The financial burden of cancer: Estimates from patients undergoing cancer care in a tertiary care hospital
© Zaidi et al.; licensee BioMed Central Ltd. 2012
Received: 25 November 2011
Accepted: 12 October 2012
Published: 15 October 2012
The emotional burden associated with the diagnosis of cancer is sometimes overshadowed by financial burden sustained by patient and the family. This is especially relevant for a developing country as there is limited state support for cancer treatment. We conducted this study to estimate the cost of cancer care for two major types of cancer and to assess the perception of patients and families regarding the burden of the cost for undergoing cancer treatment at a private tertiary care hospital.
This cross-sectional study was conducted at day care and radiotherapy unit of Aga Khan University, Hospital (AKUH) Karachi, Pakistan. All adult patients with breast and head & neck cancers diagnosed for 3 months or more were included. Data was collected using a structured questionnaire and analysed using SPSS.
Sixty seven patients were interviewed during the study period. The mean and median monthly income of these patients was 996.4 USD and 562.5 USD respectively. Comparatively the mean and median monthly cost of cancer care was 1093.13 USD and 946.42 USD respectively. The cost of the treatment either fully or partially was borne by the family in most cases (94%). The financial burden of cancer was perceived as significant by 28 (42%) patients and unmanageable by 18 (27%) patients. This perceived level of burden was associated significantly with average monthly income (p = <0.001).
Our study indicates that the financial burden of cancer care is substantial and can be overwhelming. There is a desperate need for treatment support programs either by the government or other welfare organisations to support individuals and families who are already facing a difficult and challenging situation.
The diagnosis of cancer is shocking news for any individual and his/or her family. Cancer is a chronic disease and the physical and emotional burden can sometimes be overshadowed by the financial burden incurred by the family. In developed countries and more affluent societies of the world, a large part of this burden is shared by the state. But even so, studies from the developed countries like Canada have shown that patients and families experience significant burden despite several state plans that are in place to address the issue. Wage losses due to cancer treatment in working women with breast cancer adversely affect the barely manageable situation and add to the financial burden sustained by the patient. Another study from the USA showed that financial burden can be substantial even among women with comprehensive health insurance policies. Similarly, a study from Australia publicised that lost income, health service expenditures and lost unpaid work were the greatest sources of economic burden among women with breast cancer.
In Pakistan, like many other developing countries, there is little assistance from the government and in many cases the entire costs, including direct and indirect costs, are borne by the patient and his or her family. To our knowledge there has been no study conducted in Pakistan to address this important issue. There is also very limited data from other developing countries facing a similar situation. Therefore, we conducted this study to estimate the cost of cancer care for two major types of cancers at Aga Khan University Hospital (AKUH). This is a private university hospital in Karachi that offers comprehensive cancer care. We also assessed the perceived financial burden of cancer care among patients and their care givers.
This cross-sectional study was conducted at Aga Khan University, Hospital (AKUH) Karachi Pakistan from March 2009 to March 2010. All adult patients who had been diagnosed with either breast or head & neck cancers for at least three months were included in the study. Patients were enrolled from the Day-care chemotherapy and radiation therapy units. Interviews were conducted from the patients and/or family members and data was collected using a structured pre-tested questionnaire. Interviews were conducted by a medical student after initial pilot testing. Questions included demographics, family income, treatment costs, insight regarding the treatment and expectations of the patients and families. Complete confidentiality of the information collected was ensured. No personal data was collected by which the participants could be identified afterwards. Written consent was taken from all participants. The study was approved by the Aga Khan University’s Ethical Review committee.
Data was analysed using commercially available software package for social science SPSS version 17. All costs were estimated as Rupees per month and later converted into dollars for analysis. The conversion rate of 2009-2010 was used and applied to other studies for comparison. Descriptive analysis was carried out for patients’ demographics and clinical characteristics. Means with standard deviations were calculat ed for continuous variables and proportions were calculated for categorical variables. Chi-square test was used for Univariate analysis for significance of categorical variables in determining perceived level of burden and cost anticipation of the treatment. Logistic regression was done for same categorical variables in multivariate analysis. The significance level was set at 5%. Student’s t-test was applied for multiple values of test variables.
Characteristics of patients undergoing breast and head and neck cancer care at Aga Khan University Hospital
Frequency (% age)
Type of cancer
40 (59.7 )
Head and Neck
27 (40.3 )
Patient bread earner before diagnosis
26 (38.8 )
41 (61.2 )
Cost borne by patient or family
63 (94 )
Third party support
4 (6 )
The overall average duration of the treatment was 6.7 months, that for breast cancer was 7.8 months and for head and neck cancer was 5.04 months. The cost of the treatment was either fully or partially borne by the patient or the family in 94% of the cases.
Univariate and multivariate Analysis for Cost anticipation
Cost more than anticipated
Cost not more than anticipated
Awareness of cost at outset
Type of cancer
Head and neck
Total cost groups
Perceived level of financial burden by income among patients undergoing breast and head and neck cancer care at Aga Khan University Hospital
Perceived level of Burden (n)
% age of perceived burden as significant & unmanageable in each income group
Univariate and multivariate Analysis for Perceived level of burden
Perceived level of burden
None to somewhat
Significant to unmanageable
Awareness of cost at outset
Type of cancer
Head and neck
Monthly cost groups
Monthly cost of cancer care by income (p=0.072) and months into treatment (p=0.116) among patients undergoing breast and head and neck cancer care at AKUH
Monthly cost in USD
Monthly income (USD)
Months into treatment
The association between monthly cost of treatment and months into treatment was not significant (p=0.116), although the mean monthly cost of treatment was much higher for those who were less than 6 months into treatment as compared to those who were more than 9 months into treatment (Table5).
Percent of different types of costs
Type of Expenses
Mean With (±SD)
Hospitalization, surgery and investigations
Though our study targeted a selected patients’ group from a single centre, yet it points out that the stigma of the financial burden of the cancer care could be substantial and overwhelming. The financial problems and social complexities could multiply the stress and the sufferings associated with the disease itself and the toxicities of the treatment manifolds.
The financial aspect of the disease is particularly sensitive in countries like Pakistan where almost entire cost of the treatment is borne by the patient and the immediate family with little or no support from state or health insurance policies. Hence, the diagnosis of the cancer could be devastating news not only because of nature of the disease but also because of the continuous financial drain posed by the costs of the treatment.
According to IMF as of 2010, Pakistan’s Gross domestic product (GDP) per capita stands at 1,067.971 US dollars while Gross domestic product (GDP) based on purchasing power parity (PPP) per capita stands at 2,713.272 US dollars. The average family income is 226.10USD/month but Pakistan is a country of extremes. According to human development report 2008, 60.3% of Pakistani population has daily income of 2 US dollars or less. However, our study group represented a relatively more affluent section of the society with a median family income of 996.4 USD per month. Despite this, the monthly cost of treatment i.e.1093.13 USD, far exceeded the average monthly income of the entire ‘affluent’ family (996.4 USD). This could mean utilisation of savings and other means to bridge the deficit. In the worst scenario, this might lead to falling in debt which had been reported by 34.3% of the patients. It could be inferred from the above fact that some people from underprivileged strata of the community might succumbed to the disease without getting treatment due to the affordability issue. Nevertheless, this needs to be documented from public sector before drawing a conclusion from the assumption.
Majority of the patients in our study (73%) reported that the costs were either more or much more than anticipated and 55.2% of the study subjects stated that they were not aware of the cost of treatment at outset. The cost of the treatment was underestimated by mostly those people who were oblivious of the cost from the outset. This was again not surprising as a cost related to cancer care is not a one-time expense in most cases. This is different from a one-time expense like knee replacement etc.
In Pakistan, families still rely overwhelmingly on an income of single earning member. This is usually the male member of the house. In our study all the patients with breast cancers were females and majority of them were homemakers with little income of their own. They were completely dependent on their families for the treatment expenses. The situation was even worse for the male patients, as they were the bread earners for their families in 91% of the cases. It gets almost impossible to sustain that supporting position when cancer treatment is underway for the main earning member. The emotional and physical toll could be even more difficult when the prognosis is poor.
Comparison of the overall cost from an international Study
Monthly income USD
Monthly Cost Mean USD (SD)
Cost from time since treatment Mean USD (SD)
< 250 (32%)
Arozullah et al
< 2500 (19%)
In most low income countries, people have to rely on themselves and do not necessarily look out to the government for health care needs.
The cost of the treatment is of prime importance while making treatment decisions and sometimes governs the choice of the treatment selected for a particular patient. This was reflected in an interesting trend in our study where patients with low monthly income had less monthly cost of treatment as compared to those with high monthly income. Although this did not reach statistical significance, but physicians working in Pakistan could appreciate this fact where many times a treatment is tailored to the financial situation of the patient. Similar finding has been reported from a study in USA, which showed that families with the lowest household income had least expenses. However the proportion of household income spent on cancer care was higher for low income families.
The small sample size was a major limitation in our study. Many patients refused to consent for disclosure of details regarding the income due to sensitivity of the issue. Day care and radiotherapy unit of AKUH render its’ services to approximately 20 million population of Karachi city and also receive referrals from all over the country. The patient group is diverse comprising of all ages with different malignant disorders i.e. solid tumours and lymphomas. We had targeted select types of cancers, thus, done a purposive sampling for the sake of simplicity as this was the first study of its kind from Pakistan. The age and gender distribution was a bit skewed for the very same reason. This has limited the generalisation of the results, but this could be considered a pilot study with more comprehensive studies to follow. Nevertheless, it has given an insight regarding the under-addressed prevailing issue.
Our study indicated that the financial burden of cancer care was substantial and mostly borne by the patient or the family. Most of the time, the monthly average cost of the treatment far exceeded the monthly household income and a significant proportion of patients perceived the financial burden as overwhelming. There should be financial support programs on part of the government and other organisations to cover up for the treatment costs of the cancer and to help these patients in managing the already difficult and challenging situation.
Dr Adnan Ali Zaidi
Diplomate American Board of Medical Oncology
Shaukat Khanum Cancer Memorial Hospital
Dr Tayyaba Zehra Ansari MBBS; FCPS; MRCP (UK); FCPS (Oncology)
Consultant Medical Oncologist
Aga Khan University Hospital, Karachi
Stadium Road P.O.Box 3500, Karachi 74800
I am grateful to Huda Ansari for proof reading of this manuscript.
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