Financial Toxicity in Patients With Breast Cancer Treated at Private Medicine Institutions in Brazil.

Publisher: John Wiley & Sons Ltd Country of Publication: United States NLM ID: 101595310 Publication Model: Print Cited Medium: Internet ISSN: 2045-7634 (Electronic) Linking ISSN: 20457634 NLM ISO Abbreviation: Cancer Med Subsets: MEDLINE

Original Publication: [Malden, MA] : John Wiley & Sons Ltd., c2012-

Breast Neoplasms*/economics ; Breast Neoplasms*/therapy ; Breast Neoplasms*/epidemiology ; Cost of Illness* ; Health Expenditures*; Brazil/epidemiology ; Humans ; Female ; Middle Aged ; Adult ; Aged ; Quality of Life ; Surveys and Questionnaires ; Socioeconomic Factors ; Financial Stress

Financial toxicity (FT) refers to the negative impact of the financial burden of cancer diagnosis and treatment on patients' well-being. With rising global costs of oncologic therapies, diagnostics, and supportive care, FT has become a key concern in cancer care, influencing adherence, quality of life, and outcomes. Breast cancer, given its high prevalence and socioeconomic implications, is notably associated with FT. Beyond direct medical expenses, patients often face income loss and out-of-pocket costs for supportive care, which can significantly affect their therapeutic trajectory. Addressing FT is thus essential to ensure equitable cancer care. A 34-item questionnaire, including the Comprehensive Score for Financial Toxicity (COST) tool, was administered to breast cancer patients treated at three private institutions in Brazil. Data were analyzed using descriptive statistics, linear regression, and ANOVA (p ≤ 0.05). Among 912 participants 85.1% self-identified as White. Most were married or in a stable union (67.8%), and 50.9% held a postgraduate degree. A majority (84.2%) had early-stage disease, 54.6% had been diagnosed within 2 years prior to the study, and 92.1% reported having health insurance. Despite this, 36.6% experienced a reduction in their standard of living following treatment, and 15.6% reported having to sell assets or property. The mean COST score was 24.2 (SD = 8.6; median = 25.0). Factors significantly associated with greater financial toxicity (lower COST scores) included age below 40 years, lack of health insurance, unemployment or medical leave, and household income below 10,000 BRL per month. These findings highlight the considerable financial burden experienced by breast cancer patients, even in the private healthcare system, and underscore the need for strategies to mitigate FT in oncology care.
(© 2026 The Author(s). Cancer Medicine published by John Wiley & Sons Ltd.)

S. Y. Zafar, J. M. Peppercorn, D. Schrag, et al., “The Financial Toxicity of Cancer Treatment: A Pilot Study Assessing Out‐of‐Pocket Expenses and the Insured Cancer Patient's Experience,” Oncologist 18, no. 4 (2013): 381–390.
S. Y. Zafar and A. P. Abernethy, “Financial Toxicity, Part I: A New Name for a Growing Problem,” Oncology 27 (2013): 80–149.
A. M. Gilligan, D. S. Alberts, D. J. Roe, and G. H. Skrepnek, “Death or Debt? National Estimates of Financial Toxicity in Persons With Newly‐Diagnosed Cancer,” American Journal of Medicine 131, no. 10 (2018): 1187–1199.e5.
A. J. Davidoff, M. Erten, T. Shaffer, et al., “Out‐of‐Pocket Health Care Expenditure Burden for Medicare Beneficiaries With Cancer,” Cancer 119 (2013): 1257–1265, https://doi.org/10.1002/cncr.27848.
E. C. Dowling, N. Chawla, L. P. Forsythe, et al., “Lost Productivity and Burden of Illness in Cancer Survivors With and Without Other Chronic Conditions,” Cancer 119 (2013): 3393–3401, https://doi.org/10.1002/cncr.28214.
“Breast Cancer Now Most Common Form of Cancer: WHO Taking Action,” (2025), https://www.who.int/news/item/03‐02‐2021‐breast‐cancer‐now‐most‐common‐form‐of‐cancer‐who‐taking‐action.
Ministério da Saúde, “Câncer de Mama,” (2025), https://www.gov.br/saude/pt‐br/assuntos/saude‐de‐a‐a‐z/c/cancer‐de‐mama/cancer‐de‐mama.
H. Sung, J. Ferlay, R. L. Siegel, et al., “Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries,” CA: A Cancer Journal for Clinicians 71 (2021): 209–249, https://doi.org/10.3322/caac.21660.
L. G. Gordon, K. M. D. Merollini, A. Lowe, and R. J. Chan, “A Systematic Review of Financial Toxicity Among Cancer Survivors: We Can't Pay the Co‐Pay,” Patient 10, no. 3 (2017): 295–309.
S. D. Ramsey, A. Bansal, C. R. Fedorenko, et al., “Financial Insolvency as a Risk Factor for Early Mortality Among Patients With Cancer,” Journal of Clinical Oncology 34, no. 9 (2016): 980–986.
R. J. Chan, L. Gordon, S. Y. Zafar, and C. Miaskowski, “Financial Toxicity and Symptom Burden: What Is the Big Deal?,” Supportive Care in Cancer 26, no. 5 (2018): 1357–1359, https://doi.org/10.1007/s00520‐018‐4092‐6.
“Cresce o Número de Brasileiros Com Acesso a Plano de Saúde,” (2021), Saúde Business, https://www.saudebusiness.com/mercado/cresce‐o‐numero‐de‐brasileiros‐com‐acesso‐plano‐de‐saude.
Agência Brasil, “IBGE: 59,7 Milhões de Pessoas Tinham Plano de Saúde em 2019,” (2020), https://agenciabrasil.ebc.com.br/saude/noticia/2020‐09/pesquisa‐diz‐que‐597‐milhoes‐de‐pessoas‐tinham‐plano‐de‐saude‐em‐2019.
J. A. de Souza, B. J. Yap, K. Wroblewski, et al., “Measuring Financial Toxicity as a Clinically Relevant Patient‐Reported Outcome: The Validation of the COmprehensive Score for Financial Toxicity (COST): Measuring Financial Toxicity,” Cancer 123, no. 3 (2017): 476–484, https://doi.org/10.1002/cncr.30369.
J. A. De Souza, K. Wroblewski, E. Proussaloglou, L. Nicholson, A. Hantel, and Y. Wang, “Validation of a Financial Toxicity (FT) Grading System,” JCO 35, no. 15_suppl (2017): 6615, https://doi.org/10.1200/JCO.2017.35.15_suppl.6615.
S. L. Eremenco, D. Cella, and B. J. Arnold, “A Comprehensive Method for the Translation and Cross‐Cultural Validation of Health Status Questionnaires,” Evaluation & the Health Professions 28 (2005): 212–232, https://doi.org/10.1177/0163278705275342.
L. J. Cronbach, “Coefficient Alpha and the Internal Structure of Tests,” Psychometrika 16, no. 3 (1951): 297–334, https://doi.org/10.1007/BF02310555.
J. Neter, Applied Linear Statistical Models, 4th ed. (Irwin, 1996).
T. G. Knight, A. M. Deal, S. B. Dusetzina, et al., “Financial Toxicity in Adults With Cancer: Adverse Outcomes and Noncompliance,” Journal of Oncology Practice (2018), https://doi.org/10.1200/JOP.18.00120.
S. D. Ramsey, D. K. Blough, A. C. Kirchhoff, et al., “Washington Cancer Patients Found to be at Greater Risk for Bankruptcy Than People Without a Cancer Diagnosis,” Health Aff (Millwood) 32, no. 6 (2013): 1143–1152.
V. Shankaran, L. Li, C. Fedorenko, et al., “Risk of Adverse Financial Events in Patients With Cancer: Evidence From a Novel Linkage Between Cancer Registry and Credit Records,” Journal of Clinical Oncology 40 (2022): 884–891, https://doi.org/10.1200/JCO.21.01636.
A. J. Bullock, E. W. Hofstatter, M. L. Yushak, and M. K. Buss, “Understanding Patients' Attitudes Toward Communication About the Cost of Cancer Care,” Journal of the Pancreas: JOP 8, no. 4 (2012): e50–e58, https://doi.org/10.1200/JOP.2011.000418.
Y.‐C. T. Shih and C.‐R. Chien, “A Review of Cost Communication in Oncology: Patient Attitude, Provider Acceptance, and Outcome Assessment,” Cancer 123 (2017): 928–939.
S. Y. Zafar, F. Chino, P. A. Ubel, et al., “The Utility of Cost Discussions Between Patients With Cancer and Oncologists,” American Journal of Managed Care 21, no. 9 (2015): 607–615.
S. F. Huntington, B. M. Weiss, D. T. Vogl, et al., “Financial Toxicity in Insured Patients With Multiple Myeloma: A Cross‐Sectional Pilot Study,” Lancet Haematology 2, no. 10 (2015): e408–e416.
J. Witte, K. Mehlis, B. Surmann, et al., “Methods for Measuring Financial Toxicity After Cancer Diagnosis and Treatment: A Systematic Review and Its Implications,” Annals of Oncology 30, no. 7 (2019): 1061–1070.
J. Jing, R. Feng, X. Zhang, M. Li, and J. Gao, “Financial Toxicity and Its Associated Patient and Cancer Factors Among Women With Breast Cancer: A Single‐Center Analysis of Low‐Middle Income Region in China,” Breast Cancer Research and Treatment 181, no. 2 (2020): 435–443, https://doi.org/10.1007/s10549‐020‐05632‐3.
K. Honda, B. Gyawali, M. Ando, et al., “Prospective Survey of Financial Toxicity Measured by the Comprehensive Score for Financial Toxicity in Japanese Patients With Cancer,” Journal of Global Oncology 5 (2019): 1–8.
B. Zeybek, E. Webster, N. Pogosian, et al., “Financial Toxicity in Patients With Gynecologic Malignancies: A Cross Sectional Study,” JGO: Journal of Gynecologic Oncology 2 (2021): e87.
C. Friedes, S. Z. Hazell, W. Fu, et al., “Longitudinal Trends of Financial Toxicity in Patients With Lung Cancer: A Prospective Cohort Study,” JCO Oncology Practice 17 (2021): e1094–e1109, https://doi.org/10.1200/OP.20.00721.
“Breast Cancer,” (2025), ESMO, https://www.esmo.org/guidelines/guidelines‐by‐topic/esmo‐clinical‐practice‐guidelines‐breast‐cancer/consensus‐recommendations‐breast‐cancer‐in‐young‐women‐bcy5.
R. Lentz, A. B. Benson, 3rd, and S. Kircher, “Financial Toxicity in Cancer Care: Prevalence, Causes, Consequences, and Reduction Strategies,” Journal of Surgical Oncology 120 (2019): 85–92, https://doi.org/10.1002/jso.25374.
S. Zhu and C. Lei, “Association Between Marital Status and All‐Cause Mortality of Patients With Metastatic Breast Cancer: A Population‐Based Study,” Scientific Reports 13 (2023): 9067.
G. Wiesemann, E. Anne Cox, D. S. Nichols, K. Ockerman, E. S. Satteson, and S. C. Sorice Virk, “Changes in Marital Status After Receiving the Diagnosis of Breast Versus Prostate Cancer: A Population‐Based Study,” Plastic and Reconstructive Surgery—Global Open 10, no. 10 Suppl (2022): 133–134.
G. Werutsky, M. Lopes, R. G. de Jesus, et al., “The Impact of a Breast Cancer Diagnosis on Marital Outcomes and Factors Associated With Divorce and Separation,” Revista Brasileira de Ginecologia e Obstetrícia 46 (2024): e‐rbgo60.
F. Mols, B. Tomalin, A. Pearce, B. Kaambwa, and B. Koczwara, “Financial Toxicity and Employment Status in Cancer Survivors. A Systematic Literature Review,” Support Care Cancer 28, no. 12 (2020): 5693–5708.
S. M. W. Jones, “Financial Worry in People With Cancer: Relationship to Employment and Outcomes,” Psycho‐Oncology 31, no. 11 (2022): 1835–1842.
L. C. G. Landeiro, D. M. Gagliato, A. B. Fêde, et al., “Return to Work After Breast Cancer Diagnosis: An Observational Prospective Study in Brazil,” Cancer 124, no. 24 (2018): 4700–4710.

Date Created: 20260311 Date Completed: 20260311 Latest Revision: 20260313

20260313

PMC12976455

10.1002/cam4.71664

41808378