A number of studies demonstrate that individuals with cancer are at higher risk of experiencing financial difficulty than are individuals without cancer.[
Cancer is one of the most costly medical conditions to treat in the United States.[
At the same time, commercial insurers in the United States are shifting more direct medical care costs to patients through higher premiums, deductibles, and coinsurance and copayment rates. The 2016 Commonwealth Fund Biennial Health Insurance Survey indicated that 33% of insured adults aged 19 to 64 years had medical bill problems or accrued medical debt.[
Oral cancer drug–based treatments are frequently covered under patient pharmacy benefits' specialty tier, requiring high coinsurance that patients pay out of pocket. High cost-sharing plans, including tiered outpatient prescription formularies (i.e., copays that escalate depending on whether the drug is generic or branded, and by price) may be particularly troublesome for patients with cancer who are prescribed expensive oral chemotherapeutics. The proportion of health care plans with multitiered (>3) prescription formularies, in which expensive oral specialty drugs are associated with the highest cost sharing, increased from 3% in 2004 to nearly 88% in 2017.[
When compared with individuals without a cancer history, cancer survivors have higher out-of-pocket costs, even many years after initial diagnosis,[
A number of terms have been used to describe the financial impact of cancer, its treatment, and the lasting effects of treatment, including financial distress, financial stress, financial hardship, financial toxicity, financial burden, economic burden, and economic hardship.[
Etiology and Risk Factors
The interplay between cancer and financial distress is complex and related to a number of factors, as shown in Figure 1.[
Figure 1. Conceptual framework relating severe illness, treatment choice, and health and financial outcomes. Credit: Scott Ramsey, MD, PhD.
Several factors in a household at the time a member of that household is diagnosed with cancer will influence the vulnerability to financial distress. The risk of severe distress and the period between illness and these outcomes will be influenced by the following factors:
At the time of cancer diagnosis, several factors that determine the long-range risk of financial hardship include the following:
Components of these measures include material conditions that arise from increased out-of-pocket expenses, lower income from the inability to work, and psychological response to increased household expenses and reduced income.[
The material conditions of patients and their families that may be adversely affected by a cancer diagnosis and treatment are typically measured as follows:[
In addition, a patient's psychological response to increased financial burden associated with a cancer diagnosis and treatment is typically measured as financial stress, distress, or worry.[
A number of studies have measured components of at least one aspect of financial hardship,[
The following sections describe the prevalence of specific measures of financial hardship, including out-of-pocket costs, productivity loss, asset depletion and medical debt, bankruptcy, and financial distress and worry.
Prevalence of high out-of-pocket costs
Out-of-pocket costs are one of the most common measures of financial hardship and are the amounts that patients pay directly for their medical care, including insurance copayments, coinsurance, and deductibles for prescription and nonprescription medications, hospitalizations, outpatient services, and other types of medical care.[
In a study of long-term breast cancer survivors, 18% paid between $2,001 and $5,000 in out-of-pocket expenses, and 17% paid more than $5,000.[
In a study conducted using the nationally representative Medical Expenditure Panel Survey (MEPS), 4.3% of cancer survivors aged 18 to 64 years reported high out-of-pocket burden compared with 3.4% of those without a cancer history.[
Prevalence of productivity loss
Productivity loss is typically measured as the inability to work or pursue usual activities, days lost from work or disability days, reduction in work hours, and days spent in bed. Productivity loss may be quantified directly from employment data [
Prevalence of asset depletion and medical debt
Several studies have reported the prevalence of asset depletion and medical debt for cancer survivors, although this information is rarely reported in relation to individuals without a cancer history or before and after a cancer diagnosis. Further, most estimates are based on self-report, and little validation work has been conducted.
Studies of cancer survivors have suggested that between 33% and 80% of the survivors have used savings to finance medical expenses,[
Incidence and prevalence of bankruptcy
One of the few studies to measure the incidence of financial hardship reported that 1.7% of cancer survivors filed for bankruptcy in the 5 years after diagnosis.[
Prevalence of financial stress, distress, or worry
Several studies have found a prevalence of financial stress and worry about paying medical bills for cancer ranging from 22.5% in a nationally representative sample [
Prevalence of financial hardship as a composite measure
Several studies combine multiple components of financial hardship using summary measures, scores, or measures, including the Comprehensive Score for Financial Toxicity (COST) measure and the Personal Financial Wellness (PFW) Scale (formerly known as the InCharge Financial Distress/Financial Well-Being [IFDFW] Scale), but the results are rarely presented in relation to the general population and can be difficult to interpret.
In a study of patients with multiple myeloma undergoing treatment at a single academic cancer center, cancer survivors had a mean COST score of 23 (score range, 0–44, with lower values equivalent to higher burden).[
Several disease-related, sociodemographic, and health insurance–related factors have been implicated as contributors to increased risk of financial toxicity among cancer patients and survivors.
Disease- and Treatment-Related Risk Factors
Patients with advanced-stage cancers, cancers requiring chemotherapy or radiation therapy, and those with underlying comorbidities have been shown to have a higher risk of financial hardship after diagnosis than do those without these characteristics.[
A similar association was seen in an analysis using data from the 2008–2010 Medical Expenditures Panel Survey (MEPS) Household Component to measure loss of employment and productivity in individuals with and without cancer.[
Another study used multiple years of the MEPS (2008‒2013) to evaluate the associations between cancer history, chronic conditions, and productivity losses.[
Receipt of cancer-directed treatment and the presence of other comorbidities were also found to be associated with higher out-of-pocket spending in the Medicare population. In a study using data from the Medicare Current Beneficiary Survey linked to Medicare claims (1997–2007), 2-year mean out-of-pocket spending was higher by $1,526 among patients receiving chemotherapy and $1,470 among patients receiving radiation therapy compared with patients who did not receive treatment (P < .01).[
These studies together suggest that cancer survivors across a broad age range with advanced cancers, recurrent cancers, or cancers that require treatment (likely a marker of more-advanced disease) are more likely to face higher out-of-pocket spending and are at higher risk of financial hardship. Chronic treatment-related spending in combination with inability to regain employment and income resulting from progressive disease and debility may contribute to the association between advanced disease and greater financial burden.
Sociodemographic Risk Factors
A number of studies have consistently demonstrated an association between younger age at cancer diagnosis and higher risk of various types of financial hardship.[
In a study of bankruptcy rates among western Washington residents with and without cancer, bankruptcy rates were highest among both cancer survivors and noncancer controls aged 20 to 34 years (10.06 and 3.15 per 1,000 person-years, respectively) and lowest among survivors and controls aged 80 to 90 years (0.94 and 0.57 per 1,000 person-years, respectively).[
In an analysis of data from the 1,202 adult cancer survivors identified from the 2011 MEPS Experiences with Cancer questionnaire, material financial hardship (defined as bankruptcy, loans, debt, inability to pay for care, or making other financial sacrifices) was more common among cancer survivors younger than 65 years compared with those 65 years and older (28.4% vs. 13.8%; P < .001).[
Accumulating evidence suggests that adult survivors of childhood cancers may be especially vulnerable to financial hardship.[
Financial hardship among younger patients, however, may not solely result from higher out-of-pocket spending for cancer care. In a study using data from the 2001–2008 MEPS, a higher proportion of individuals aged 55 to 64 years reported spending 20% or more of their incomes on health care and premiums relative to younger individuals aged 18 to 39 years (10.1% vs. 7.1%; P = .05). This discrepancy suggests that high out-of-pocket spending alone does not lead to financial hardship.
As might be expected, cancer patients in lower-income household groups are also at increased risk of treatment-related financial hardship. No clear income threshold below which financial hardship risk markedly increases has been identified because annual household income has been categorized differently across studies. For example, in one study of cancer patients aged 18 to 64 years identified from the 2012 Livestrong survey, income between $41,000 and $80,000 and income of $40,000 or below were both associated with increased risk of borrowing money or going into debt compared with income of $81,000 and higher (OR, 2.46 and 3.52, respectively; P < .0001).
Other studies have shown increased risk of financial hardship among individuals with household incomes below thresholds of $50,000 or $20,000.[
Race and ethnicity
Race and ethnicity are strongly associated with disparities in cancer health outcomes, including survival.[
In a study using data from 3,242 lung and colorectal cancer survivors participating in the Cancer Care Outcomes Research and Surveillance Consortium (CanCORS) study, African American race was associated with an increased risk of self-reported economic burden relative to White race among patients with colorectal cancer (OR, 1.69; 95% CI, 1.24–2.30) after researchers adjusted for other sociodemographic and clinical factors.[
In another population-based survey of 3,133 women with breast cancer, Spanish-speaking women were at greater risk of financial decline related to breast cancer compared with White women (OR, 2.76; P = .006), whereas English-speaking Latina and African American women did not share this increased risk.[
Both analyses were adjusted for key demographic variables, including income, age, marital status, and education, which might also influence risk of financial hardship. Strong associations between minority race and ethnicity and financial hardship have not been demonstrated in other studies. However, these findings suggest that further research among cancer survivors is warranted.
Loss of productivity and employment can be considered both a risk factor for (predictor of) financial toxicity and a measure of financial toxicity (outcome). Several studies have shown that cancer patients experience loss of work, difficulty in returning to work, declines in income, and general loss of productivity as a result of cancer diagnoses.[
In an analysis of data from 1,202 adult cancer survivors from the 2011 MEPS Experiences with Cancer questionnaire, change in employment after diagnosis (switching to part-time work and taking extended leave) was associated with a substantially increased risk of material financial hardship compared with no change (49.1% vs. 20.2%; P < .001).[
Patients who lack health insurance coverage are at elevated risk of many adverse experiences, including substantial financial hardship, particularly in an era of rapidly rising costs for cancer care. However, the presence of health insurance does not completely shield enrollees from high levels of out-of-pocket spending on health care services.
In the Medicare population, access to supplemental insurance and Medicare Part D plans has helped shield patients from some of the out-of-pocket cost burden. In an analysis of data from MEPS 2002–2010, outpatient prescription costs for adults older than 65 years decreased by 43% after the introduction of Medicare Part D, while younger patients (not yet Medicare-eligible) did not experience a similar decline in out-of-pocket expenditures for prescription drugs over the same period.[
The influence of type of insurance plan on the risk of financial hardship among younger patients (i.e., younger than 65 years) has not been thoroughly explored. One study found that patients with public insurance (Medicaid or Medicare) have an increased risk of financial hardship compared with patients who have private insurance (OR, 1.95; P < .0001).[
Several retrospective cohort and cross-sectional studies have investigated the associations between financial burden from cancer care and treatment adherence, quality of life, satisfaction with care, incurring debt, filing for bankruptcy, and health outcomes. Cohort and cross-sectional studies are prone to study biases inherent to such study designs; therefore, caution must be exercised when interpreting the reported findings. Thus far, no evidence from randomized controlled clinical trials is available to guide patients and physicians about outcomes related to the financial toxicity among individuals diagnosed with cancer.
Access and Adherence to Treatments
Several retrospective cohort studies have evaluated the effect of prescription copayment amounts for cancer drugs on patient compliance with therapy.[
A cross-sectional study using data from the 2011 to 2014 National Health Interview Survey found that individuals aged 18 to 64 years with a recent or previous cancer diagnosis were more likely to report changing their prescription drug use (e.g., not filling prescriptions or skipping doses) for financial reasons than those individuals without a history of cancer.[
Other studies examined the association between copayment amounts for adjuvant endocrine therapy, aromatase inhibitors (AIs), and tamoxifen and noncompliance in women with breast cancer.[
A cross-sectional survey study of adult patients (N = 300) receiving cancer therapy at Duke Cancer Institute found that 16% of patients reported high or overwhelming financial distress, 27% reported medication nonadherence, and 4.67% reported chemotherapy nonadherence.[
Furthermore, this study found that an increased likelihood of nonadherence was associated with the following characteristics:
A statistically significant decreased risk of nonadherence was associated with having private insurance (adjusted OR, 0.31; 95% CI, 0.14–0.72).
A cross-sectional cohort study of 10,508 patients for whom oral chemotherapy was initiated between 2007 and 2009 examined the association between prescription abandonment rates and cost sharing.[
Anecdotal reports also suggest that terminally ill cancer patients are foregoing the opportunity to obtain lethal doses of barbiturates in states with death-with-dignity laws because the price of these generic medications has increased to approximately $3,000 for a typical prescription.[
Quality of Life and Perceived Quality of Care
In a prospective, observational, population- and health care systems–based cohort study, the associations between financial burden, quality of life, and perceived quality of care were investigated using Cancer Care Outcomes Research and Surveillance Consortium (CanCORS) II data. Patient-reported health-related quality of life was measured using the EuroQol five-dimensions questionnaire (EQ-5D).
From 2003 to 2006, patients were enrolled in the U.S. CanCORS study within 3 months of receiving either a colorectal or lung cancer diagnosis. For the CanCORS II study, among the surviving CanCORS patients, one disease-free subcohort and one advanced-disease subcohort were selected and resurveyed about their quality of life. The median time from diagnosis was 7.3 years. An adjusted structural equation modeling analysis found that higher financial distress was negatively associated with health-related quality of life (adjusted beta, -0.06 per burden category; 95% CI, -0.08 to -0.05); however, financial distress was not associated with perceived quality of care (OR, 1.09; 95% CI, 0.93–1.29).[
Another cohort study using CanCORS data [
Several cross-sectional studies evaluated the impact of the financial burden of cancer care on patient quality of life. A survey analysis involving 149 patients with advanced-stage cancer in Texas at a public hospital (n = 72) and a comprehensive cancer center (n = 77) found that the median intensity of financial distress was double among patients treated in a public hospital compared with those treated in a comprehensive cancer center (on a scale of 0 = best to 10 = worst; 8 vs. 4; P = .0003).[
A study of 2,108 patients from the 2010 National Health Interview Survey (NHIS) found that individuals who responded a lot (8.6%) to the survey question To what degree cancer causes financial problems for you and your family? were more likely to report the following when compared with those who reported no financial burden:[
Utilizing the 2011 Medical Expenditure Panel Survey (MEPS) data, one study [
Satisfaction With Care
A review study documented that approximately 60% of people across a wide range of studies reported positive attitudes about cost-related discussions with their health care providers. Despite this, less than one-third of patients have had these discussions.[
Financial Debt and Bankruptcy
Two studies considered the impact of the financial burden of cancer care on incurring debt and bankruptcy.[
One cross-sectional study, using the Livestrong 2012 survey data of 4,719 cancer survivors, reported that 63.8% of the survivors had worried about paying large bills related to cancer, 33.6% had gone into debt, 3.1% had filed for bankruptcy, and 39.7% had to make other kinds of financial sacrifices because of their cancer, its treatment, or the lasting effects of treatment.[
Furthermore, this study found that an increased likelihood of filing for bankruptcy was associated with the following characteristics of cancer patients:[
Similar patient characteristics were reported for those going into medical debt.[
Another retrospective cohort study, using data from the 1995–2009 western Washington Surveillance, Epidemiology, and End Results (SEER) Cancer Registry–linked U.S. Bankruptcy Court for the Western District of Washington data, found that patients with cancer diagnoses were more likely (hazard ratio [HR], 2.65; P < .05) to file for bankruptcy compared with patients without cancer.[
A clearly worded grading system has been developed to identify different levels of financial toxicity.[
Impact on Caregivers
Informal cancer caregivers often share in the experience of financial toxicity by spending money on food, medications, and other patient needs in addition to taking time off from work to provide logistical, emotional, and medical support. In a recent survey of over 5,000 cancer patients whose caregivers were friends or family members, approximately 25% reported that their caregivers made significant employment changes after the cancer diagnosis, and 8% of survivors had caregivers who took at least 2 months of leave from work.[
Terminally ill cancer patients from households reporting financial hardship had a higher likelihood of receiving intensive life-prolonging care (defined as receiving ventilation or resuscitation to prolong life) than did those who did not report financial hardship (OR, 3.22; 95% CI, 1.38−7.53). In a longitudinal survey of 281 terminally ill cancer patients, 29% reported using most or all of their household's financial savings because of illness.[
In one retrospective cohort study of cancer patients who filed for bankruptcy compared with those who did not according to data in the western Washington SEER Cancer Registry, filing for bankruptcy was associated with an increased risk of mortality (adjusted HR, 1.79; 95% CI, 1.64–1.96).[
Internal and External Validity Concerns With Observational Studies
Data from randomized controlled trials offer the strongest evidence for establishing the efficacy of treatment on cancer outcomes. However, because cancer patients cannot ethically be subjected to financial toxicity through randomization, the current body of evidence is primarily from observational data, particularly from cross-sectional and cohort studies. Large nationally representative surveys can provide the best estimates of the prevalence of certain conditions.
However, observational studies are prone to biases that may limit the validity of their findings. Several sources of bias are likely to be particularly important in observational studies assessing the association of financial toxicity with future outcomes, hence creating a challenge in interpreting the results of such studies.
In cross-sectional survey studies, high nonresponse rates may lead to the possibility of nonresponse bias in reported estimates if the potential answers of nonrespondents vary from those who did respond. Another source of bias in survey research is reporting bias, which refers to the selective revealing of information by respondents that they believe is more socially desirable.
Another source of bias in observational studies is reverse causality, which may weaken any true association between financial toxicity and its potentially related outcomes. In one study,[
Considering the conceptual framework for cancer and its impact on health care use, health outcomes, and financial effects, based on extant models, allows exploration of current evidence, gaps in evidence, and areas for future research.[
Although many individual risk factors for financial hardship have been identified, the evidence that demonstrates the degree to which these factors contribute to the risk of later financial hardship is insufficient, as is information about the interplay between these factors and clinical factors at the time of diagnosis.
Specific areas in need of further study to address their influence on the risk of financial distress after a cancer diagnosis include:
Because ample evidence exists that financial distress occurs even among patients with health insurance, the role that forms of insurance play in protecting individuals from financial distress requires further study. Medicare may at least partially protect older persons from financial harm; however, in addition to this universal benefit for persons older than 65 years, other factors that are associated with older age might also reduce the risk of financial distress, namely, retired adults typically have higher levels of assets (e.g., owning a home outright), pensions or retirement accounts as sources of income, and Social Security. Another factor is that physicians may treat older patients less intensively and thus less expensively.
For adults of working age, characteristics of work-sponsored or individually purchased commercial insurance that vary from plan to plan—specifically, deductibles, copay levels, and coverage exclusions—may influence the risk of financial distress. These factors also warrant further study.
After patients are diagnosed with cancer and miss work during treatment, their ability to continue to work or return to work greatly influences their future risk of financial hardship. Studies are needed that relate particular treatments, modalities of treatment (e.g., infusional therapy vs. oral therapy), and toxicities of treatments with work absenteeism, loss of productivity, and likelihood of returning to the workforce.
Implementation of the U.S. Affordable Care Act in 2008 provided a natural experiment to determine whether expanding access to health insurance for millions of Americans had an impact on rates of financial distress or insolvency for persons with cancer. Proposed pilots for different Medicare payment systems may also offer opportunities for quasi-experimental approaches that compare implementation with nonimplementation.[
After diagnosis, treatment choice could, in theory, influence the likelihood of experiencing financial difficulties. For many cancers, guidelines include options that are considered equivalent therapeutically, yet the costs of the treatments might vary by 50-fold or more.[
Cancer management is unusual among medical interventions because intensive treatment at specialized facilities for weeks or months is often involved. For many patients, nonmedical costs associated with seeking treatment, such as the cost of transportation and lodging during treatment, can take a financial toll on families. The role that nonmedical costs play in financial hardship is an area in need of further study.
Financial Distress and Outcomes
Evidence from multiple retrospective studies shows that patients experiencing financial distress have reduced adherence to planned therapies, lower quality of life, and diminished survival. These studies have limitations because certain unmeasured clinical and financial factors that may influence treatment choice might also influence outcomes. Prospective or retrospective studies that include a more-comprehensive picture of financial status at diagnosis and clinical and patient factors that might influence treatment choice would provide a more accurate picture of the causal pathway between financial distress and outcomes.
Interventions Aimed at Reducing Financial Distress Among Cancer Patients
Several interventions specifically designed to reduce rates of financial distress among cancer patients have been proposed. Some are being implemented, but, to date, there have been no prospective studies evaluating the impact of these interventions on the rates and severity of financial distress, care choices, quality of life, or survival. Several of the most commonly discussed interventions are reviewed below.
Financial navigators are being used in community and academic settings to help cancer patients avoid adverse financial consequences after a cancer diagnosis.[
One prospective study (S1417CD [NCT02728804]), conducted in the National Cancer Institute Cooperative Cancer Clinical Trials Network, Implementation of a Prospective Financial Impact Assessment Tool in Patients with Metastatic Colorectal Cancer, evaluated the incidence of treatment-related financial hardship among patients with newly diagnosed metastatic colorectal cancer.[
Price transparency to facilitate treatment choice
Studies of price transparency initiatives, such as one that required California hospitals to publish their charges, have not found that they significantly influence patient treatment choice or pricing of goods and services by health care providers.[
More information is needed regarding how responsive cancer patients, their families, and/or their providers might be to offers of pricing transparency, direct or indirect financial assistance, or further reductions in out-of-pocket payment requirements.
Closely related to price transparency is the concept of value-based pricing: a concept in which patients' out-of-pocket expenditures are tied to external assessment of value for competing therapies for particular conditions. The objective of value-based pricing is to steer patients to higher-value therapies through financial incentives (higher value = lower out-of-pocket responsibility). Although value-based pricing has been implemented for several clinical conditions (e.g., hypertension, diabetes), and evidence exists that this type of pricing increases the utilization of higher-value services, it has not been applied in oncology. Because of the ongoing transformation in how medical providers are paid for the care of cancer patients, there is a need to better identify opportunities and challenges to increasing awareness of and solutions to patient financial toxicity in the context of alternative payment models and quality measure reforms.
It is also unclear when in the care trajectory more information and financial assistance are needed and will be most effective in encouraging treatment initiation and continuance. For example, most employer-based insurance policies have an annual out-of-pocket maximum, beyond which the insurer assumes 100% of the cost of care. Many patients with late-stage cancer reach the maximum quickly, in which case the insurer bears the full cost of anticancer treatments for the remainder of the benefit year.
Health insurance reform
By providing millions of previously uninsured Americans with health insurance, the Massachusetts health insurance plan and the U.S. Affordable Care Act have presented an opportunity for natural pre-post experiments for health care policies that are aimed at reducing the financial exposure of an individual during severe illness. Because insurance appears to mitigate rather than eliminate the risk of financial distress from a cancer diagnosis and treatment, other interventions aimed at improving financial outcomes for insured persons are likely needed.
Another policy targeting providers and patients would be to require the use of patient decision aids that include benefits-cost and financial-toxicity assessments and assistance through measures-of-quality for fee-for-service Medicare payments under Medicare Access and CHIP (Children's Health Insurance Program) Reauthorization Act (MACRA) legislation.[
Reducing and/or eliminating patient copayment/coinsurance for pathway -adherent cancer care in the fee-for-service Medicare program and/or commercial plans would also likely act to reduce patient and family burden across multiple treatment modalities—radiation, drugs, inpatient and outpatient coinsurance, and copayments.[
Cancer Treatment Costs References
Cancer treatment cost information can be difficult to access. Listed below are links to publicly available websites that contain updated information on costs related to cancer care:
The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.
Editorial changes were made to this summary.
This summary is written and maintained by the PDQ Adult Treatment Editorial Board, which is editorially independent of NCI. The summary reflects an independent review of the literature and does not represent a policy statement of NCI or NIH. More information about summary policies and the role of the PDQ Editorial Boards in maintaining the PDQ summaries can be found on the About This PDQ Summary and PDQ® - NCI's Comprehensive Cancer Database pages.
Purpose of This Summary
This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the treatment of cancer and financial toxicity. It is intended as a resource to inform and assist clinicians in the care of their patients. It does not provide formal guidelines or recommendations for making health care decisions.
Reviewers and Updates
This summary is reviewed regularly and updated as necessary by the PDQ Adult Treatment Editorial Board, which is editorially independent of the National Cancer Institute (NCI). The summary reflects an independent review of the literature and does not represent a policy statement of NCI or the National Institutes of Health (NIH).
Board members review recently published articles each month to determine whether an article should:
Changes to the summaries are made through a consensus process in which Board members evaluate the strength of the evidence in the published articles and determine how the article should be included in the summary.
The lead reviewers for Financial Toxicity and Cancer Treatment are:
Any comments or questions about the summary content should be submitted to Cancer.gov through the NCI website's Email Us. Do not contact the individual Board Members with questions or comments about the summaries. Board members will not respond to individual inquiries.
Levels of Evidence
Some of the reference citations in this summary are accompanied by a level-of-evidence designation. These designations are intended to help readers assess the strength of the evidence supporting the use of specific interventions or approaches. The PDQ Adult Treatment Editorial Board uses a formal evidence ranking system in developing its level-of-evidence designations.
Permission to Use This Summary
PDQ is a registered trademark. Although the content of PDQ documents can be used freely as text, it cannot be identified as an NCI PDQ cancer information summary unless it is presented in its entirety and is regularly updated. However, an author would be permitted to write a sentence such as "NCI's PDQ cancer information summary about breast cancer prevention states the risks succinctly: [include excerpt from the summary]."
The preferred citation for this PDQ summary is:
PDQ® Adult Treatment Editorial Board. PDQ Financial Toxicity and Cancer Treatment. Bethesda, MD: National Cancer Institute. Updated <MM/DD/YYYY>. Available at: https://www.cancer.gov/about-cancer/managing-care/track-care-costs/financial-toxicity-hp-pdq. Accessed <MM/DD/YYYY>. [PMID: 27583328 ]
Images in this summary are used with permission of the author(s), artist, and/or publisher for use within the PDQ summaries only. Permission to use images outside the context of PDQ information must be obtained from the owner(s) and cannot be granted by the National Cancer Institute. Information about using the illustrations in this summary, along with many other cancer-related images, is available in Visuals Online, a collection of over 2,000 scientific images.
Based on the strength of the available evidence, treatment options may be described as either "standard" or "under clinical evaluation." These classifications should not be used as a basis for insurance reimbursement determinations. More information on insurance coverage is available on Cancer.gov on the Managing Cancer Care page.
More information about contacting us or receiving help with the Cancer.gov website can be found on our Contact Us for Help page. Questions can also be submitted to Cancer.gov through the website's Email Us.
Last Revised: 2022-03-04
This information does not replace the advice of a doctor. Healthwise, Incorporated, disclaims any warranty or liability for your use of this information. Your use of this information means that you agree to the
Healthwise, Healthwise for every health decision, and the Healthwise logo are trademarks of Healthwise, Incorporated.
Individual and family medical and dental insurance plans are insured by Cigna Health and Life Insurance Company (CHLIC), Cigna HealthCare of Arizona, Inc., Cigna HealthCare of Illinois, Inc., and Cigna HealthCare of North Carolina, Inc. Group health insurance and health benefit plans are insured or administered by CHLIC, Connecticut General Life Insurance Company (CGLIC), or their affiliates (see
All insurance policies and group benefit plans contain exclusions and limitations. For availability, costs and complete details of coverage, contact a licensed agent or Cigna sales representative. This website is not intended for residents of New Mexico.