studies met inclusion criteria. Financial influences operated across three domains: Physician-industry, physician-patient, and physician-physician. Industry payments and financial incentives were consistently associated with increased prescribing of promoted or profitable drugs, particularly when incentives were large or salient. Patient out-of-pocket costs frequently influenced recommendations, though cost discussions were less common than cost-informed decisions. Physicians endorsed cost-conscious care in principle but reported tension between stewardship and norms of offering all potentially beneficial therapies, alongside limited access to cost information.

Financial factors influence oncology treatment decisions at multiple levels, with system- and industry-level incentives exerting strong downstream effects. Physicians are tasked with delivering cost-conscious care without sufficient tools or structural support, highlighting the need for broader system-level interventions.

Supporting cost-conscious cancer care requires system-level redesign, not sole reliance on individual clinician behavior. Policies should embed financial considerations upstream through formularies, reimbursement policies, and clinical guidelines, while improving transparency for both clinicians and patients. Efforts should also strengthen regulation of industry-physician relationships and integrate financial navigation and decision-support tools into oncology care.