Abstract
Introduction
Patients and their families face financial difficulties during cancer care. This study aims to assess patients’ unmet needs and financial challenges during diagnosis and treatment, representing the first research in the Republic of Georgia to address these economic issues.
Methods
In this multicenter, retrospective, observational study, a questionnaire was distributed, and clinical data were collected from 181 patients undergoing active cancer treatment across 7 tertiary hospitals. The primary outcomes of the study were the patient-reported experience of cancer-related financial burden on the family and the frequency of debt taken for cancer diagnosis or treatment.
Results
The median age was 63, with 55.2% being female. Most patients (135/181, or 74.5%) reported a “moderate” or “heavy” economic burden from cancer care. During diagnosis and treatment, 129 patients (71.3%) incurred out-of-pocket costs, and 44.2% took out loans for care, with 10 patients (5.6%) doing so multiple times. The most common reason for debt (76/181) was to cover diagnostic procedures. Only 57 patients (31.5%) reported stable employment at the time of the survey, and among the 149 employed/self-employed, 50 (33.5%) experienced work-related issues due to cancer. Younger patients (≤65) had a tendency to take on debt more frequently (49.5%) compared to older (>65) patients (37%), but this difference was not statistically significant (P-value .097).
Conclusion
Cancer care in Georgia imposes a heavy financial burden, with significant out-of-pocket costs for most patients. Improved access to financial assistance is required to better avoid potential inequities.
Introduction
Cancer is a significant global health threat, with low- and middle-income countries (LMICs) accounting for 57% of new cases and 65% of deaths.1,2 The overall cancer burden is rising rapidly, with a projected 60% increase in cases in LMICs over the next 20 years. 3
Current progress in cancer detection and treatment has significantly enhanced outcomes for various types of cancer. 4 However, innovative therapies and technological advancements in cancer care remain costly and often inaccessible, particularly in LMICs. 5 High treatment costs and limited availability pose substantial challenges in developing countries. Additionally, the increasing expenses associated with cancer care can lead to higher out-of-pocket (OOP) costs, medical debt, and even bankruptcy. 6 It is widely recognized that cancer patients and their families or caregivers face economic hardships, even within universal healthcare systems.7,8
Financial toxicity (FT) in cancer care refers to the harmful effects of financial strain resulting from a cancer diagnosis on patients, their families, and society.9-12 It has been shown to be a significant predictor of quality of life for cancer patients. 13 Financial challenges are closely tied to national economic policies on healthcare, shedding light on the differences in FT burdens experienced by cancer patients in various countries. 9 Despite its growing recognition as a critical component of cancer care globally, there is currently no published data or formal analysis on financial toxicity in Georgia. As a country with constrained healthcare resources and systemic gaps in cancer care, understanding and addressing FT is urgently needed to ensure equitable access to treatment and to mitigate its harmful effects on patients and their families.
Georgia is a middle-income country in the Caucasus region, situated at the crossroads of Eastern Europe and Western Asia, with a population of approximately 3.7 million. 14 The current healthcare system is funded through a mix of public resources and private insurance, covering nearly the entire population. The Universal Health Coverage (UHC) program encompasses provisions for cancer treatment, including surgery, radiation therapy, and systemic therapy. Recently, some new drugs registered in the country, such as immunotherapy and targeted therapy, are also fully covered by UHC. 15
Cancer patients frequently face substantial financial hardships during treatment, which can exacerbate the physical and emotional challenges of a cancer diagnosis.
The study of Kakhniashvili et al reported a statistically significant link between depression and financial status, as well as educational level and employment, in Georgian breast cancer patients. Lower household income emerged as a key predictor of clinical depression among these cancer patients. 16
We conducted a study to evaluate cancer patients’ unmet needs and financial challenges during diagnosis and treatment. We gathered empirical data on the financial burden of cancer care, identified research gaps, and established key priorities to improve policy and practice for cancer patients in Georgia.
Methods
In this multi-center, retrospective, observational study, the questionnaire was distributed, and clinical data were collected during treatment from 181 patients with cancer at seven tertiary hospitals in Georgia (three regional hospitals and four from Tbilisi, the capital city). Hospitals accrued participants over the three months period, between August 01.2023 and November 01, 2023. The patients were recruited after they came for appointments and the majority of them 181 out of 200 agreed to participate in the survey. The response rate was 90.5%. The start dates varied based on local ethics board approval. We have de-identified all patient details.
The selection criteria included patients aged 18 years and older with any solid tumor who were undergoing active anti-cancer treatment (systemic therapy or radiotherapy) in outpatient departments and had the ability to read, write, and understand Georgian. Exclusion criteria comprised individuals with cognitive dysfunction, cancer survivors not receiving anti-cancer treatment, those with hematologic malignancies, and patients receiving end-of-life supportive care.
The questionnaire consisted of 13 closed questions, scored 1 to 4 (Likert scale) related to the out-of-pocket costs faced by cancer patients. The questionnaire used in this study was a researcher-designed tool, developed specifically to assess the financial burden of cancer patients in a resource-limited setting. It was pilot-tested in 45 patients (25%). The survey included questions such as whether the cancer diagnosis had impacted the respondent’s or their family’s financial situation, whether they had to take out a loan for diagnosis or treatment, whether their family depended on their income, etc.
Patients’ Characteristics
The primary outcomes of the study were the patient-reported experience of cancer-related financial burden on the family (categorized as not at all, mild, moderate, or heavy) and the frequency of debt taken during cancer diagnosis or treatment. We also examined the correlation between various socio-demographic characteristics and their impact on the family’s financial status. For all bi-variate analyses chi‐square test (P < .05) was used to test differences.
The study was approved by the Institutional Review Board of Caucasus Medical Centre (approval number № ე-36/07-23), and this approval was accepted by all participating hospitals. All patients provided written informed consent for interviews and approved access to their medical records.
The reporting of this study conforms to STROBE guidelines. 17
Results
The median age was 63 years (31 to 93), with female dominance 100 out of 181(55.2%). Of the 181 patients, 127 (70.2%) were married, and 57(31.5%) were employed. A majority of patients, 135/181 (74.5%) reported a “moderate” or “heavy” economic burden on the family from cancer care (Figure 1). During cancer diagnosis and treatment more than two-thirds of patients, 129 (71.3%) needed to pay out-of-pocket fees, and 44.2% of patients (80/181) took out loans to pay for cancer care. Also, 10 (5.6%) patients did this several times (Figure 2). The most frequent reason patients (76/181) took on a debt before starting treatment was to pay for diagnostic procedures. The Financial Burden of Cancer on Family Debt for Diagnostics/Treatment
Only 57/181 (31.5%) patients reported holding stable employment at the time of the survey. Of 149 employed/self-employed patients, 50 (33.5%) reported experiencing work-related problems due to cancer.
We didn’t find a significant correlation between marital status, employment status, and economic burden on the family during cancer care. Younger patients (≤65) had a tendency to take on debt more frequently (51/103, 49.5%) compared to older (>65) patients (29/78, 37%), but this difference was not statistically significant (P-value .097); (Figure 3). Credit by Age Groups
Discussion
To our knowledge, this is the first study in Georgia to assess the financial burden of cancer care on patients and their families. In this retrospective, multi-centered, cross-sectional study, approximately 75% of patients experienced cancer-related financial hardship, which was an unexpectedly high number, despite the fact that the universal healthcare system in the country should fully cover the costs of cancer treatment. It seems the main additional expenses are related to primary diagnostic procedures, laboratory tests, and concomitant medications. Moreover, loss of earnings during treatment may be significant, especially in less skilled occupations.
Cancer patients frequently face substantial financial hardships during their treatment, which can intensify the physical and emotional struggles associated with a cancer diagnosis. This financial pressure may adversely affect their commitment to treatment, overall quality of life, and survival outcomes.13,18
The expenses associated with cancer diagnosis, treatment, and care create significant financial toxicity, particularly in resource-limited countries. A systematic review and meta-analysis of 31 studies from LMICs revealed that the prevalence of objective financial toxicity among cancer patients varied widely, from 17.7% to 93.4%. 19 Research from India 20 and several Southeast Asian countries 21 has reported a high prevalence of financial toxicity among cancer patients. A study from Pakistan indicated that 42% of patients perceived the financial burden of cancer as significant, while 27% viewed it as unmanageable. 22 A recent study from the USA revealed that nearly 45% of cancer survivors experience financial hardship during and after their treatment. Researchers analyzed data from the 2021 Health Information National Trends Survey, which included 1212 respondents. The primary outcome measured was the patient-reported experience of cancer-related financial hardship, categorized as “not at all,” “a little,” “some,” or “a lot.” In contrast to our study, 70.5% of participants had private or employer-based health insurance. Overall, almost 45% of cancer survivors reported some level of financial hardship, while 56.4% indicated they faced no hardship at all. The authors found that younger age, lower income, advanced cancer stage, higher social vulnerability, and having Medicare insurance were linked to an increased likelihood of experiencing financial hardship. 23 In Italy, where the state provides services free at the point of use, a study analyzing pooled data from 16 prospective multicenter trials found that 22.5% of patients still experienced financial toxicity, which was significantly associated to an increased risk of death. 24
In our study, during cancer diagnosis/treatment 71.3% of patients reported additional out-of-pocket fees, and 44.2% of patients took on loans during cancer care. OOP expenses are the most common financial burden for cancer patients, even in countries with universal healthcare. 25 In Australia—where universal health insurance exists alongside optional private insurance—cancer patients encounter high medical costs and additional hidden expenses. 26 On the other hand, in the USA, where private healthcare systems prevail, cancer survivors were found to experience financial hardship, including OOP expenses, income loss, and missed workdays. 27 A systematic review by Alzehr et al found that 14%-57.8% of cancer patients and their families/caregivers face out-of-pocket expenses, income loss, and lost productivity. 28 A key finding from the review by Nicolas Iragorri and colleagues 29 revealed that patients in countries with universal healthcare systems, such as Canada, the UK, France, and Australia, faced significant OOP expenses, particularly for non-medical costs.
Our data indicates that one-third of employed patients reported work-related issues due to cancer, including job loss. Furthermore, findings from various studies suggest that cancer patients frequently struggle to maintain full-time employment, often needing to reduce their working hours or even stop working altogether.30-32 Cancer patients during treatment have treatment-related side effects, which also affect impact on their daily activities and especially work ability.
Losing a job after a cancer diagnosis can result in both short-term economic challenges (such as paying bills or buying food) and long-term consequences (like the risk of losing a home). 33 The reviews highlight the effects on employment status, noting that a cancer diagnosis is linked to both reduced income and changes in employment status, such as decreased work hours and retirement.31,33 A study by Danielle Wing Lam prospectively examines the loss of work productivity and activity impairment among Chinese women with breast cancer. The authors’ post-hoc analysis indicated that patients facing more significant financial challenges were less likely to have health insurance. 34
Our study found that younger patients incur debt more frequently than older patients. This may be due to their inability to work because of health issues, which can result in more missed workdays or increased time spent in bed, but also because they anticipate being in work longer enabling them to pay off the loans, something perhaps not available to retired older people, for example. Additionally, younger patients often have less savings and fewer assets, along with potential educational debt and financial responsibilities such as caring for young children, making it challenging for them to manage the OOP costs of cancer care. In a study involving 1200 adult cancer survivors, material financial hardship—such as loans, debt, and difficulties in paying for care—was found to be more prevalent among survivors under 65 compared to those aged 65 and older (28.4% vs 13.8%). 35
We found that 44.2% of patients incur debt for cancer care. The literature indicates that medical debt is a concern not only in LMICs but also affects insured individuals in high-income countries. 36
Our study has several limitations, including potential inaccuracies in patient self-reported data and the possibility of unmeasured factors influencing the results. The primary limitation is the lack of sample size calculation, as we were unable to determine it due to the absence of prior data on the proportion of cancer patients experiencing financial toxicity. Additionally, the potential for selection bias exists and the sampling method was non-random, restricting our ability to generalize the findings. However, the sample was recruited from seven major hospitals across the country, giving a reasonably good coverage of the population.
Despite the above limitations, our study offers several notable strengths. Most importantly, this is the first investigation in Georgia to comprehensively examine the financial burden of cancer care on patients and their families. By using a multi-centered approach and collecting data from major hospitals across the country, we were able to capture a diverse and representative picture of the issue at a national level. The study also provides valuable insights into specific drivers of financial hardship—such as out-of-pocket diagnostic costs, treatment-related work loss, and the disproportionate burden on younger patients—that have not previously been documented in this context. These findings not only fill a significant knowledge gap but also lay the groundwork for future research and policy reforms aimed at reducing financial toxicity in cancer care in Georgia and similar resource-limited settings.
Based on our results, the actionable steps for policymakers and stakeholders include expanding universal healthcare to cover primary diagnostic tests, lab investigations, and medications, and reducing out-of-pocket costs by introducing needs-based financial aid for low-income patients, by enhancing job security and income support during treatment, by establishing national tracking of financial toxicity, and by integrating financial counseling into cancer care teams to guide patients and prevent debt.
Conclusion
Our study indicates that cancer diagnosis, treatment, and care impose high levels of financial toxicity on cancer patients and their families in Georgia. Despite the fact, that universal government insurance covers cancer treatment costs, for the majority of patients, out-of-pocket costs are substantial. Improved access to financial assistance is required to better avoid the financial burden of cancer care. Further research is planned, all over the country to clarify these problems and identify priorities for government and stakeholders.
Footnotes
Acknowledgments
We thank prof Richard Fielding for his invaluable recommendations and suggestions.
Ethical Considerations
Ethical approval was obtained from the Institutional Review Board of Caucasus Medical Centre (approval number: ე-36/07-23; approval date: 05 July 2023), and this approval was accepted by all participating hospitals.
Informed Consent
Written informed consent was obtained from the patient(s) for their anonymized information to be published in this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Ivane Kiladze- reports receiving fees for serving on an advisory board and lecture fees from Merck Sharp & Dohme, lecture fees from AstraZeneca and Sevier. Other authors declare no conflicts of interest.