ASCO 2019: Elephant in the Room: Financial Toxicity in Cancer Care

Chicago, IL (  Dr. Lowell Schnipper gave a presentation on the financial toxicity aspect of cancer care.

Understanding the global burden of cancer is imperative for healthcare personnel treating cancer patients. In 2015 there were 17.5 million cancer case, 8.7 million deaths, and 208.3 million DALYs (which is the disability-adjusted life year, defined as a measure of overall disease burden, expressed as the number of years lost due to ill-health, disability or early death). From 2005 to 2015, the incident cancer cases had increased by 33%. A total of 12.6% were due to population growth, 16.4% due to an aging population, and 4.1% due to increasing age-specific incidence rate. A total of 66% increase in prostate cancer cases has been seen since 2005.1

When analyzing the death rates of cancer worldwide (Figure 1), 7.4 million deaths had occurred in 2007, which were 13% of all deaths that year. About 72% of all cancer deaths in 2007 occurred in low- and middle-income countries. Deaths projected to continue rising, with an estimated 12 million deaths in 2030. Importantly, healthcare costs are rising and outpace earnings and inflation.

Figure 1 - Cancer incidence and mortality worldwide:
ASCO Financial Toxicity in Cancer Care 1

In recent years, there have been new and promising cancer therapies demonstrating improved results in some diseases. However, there is still a long way to go in many other cancers, with only marginal gains attained with these novel therapies. Importantly, the cost of these novel drugs, treatments, and services continue to rise exponentially, making it quite unaffordable in most of the world. By 2020 the US cancer cost is estimated to be 173 billion dollars. The average amount that an insured cancer patient pays out of pocket per year is 4,800 US dollars. Almost 30% of these insured patients spend more than 20% of their income on out-of-pocket health care costs. Lastly, cancer patients were 2.65 times more likely to go bankrupt than people without cancer (Figure 2). This financial toxicity causes significant hardship in cancer patients that must be acknowledged and dealt with.2 This is particularly an issue for younger patients (aged 18-64).3 The out-of-pocket financial costs for selected cancer medication are shown in figure 3. These factors might explain the relationship between extreme financial distress and greater risk of mortality (Figure 4).

Figure 2 – Cancer care and financial toxicity:
ASCO Financial Toxicity in Cancer Care 2

Figure 3 – Out-of-pocket costs for selected cancer medications:
ASCO Financial Toxicity in Cancer Care 3

Figure 4 – Correlation between financial distress and increased risk of mortality:
ASCO Financial Toxicity in Cancer Care 4
ASCO is trying to address this unique and specific problem with initiatives and a value framework, as seen in Figure 5. These initiatives are focusing on increased physician-patient dialogue, informed patient decision-making, a reference point for payer evaluations, and utilizing physicians as trusted advocates. ASCO’s position statement on addressing the affordability of cancer drugs includes:

  1. Value-based solutions that are patient-centered and evidence-driven that should inform drug prices in the US
  2. The oncology community should define value and provide a framework to assess the value of cancer treatments
  3. There should be a real and consistent relationship between the value of a given drug and its cost to patients and the healthcare system
  4. Cost-containment strategies should not shift the cost burden to patients or providers
  5. Cost containment strategies should incentivize and not hamper innovation that results in clinically meaningful improvements in patient outcomes.

Figure 5 – ASCO initiatives and value framework attempting to address the issue of financial toxicity:
ASCO Financial Toxicity in Cancer Care 5

Presented by: Lowell E. Schnipper, MD, FASCO, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA 

Written by: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre, @GoldbergHanan at the 2019 ASCO Annual Meeting #ASCO19, May 31- June 4, 2019, Chicago, IL USA


  1. Fitzmaurice C. et al. Global, Regional, and National Cancer Incidence, Mortality, Years of Life Lost, Years Lived with Disability, and Disability-Adjusted Life-years for 32 Cancer Groups, 1990 to 2015: A Systematic Analysis for the Global Burden for Disease Study. JAMA ONC 2017;3(4):524-548. 
  2. Milwood et al. Health Aff. 2016
  3. Yaroff et al. JCO 2016