# Patient-Reported Financial Burden in Head and Neck Cancer Undergoing Radiotherapy

## TL;DR

This study examines the financial burden faced by head and neck cancer patients undergoing radiotherapy in Romania, finding significant out-of-pocket costs and financial stress.

## Contribution

The study provides real-world data on financial toxicity in head and neck cancer patients from a country with universal healthcare.

## Key findings

- 39.8% of patients experienced financial toxicity, with transportation and nutritional supplements being the largest out-of-pocket expenses.
- Divorced patients and those retired due to chronic conditions were most vulnerable to financial distress.
- Financial toxicity was significantly associated with employment and marital status but not with tumor site or treatment type.

## Abstract

Financial toxicity has been recently recognized as an important research topic and a prognostic factor for oncology patients’ outcomes. Head and neck cancer patients are at high risk for financial toxicity as they have lower work returns and more out-of-pocket costs due to treatment-related adverse effects. Real-world data about financial toxicity can help define the patients at risk and identify potential solutions to decrease its occurrence and impact. Our manuscript brings interesting data from an upper-middle-income country with a high prevalence of head and neck cancers and universal healthcare coverage. We included patients from four centers situated in different geographical areas, who received multidisciplinary treatment according to international guidelines, comprising standard-of-care radiotherapy. We evaluated both objective and subjective components of financial toxicity, including a validated questionnaire and the amount of out-of-pocket payments, and correlated the data with demographic and clinical parameters.

Background/Objectives: Financial toxicity (FT) refers to the financial burden directly or indirectly caused by a patient’s medical care. Patients with head and neck cancer (HNC) are particularly vulnerable to FT due to lower rates of return to work and higher out-of-pocket payments (OOPP). In this cross-sectional study, we assessed the amount and types of OOPP, as well as the prevalence of FT, in HNC patients who had completed curative radiotherapy. Methods: We included HNC patients who underwent curative-intent radiotherapy at four private clinics in Romania, within 12 months of completing treatment. Participants completed a 25-item questionnaire capturing sociodemographic information, insurance status, income, and OOPP. To assess subjective FT, we used the validated nine-item Financial Index of Toxicity (FIT), which measures three FT domains: financial stress, financial strain, and lost productivity. Each domain and the total score range from 0 to 100, with higher scores indicating greater financial toxicity. Descriptive statistics were used to summarize patient characteristics. Pearson’s chi-square, t-tests, and one-way ANOVA were used to assess statistical associations, with a significance threshold of p < 0.05. Results: Among 113 patients (mean age: 59), the majority were male (74.3%) and married (74.3%), with 40% having completed university or higher education. The most frequent tumor sites were the oropharynx (29 cases), larynx (22), and oral cavity (21). Concurrent chemoradiation was the most common treatment modality (47%). The mean total FT score was 18.8. Overall, 39.8% of patients experienced financial toxicity, and 29.2% scored above the mean in financial stress. Moderate financial strain (score > 21) was reported by 39.8% of participants, and approximately one-third reported loss of productivity. Transportation and nutritional supplements were the most common OOPP categories. Notably, 42% of patients spent at least 400 euros—equivalent to Romania’s monthly minimum income—on transportation during radiotherapy. FT was significantly associated with employment and marital status, but not with tumor site or treatment type. Conclusions: Among Romanian HNC patients treated with curative radiotherapy, we found substantial OOPP, particularly for transportation and nutritional supplements. While overall FT levels were moderate, divorced patients and those retired due to other chronic conditions were the most vulnerable to financial distress. Financial toxicity can directly affect treatment adherence, survival, and quality of life. By integrating financial counseling, social support, and broader coverage of treatment-related expenses, healthcare systems can mitigate FT for these patients.