Income, Race, Household Size Linked to Financial Toxicity in Sarcoma

Close to half of adults with sarcoma reported some degree of financial toxicity, with a greater burden among patients receiving active treatment and those with metastatic disease, according to a cross-sectional study published in Cancer Reports.¹ Of 1125 participants, 502 (44.6%) had COmprehensive Score for financial Toxicity (COST) scores consistent with mild, moderate, or severe financial toxicity.

Younger age, female sex, lower household income, non-White race, and larger household size were associated with greater financial toxicity. Higher anxiety, depression, pain interference, and sleep disturbance scores were also linked to greater financial toxicity, although the authors noted that their design could not establish the direction of these associations.

Survival for sarcomas, a diverse group of rare solid tumors, has improved over the last several decades as the cost of cancer treatment has also risen, the authors explained. Most data on financial toxicity come from more common cancers, such as breast, prostate, colorectal, and lung cancers, and no prior US study had reported financial toxicity prevalence in sarcoma.¹ In a multicenter German study of 1103 patients with sarcoma, 44.7% reported financial toxicity, and patients had 2.5 times the odds of reporting financial difficulties compared with an age- and sex-matched general population.²

“Sarcoma treatment is often prolonged, at times requiring hospitalization for therapy and treatment-related complications, which can substantially disrupt employment, education, and opportunities for financial stability,” the authors wrote.¹ They added that younger patients have fewer financial reserves and less time to build savings.

Researchers analyzed data from the Cohort to Augment the Understanding of Sarcoma Survivorship Across the Lifespan, which enrolled adults with sarcoma treated at Vanderbilt University Medical Center in Nashville, Tennessee, between April 2022 and August 2025. Of 1499 adults enrolled, 1125 completed the COST, including 515 receiving active therapy and 610 off therapy. The COST is an 11-item measure validated among patients with stage IV solid tumors receiving chemotherapy.^3,4 Scores range from 0 to 44, with lower scores indicating greater financial toxicity, and the authors classified scores of 26 or higher as no financial toxicity, 14 to 25 as mild, 1 to 13 as moderate, and 0 as severe.¹ The median age was 56.3 years (IQR, 41.5-67.3), 54.7% were female, 85.2% identified as White, and 23.4% had metastatic disease.

Risk Factors for Financial Toxicity in Sarcoma

The median COST score was 27.0 (IQR, 18.0-35.0), and 55.4% of participants had no financial toxicity, 29.2% had mild financial toxicity, 15.1% had moderate financial toxicity, and 0.4% had severe financial toxicity. Some level of financial toxicity was reported by 48.9% of patients receiving therapy and 41.0% of those off therapy.

In the full cohort, COST scores were higher, indicating less financial toxicity, with each 10-year increase in age (1.28 points; 95% CI, 0.86-1.70; P < .001), male sex (1.93 points; 95% CI, 0.78-3.08; P = .001), and each $10,000 increase in household income (0.87 points; 95% CI, 0.72-1.01; P < .001). Lower scores were associated with non-White race (–1.77 points; 95% CI, –3.41 to –0.13; P = .035), each additional household member (–0.73 points; 95% CI, –1.25 to –0.22; P = .0055), metastatic disease (–2.36 points; 95% CI, –3.80 to –0.91; P = .0015), and active treatment (–1.61 points; 95% CI, –2.97 to –0.24; P = .021).

Among patients receiving therapy, age, income, male sex, and metastatic disease (–2.89 points; 95% CI, –4.85 to –0.92; P = .0041) remained significantly associated with COST scores.

Among patients off therapy, age, income, and household size were significant, but metastatic disease was not. “This likely reflects that household income, a fixed resource, must stretch further with increasing numbers of members,” the authors wrote with regard to household income.

Anxiety, Depression, and Pain Linked to Financial Toxicity

Among 832 participants who also completed all 7 domains of the Patient-Reported Outcomes Measurement Information System (PROMIS)-57 profile, each 10-point increase in T-score for anxiety (–0.77; 95% CI, –1.45 to –0.08; P = .028), depression (–2.11; 95% CI, –2.96 to –1.26; P < .001), pain interference (–1.36; 95% CI, –2.17 to –0.55; P = .0011), and sleep disturbance (–0.68; 95% CI, –1.35 to –0.004; P = .049) was associated with lower COST scores. Fatigue, physical function, and social roles scores were not significantly associated with financial toxicity.

The study was limited by its cross-sectional, single-center design and a predominantly White population, and the authors noted that associations between race and outcomes should be interpreted with caution. Participants who completed both the COST and PROMIS-57 differed from those who did not in ways suggesting a bias toward socioeconomic advantage, so financial toxicity may have been underestimated, they wrote. Objective financial measures, such as out-of-pocket costs and medical debt, were also unavailable.

The authors called for integrating financial toxicity screening into routine cancer care and expanding access to patient and financial navigation services. They also recommended item-level analyses of the COST measure and qualitative research with patients, survivors, and families.

“Recognizing individuals at greatest risk for [financial toxicity] can inform strategies to mitigate its contribution to cancer-related adverse outcomes and patient [quality of life],” the authors concluded. “… With identification of [financial toxicity] among patients, we may empower provider-patient communication to identify financial barriers, expand access to patient and financial navigation services, increase awareness of psychosocial needs, and integrate [financial toxicity] screening into routine cancer care. Collectively, such efforts may have the potential to reduce [financial toxicity] and improve both patient well-being and treatment outcomes.”

References

1. Robinson MJ, Sun L, Koyama T, et al. Prevalence and risk factors for financial toxicity among sarcoma patients during and following treatment across the lifespan. Cancer Rep (Hoboken). 2026;9(10):e70686. doi:10.1002/cnr2.70686

2. Büttner M, Singer S, Hentschel L, et al. Financial toxicity in sarcoma patients and survivors in Germany: results from the multicenter PROSa study. Support Care Cancer. 2022;30(1):187-196. doi:10.1007/s00520-021-06406-3

3. de Souza JA, Yap BJ, Wroblewski K, et al. Measuring financial toxicity as a clinically relevant patient-reported outcome: the validation of the COmprehensive Score for financial Toxicity (COST). Cancer. 2017;123(3):476-484. doi:10.1002/cncr.30369

4. Dangi-Garimella S. COST: a new tool to measure financial toxicity as a PRO. AJMC^®. October 10, 2016. Accessed October 21, 2026. https://www.ajmc.com/view/cost-a-new-tool-to-measure-financial-toxicity-as-a-pro