Cancer-related out-of-pocket costs in advanced cancer patients in Spain: Functional dependence and socioeconomic inequalities

Abstract

[EN]Background: Advanced-stage cancer imposes a substantial economic burden on patients and families, even within universal public healthcare systems. Non-reimbursed direct costs—such as medications, parapharmacy products, and orthopaedic materials—pose a particularly severe impact on individuals with functional dependence and limited institutional support. This study focuses on the objective component of financial burden, operationalised as unreimbursed out-of-pocket (OOP) costs from a patient/household perspective. Methods: A cross-sectional observational study was conducted at a public hospital in Spain between January 2022 and January 2024, including 201 patients with advanced-stage cancer. Socio-demographic, clinical, and economic data were collected through structured interviews, including annual out-of-pocket expenses for the previous 12 months (nominal euros, 2022–2024, without inflation adjustment), alongside functional assessments (Barthel Index, Lawton–Brody Scale, ECOG Performance Status, EQ-5D). Non-parametric tests (Mann Whitney U and Kruskal–Wallis; α =0.05) examined associations, and exploratory multivariate regression models were applied to adjust for functional and socioeconomic factors. Results: In the previous year, 67.7 % of participants reported pharmacy or parapharmacy expenses, and 10 % spent more than €1200. Orthopaedic costs were incurred by 54.2 %, despite theoretical public coverage; 23.9 % spent more than €600. Functional impairment was frequent, with 38.3 % of patients presenting ECOG ≥3. Only 25.4 % received any financial support, while the majority reported none. Pharmacy-related expenses were significantly higher among patients with greater functional dependence and income reductions (p < 0.05). Additional associations were found with marital status and pre-diagnosis income. Conclusion: Unreimbursed out-of-pocket costs represent a major source of objective financial burden in advanced cancer, disproportionately affecting patients with functional dependence and reduced household income. Current co-payment exemptions insufficiently capture vulnerable profiles. Policy summary: These findings support national (Spain’s Cancer Strategy 2021–2025) and European (Cancer Inequalities Registry) frameworks aimed at reducing social and economic inequalities in cancer care.