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Meta-Analysis
. 2023 Feb 1;6(2):e2255388.
doi: 10.1001/jamanetworkopen.2022.55388.

Financial Toxicity Among Patients With Breast Cancer Worldwide: A Systematic Review and Meta-analysis

Anam N Ehsan  1   2 , Catherine A Wu  3   4 , Alexandra Minasian  2 , Tavneet Singh  5 , Michelle Bass  6 , Lydia Pace  2   3 , Geoffrey C Ibbotson  7   8 , Nefti Bempong-Ahun  7   8 , Andrea Pusic  2   3 , John W Scott  9 , Rania A Mekary  2   5 , Kavitha Ranganathan  1   2   3
Affiliations
Meta-Analysis

Financial Toxicity Among Patients With Breast Cancer Worldwide: A Systematic Review and Meta-analysis

Anam N Ehsan et al. JAMA Netw Open. .

Abstract

Importance: Financial toxicity (FT) is the negative impact of cost of care on financial well-being. Patients with breast cancer are at risk for incurring high out-of-pocket costs given the long-term need for multidisciplinary care and expensive treatments.

Objective: To quantify the FT rate of patients with breast cancer and identify particularly vulnerable patient populations nationally and internationally.

Data sources: A systematic review and meta-analysis were conducted. Four databases-Embase, PubMed, Global Index Medicus, and Global Health (EBSCO)-were queried from inception to February 2021. Data analysis was performed from March to December 2022.

Study selection: A comprehensive database search was performed for full-text, English-language articles reporting FT among patients with breast cancer. Two independent reviewers conducted study screening and selection; 462 articles underwent full-text review.

Data extraction and synthesis: A standardized data extraction tool was developed and validated by 2 independent authors; study quality was also assessed. Variables assessed included race, income, insurance status, education status, employment, urban or rural status, and cancer stage and treatment. Pooled estimates of FT rates and their 95% CIs were obtained using the random-effects model.

Main outcomes and measures: FT was the primary outcome and was evaluated using quantitative FT measures, including rate of patients experiencing FT, and qualitative FT measures, including patient-reported outcome measures or patient-reported severity and interviews. The rates of patients in high-income, middle-income, and low-income countries who incurred FT according to out-of-pocket cost, income, or patient-reported impact of expenditures during breast cancer diagnosis and treatment were reported as a meta-analysis.

Results: Of the 11 086 articles retrieved, 34 were included in the study. Most studies were from high-income countries (24 studies), and the rest were from low- and middle-income countries (10 studies). The sample size of included studies ranged from 5 to 2445 people. There was significant heterogeneity in the definition of FT. FT rate was pooled from 18 articles. The pooled FT rate was 35.3% (95% CI, 27.3%-44.4%) in high-income countries and 78.8% (95% CI, 60.4%-90.0%) in low- and middle-income countries.

Conclusions and relevance: Substantial FT is associated with breast cancer treatment worldwide. Although the FT rate was higher in low- and middle-income countries, more than 30% of patients in high-income countries also incurred FT. Policies designed to offset the burden of direct medical and nonmedical costs are required to improve the financial health of vulnerable patients with breast cancer.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Pusic reported receiving a patent for BREAST-Q, with royalties paid when it is used in for-profit industry-sponsored clinical trials; being codeveloper of the QPROMS owned by Memorial Sloan Kettering Cancer Center and receiving a portion of licensing fees when QPROMS are used in industry-sponsored clinical trial; and being a trustee of the American Society of Plastic Surgeons. Dr Scott reported receiving funding from the Agency for Healthcare Research and Quality as principal investigator on grant K08-HS028672 and as a coinvestigator on grant R01-HS027788 outside the submitted work; Dr Scott also reported receiving salary support from Blue Cross Blue Shield of Michigan through the collaborative quality initiative known as Michigan Social Health Interventions to Eliminate Disparities. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Flow Diagram of Included Studies
Figure 2.
Figure 2.. Forest Plot for Financial Toxicity Rate, Subgrouped by High-Income Countries (HICs) and Low-to-Middle Income Countries (LMICs)
See this image and copyright information in PMC

References

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