Non-Communicable Diseases (NCD) are responsible for around half the deaths in the developing countries, majorly affecting the older age group. Among NCDs, cancer related deaths are increasing very rapidly and by 2040, patients aged ≥65 years will comprise 69% of all new cancer diagnoses.[1] With advances in cancer treatment, long-term survival rates have improved in recent decades, resulting in extended life expectancies. [2,3]

The treatment of cancer is often a long-term process, which exacts a physical and emotional toll not only on the patients but also their caregivers. This is even more apparent in LMICs, where the available resources are scarce in proportion to the population served. The financial burden experienced by patients undergoing cancer treatment and the deleterious effects of such treatments on the financial security of the patient are often referred to as financial toxicity [4].The financial toxicity of cancer care is an area of research that is ever-growing in importance [5–7]. As newer and more effective therapeutic options are discovered, often with exorbitant price tags, the financial burden faced by patients continues to increase. In LMICs, access to even basic chemotherapeutic drugs, supportive care medicines, testing modalities, machines, and other facilities is limited [8–10]. As per a recent report, 32–57.7% of cancer medicines on the WHO Essential Medicines list were available in LMICs, only if patients were willing to incur their full costs [11]. Thus, even standard therapies impose a heavy financial burden. This burden is particularly felt by older people, many of whom are retired from their primary occupation and are dependent on their savings or on their families for financial assistance for therapy. Older adults with cancer are at higher risk of financial toxicity than those receiving treatment for other chronic diseases [12].

A recent study in  India has shown that cancer patients and their caregivers go through tre mendous psychological stress from the time of diagnosis till the end of life. Out of pocket expenditure and the financial catastrophe caused because of the treatment adds onto it. Non-medical costs including transportation, accommodation, and cost of childcare add on to this burden, more so for the lower socioeconomic status (SES).[13,14]

 The burden of cancer is increasing at an alarming rate and cost of treatment is exorbitantly high especially for people of older age group. Majority of the cancer patients face catastrophic out of pocket expenditure and financial toxicity which effects treatment outcome. Most of the studies in India focus on non communicable diseases as a whole or as a one single type of cancer in all age groups. As cancer incidence is rising, this study focuses on financial toxicity, out-of-pocket expenditure, and treatment outcomes among geriatric cancer patients in Kashmir.

The prospective observational study was conducted in a tertiary care centre NOORA HOSPITAL in Kashmir providing oncology services among geriatric patients diagnosed with cancer and receiving treatment at the study centre from January 2025 to September 2025. Ethical clearance was taken from hospital ethics committee of hospital before commencement of study. Written informed consent was taken from patients after explaining them about procedure of the study. Consecutive sampling was done. Sample size was calculated using the formula: n = \frac{Z^2 \times p \times q}{d^2} Where: p = prevalence of financial toxicity (assume ~50% if unknown for maximum sample) d = allowable error (10%) Z = 1.96 Final sample size came out to be of 120 patients. Patients were selected on the basis of inclusion and exclusion criteria. Inclusion Criteria • Age ≥ 60 years • Confirmed diagnosis of cancer (any site) • Planned for or undergoing treatment (surgery/chemotherapy/radiotherapy) • Willing to give informed consent Exclusion Criteria • Critically ill patients unable to respond • Patients with severe cognitive impairment • Patients awaiting PmJay services • Patients refusing consent Pre-designed, pre-tested, and semi-structured questionnaire was used to determine the socio demographic characteristics, economical details (BG prasad scale,2025)[15], cancer diagnosis details and treatment outcomes and out of pocket expenditure details related to the participants. All the questions with regard to charges incurred in the past on various aspects such as consultation, medicines, diagnostics and surgery were enquired retrospectively from the onset of symptoms to the registration of individual as a cancer patient in the cancer centre. OOPE was calculated based upon the collected data. For measuring financial toxicity we used COST- FACIT scale. COST FACIT comprises 12 questions, of which 11 items are scored, and the 12th question is a summary item (“My ill ness has been a financial hardship to my family and me”). The COST-FACIT questionnaire is scored from 0 to 44, and the scores are categorized as follows: ≥ 26 = no impact/grade 0, 14–25 = mild impact/grade 1, 1–13 = moderate impact/ grade 2, and 0 = severe impact/grade 3.[16] Data were analysed using SPSS software 25.0 with level of significance p<0.05. The categorical variables were represented in the form of frequency tables. Median (IQR) was used as the measure of the central tendency for the continuous variables. Non parametric tests of significance like the Man Whitney U test and Kruskal Wallis test were used for determining the difference between the median of two groups of the particular independent variables. Also, the chi-square test and Fischer exact test were used as a test of significance. Spearman’s correlation was used to show an association between independent and dependent variables. Linear regression was applied to know the variability of dependant variables due to significantly correlated variables.

The study included 120 elderly cancer patients, with the majority (60%) aged 60 to 70 years. Males represented 56.7% of the participants. Most patients resided in rural areas (65%) and belonged to lower socioeconomic classes (Class IV–V: 45%). Illiteracy was noted in 36.7% of participants, indicating a predominantly vulnerable population as shown in table 1.

Table 1: Socio-demographic Characteristics of Study Participants

Lung cancer (20%) , gastrointestinal cancer (26.7%) and breast cancer (15%) were the most common types of cancer. A large number of them (68.3%) showed up at advanced stages (Stage III–IV). The most common type of treatment was chemotherapy (43.3%), followed by combined therapies (28.3%) as shown in table 2, graph 1.

Table 2: Clinical Profile of Patients

The median total out-of-pocket expense was INR 3.8 lac, with a range of INR 90,000 to INR 13lac. Medicines made up the biggest part of the spending, followed by surgery and investigations shown in table 3.

Table 3: Out-of-Pocket Expenditure (OOPE) Distribution

Moderate financial toxicity (Grade 2) was noted in 43.3% of patients, whereas 11.7% exhibited severe financial toxicity. Only 15% said they didn't have any financial problems, which shows that cancer care has a big effect on the economy for this group of people as shown in table 4.

Table 4: Financial Toxicity (COST-FACIT Score Classification)

There was a statistically significant link between socioeconomic status and financial toxicity (p < 0.001). Patients in lower socioeconomic classes (Class IV–V) exhibited markedly elevated levels of moderate to severe financial toxicity in comparison to those in higher classes as shown in table 5.

Table 5: Association Between Financial Toxicity and Socioeconomic Status

A robust negative correlation (r = -0.62, p < 0.001) was identified between total out-of-pocket expenditure and COST-FACIT scores, signifying that elevated expenditures correlated with heightened financial toxicity as shown in table 6.

Table 6: Correlation Between OOPE and Financial Toxicity

Financial toxicity significantly influenced treatment efficacy (p = 0.002). Patients experiencing significant financial stress demonstrated increased treatment interruption rates (42.8%) and reduced treatment completion rates (42.9%), highlighting the detrimental effect of economic strain on care continuity as shown in table 7, graph 2.

Table 7: Treatment Outcomes and Financial Toxicity

I The financial aspect of cancer treatment is particularly sensitive subject in developing countries because there is very little or no support from health insurance policies. Unintended consequences of financial toxicity of cancer treatment range from reduced spending on other sale of assets to medical debt leading to bankruptcy. Studies that surveyed cancer patients[17] about financial matters found that up to 40% patients experience severe financial distress. Financial considerations related to the rising cost of cancer care also have direct impact on patient’s choice of treatment and adherence to therapy plans.[18] Numerous studies have demonstrated that as out-of pocket costs increase fewer patients initiate treatment and those who do are more likely to discontinue early.[19] This study focuses on financial toxicity, out-of-pocket expenditure, and treatment outcomes among geriatric cancer patients in Kashmir.

Our study focuses on geriatric cancer patients of Kashmir region where most patients found were in the age group of 60-65 years. Study conducted by Manzoor F et al., in their study quoted that total of 5,392 cases of malignancies were taken, with a mean age at diagnosis of 56.73 years (SD = 15.96). Maximum number of cases were recorded in the age group of 60–69 years.[20] In our study most patients resided in rural areas (65%) and belonged to lower socioeconomic classes (Class IV–V: 45%). Illiteracy was noted in 36.7% of participants, indicating a predominantly vulnerable population. Khan A et al., shows that majority of cancer patients belonged to rural area. Participants were mostly educated till intermediate and were agricultural workers/ unemployed or housewife with MPCI of Rs 2776.2 maximally belonging to class V socio-economic group. Khan A et al., also show that the majority (80%) of cancer patients belong to a low socio-economic class. Most of the participants were of oral cancer, diagnosed mostly at

medical colleges, and were given chemotherapy, radiotherapy, and surgical intervention.[21,22]

The median total out-of-pocket expense was INR 3.8 lac with a range of INR 90,000 to INR 13 lac. Medicines made up the biggest part of the spending, followed by surgery and investigations. In a study conducted by Wani MA et al., in Sher-i-Kashmir Institute of Medical Science found that the major cost components of in-patient cancer chemotherapy are cost of drugs and materials as 46.88% and labor as 48.45%. The average unit cost per patient per bed day for in-patient chemotherapy is Rs. 5725.12 ($125.96). This includes expenditure incurred both by the hospital and the patient (out of pocket).[23]  In a study conducted by Barwal V K et.al.,[24] mean OOPE was found to be ₹36,812 , whereas in the study conducted by Mohiuddin SA et al.,[25] mean OOPE was found to be ₹84,643.20 ($1,032.65). This difference could have been due to the fact that only lung cancer patients were included, and the sample size was limited in their study. Many patients had significant investigation costs since specific diagnostic modalities, such as PET scans and genetic and molecular diagnostic modalities, were not readily available, even though basic investigations were supplied free of charge under various government schemes. By expanding the facilities for investigations, these expenses could be reduced.

In our study moderate financial toxicity (Grade 2) was noted in 43.3% of patients, whereas 11.7% exhibited severe financial toxicity. Only 15% said they didn't have any financial problems, which shows that cancer care has a big effect on the economy for this group of people. In a study conducted by Noronha V et al., [26] the prevalence of financial toxicity was 73.7% as per the COST-FACIT scale (n = 703). Higher financial toxicity on the COST-FACIT scale was associated with poor financial well-being on the CFPB scale. A study conducted by Shankaran V et al concluded that significant number if patients (38%) reported financial hardships as a result of treatment despite having health insurance coverage. Lower income and unemployment or disability were mostly associated with treatment nonadherence. Cancer affected households experience a greater number of hospital admissions and Outpatient visits compared to match controls. Given the low population coverage of health insurance and poorly run public sector, there is large burden of out-of pocket spending on households affected by cancer. Addressing the financial sequelae of cancer diagnosis appears to have positive social and psychological con sequences that could significantly enhance the clinical management of cancer and quality of life for cancer patients.[27,28]

In present study it was found that financial toxicity significantly influenced treatment efficacy. Patients experiencing significant financial stress demonstrated increased treatment interruption rates and reduced treatment completion rates. This was similar to results shown in previous study done by Noronha V et al., [26]. Patients with greater financial distress were more inclined to discontinue treatment and less likely to fulfill prescribed therapy. This shows a key way that financial stress leads to worse clinical outcomes. A lot of research has shown that people who can't afford their treatment often stop it, which leads to disease progression, lower survival rates, and worse quality of life.

This study highlights the substantial financial strain faced by elderly cancer patients in Kashmir, with most having moderate to severe financial toxicity. Significant out-of-pocket expenses, particularly for pharmaceuticals and diagnostic testing, are a primary source of financial strain. A pronounced negative connection between OOPE and COST-FACIT scores underscores the escalating financial toxicity associated with increased expenditure. Socioeconomic status emerged as a critical determinant, disproportionately affecting lower-income populations. Financial toxicity significantly adversely impacted treatment adherence, leading to increased interruption rates and reduced completion rates. The results indicate a necessity for enhanced insurance coverage, more focused financial assistance systems, and policy modifications to alleviate economic burdens. Addressing financial toxicity is crucial not only for enhancing quality of life but also for ensuring that elderly cancer patients receive improved treatment.

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