Cancer surgery at a cost: Understanding financial toxicity among patients in Pakistan

Document Type

Article

Department

Surgery

Abstract

Introduction: Cancer treatment often results in high out-of-pocket costs, causing financial toxicity (FT). While widely studied in high-income countries, data from low- and middle-income countries like Pakistan are scarce. This study evaluates the prevalence and determinants of FT among gastrointestinal cancer surgery patients.
Methods: This cross-sectional study included gastrointestinal cancer patients who underwent surgery at three tertiary hospitals in Karachi: Aga Khan University Hospital (a private, fee-based institution), Jinnah Postgraduate Medical Center (a public, no-cost facility), and the Cancer Foundation Hospital (a private, subsidized center). Data on demographics, surgery type, income, healthcare costs, and treatment modalities were collected. FT was measured using the Comprehensive Score for Financial Toxicity–Functional Assessment of Chronic Illness Therapy. Multivariable negative binomial regression was used to identify factors associated with FT, reported as incidence rate ratios (IRRs).
Results: Among 221 patients, 56.6% were treated at Aga Khan University, 23.5% at Jinnah Postgraduate Medical Center, and 19.9% at the Cancer Foundation Hospital. Mean age was 50 ± 14.6 y, and 58.8% were male. The median International Wealth Index was 83 (interquartile range [IQR]: 62.0-96.9). With only 10.9% of patients insured, the mean Comprehensive Score for Financial Toxicity–Functional Assessment of Chronic Illness Therapy score was 16.1 ± 7.2; 47.5% experienced mild FT (score 14-26), while 41.2% experienced moderate to severe FT (score ≤14). Female patients reported significantly lower FT (IRR = 1.21, 95% confidence interval: 1.07-1.54). Compared to those who underwent surgery alone, those who received surgery with chemotherapy (IRR = 0.81; 95% CI: 0.71-0.93) or surgery with chemotherapy and radiation combined (IRR = 0.82; 95% CI: 0.69-0.98) reported significantly higher FT. Patients in the middle-income group (Tertile 2: $89-179/mo) had significantly lower FT than those in the lowest income tertile (tertile 1: < $72/mo) (IRR = 0.83; 95% CI: 0.71-0.97). Spending ≥40% of annual income on healthcare was also associated with increased FT (IRR = 0.83; 95% CI: 0.71-0.97). By procedure type, patients who received palliative diversion reported significantly lower FT than those who had rectal resections (IRR = 1.30; 95% CI: 1.05-1.61).
Conclusions: FT was highly prevalent, affecting 88.7% of patients who underwent cancer surgery. It was mainly linked to patients’ economic status and the share of income spent on healthcare, regardless of cancer type, stage, or insurance. These findings underscore the urgent need for financial protection strategies such as counseling services, subsidized insurance, or targeted income support to reduce financial hardship and ensure access to cancer care in Pakistan.

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Publication (Name of Journal)

Journal of Surgical Research

DOI

10.1016/j.jss.2026.03.090

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