Beyond drug toxicity: the hidden burden of financial toxicity in hepatocellular carcinoma
Leonardo G. Da Fonseca
Keywords: Liver cancer; financial toxicity; economy; prognostic
Submitted Mar 07, 2026. Accepted for publication Mar 25, 2026. Published online Apr 28, 2026.
doi: 10.21037/jgo-2026-0215
Financial toxicity refers to the objective financial burden and the subjective financial distress experienced by patients as a consequence of cancer diagnosis and treatment. It encompasses direct costs (out-of-pocket expenses for diagnostics, medications, and procedures), indirect costs (transportation, lodging, and time away from work), and opportunity costs (loss of income and reduced productivity) (1).
Unlike traditional adverse events graded by symptoms, laboratory abnormalities, or imaging findings, financial toxicity captures the economic “side effect” of cancer therapy. Its measurement has been standardized through validated tools such as the Comprehensive Score for Financial Toxicity-Functional Assessment of Chronic Illness Therapy (COST-FACIT), which evaluates perceived financial strain and its psychosocial impact (2). Importantly, financial toxicity is not merely an economic metric—it is clinically consequential. Multiple studies across malignancies have shown associations between financial toxicity and reduced treatment adherence, delays in care, inferior quality of life, increased psychological distress, and even higher mortality (3,4).
The article “Financial Toxicity in Patients with Newly Diagnosed Hepatocellular Carcinoma”, published in the Journal of Gastrointestinal Oncology by Lee et al. [2025], addresses an increasingly urgent but often under-recognized dimension of cancer care: the economic burden faced by patients and families. In an era marked by rapid therapeutic innovation in hepatocellular carcinoma (HCC), escalating drug prices, and widening global inequities in access to care, financial toxicity must be considered not as an ancillary issue but as a relevant factor for clinical outcomes. By demonstrating that nearly half of patients with newly diagnosed HCC report financial toxicity even before treatment initiation, the authors provide compelling evidence that financial distress is not merely a consequence of therapy—it is often present at baseline. The study highlights several sociodemographic variables significantly associated with worse financial toxicity: younger age (<65 years), Hispanic ethnicity, non-English primary language, unemployment, lower educational attainment, absence of planned surgical treatment, and worse quality of life (5).
These associations suggest structural vulnerability among younger patients, who may not yet be eligible for age-based public insurance and who often require greater financial reserves to meet family, housing, and daily living expenses (6). Non-English speakers may face navigation barriers across the continuum of HCC care, including risk-factor awareness, screening, and treatment access. Similarly, Hispanic patients experience comparable barriers, as reported cohort studies from Latin America (7). Lower educational attainment can limit health literacy and access to resources, and unemployment removes an essential financial buffer (8). Finally, the fact that financial toxicity was associated with worse baseline quality of life is particularly concerning. It suggests a bidirectional cycle: financial stress worsens psychosocial well-being, and diminished well-being may impair resilience and coping capacity.
The finding that the absence of planned surgery correlates with higher financial toxicity may reflect deeper structural inequities. Surgical candidates often present at earlier stages and may have better preserved liver function, awareness of risk factors (e.g., viral hepatitis and alcohol abuse), greater access to screening, and stronger healthcare engagement—factors intertwined with socioeconomic stability (9). These data underscore that HCC is a malignancy that disproportionately affects vulnerable populations—patients with chronic liver disease, lower socioeconomic status, minority ethnic backgrounds, and, frequently, limited access to structured health systems (10).
As HCC therapeutics evolve—including immune checkpoint inhibitors, combination regimens, and targeted agents—efficacy metrics traditionally include overall survival, progression-free survival, and response rates. However, these endpoints may not fully capture real-world effectiveness. A treatment that prolongs survival but induces severe financial hardship may lead to early discontinuation, non-adherence, and ultimately worse outcomes (1). Therefore, financial toxicity assessments can be a valuable tool to incorporate into real-world evidence frameworks by evaluating longitudinal COST-FACIT scores, associations between financial toxicity and treatment adherence, and the impact of these associations on survival outcomes. Integrating financial toxicity assessment into comparative effectiveness research may also inform value-based oncology. In an era where multiple regimens yield modest survival differences but vastly different cost structures, economic aspects should influence therapeutic selection. This may lead to the idea that financial toxicity behaves like a biologically meaningful variable. It influences treatment exposure, survivorship trajectories, and overall outcomes. In that sense, financial toxicity is not peripheral—it is prognostic.
Considering that HCC is a global disease, the burden of financial toxicity differs dramatically across health systems and countries. HCC disproportionately affects regions such as East Asia, sub-Saharan Africa, and parts of Latin America, where healthcare financing structures vary widely (10). Even within high-income countries, minority populations and immigrants experience disproportionate economic strain. In publicly funded healthcare systems, direct out-of-pocket costs may be limited, but indirect costs—travel, time off work, caregiving demands—remain substantial. In mixed or privatized systems, cost-sharing mechanisms, deductibles, and drug copayments amplify exposure (9).
Financial toxicity should be addressed proactively across the continuum of HCC care to mitigate its impact. While individual clinicians play a critical role in early identification and communication, durable solutions require coordinated action spanning patients, healthcare institutions, and policymakers. Table 1 below outlines pragmatic, multilevel strategies that emphasize shared responsibility and measurable impact.
Table 1
| Action | Key factors | Expected impact |
|---|---|---|
| Screen social risk factors | Physicians, nurses, multidisciplinary teams, and social workers | Early identification of vulnerable patients; targeted supportive interventions |
| Embed financial navigation services | Hospital administrators, social services, and cancer programs | Insurance optimization; access to assistance programs; reduced non-medical cost burden |
| Expand public insurance eligibility | Policymakers, public health systems | Protection of structurally vulnerable patients |
| Cap out-of-pocket drug costs | Policymakers, regulatory agencies | Prevention of catastrophic expenditures; improved access to therapy |
| Initiate routine cost discussions | Physicians, advanced practitioners | Reduced out-of-pocket spending; improved adherence; enhanced shared decision-making |
| Use validated screening tools (e.g., COST-FACIT) | Clinicians, researchers, administrators | Standardized detection; generation of real-world data |
| Include in quality benchmarks | National cancer societies, accreditation bodies | Institutional accountability; normalization of financial well-being as a quality metric |
COST-FACIT, Comprehensive Score for Financial Toxicity-Functional Assessment of Chronic Illness Therapy.
Finally, financial toxicity in newly diagnosed HCC is prevalent, measurable, and clinically meaningful. It reflects deep structural inequities and may adversely affect adherence, quality of life, and survival, as demonstrated by Lee et al. As the oncology community embraces precision medicine, we must also embrace precision support—identifying patients at risk of economic hardship and intervening early. Therefore, several aspects of financial toxicity represent modifiable determinants of outcome. By integrating screening, fostering cost transparency, embedding financial navigation, and advocating for policy actions, we can move toward a model of HCC care that is not only biologically effective but also economically sustainable, aligning sustainability with the therapeutic advances that have transformed the HCC landscape.
Acknowledgments
None.
Footnote
Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Gastrointestinal Oncology. The article did not undergo external peer review.
Funding: None.
Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://jgo.amegroups.com/article/view/10.21037/jgo-2026-0215/coif). L.G.D.F. reports honoraria for lectures for Bayer, Roche, AstraZeneca, MSD, and Sirtex. The author has no other conflicts of interest to declare.
Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
References
- Abrams HR, Durbin S, Huang CX, et al. Financial toxicity in cancer care: origins, impact, and solutions. Transl Behav Med 2021;11:2043-54. [Crossref] [PubMed]
- Thomy LB, Crichton M, Jones L, et al. Measures of financial toxicity in cancer survivors: a systematic review. Support Care Cancer 2024;32:403. [Crossref] [PubMed]
- Liu F, Shan H, Bing W, et al. Relationship between symptom burden and benefit finding in patients with gastrointestinal cancers undergoing chemotherapy: the chain-mediating role of comprehensive needs and communication pattern. Support Care Cancer 2025;33:816. [Crossref] [PubMed]
- Kitaw TA, Tilahun BD, Zemariam AB, et al. The financial toxicity of cancer: unveiling global burden and risk factors - a systematic review and meta-analysis. BMJ Glob Health 2025;10:e017133. [Crossref] [PubMed]
- Lee S, Garita E, Sucre S, et al. Financial toxicity in patients with newly diagnosed hepatocellular carcinoma: a cross-sectional study. J Gastrointest Oncol 2025;16:2203-12. [Crossref] [PubMed]
- Di Giuseppe G, Pagalan L, Jetha A, et al. Financial toxicity among adolescent and young adult cancer survivors: A systematic review of educational attainment, employment, and income. Crit Rev Oncol Hematol 2023;183:103914. [Crossref] [PubMed]
- da Fonseca LG, Izquierdo-Sanchez L, Hashizume PH, et al. Cholangiocarcinoma in Latin America: a multicentre observational study alerts on ethnic disparities in tumour presentation and outcomes. Lancet Reg Health Am 2024;40:100952. [Crossref] [PubMed]
- Mols F, Tomalin B, Pearce A, et al. Financial toxicity and employment status in cancer survivors. A systematic literature review. Support Care Cancer 2020;28:5693-708.
- Allaire M, Da Fonseca LG, Sanduzzi-Zamparelli M, et al. Disparities in access to systemic therapies for patients with hepatocellular carcinoma: an analysis from the International Liver Cancer Association. Lancet Reg Health Eur 2025;57:101408. [Crossref] [PubMed]
- Chan SL, Sun HC, Xu Y, et al. The Lancet Commission on addressing the global hepatocellular carcinoma burden: comprehensive strategies from prevention to treatment. Lancet 2025;406:731-78. [Crossref] [PubMed]
