The Out-of-Pocket Cost Burden of Cancer Care-A Systematic Literature Review

Abstract

Background: Out-of-pocket costs pose a substantial economic burden to cancer patients and their families. The purpose of this study was to evaluate the literature on out-of-pocket costs of cancer care.

Methods: A systematic literature review was conducted to identify studies that estimated the out-of-pocket cost burden faced by cancer patients and their caregivers. The average monthly out-of-pocket costs per patient were reported/estimated and converted to 2018 USD. Costs were reported as medical and non-medical costs and were reported across countries or country income levels by cancer site, where possible, and category. The out-of-pocket burden was estimated as the average proportion of income spent as non-reimbursable costs.

Results: Among all cancers, adult patients and caregivers in the U.S. spent between USD 180 and USD 2600 per month, compared to USD 15-400 in Canada, USD 4-609 in Western Europe, and USD 58-438 in Australia. Patients with breast or colorectal cancer spent around USD 200 per month, while pediatric cancer patients spent USD 800. Patients spent USD 288 per month on cancer medications in the U.S. and USD 40 in other high-income countries (HICs). The average costs for medical consultations and in-hospital care were estimated between USD 40-71 in HICs. Cancer patients and caregivers spent 42% and 16% of their annual income on out-of-pocket expenses in low- and middle-income countries and HICs, respectively.

Conclusions: We found evidence that cancer is associated with high out-of-pocket costs. Healthcare systems have an opportunity to improve the coverage of medical and non-medical costs for cancer patients to help alleviate this burden and ensure equitable access to care.

Keywords: cancer; catastrophic expenditure; economic burden; financial hardship; out-of-pocket costs.

Figure 1

Preferred Reported Items for Systematic Reviews and Meta-Analyses (PRISMA) diagram. Note: This diagram shows the flow of information through the different sections of the systematic review, including the identified, excluded and included studies after the title/abstract and full-text reviews.

Figure 2

Range of monthly out-of-pocket costs per patient by country. Countries in the European Union (EU) include Italy, France, Ireland, and Germany. Costs are expressed in 2018 USD. Not enough data were available to include a range of costs (in 2018 USD) for other countries. Average costs per patient per month were also estimated: USD 300 in the U.S., USD 200 in Canada, USD 180 in the E.U. and USD 70 in Australia Not enough data were available to stratify these estimates by cancer site.

Figure 3

Average monthly out-of-pocket costs per patient by spending categories. Note: The medical expenditure categories were defined as prescription or over-the-counter drugs and medications, home and clinical medical visits, and in-hospital care. The non-medical categories included transport, travel and lodging, and formal and informal caregiver costs (e.g., daycare for pediatric patients). Costs are presented for comparison between the U.S. and countries with universal healthcare coverage. Not enough data was available to estimate costs for low- and middle-income countries. Costs are expressed in 2018 USD. Not enough data were available to stratify these estimates by cancer site.

Figure 4

Average monthly out-of-pocket costs per patient by cancer site with 95% confidence intervals from high-income countries. Note: Studies that included patients with multiple cancer sites are reported under the ‘All cancer’ and ‘pediatric cancer’ categories. Costs are expressed in 2018 USD. Not enough data were available to report average costs per cancer site for low- and middle-income countries, or for individual high-income countries.

Figure 5

Average monthly out-of-pocket costs per patient by cancer site in the U.S. Note: Studies that included patients with multiple cancer sites are reported under the ‘All cancer’ category. Costs are expressed in 2018 USD. Not enough data were available to report average costs per cancer site for low- and middle-income countries, or for other high-income countries.

Figure 6

Average out-of-pocket costs per patient as a percentage of income. Legend: LMIC = low- and middle-income countries; HIC = high-income countries; ASG = Action Study Group; blue bars represent studies from HICs; green bars represent studies from LMICs. Note: This figure shows the costs from individual studies that estimated out-of-pocket expenditures relative to annual income. A weighted average was calculated for high-income countries (in green) and low-and middle- income countries (blue). Studies conducted in high-income countries include the U.S., Canada, and Australia. Studies conducted in low- and middle-income countries include China, Malaysia, India, Haiti, Brunei, Thailand, Indonesia, Philippines, Vietnam, Laos, Cambodia, and Myanmar.

Figure 7

Quality assessment of individual studies. Note: This figure shows the proportion of studies with low, unclear or high risk of bias, as per the Ottawa-Newcastle Assessment Tool for cohort and cross-sectional studies. The dimensions evaluated for risk of bias were patient selection, comparability, and outcome assessment.