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. Sub-group 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; I² = 0%), multiple cycles of chemotherapy (1.94% [95% CI, 1.00, 3.75]; p = 0.05; I² = 43%) and private health facilities (2.87% [95% CI, 1.89, 4.35]; p < 0.00001; I² = 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.