Financial toxicity adds to burden of cancer survivors in Singapore

Financial toxicity (FT) exists and is not uncommon among adult cancer survivors, potentially contributing to further decline in quality of life (QoL), according to a Singapore study. Moreover, those of lower socioeconomic status are particularly at risk of FT.

“Financial toxicity should not be considered in isolation, as it correlates with poorer QoL,” said lead study author Dr Weishan Ivy Ng, Department of Radiation Oncology, National University Cancer Institute Singapore, Singapore, and colleagues.

“Finally, cancer diagnosis and treatment have an impact on patients’ household members, and additional resources should be devoted to reduce this burden for patients at risk,” they added.

Lead investigator Prof Balamurugan A Vellayappan, Department of Radiation Oncology, National University Cancer Institute, Singapore, defined FT as “harm that the cost of cancer care does to a patient and their family.”

“The word ‘toxicity’ in oncology is used for treatment side effects such as nausea or fatigue. Financial harm should be measured and managed in the same way,” Vellayappan said.

“It is much broader than mental health. There is a material side—bills, transport, hired help, and above all lost income,” he added.

Ng, Vellayappan, and colleagues conducted a cross-sectional survey on 76 survivors of nasopharyngeal or breast cancer at the National University Hospital Singapore. They measured FT and QoL among participants using the Comprehensive Score on Financial Toxicity (COST) and Functional Assessment of Cancer Therapy-General (FACT-G) questionnaires.

Furthermore, the associations between FT and a range of variables and between FT and QoL were explored using two multivariate regression models.

Of the patients, 63 percent experienced mild-to-moderate FT. Overall, the mean COST score was 18.0 (out of 44) and the mean FACT-G score was 68.3 (out of 108). [Singapore Med J 2026;67:497-503]

A positive association was observed between COST and FACT-G scores (r, 0.45). Notably, however, no correlation was noted between out-of-pocket (OOP) expenditure and FT.

“OOP expenses was surprisingly not directly related to FT, likely due to the presence of effective means-tested subsidies,” wrote Ng and colleagues.

“The consequence that concerns clinicians most is behavioural. Patients under financial strain stretch prescriptions, defer scans, or decline treatment, usually without telling the medical team,” Vellayappan said. “That is when a financial problem becomes a medical one.”

Predictors

The following factors showed a significant association with FT among adult cancer survivors: government-subsidized housing, lower education levels, hire of a formal caregiver, and the need for household members to take on extra employment.

The feeling of financial well-being also showed a positive and significant association with a patient’s QoL, controlling for other factors. Specifically, a 1-point increase in COST score correlated with a 0.7-point increase in FACT-G score (p=0.002).

A decline in QoL also correlated with adverse changes, such as when household members had to work more to augment the household income (−15.2; p=0.02) or when their MediSave account was being used to pay for medical expenses (−0.3; p=0.04). On the other hand, patients of Malay and Indian ethnicities tended to report higher QoL.

“In our study, one-third of the household members of cancer patients had to take on additional employment to supplement their household income, and this may directly affect the amount of care and help received by the patient from these working family members,” Ng and colleagues said.

COST score

A notable finding from the regression analysis was the lower COST scores, indicating increased financial well-being, among patients who spent part of their treatment requiring hospitalized care. This was in contrast to that by de Souza and colleagues, who reported an association between three hospital admissions and worse COST score. [Cancer 2016;123:476-484]

“We postulate that this may be due to patients’ access to specific subsidies and insurance coverage that were made available during and after hospitalization,” Ng and colleagues said.

“Certain private medical insurance policies extend the coverage of outpatient treatment costs for up to 3 months after hospitalization. This benefit alleviates costs that would have otherwise been borne by the patient,” they added.

OOP expenses

A cancer diagnosis had a significant financial impact, according to the authors. In the current cohort, the average OOP expense was approximately SGD 25,000, which is more than fivefold greater than the national median gross monthly income of SGD 4,534 in 2020. [https://stats.mom.gov.sg/Pages/Income-Summary-Table.aspx]

“We found that about half of our patients reported a change in their employment and income status after their diagnosis,” wrote Ng and colleagues.

“About one-third of the household members had to take on extra employment to supplement income. Despite this, half of them still reported a decrease in household income,” they added.

When asked what can be done, Vellayappan said individuals must “understand your coverage while you are well, since insurance cannot be arranged after a diagnosis.”

Based on national survey data, four in 10 Singapore residents do not feel financially prepared for cancer, and only about a third knew about the Cancer Drug List changes, according to Vellayappan.

“After a diagnosis, raise cost early. Ask for an estimate for the whole course of treatment, ask whether an alternate regimen of equivalent effectiveness exists, ask for a medical social worker at the outset rather than once bills are finalized, and discuss adjusted hours with an employer rather than resigning,” Vellayappan said.

“Above all, talk to your care team about it. If cost is the reason a patient is considering skipping something, the care team needs to know,” he added.