Financial Toxicity of Cancer Care Nursing CE Course

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Financial Toxicity of Cancer Care

Disclosure Statement

This module provides an in-depth review of the rising costs of cancer care, the impact of financial toxicity on patients with cancer, and the crucial role of nurses in addressing this growing challenge. 

Upon completion of this module, nurses should be able to:

• define financial toxicity in cancer care and examine its prevalence and significance
• identify the key components of financial toxicity, including both direct and indirect costs of treatment
• assess the consequences of financial strain on patient well-being, treatment adherence, and overall health outcomes
• explore nursing strategies to recognize and address financial distress among patients
• connect patients with advocacy resources and financial assistance programs to improve access to affordable care

Background

Medical debt is a widespread problem in the United States, impacting a large proportion of the population. A 2021 study published in JAMA found that as of 2020, 17.8% of individuals with credit reports had medical debt sent to collections (Kleunder et al., 2021). Similarly, a 2022 Kaiser Family Foundation survey revealed that 41% of adults carried some form of medical or dental debt (Kaiser Family Foundation, 2022). Cancer patients are particularly vulnerable to financial strain, often experiencing what is known as financial toxicity—the stress and economic hardship caused by the cost of treatment. Currently, nearly one-half of patients with cancer face financial toxicity, emphasizing the severe economic challenges associated with a cancer diagnosis (Smith et al., 2022). Financial toxicity encompasses direct and indirect costs of care and can lead to significant psychosocial distress, treatment delays, reduced adherence to therapy, and diminished quality of life (QOL). It is increasingly recognized as a critical factor affecting patient outcomes and survival. Understanding the multifaceted nature of financial toxicity in cancer care is crucial for nurses, as they play a vital role in identifying at-risk populations and guiding patients toward financial assistance resources. By enhancing awareness and offering practical interventions, this module empowers nurses to proactively reduce financial barriers, improve patient-centered care, and advocate for sustainable solutions (Burbage, 2020; Centers for Disease Control and Prevention [CDC], 2021; Chan & Nekhlyudov, 2024).

Cancer Statistics

According to the American Cancer Society (ACS), more than 2 million people in the United States will be diagnosed with cancer in 2025, and over 600,000 lose their lives to the disease. Cancer is the second leading cause of death. The lifetime risk of cancer remains high, with approximately one in five patients assigned male at birth and one in six patients assigned female at birth developing cancer. The number of individuals living with cancer is steadily increasing. Improved screening, early detection, and advancements in treatment have contributed to this rise, allowing more individuals to live beyond their initial diagnosis (ACS, 2025). In the United States, more than 18 million people had a history of cancer as of 2022, with projections indicating this number will exceed 26 million by 2040 (Tonorezos et al., 2024). As populations age and medical interventions improve, the prevalence of cancer survivors will continue to grow. In the United States, about 70% of patients with cancer live at least 5 years beyond diagnosis, and nearly half surpass the 10-year mark. A significant proportion of these survivors—about 20%—have lived 20 or more years after their initial diagnosis. The majority of survivors are older adults, with approximately 45% falling within the 65 to 80 age range and another 20% aged 80 and older. Additionally, patients assigned female at birth are more likely than those assigned male to be cancer survivors, reflecting differences in cancer types, health care access, and early detection efforts (ACS, 2022).

A concerning trend has emerged in recent years, with cancer incidence rising among younger populations. Those born in the 1980s and 1990s face a higher risk of developing cancer than previous generations. Notably, seventeen types, including breast, pancreatic, and colon, are becoming increasingly common in younger age groups. Lifestyle factors such as elevated body mass index (BMI), poor dietary habits, and environmental exposures have been identified as contributing factors. This shift has significant implications for public health efforts, as younger patients often face unique treatment challenges and long-term survivorship concerns. Despite these hardships, progress has been made in reducing overall cancer mortality rates. Since 1991, cancer deaths in the United States have declined by 34%, largely due to improved treatments, earlier detection, and reduced smoking rates (ACS, 2022).

auto;text-align:center;line-height:normal;">Scope of the Problem

The high costs of cancer treatment place a significant strain on patients and their families, but it extends beyond individuals, affecting health care systems, insurers, economies, and public health. As treatment advancements improve survival rates, the prolonged duration of care contributes to escalating expenses, making financial distress a growing concern in oncology (Abrams et al., 2021; Kitaw et al., 2025). According to the CDC (2024a), the expenses associated with cancer treatment are steadily increasing and are projected to surpass $240 billion by 2030. In 2020, breast cancer incurred the highest treatment expenses compared to all cancer types, comprising 14% of total costs. This amounted to $26.2 billion for medical services and an additional $3.5 billion for prescription medications (CDC, 2024b). Colorectal cancer (CRC) ranks as the second most expensive cancer to treat, comprising 11.6% of total costs. In 2020, medical services for CRC amounted to $23.7 billion, with prescription drug costs reaching $600 million (CDC, 2024c).

Health care disparities are exacerbated by financial toxicity, particularly in low- and middle-income countries where access to affordable treatment is limited. Patients in these regions often face catastrophic health expenditures, forcing difficult trade-offs between treatment and essential living expenses. A systematic review found financial distress among breast cancer patients significantly higher in low- and middle-income countries (78.8%) compared to high-income countries (35.3%), highlighting inequities in cancer care affordability (Ehsan et al., 2023). Even in high-income nations, access to equitable cancer care is influenced by socioeconomic status, employment benefits, and geographic location. Rural patients, for instance, may encounter additional financial burdens due to travel expenses for specialized care, prolonged treatment timelines, and reduced access to financial assistance programs. On a macroeconomic level, financial toxicity affects workforce productivity and economic stability. Cancer-related job losses, absenteeism, and reduced work hours result in lost wages and employer productivity losses (Abrams et al., 2021; Kitaw et al., 2025). Caregivers of patients with cancer are also impacted, as approximately 25% have had to make significant employment changes, with 8% requiring at least two months of leave (National Cancer Institute [NCI], 2024). Businesses may experience increased health care costs due to long-term disability claims and insurance premiums. Public health programs and social safety nets, such as Medicaid, face mounting pressure to support growing numbers of financially distressed patients with cancer (Abrams et al., 2021; Kitaw et al., 2025).

Risk Factors for Financial Toxicity

Certain populations face disproportionate financial burdens in cancer care, particularly racial and ethnic minorities, the unemployed, and those without adequate health insurance. Uninsured patients are more than twice as likely to experience financial distress compared to those with insurance (Smith et al., 2020). Financial toxicity is notably prevalent in adults under 65, who experience higher out-of-pocket (OOP) expenditures and economic hardship than older survivors. Younger patients face greater economic hardship due to early career instability, student loan debt, limited savings, ongoing financial obligations, and lack of Medicare coverage, placing those with high-deductible plans at even greater risk. According to the NCI (2024), nearly 15% of cancer patients under 65 allocate at least 20% of their income to OOP expenses. Almost half of all Medicare beneficiaries diagnosed with cancer spend at least 10% of their income on cancer-related costs, with up to 25% of survivors depleting their savings and 10% struggling to afford basic necessities (ACS Cancer Action Network [ACSCAN], 2020, 2022; NCI, 2024).

Even with commercial insurance, patients encounter unpredictable and unmanageable costs. The ACSCAN (2020, 2022) reports that high deductibles, copays, coinsurance, and noncovered expenses contribute to substantial financial strain. Additional cost variables include treatment options, access to cancer specialists, and whether care is received in-network or out-of-network. Newly diagnosed patients face the highest OOP costs in the first few months following diagnosis until insurance deductibles and maximums are met, but these expenses reaccumulate annually as treatment continues. Based on an analysis of breast, lung, and CRC costs, average OOP expenses (including premiums, deductibles, and copays) range from $6,000 to $10,000 per year (ACSCAN, 2020, 2022).

Financial toxicity also varies depending on cancer type, stage, and treatment regimen. Patients with advanced-stage cancers; those requiring immunotherapy, chemotherapy, or radiation; and individuals with comorbidities face heightened financial burdens due to prolonged treatment, increased side effects, and work absenteeism. Cancer-related job loss and reduced productivity lead to significant wage losses. Financial strain persists throughout the cancer trajectory, particularly in cases of disease progression, complications, or recurrence (ACS, 2022; CDC, 2021; NCI, 2024). Childhood cancer survivors are highly vulnerable to financial hardship due to the long-term physical, emotional, and psychological effects of treatment. Many experience disrupted education and employment, increasing their risk of future economic instability. Additionally, they face an elevated risk of secondary malignancies and late treatment effects, further compounding financial challenges (Nathan et al., 2022).

Financial distress is further exacerbated at the end of life (EOL). In the United States, costs during the final 4 months of life are approximately $10,000 higher for cancer patients compared to those without cancer (Jo et al., 2023). However, hospice referrals reduce hospitalizations, intensive care unit (ICU) stays, and invasive procedures, saving an estimated $90,000 in costs. Medicare provides comprehensive support for hospice care. According to the Centers for Medicare & Medicaid Services (CMS), once hospice benefits start, Original Medicare covers all services related to the terminal illness, ensuring necessary EOL care without additional financial burdens (CMS, n.d.). Most private insurers also provide coverage for hospice once OOP maximums are met when deemed medically necessary.

Direct and Indirect Costs of Cancer

Direct costs of cancer are expenses specifically related to cancer and its treatment. There are three primary approaches to cancer treatment: surgery, radiation, and systemic therapy. Systemic therapy includes pharmacologic treatments such as chemotherapy, targeted therapy, hormonal therapy, and immunotherapy. While some patients receive all three treatment modalities, others may require only one or two types; thus, costs to each patient vary depending on the type and extent of the treatment. While most direct treatment costs are incurred by one of these three primary treatment approaches, additional direct costs for insured patients may include copays for oral and intravenous medications, hospitalizations, emergency department visits, outpatient office visits, diagnostic testing, radiology imaging, laboratory testing, and supportive care. Direct costs to uninsured patients are substantially higher and typically include the full cost of each treatment or health care service provided. Indirect costs are more difficult to quantify but are just as significant and problematic for patients and their families as they further compound the financial strain. Indirect costs can include, but are not limited to, the following (ACSCAN, 2020, 2022; Dee, 2023; Franklin et al., 2024; NCI, 2024):

• lost wages, reduced work hours, or job loss (patients and caregivers)
• transportation fees associated with getting to and from medical appointments and pharmacies (e.g., gas, tolls, parking, public transportation fares)
• disability
• cost for caregivers, home health aides, childcare
• wigs and other cosmetic items to address side effects
• travel and lodging near treatment facilities
• legal services
• fertility treatments or adoption fees
• nutritional expenses, including supplementation
• mental health services not covered by the third-party payer
• physical therapy or occupational therapy to manage side effects
• psychosocial therapy
• cost of medical supplies and durable medical equipment (DME), such as walkers, canes, and commodes

Cost of Cancer Drugs

The cost of cancer drugs has escalated significantly in recent years, with newly approved treatments carrying higher price tags. A study analyzing 224 cancer drug approvals across 119 different medications found that the median annual cost of treatment was $196,000. Among the most expensive were gene and viral therapies, with median costs reaching $448,000, followed by small molecule therapies, at $244,000, and biologics, at $185,000 (Miljkovic et al., 2023). Several widely used cancer drugs illustrate these high costs. Nivolumab (Opdivo), an immunotherapy drug developed by Bristol Myers Squibb, costs approximately $200,000 per year. Imatinib (Gleevec) is a breakthrough oral cancer drug used to treat certain leukemias, myelodysplastic syndromes, digestive tract tumors, and other cancers. While this drug initially entered the market, in 2001, costing $30,000 per year, its cost now exceeds $108,000 per year, raising concerns over pricing ethics. Palbociclib (Ibrance), a targeted breast cancer treatment, has an annual cost of around $118,200 before discounts (Financial Times, n.d.).

Pembrolizumab (Keytruda) is a widely used immunotherapy drug that has shown significant success in treating multiple cancers (e.g., melanoma, lung, kidney, skin, and head and neck cancers). However, immunotherapy carries an enormous price tag (Fischer, 2023). According to the manufacturer, the list price for each dose of pembrolizumab (Keytruda) is $11,565.16 when given every three weeks  and $23,138.32 when administered every six weeks. As of September 2024, the annual cost of treatment with pembrolizumab (Keytruda) equates to approximately $191,000 (Merck & Co, n.d.). Chimeric antigen receptor (CAR) T-cell therapy is a cutting-edge but highly expensive form of immunotherapy that can be potentially lifesaving. CAR T-cell therapy involves genetically modifying a patient’s T cells in a laboratory to improve their ability to recognize and destroy cancer cells. By introducing a specialized receptor known as a CAR, these modified T cells can specifically target and attack cancerous cells once reinfused into the patient. The cost of CAR T-cell therapy in the United States typically ranges from $375,000 to $500,000. However, when considering additional medical expenses—such as hospital stays, supportive care, and management of treatment-related complications—the total cost per patient can exceed $1 million. These expenses encompass the CAR T-cell product itself, inpatient care, and necessary interventions to address potential side effects (Choi et al., 2022).

For many patients, soaring cancer drug prices translate into substantial OOP expenses. Some individuals pay between $10,000 and $25,000 annually for oral cancer medications, contributing to an estimated $16 billion in OOP cancer treatment expenses in the United States each year. Newly introduced cancer drugs now average $283,000 annually, representing a 53% increase from $185,620 in 2017 (Mesothelioma Center, n.d.). Chemotherapy costs vary widely based on drug type and treatment regimen. Monthly expenses for common and generic chemotherapy agents range from $1,000 to $12,000, potentially resulting in annual costs of up to $48,000 for patients requiring multiple cycles of treatment. Even those with insurance may encounter substantial OOP expenses due to copays and coinsurance. In 2023, Medicare Part D beneficiaries faced average annual OOP costs of $11,284 for oral cancer drugs. However, legislative changes were proposed in 2024 to reduce this to approximately $3,927 per year, yielding potential savings of more than $7,000 per patient (Barkett, 2022; Fasola, 2025).

              Multiple factors, including pharmaceutical pricing strategies, the structure of the US health insurance market, and patient cost-sharing mechanisms such as premiums, deductibles, copays, and coinsurance, drive the increasing cost of cancer medications. Insurance, intended to protect patients from exorbitant health care costs, often fails to provide sufficient relief. Additionally, the shift from community-based oncologic care to hospital-based outpatient treatment has contributed to rising costs, as hospital-administered therapies tend to be more expensive (CDC, 2021). Receiving infusions in a hospital-based outpatient setting often results in higher overall drug costs and OOP costs compared to a clinic or office (Fischer, 2023).

Consequences of Financial Toxicity

Financial toxicity has significant short- and long-term consequences for patients and their families, often leading to reduced health-related QOL, lower treatment adherence, and diminished overall care. Many patients face difficult choices that jeopardize their health, such as delaying or forgoing treatment, altering medication dosages, skipping appointments, or discontinuing therapy. A systematic review found that financial distress is strongly associated with worse health-related QOL and nearly doubles the likelihood of nonadherence to cancer medications. Some studies even link financial hardship to increased mortality rates, underscoring its serious impact on survival. Patients on oral cancer treatments are particularly vulnerable, frequently forced to choose between financial ruin and lifesaving care. The high cost of these medications often results in treatment delays, incomplete prescriptions, and missed doses, all of which negatively affect survival and well-being. Cancer survivors experiencing financial hardship are also more likely to postpone or abandon essential care, including maintenance therapy, further worsening health outcomes (Smith et al., 2020).

Beyond its physical toll, financial toxicity profoundly affects mental health, leading to patients reporting heightened anxiety, depression, panic, fear of recurrence, and posttraumatic stress disorder (Smith et al., 2022). The long-term consequences extend beyond treatment, as many patients accumulate overwhelming medical debt, deplete their savings, and face long-term financial instability. Some are unable to return to work or secure employment due to lasting side effects, leading to further economic hardship. According to the NCI (2024), cancer treatments can cause permanent disabilities, such as peripheral neuropathy, which may prevent patients from resuming their previous occupations. Additionally, research indicates that patients with cancer are more than twice as likely to file for bankruptcy compared to those without cancer.

Legislation and Oral Drug Parity Laws

The escalating costs of cancer medications have raised concerns regarding the sustainability of health care systems and the accessibility of lifesaving or life-prolonging treatments. While innovative therapies provide hope, their high prices necessitate a balance between rewarding and supporting pharmaceutical advancements and ensuring patient access. Strategies to address these issues include policy reforms to regulate drug pricing, implementation of value-based pricing models, and increased transparency in drug development costs. Policy interventions play a crucial role in mitigating the financial toxicity associated with cancer care. Strategies such as value-based insurance design, expanded Medicaid coverage, price transparency regulations, and caps on OOP spending have been proposed to alleviate the economic burden on patients (Leighl et al., 2021).

Additionally, initiatives like the Drug Rediscovery Protocol (DRUP) focus on expanding the use of existing drugs by evaluating their effectiveness in patients with advanced or metastatic cancer whose treatment options are limited. DRUP is a Netherlands-based clinical trial that investigates the safety and efficacy of targeted therapies and immunotherapies when used outside their originally approved indications. Rather than repurposing drugs in the traditional sense, this program facilitates access to off-label treatments based on a tumor’s molecular profile. It is a collaborative effort involving physicians, researchers, pharmaceutical companies, and insurance providers to improve access to precision therapies. The program not only offers potential treatment options for individuals who have exhausted standard care but also generates real-world data that may support expanded drug approvals in the future (Mohammad et al., 2024).

The Patient Protection and Affordable Care Act (ACA) aimed to enhance access to health insurance and reduce costs through tax credits, primarily benefiting previously uninsured individuals with low household incomes. However, despite increased insurance coverage, cancer survivors continue to face significant challenges in accessing and affording healthcare compared to adults without cancer. For patients insured through their employers—a substantial proportion of the US population—the ACA’s provisions have had limited impact in curbing the escalating costs of cancer care. To address the financial burden associated with oral cancer medications, many states have enacted oral chemotherapy parity laws. These laws require health insurers to provide coverage for oral anticancer drugs equivalent to that for traditional intravenous chemotherapy agents under medical benefit plans. As of 2023, 43 states and the District of Columbia have implemented such laws to promote equitable cost-sharing. These state-driven laws mandate that any health plan covering intravenous cancer therapy must offer similar coverage for oral cancer medications, aiming to eliminate cost-sharing disparities that hinder access to lifesaving treatments. However, these parity laws have limitations. They are not mandated at the federal level and often do not apply to certain types of health plans, including federally mandated programs like Medicare or many employer-sponsored plans. Additionally, parity laws do not necessarily lower costs when both intravenous and oral treatment options are expensive. Consequently, only a subset of patients—such as those on oral therapies where the comparable intravenous drug is less costly—may benefit from these laws. Patients prescribed newer, more expensive oral agents often do not experience financial relief under current parity provisions (International Myeloma Foundation, n.d.; Leukemia & Lymphoma Society [LLS] n.d.-a; Spargo et al., 2021).

The Cancer Drug Parity Act, initially introduced in 2017 and reintroduced in 2021 (H.R. 4385), seeks to address these gaps in coverage at the federal level. This legislation proposes that patient-administered cancer drugs should not be subject to prior authorization, step therapy, or differing cost-sharing requirements compared to provider-administered anticancer medications. Despite its potential to standardize coverage and reduce financial barriers, the act has seen limited progress (US Congress, 2021). Expanding parity law protections to include private insurance could improve access to oral cancer therapies. However, mandating coverage for newer, costly oral agents may lead private insurers to raise insurance premiums, potentially offsetting the intended benefits. Therefore, a strategic restructuring of parity laws is necessary to address these challenges effectively. Integrating financial navigation services within oncology practices has shown promise in reducing financial toxicity. These services assist patients in understanding their insurance benefits, identifying financial assistance programs, and making informed decisions about their care. Studies have demonstrated that such programs can lead to substantial cost savings for both patients and health care systems, thereby improving QOL and treatment adherence (Leighl et al., 2021; NCI, 2023; Wheeler et al., 2024).

While policy interventions like the ACA and state-level parity laws have made strides in addressing financial toxicity in cancer care, significant challenges remain. Comprehensive strategies that include federal legislation are essential to mitigate the economic burden on cancer patients effectively. Addressing the high cost of cancer drugs requires a multifaceted approach, such as (Leighl et al., 2021; Luo et al., 2023; Rajkumar, 2020):

• Policy Reforms: Implementing policies that promote value-based pricing and enhance price transparency can help align drug prices with their clinical benefits. For example, the United States lacks a system for value-based pricing, allowing new cancer drugs to be priced at high levels regardless of their value. Establishing an agency authorized to set ceiling prices based on incremental value and monitor future price increases could help address this issue.
• Biosimilars and Generics: Encouraging the development and adoption of biosimilars and generic drugs introduces competition, potentially lowering prices. A biosimilar is a biologic medical drug that is highly similar to the already approved reference drug in terms of structure, function, and clinical effectiveness. The introduction of biosimilars has significantly reduced the prices of oncology biologics both globally and in the United States. For instance, the cost of filgrastim (Neupogen), a commonly used medication to stimulate the production of white blood cells, decreased by approximately 30% to 40% following the introduction of its biosimilar.
• Alternative Funding Models: Exploring innovative funding mechanisms, such as public–private partnerships, can bridge funding gaps and accelerate drug development. Innovative financing strategies for cancer care, including public–private partnerships and other levies, have been proposed to reduce costs.
• International Collaboration: Global efforts to negotiate drug prices and share pricing information can empower countries to secure more favorable pricing agreements. Further, joint purchasing of high-cost medications could enhance the negotiation power of low- and middle-income countries, decrease administrative costs, and create lower prices through international collaboration.

Nurses play a crucial role in advocating for policy change by leveraging their expertise, patient experience, and professional networks. Oncology nurses are encouraged to get involved by participating in policy committees within organizations like the Oncology Nursing Society (ONS), the American Society of Clinical Oncology (ASCO), and the American Nurses Association (ANA), which advocate for lower drug costs and improved patient access. By supporting and participating in policy committees and efforts that promote price transparency and expanded insurance coverage, nurses can help shape legislative priorities and draw attention to these important topics (Burbage, 2020).

Nursing Interventions to Mitigate Financial Toxicity

There is a lack of evidence-based interventions to effectively alleviate the disproportionate financial hardship experienced by cancer patients and survivors. In recent years, growing recognition of the consequences of financial toxicity has prompted efforts to integrate financial screening and support into oncology care. The ONS emphasizes the role of nurses in addressing financial toxicity, advocating for routine financial assessments, interprofessional collaboration, and policy advocacy. While it is not practical for every oncology nurse to perform financial toxicity assessments for every patient, nurses are advised to at least be alert to patient and family concerns about the cost of care. Facilitating these discussions and connecting patients with resources is the critical first step in combatting this problem (Burbage, 2020; Ferguson & Burbage, 2020; McMullen, 2019; Tipton, 2023).

Early identification of financial distress is crucial in mitigating its effects. Organizations such as the ASCO recommend using validated tools like the Comprehensive Score for Financial Toxicity (COST) and the Patient-Reported Outcome for Fighting Financial Toxicity (PROFFIT) to assess a patient’s financial strain. COST is an 11-item questionnaire using a 5-point Likert scale inquiring about financial costs, resources, and concerns. This tool has been validated and translated into multiple languages, making it a widely used instrument in financial toxicity studies. However, despite its frequent use in research, the COST tool has limitations. It was originally developed based on interviews and surveys from a cohort of 100 cancer patients and survivors, the majority of whom were white (74%), around 60 years old, and covered by private insurance or Medicare (94%). Most participants were diagnosed with solid tumors, with only 3% diagnosed with leukemia. Although the tool has since been applied to various cancer types, the initial study population lacked representation from uninsured individuals and those with hematologic malignancies, both of whom often encounter distinct treatment trajectories and financial challenges. Further, in clinical settings, COST may be difficult to implement due to its length. Since its introduction, researchers have explored modifications and alternative tools to streamline the assessment of financial burden, allowing for quicker screening in practice (Tsu & Shankaran, 2024).

PROFFIT is a newer tool designed to measure financial strain and provide insights into the impact on a patient’s well-being. It supports healthcare providers in identifying patients at risk of financial distress so appropriate interventions can be implemented. The questionnaire consists of patient-reported measures evaluating different dimensions of financial toxicity, such as direct medical costs, indirect costs, psychological distress, and coping mechanisms related to financial hardship. The responses help categorize patients based on their level of financial burden, guiding healthcare providers toward possible financial assistance programs, counseling, or policy changes. PROFFIT has undergone validation studies to confirm its accuracy and reliability in measuring financial toxicity and is easy to use at the point of care (Arenare et al., 2023). The American College of Physicians (ACP) has also devised several free online tools and resources to help clinicians and nurses with cost-of-care discussions. The ACP’s Cost Distress Screening Tool can identify patients with potential financial distress. Its complement, Cost of Care Resources for Clinicians and Patients, offers practical solutions to the most common issues (ACP, n.d.).

Beyond assessing for financial toxicity, nursing interventions to reduce financial toxicity include providing education on budgeting and financial planning to help patients manage OOP expenses, facilitating referrals to financial navigators and social workers who can assist with cost management, and compiling and sharing community and national financial assistance resources with patients (ACS, 2022; CDC, 2021; Ferguson & Burbage, 2020; McMullen, 2019; Tipton, 2023).

Patient Assistance Programs (PAP) and Resources

Several organizations offer copay assistance to help patients manage the costs of their medications, transportation, and other essential services. The LLS (n.d.-b) provides support for treatment-related expenses, including copays, prescription medications, and insurance premiums. Similarly, the CancerCare Co-Payment Assistance Foundation assists patients in overcoming financial barriers by covering copayments for prescribed treatments. CancerCare also offers financial assistance for transportation and childcare, helping to alleviate some of the indirect cost burden of cancer (CancerCare, n.d.). NeedyMeds is a resource that nurses can use to help patients locate financial assistance programs, but it does not directly provide copayment support. Additionally, the Healthcare Hospitality Network (HHN, n.d.) provides resources for securing lodging near treatment centers, reducing accommodation expenses for patients and their families. Many pharmaceutical companies have established PAPs, which offer medications at reduced or no cost to qualified patients. These programs often assist with insurance reimbursement, referrals to copay relief programs and help with applications for assistance. However, these programs frequently exclude individuals with government insurance, such as Medicare and Medicaid, requiring alternative sources of financial aid. Nurses can help patients navigate these complex application processes, ensuring they receive available assistance (NCI, 2024). Nurses can also guide patients in accessing these resources to ensure continuity of care. Some examples of PAPs and advocacy organizations that help cover the cost of cancer treatment are listed in Table 1 (ACS, 2022; Ferguson & Burbage, 2020; Tipton, 2023).

Table 1

PAPs and Advocacy Organizations for Cancer Treatment

(ACS, 2022; Ferguson & Burbage, 2020; Tipton, 2023)

Financial toxicity is a major barrier to equitable cancer care and has far-reaching impacts on the individual and system levels. Nurses play a critical role in mitigating this burden by identifying at-risk patients, facilitating access to financial assistance, and advocating for policy changes. By integrating financial discussions into clinical care and leveraging available resources, nurses can ensure that patients receive the treatments they need without undue economic strain. Addressing financial toxicity requires a multifaceted approach, but with dedicated nursing intervention, systemic improvements, and patient advocacy, meaningful progress can be made in reducing the economic burden of cancer care (Burbage, 2020; McMullen, 2019; Rodriguez, 2025).

References

Abrams, H. R., Durbin, S., Huang, C. X., Johnson, S. F., Nayak, R. K., Zahner, G. J., & Peppercorn, J. (2021). Financial toxicity in cancer care: Origins, impact, and solutions. Translational Behavioral Medicine, 11(11), 2043–2054. https://doi.org/10.1093/tbm/ibab091

American Cancer Society. (2022). Cancer treatment & survivorship facts & figures (2022–2024). https://www.cancer.org/research/cancer-facts-statistics/survivor-facts-figures.html

American Cancer Society. (2025). Cancer facts & figures 2025. https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2025/2025-cancer-facts-and-figures-acs.pdf

American Cancer Society Cancer Action Network. (2020). The costs of cancer: 2020 edition. https://www.fightcancer.org/policy-resources/costs-cancer

American Cancer Society Cancer Action Network. (2022). The costs of cancer survivorship-2022. https://www.fightcancer.org/policy-resources/costs-cancer-survivorship-2022

American College of Physicians. (n.d.). Health transparency: Talking to patients about the cost of their health care. Retrieved March 9, 2025, from https://www.acponline.org/clinical-information/high-value-care/resources-for-clinicians/cost-of-care-conversations

Arenare, L., Porta, C., Barberio, D., Terzolo, S., Zagonel, V., Pisconti, S., Del Mastro, L., Pinto, C., Bilancia, D., Cinieri, S., Rizzo, M., Migliaccio, G., Montesarchio, V., Del Campo, L., De Lorenzo, F., Iannelli, E., Traclò, F., Gitto, L., Jommi, C., Vaccaro, C. M., Barberio, M., Bryce, J., Gallo, C., &. . . Perrone, F. (2023). Confirmatory validation analysis of the PROFFIT questionnaire to assess financial toxicity in cancer patients. ESMO Open, 8(6), 102192. https://doi.org/10.1016/j.esmoop.2023.102192

Barkett, N. (2022). Does oral chemotherapy always equate to financial distress? Journal of Oncology Navigation & Survivorship, 13(7). Retrieved March 15, 2025, from https://jons-online.com/issues/2022/july-2022-vol-13-no-7/does-oral-chemotherapy-always-equate-to-financial-distress

Burbage, D. (2020). Oncology nurses have a responsibility to manage the financial toxicities of cancer. Oncology Nursing Society. https://www.ons.org/publications-research/voice/conferences/09-2020/oncology-nurses-have-responsibility-manage

CancerCare. (n.d.). CancerCare co-pay assistance foundation. Retrieved March 15, 2025, from https://www.cancercare.org/copayfoundation

The Centers for Disease Control and Prevention. (2021). Annual report to the nation part 2: Patient economic burden of cancer care more than $21 billion in the United States in 2019. https://archive.cdc.gov/www_cdc_gov/media/releases/2021/p1026-cancer-annual-report.html

The Centers for Disease Control and Prevention. (2024a). Fast facts: Health and economic costs of chronic conditions. https://www.cdc.gov/chronic-disease/data-research/facts-stats/index.html

The Centers for Disease Control and Prevention. (2024b). Health and economic benefits of breast cancer interventions. https://www.cdc.gov/nccdphp/priorities/breast-cancer.html

The Centers for Disease Control and Prevention. (2024c). Health and economic benefits of colorectal cancer interventions. https://www.cdc.gov/nccdphp/priorities/colorectal-cancer.html

The Centers for Medicare & Medicaid Services. (n.d.). Hospice care. Retrieved March 15, 2025, from https://www.medicare.gov/coverage/hospice-care[CE1]

Chan, R., & Nekhlyudov, L. (2024). Overview of cancer survivorship care for primary care and oncology providers. UpToDate. Retrieved March 8, 2025, from https://www.uptodate.com/contents/overview-of-cancer-survivorship-care-for-primary-care-and-oncology-providers

Choi, G., Shin, G., & Bae, S. J. (2022). Price and prejudice? The value of chimeric antigen (CAR) T-cell therapy. International Journal of Environmental Research and Public Health, 19(12366). https://doi.org/10.3390/ijerph191912366

Dee, E. C. (2023). Family and caregiver financial toxicity associated with cancer—A global, inequitable, and urgent consideration. JAMA Network Open, 6(6), e2319317. https://doi.org/10.1001/jamanetworkopen.2023.19317

Ehsan, A. N., Wu, C. A., Minasian, A., Singh, T., Bass, M., Pace, L., Ibbotson, G. C., Bempong-Ahun, N., Pusic, A., Scott, J. W., Mekary, R. A., & Ranganathan, K. (2023). Financial toxicity among patients with breast cancer worldwide: A systematic review and meta-analysis. JAMA Network Open, 6(2), e2255388. https://doi.org/10.1001/jamanetworkopen.2022.55388

Fasola, M. (2025). The cost of cancer. Southeastern Radiation Oncology Group. https://treatcancer.com/blog/cost-of-cancer/

Ferguson, K., & Burbage, D. (2020). Addressing financial toxicity takes an interdisciplinary approach. ASCO Daily News. https://dailynews.ascopubs.org/do/addressing-financial-toxicity-takes-interdisciplinary-approach

Financial Times. (n.d.). The high cost of cancer drugs and their impact on patients. Retrieved March 15, 2025, from https://www.ft.com/content/4dfc5540-da29-4701-b773-[CE2]

Fischer, L. (2023). Immunotherapy works for some patients, but it is costly and use remains suboptimal. Oncology Nursing News. https://www.oncnursingnews.com/view/immunotherapy-works-for-some-patients-but-it-is-costly-and-use-remains-suboptimal

Franklin, M., Pollard, D., Sah, J., Rayner, A., Sun, Y., Dube, F., Sutton, A., & Qin, L. (2024). Direct and indirect costs of breast cancer and associated implications: A systematic review. Advances in Therapy, 41, 2700–2722. https://doi.org/10.1007/s12325-024-02893-y

Healthcare Hospitality Network. (n.d.). Looking for a healthcare hospitality house? Retrieved March 15, 2025, from https://www.hhnetwork.org/

International Myeloma Foundation. (n.d.). Patient and provider advocates applaud Senate reintroduction of Cancer Drug Parity Act. Retrieved March 15, 2025, from https://www.myeloma.org/news-events/multiple-myeloma-news/patient-provider-advocates-applaud-Senate-reintroduction-Cancer-Drug-Parity-Act

Jo, M., Lee, Y., & Kim, T. (2023). Medical care costs at the end of life among older adults with cancer: A national health insurance data-based cohort study. BMC Palliative Care, 22(76), 1–9. https://doi.org/10.1186/s12904-023-01197-2

Kaiser Family Foundation. (2022). KFF health care debt survey: Main findings. Retrieved March 9, 2025, from https://www.kff.org/report-section/kff-health-care-debt-survey-main-findings

Kitaw, T. A., Tilahun, B. D., Zemariam, A. B., Getie, A., Bizuayehu, M. A., & Haile, R. N. (2025). The financial toxicity of cancer: Unveiling global burden and risk factors—A systematic review and meta-analysis. BMJ Global Health, 10(e017133). https://doi.org/10.1136/bmjgh-2024-017133

Kleunder, R., Mahoney, N., Wong, F., & Yin, W. (2021). Medical debt in the US, 2009–2020. JAMA Network, 326(3), 1–8. https://doi.org/10.1001/jama.2021.8694

Leighl, N. B., Nirmalakumar, S., Ezeife, D. A., & Gyawali, B. (2021). An arm and a leg: The rising cost of cancer drugs and impact on access. American Society of Clinical Oncology Educational Book, 41. e1–12. https://doi.org/10.1200/EDBK_100028

Leukemia & Lymphoma Society. (n.d.-a). Advancing oral parity because the way we treat cancer has changed. Retrieved March 15, 2025, from https://www.lls.org/advocate/advancing-oral-parity-because-way-we-treat-cancer-has-changed

Leukemia & Lymphoma Society. (n.d.-b). Patient financial assistance programs. Retrieved March 15, 2025, from https://www.lls.org/support-resources/financial-support

Luo, X., Du, X., Li, Z., Li, Z., Zhang, Z., Wu, B., & Ding, J. (2023). Clinical benefit, price, and uptake for cancer biosimilars vs reference drugs in China: A systematic review and meta-analysis. JAMA Network Open, 6(10), e2337348. https://doi.org/10.1001/jamanetworkopen.2023.37348

McMullen, L. (2019). Patient assistance programs: A valuable resource for oncology nurses. Clinical Journal of Oncology Nursing, 23(5 Suppl.), 19–24. https://doi.org/10.1188/19.CJON.S2.19-24[CE3]

Merck & Co. (n.d.). Financial support options for KEYTRUDA® (pembrolizumab). Retrieved March 15, 2025, from https://www.keytruda.com/financial-support/

Mesothelioma Center. (n.d.). High cost of cancer treatment: Why it keeps rising and what patients can do. https://www.asbestos.com/featured-stories/high-cost-of-cancer-treatment/

Miljkovic, M. D., Tuia, J., Olivier, T., Haslam, A., & Prasad, V. (2023). Cancer drug price and novelty in mechanism of action. JAMA Network, 6(12), e2347006. https://doi.org/10.1001/jamanetworkopen.2023.47006

Mohammad, S. F. H., Timmer, H. J. L., Zeverijn, L. J., Guerts, B. S., Spiekman, I. A. C., Verjek, K., Verbeek, F. A. J., Verheul, H. M. W., Voest, E. E., & Gelderblom, H. (2024). The evolution of precision oncology: The ongoing impact of the drug rediscovery protocol (DRUP). Acta Oncologica, 63, 368–372. https://doi.org/10.2340/1651-226X.2024.34885

Nathan, P. C., Huang, I., Chen, Y., Math, M., Henderson, T. O., Park, E. R., Kirchhoff, A. C., Robison, L. L., Krull, K., Leisenring, W., Armstrong, G. T., Conti, R. M., Yasui, Y., & Yabroff, K. R. (2022). Financial hardship in adult survivors of childhood cancer in the era after implementation of the Affordable Care Act: A report from the childhood cancer survivor study. Journal of Clinical Oncology, 41(5). https://doi.org/10.1200/JCO.22.00572

National Cancer Institute. (2023). Financial navigation can reduce the financial toxicity of cancer care. https://www.cancer.gov/news-events/cancer-currents-blog/2023/cancer-care-financial-navigation-saves-money

National Cancer Institute. (2024). Financial toxicity and cancer treatment (PDQ®)—Health professional information. https://www.cancer.gov/about-cancer/managing-care/track-care-costs/financial-toxicity-hp-pdq

Rajkumar, S. V. (2020). The high cost of prescription drugs: Causes and solutions. Blood Cancer Journal, 10(71). 1–6. https://doi.org/10.1038/s41408-020-0338-x

Rodriguez, T. (2025). Targeting financial toxicity in cancer care. Oncology Nurse Advisor. https://www.oncologynurseadvisor.com/features/financial-toxicity-cancer-patients-assistance/

Smith, G. L., Lopez-Olivo, M. A., Advani, P. G., Ning, M. S., Geng, Y., Gioradno, S. H., & Volk, R. J. (2020). Financial burdens of cancer treatment: A systematic review of risk factors and outcomes. Journal of National Comprehensive Cancer Network, 17(10), 1184–1192. https://doi.org/10.6004/jnccn.2019.7305

Smith, G. L., Banegas, M. P., Acquati, C., Chang, S., Chino, F., Conti, R. M., Greenup, R. A., Kroll, J. L., Liang, M. I., Pisu, M., Primm, K. M., Roth, M. E., Shankaran, V., & Yabroff, R. (2022). Navigating financial toxicity in patients with cancer: A multidisciplinary management approach. CA: A Cancer Journal for Clinicians, 72(5), 437–453. https://doi.org/10.3322/caac.21730

Spargo, A., Yost, C., Squires, P., Raju, A., Schroader, B., & Brown, J. D. (2021). The effects of oral anticancer parity laws on out-of-pocket spending and adherence among commercially insured patients with chronic myeloid leukemia. Journal of Managed Care & Specialty Pharmacy, 27(5), 1–11. https://doi.org/10.18553/jmcp.2021.27.5.554

Tipton, J. (2023). Oncology providers can transform the trajectory of financial toxicity. ONS Voice. https://www.ons.org/publications-research/voice/news-views/02-2023/oncology-providers-can-transform-trajectory

Tonorezos, E., Devasia, T., Mariotto, A. B., Mollica, M. A., Gallicchio, L., Green, P., Doose, M., Brick, R., Streck, B., Reed, C., & de Moor, J. S. (2024). Prevalance of cancer survivors in the United States. Journal of the National Cancer Institute, 116(11), 1784–1790. https://doi.org/10.1093/jnci/djae135

Tsu, C. T., & Shankaran, V. (2024). Defining the role of the modern oncology provider in mitigating financial toxicity. Journal of American College of Radiology, 20(1), 51–56. https://doi.org/10.1016/j.jacr.2022.10.011

US Congress. (2021). H.R. 4385—Cancer Drug Parity Act of 2021. 117th Congress. Retrieved March 15, 2025, from https://www.congress.gov/bill/117th-congress/house-bill/4385

Wheeler, S. B., Manning, M. L., Gellin, M., Padilla, N., Spees, L. P., Biddell, C. D., Petermann, V., Deal, A., Rogers, C., Rodrigeuz-O’Donnell, J., Samuel-Ryals, C., Reeder-Hayers, K., & Rosenstein, D. (2024). Impact of a comprehensive financial navigation intervention to reduce cancer-related financial toxicity. JNCCN-Journal of the National Comprehensive Cancer Network, 22(8), 557–562.

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