# Association between time to treatment and financial toxicity among women with breast cancer in Ethiopia: a multicentre study in a low-resource setting

## TL;DR

This study finds that longer delays in starting breast cancer treatment in Ethiopia are linked to greater financial burden for patients, especially those with lower income.

## Contribution

The study identifies financial toxicity predictors in a low-resource setting, emphasizing the impact of treatment delay and socioeconomic factors in Ethiopia.

## Key findings

- Longer time to treatment initiation is significantly associated with higher financial toxicity among Ethiopian breast cancer patients.
- Lower income, rural residence, and reliance on borrowed funds are significant predictors of increased financial toxicity.
- Financial toxicity disparities exist across hospitals providing breast cancer care in Ethiopia.

## Abstract

Breast cancer imposes a substantial financial burden on patients, especially in low-income countries like Ethiopia where out-of-pocket (OOP) payments dominate health financing. This study aimed to assess the association between time to treatment initiation and financial toxicity (FT), among women with breast cancer in Ethiopia.

A cross-sectional study was conducted from July to September 2024 among 458 women receiving breast cancer care at three tertiary hospitals in Ethiopia. Participants were interviewed using a validated Amharic version of the COST-FACIT tool, with additional data obtained from interviews and clinical records. The primary outcome was FT score, which ranged from 0 to 44, with a lower score indicating greater financial toxicity. Multivariable linear regression was used to assess the association between FT and the total treatment interval (TTI) from symptom recognition to treatment initiation, adjusting for sociodemographic, clinical, health insurance, and cost-coping behavioral factors.

The median FT score was 10 (IQR:5 to 16), indicating a high level of financial toxicity among the study participants. Most participants (71%) had a TTI longer than 90 days, which was associated with higher financial toxicity (median FT score 9 compared with 14 in those with ≤ 90 TTI days, p < 0.001). Longer TTI was a significant predictor (B = –2.50; 95% CI: –4.06 to –0.95; p = 0.002) of higher financial toxicity, after adjustment for variations of covariates. Other significant predictors of higher financial toxicity included younger age (< 40 years: B = –4.37; p = 0.001; 40–59 years: B = –3.53; p = 0.003), lower income (≤ 2,100 ETB: B = –5.40; 2,101–3,254 ETB: B = –3.91; p < 0.001), rural residence (B = –2.28; p = 0.039), on active treatment (B = –3.59; p = 0.001), and reliance on borrowed/assisted financing for OOP (B = –4.59; p < 0.001). There also existed FT disparities across the three hospitals.

Financial toxicity is evident in Ethiopian women with breast cancer, particularly among those with lower socioeconomic status. Longer TTI is associated with higher financial toxicity. These findings highlight the limited role of the current health insurance arrangement in addressing the level and inequality of financial toxicity associated with breast cancer care in Ethiopia.

The online version contains supplementary material available at 10.1007/s00520-026-10570-9.