Financial toxicity of cancer care in low- and middle-income countries: a systematic review and meta-analysis

Introduction The costs associated with cancer diagnosis, treatment and care present enormous financial toxicity. However, evidence of financial toxicity associated with cancer in low- and middle-income countries (LMICs) is scarce. Aim To determine the prevalence, determinants and how financial toxicity has been measured among cancer patients in LMICs. Methods Four electronic databases were searched to identify studies of any design that reported financial toxicity among cancer patients in LMICs. Random-effects meta-analysis was used to derive the pooled prevalence of financial toxicity. Subgroup analyses were performed according to costs and determinants of financial toxicity. Results A total of 31 studies were included in this systematic review and meta-analysis. The pooled prevalence of objective financial toxicity was 56.96% (95% CI, 30.51, 106.32). In sub-group meta-analyses, the objective financial toxicity was higher among cancer patients with household size of more than four (1.17% [95% CI, 1.03, 1.32]; p =0.02; I-2 = 0%), multiple cycles of chemotherapy (1.94% [95% CI, 1.00, 3.75]; p =0.05; I-2 = 43%) and private health facilities (2.87% [95% CI, 1.89, 4.35]; p<0.00001; 1 2 = 26%). Included studies hardly focused primarily on subjective measures of financial toxicity, such as material, behavioural and psychosocial. One study reported that 35.4% (n=152 of 429) of cancer patients experienced high subjective financial toxicity. Conclusions This study indicates that cancer diagnosis, treatment and care impose high financial toxicity on cancer patients in LMICs. Further rigorous research on cancer-related financial toxicity is needed.