A comprehensive health economic evaluation of advanced cancer care in india: financial burden, quality of life, and the role of government insurance schemes

Financial burden of cancer treatment comprises of more than 50% out-of-pocket expenditure resulting in financial toxicity (FT) and adversely affecting quality of life (QoL) of cancer patients in India. We aimed to investigate FT of cancer treatment and its impact on patients’ QoL. We conducted a cross-sectional observational study of 1-year duration at a tertiary care centre and recruited 96 patients after receiving ethics approval. Advanced cancer patients (stage III-IV), aged ≥ 18 years and receiving anticancer therapy for ≥ 6 months were included, while patients with critical or active psychiatric illnesses were excluded. Data on demography, type, and stage of cancer, direct, indirect, medical, and non-medical costs, subjective (SFB) and objective financial burdens (OFB) were collected. All patients were subjected to European Organisation for Research and Treatment of Cancer (EORTC) and COmprehensive Score for Financial Toxicity-Functional Assessment of Chronic Illness Therapy (COST-FACIT) questionnaires. Mean age was 59.1 years and 55.3% patients were female. Most common cancers were lung and haematological (39.6%). Median direct medical, and nonmedical, and indirect costs were Indian National Rupee (INR) 145,200 (range: 17800-1384000), 43,000 (range: 2000-522000) and 8500 (range: 1000-210000) respectively. Mean out-of-pocket expenditures was 47.2%. SFB scores for diagnosis related burden were high, but treatment related SFB scores were low. Median COST-FACIT score was 22 (range = 0–40). FT measured using COST-FACIT questionnaire showed that 21.9% patients were in grade III or severe, 17.7% were in grade II or moderate, and 17.7% patients were in grade I or mild and 42.7% in grade 0 suggesting absence of FT. We found mean EORTC scores were significantly lower than reference scores for physical, social, cognitive and emotional scales indicating poorer functioning or overall health status while higher for financial difficulties, and lower for global QoL. The mean scores were also higher for symptom scales reflecting a greater burden of symptoms for the study cohort. Though Government insurance schemes provided significant benefit for treatment, QoL was poor, and FT was high for patients with advanced cancer, emphasizing on the need of more patient friendly schemes for cancer.