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Financial impacts of cancer found to intensify disease burden among German patients

Survey shows that cancer can lead to income loss, associated with adverse psychological effects in addition to material hardship
16 Oct 2018
Bioethical Principles and GCP;  Cancer Care Equity Principles and Health Economics

Lugano - Munich – A study (1) conducted in Germany draws attention to the fact that the socio-economic burden of cancer is real in Europe too, and not only in the context of the US healthcare system where it has been associated with higher morbidity and mortality. The results to be presented at the ESMO 2018 Congress in Munich show that income loss is the main source of perceived financial hardship, and that this is associated with adverse psychological effects in patients.


The work also highlights the absence of clear definitions and valid instruments with which to examine this issue. Prof. Eva Winkler, study author, medical oncologist at the National Centre for Tumour Diseases (NCT) in Heidelberg, explained the background: “We conducted a systematic literature review of the tools used to measure the subjective financial burden of cancer patients: of the 39 studies we found, most came from the USA, and the instruments they used were either not transferrable to the German context or not sufficiently focused on the subject,” she said.

Study co-author Dr. Katja Mehlis from the NCT added: “We were, however, able to identify three broad dimensions through which subjective financial burden could be assessed: material aspects, psychological effects and behavioural changes such as support seeking and coping strategies. Based on this, we developed our own, yet non-validated set of questions covering income, cancer-related out-of-pocket costs, distress and lifestyle changes.”

A total of 247 patients, 122 diagnosed with neuroendocrine tumours and 125 treated for colorectal cancer, responded to the survey between November 2016 and March 2017. The results brought to light financial impacts in a significant proportion of patients: 80.6% of respondents stated that they faced higher out-of-pocket costs related to their illness.

Although most medical costs in Germany are covered by a person’s health insurance, patients do have to contribute co-payments for prescription drugs. Cancer patients may additionally face travel expenses to get to the hospital or medical centre, as well as potentially having to pay for care, housekeeping or childcare. For over three quarters of the patients who responded to the survey, disease-related out-of-pocket costs amounted to less than 200 euros monthly.

Cancer-related income loss was reported by 37.2% of survey participants. “In our study, this effect was more serious than out-of-pocket costs, as the suffered losses exceeded 800 euros per month in almost half of cases. They were mainly due to patients being unable to work or forced to reduce their working hours,” said Mehlis.

The analysis further showed that high financial loss relative to income was significantly associated with a lower estimation of patients’ quality of life and more distress. “The financial impacts that a majority of these patients experienced seem to have contributed to the burden of their disease: the bigger the loss was in proportion to their previous income level, the more negatively they rated their personal situation,” Winkler observed.

“More research is needed to determine what actions are necessary at the system level – for example an extension of the period of eligibility for sickness benefits – or at the individual level, like targeted consulting and support services,” she said. “To do this, we will need a valid instrument to measure ‘subjective financial burden’ in the German context, based on a precise definition of the concept.”  

Dr. Dirk Arnold of Asklepios Tumorzentrum in Hamburg, Germany, commented for ESMO: “There have been efforts in Germany, including by national entities like the Federal Joint Committee and the Robert Koch Institute, to look at the costs of oncology treatment for cancer patients – but they have focused only on drug and procedure-related expenses. With this new study, we can see not just that the financial implications of a cancer diagnosis are much broader, but also that the monetary losses associated with this disease have significant psychosocial consequences.”

“We should draw lessons from these findings: just as cancer patients receive consultations about lifestyle issues, like nutrition, so too should the financial aspect somehow be integrated into the social counselling programmes we offer them,” Arnold continued. “The fact that medical expenses for patients in Germany – and Europe more generally – are relatively low compared to other parts of the world, should not lead us to underestimate the importance of their perceived financial burden and leave them alone with it. Going forward, it would be interesting to see if assessments of this burden in other European countries produce similar results.”

Arnold added: “Alleviating the financial burden of cancer: is one of ESMO’s key commitments: earlier this year, ESMO issued a paper on this subject in the context of the implementation of the 2017 World Health Assembly Resolution on Cancer prevention and control.

This paper is the first to articulate the response and commitment oncologists to advance global cancer control through the framework of the 2017 WHA Cancer Resolution and universal health coverage. It addresses key topics like cancer prevention, timely access to treatment and care, palliative and survivorship care, as well as comprehensive data collection through robust cancer registries. The authors also offer a concrete set of actions and policy recommendations for improving patient care.

ESMO’s commitment to lessening the burden of cancer is not new: sustainable cancer care is one of the three pillars of the Society’s 2020 Vision, and various initiatives have been launched in this field over the years. Among other things, ESMO contributed in 2016 to the revision of the WHO Model List of Essential Medicines – the list of vital medicines that should be available to patients everywhere for free or at affordable prices – and added 16 anti-cancer drugs including targeted therapies. With the introduction of its own classification tool, the ESMO Magnitude of Clinical Benefit Scale, the Society provided a standardised, evidence-based approach to evaluating cancer medicines, thus helping to guide health systems in their decision-making and resource allocation. In collaboration with the Economist Intelligence Unit (EIU), ESMO also published in 2017 a report on the shortage of inexpensive cancer medicines in Europe, raising awareness for a critical issue that has immediate consequences for patient care and treatment outcomes.

Notes to Editors

Please make sure to use the official name of the meeting in your reports: ESMO 2018 Congress
Official Congress hashtag: #ESMO18


  1. Abstract 1576P_PR ‘Financial toxicity in German cancer patients. How does a chronic disease impact the economic situation?’ will be presented by Eva Winkler during the Poster Display Session on Monday, 22 October 2018, 12:45 to 13:45 (CEST) in the Poster Area Networking Hub - Hall A3. Annals of Oncology, Volume 29 Supplement 8 October 2018
About the European Society for Medical Oncology (ESMO)

ESMO is the leading professional organisation for medical oncology. With 18,000 members representing oncology professionals from over 150 countries worldwide, ESMO is the society of reference for oncology education and information. ESMO is committed to offer the best care to people with cancer, through fostering integrated cancer care, supporting oncologists in their professional development, and advocating for sustainable cancer care worldwide.

1576P_PR - Financial toxicity in German cancer patients: How does a chronic disease impact the economic situation?

E.C. Winkler1, K. Mehlis1, B. Surmann2, J. Witte2, R. Lingnau2, L. Apostolidis3, J. Walther1, W. Greiner2
1Medical Oncology, Nationales Zentrum für Tumorerkrankungen (NCT), Heidelberg, Germany, 2Health Economics and Health Care Management, Bielefeld University, Bielefeld, Germany, 3Department of Medical Oncology, National Center for Tumor Diseases, University Hospital Heidelberg, Heidelberg, Germany

Background: So far, the patient-level effect of the cost of cancer care is a topic that has been discussed primarily in the US health care system. In Germany, the economic impact of cancer is poorly understood. This study aims to provide data on consequences of a neuroendocrine (NET) or colorectal (CRC) tumor diagnosis on patients' financial situation.

Methods: (1) With a systematic literature review we identified instruments and dimensions that have been used to measure “subjective financial burden”. (2) Informed by this analysis a survey on income, cancer-related out-of-pocket costs, distress (DT), and quality of life (EORTC-LQ) was developed and applied in a prospective study which recruited 247 patients (n=125 CRC/n=122 NET) from 11/2016-3/2017 at the National Center for Tumor Diseases, Germany.

Results: (1) Out of 40 eligible studies only 13 used pre-existing instruments. Three major dimensions to assess the subjective financial burden were identified: (i) material aspects consisting of financial spending and financial resources of the patients, (ii) psychological effects and (iii) behavioral changes including support seeking and coping strategies concerning the organization of care and lifestyle. The most common dimension queried in the studies were material aspects, whereas behavioral changes and in particular support seeking, were the least integrated themes within the studies. (2) In our survey, 80.6% (n=199) of patients stated to have higher out-of-pocket costs, 37.2% (n=92) reported income loss as a sequel to their disease. A multiple linear regression analysis showed effects of economic deteriorations on patient's quality of life and distress: high financial loss relative to income was significantly associated with a lower estimation of patient's quality of life (p=0.00) and more distress (p=0.00).

Conclusions: While some standardized instruments already are available for the US context, a valid instrument to measure the subjective financial effects of cancer is needed for the German context. As distress and reduced quality of life due to financial problems seem to intensify the burden that already results from a cancer diagnosis, there is a need for targeted support measures at the individual and system level.

Legal entity responsible for the study: Eva Winkler

Funding: The study is funded by Ipsen Pharma GmbH

Disclosure: All authors have declared no conflicts of interest

Last update: 16 Oct 2018

This press release contains information provided by the authors of the highlighted abstracts and reflects the content of those abstracts. It does not necessarily reflect the views or opinions of ESMO who cannot be held responsible for the accuracy of the data. Commentators quoted in the press release are required to comply with the ESMO Declaration of Interests policy and the ESMO Code of Conduct.

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