Systematic reviews consistently show that younger age, non-white race, and distance from treatment centers are important risk factors for increased FT [23]. The adjusted probability of “material hardship” decreased from 34% in patients aged 18 to 54 years, to 23% in patients aged 55 to 64 years, 18% in patients aged 65 to 74 years, and 10% in those aged $\ge$75 years [24]. Younger patients may have a higher reliance on employer-provided insurance or possess limited savings from employment, thereby exposing this age group to a greater risk of financial vulnerability. According to one analysis, GO patients aged 65 years had a 2.6-fold increased likelihood of experiencing FT [19]. Additionally, a systematic review encompassing all cancer patients revealed a correlation between worsening FT and dose-dependent responses with decreasing age [23]. The unequal distribution of health-related services poses challenges for non-white races. Ethnic minorities often encounter difficulties in accessing medical resources and information due to historical factors, cultural differences, and social status [9, 11]. Consequently, they face obstacles in obtaining proper and timely medical advice, further exacerbating their financial burden. Individuals with lower incomes, no insurance, or who are unemployed may also be at greater risk of FT [19, 21, 24], as well as those with a lower education level [10]. Unemployment is the most important factor leading to the financial strain experienced by GO patients. Most patients move from stable, full-time jobs to part-time jobs or unpaid leave in order to receive continuous treatment for their disease. Compared with other cancer patients, GO patients have a higher risk of unemployment, longer absence from work due to illness [25], reduced sources of income, and are more susceptible to FT. Free medical insurance and employee medical insurance have a protective effect against FT [11, 26]. The payment method for medical expenses and marital status have also been associated with FT [11]. Patients with private insurance are less likely to experience FT [9]. Marital status impacts whether women receive more economic and spiritual support from their families. Unmarried GO patients may experience greater anxiety, psychological pain and economic pressure.

In addition to the length of hospitalization [10], type of treatment [10], systemic treatment [11] and other factors, the occurrence of postoperative complications [21] also affects the economic burden on GO patients. Patients with more complications after surgery often require a longer hospital stay and may therefore have to pay more. The initial treatment after diagnosis is also an important cause of increased economic burden [9]. Cancer treatment is usually comprehensive, including chemotherapy, radiation therapy and surgery. The costs incurred naturally increase with the number of treatments received. Imaging examinations and outpatient visits also contribute to the financial burden [11]. Not only do these tests and visits add more expense, but they can also be accompanied by other non-medical expenses such as transportation costs, parking fees, nutrition costs, and time burdens. It is important to note that no specific cancer type or stage is consistently associated with increased FT [18, 23]. However, patients receiving chemotherapy for gynecological tumors are more likely to report high FT [9].

Multiple studies have confirmed that the FT of GO patients is closely related to the tumor type, disease stage, time after diagnosis and specific treatments [10, 11, 21, 27, 28, 29, 30]. Among these factors, the tumor type exerts a particularly strong influence. The FT of GO, particularly cervical and ovarian cancers, is markedly higher than that of other common cancer types, such as breast cancer. Cervical cancer patients exhibit a slightly higher level of FT compared to patients with other gynecological tumors. This difference is primarily due to the extended treatment duration, the extensive use of high-cost targeted and immunotherapy agents, and the inherent vulnerability of the patient population. The latter is evidenced by the high incidence and low screening rates in low-income regions, leading to a predominance of advanced-stage cases and elevated recurrence rates [27, 28]. In contrast, breast cancer has a reduced per capita treatment cost thanks to the popularization of early screening. The high recurrence rate of GO further exacerbates the economic burden due to the repeated cost of treatment [29]. The time elapsed after diagnosis has a crucial impact on FT. Early diagnosis and timely treatment usually mean simpler, more effective and lower-cost options. Delayed diagnosis or missing the best treatment opportunity often requires more complex, time-consuming and expensive treatments [10]. Although there are differences in the association between FT and the tumor type and stage, the national data show that patients with cervical cancer and ovarian cancer experience a greater FT than those with uterine cancer, reflecting the higher utilization of medical resources, out-of-pocket expenses, and time costs associated with more intensive treatment regimens [21]. The risk of FT was almost double in patients who received chemotherapy as the initial treatment [11]. However, a similar increased risk was not observed in patients who received only radiotherapy and/or surgical treatment [10]. Meanwhile, the incidence of FT gradually increased as the number of ordered imaging examinations increased. An increased number of clinical visits also correlated positively with FT. Finally, participation in clinical trials often requires frequent travel by patients and caregivers, thus presenting an obstacle to the participation of economically disadvantaged groups in trials [30]. These factors jointly determine the unique and heavy financial burden on patients with GO.

The cost structure of gynecological cancer treatment varies by tumor type, treatment modality and region. Direct medical costs (surgery, chemotherapy, and radiotherapy) constitute the primary economic burden, while indirect costs (e.g., transportation, lost income, and caregiving) account for 13% of FT sources [22, 31]. The proportion of out-of-pocket (OOP) payments in treatment expenses often triggers catastrophic consequences, with a global average OOP proportion of 18%. In developing countries, OOP proportions are generally higher, such as 72% in Nigeria and 67% in Bangladesh. By contrast, developed nations like the UK (10%) and the U.S. (11%) exhibit relatively lower OOP proportions [32]. Many patients incur debt or resort to borrowing, selling assets, or abandoning treatment to sustain basic living needs. In Malaysia, 64% of gynecological cancer households face catastrophic health expenditure (CHE; medical spending $\ge$40% of disposable household income), and 17% fall into poverty [33]. In Vietnam, 41% of breast cancer patients require loans, asset sales or treatment discontinuation [34]. Inadequate social safety nets further exacerbate the burden; only 20%–40% of patients in LMICs have basic medical insurance with low reimbursement rates [35]. This coverage gap leads to treatment delays or abandonment and diminished quality of life. 87% of cervical cancer patients in Kenya delay care due to costs and 75% cannot afford diagnostic tests [31]. Patients in LMICs face a 2.3-fold higher risk of abandoning chemotherapy than those in Western countries (odds ratio [OR] = 1.94; 95% confidence interval [CI]: 1.00–3.75) [31]. FT reduces health-related quality of life (HRQoL) scores by 12.63 points (95% CI: 9.04–16.21), with particularly severe declines in emotional function (–16.69 points) and social function (–13.49 points) [29, 31].

Cancer treatment is expensive and changes the financial structure of the patient’s family. Previous studies have found that GO patients with moderate FT are more likely to use economic cost coping strategies, such as changing their consumption habits, borrowing money, and applying for financial assistance [10, 21]. Bouberhan et al. [9] revealed that among patients experiencing high FT, 29% resorted to borrowing money or seeking financial assistance, while 51% utilized their savings to cover nursing expenses. Additionally, 32% of patients reduced their expenditure on necessities, and 43% curtailed spending on leisure activities. Furthermore, some individuals even considered selling assets such as houses, resulting in reduced quality of life. In the years following a cancer diagnosis, individuals who survive their disease are significantly more prone to experiencing financial hardships, such as unpaid bills being referred to collection agencies, mortgage defaults, tax liens placement, or property foreclosure and repossession. These challenges persist irrespective of their pre-cancer circumstances. Moreover, individuals diagnosed with cancer exhibited a 2.65-fold increased likelihood of declaring bankruptcy compared to unaffected counterparts, consequently resulting in a 79% increased risk of mortality [36]. Even though FT among cancer survivors is less severe than bankruptcy, an excessive risk of death can still be observed [37].

Individuals adapt to their new economic realities, by changing their health-related behavior, such as delaying care or skipping medications due to the cost [38]. Recent studies found that patients with highly toxic GO were 7.3-fold more likely to delay reporting their condition or receiving medical care [9], and 4.6-fold more likely not to comply with medication compared to patients with low-grade or moderately toxic GO [10, 21]. Approximately 22% of patients with high FT reported delaying or avoiding care. Moreover, patients with severe FT showed an increased risk of non-compliance with drug therapy [10], and 9% of patients with high FT delayed surgery, radiotherapy and chemotherapy [21]. This affects subsequent treatment and increases the risk of complications, further increasing the financial burden. In addition, any passive delay in treatment will increase the risk of tumor recurrence and metastasis, and may change the original cure plan, leading to increased anxiety among GO patients [39]. The degree of adherence to medication is also sensitive to out-of-pocket costs. For example, in patients receiving oral targeted therapy, the initiation of treatment and adherence to cure are inversely correlated with out-of-pocket costs [40]. Coping behaviors may also influence how cancer patients receive medical care for non-cancer-related health problems. Similarly, there are situations in which caregivers adopt coping behaviors within the family environment. Individuals from the same family are more likely to delay or forgo care due to cost considerations relating to the cancer sufferer in the family [41].

According to relevant survey data, when the score of the Comprehensive Scale of Economic and FT was lower than 26 points, the average score of quality of life (FACT-G) of cancer patients decreased by 16.5 points [20]. A survey of gynecological tumor patients using the psychological distress thermometer provided by the National Comprehensive Cancer Network (NCCN) of the United States showed that 21.6% of the patients were in a highly troubled state [24]. It is particularly notable that among married patients with gynecological tumors, the spouse is usually the primary caregiver, and the employment status is closely related to the levels of economic and FT [21]. The long-term financial predicament of gynecological cancer survivors is mainly manifested as increased medical debts and reduced income. Approximately 12%–62% of cancer survivors are in debt due to treatment [38]. Among them, the comprehensive FT score (COST) of gynecological cancer patients after treatment decreased from 21.2 points at baseline to 12.9 points, indicating a significant increase in the economic burden [42]. The reduction in working hours or unemployment caused by treatment is the main reason for the decline in income. For instance, 38% of gynecological cancer survivors were forced to resign during treatment, and 28% of family members left their jobs as a result to provide care support [42]. Survivors have to deal with chronic health problems and the risk of secondary cancers for a long time, resulting in a continuous increase in medical expenses. Data shows that the annual medical expenses of cancer survivors are approximately twice those of the cancer-free population and 75% of gynecological cancer patients have at least one chronic disease, further pushing up the costs [43]. Young patients (under 65 years old), ethnic minorities (Blacks, Hispanics), and low-income families (annual income $\$$60,000) have a higher risk of bankruptcy [42]. To cope with medical expenses, families may cut non-medical expenditures (such as education and housing), or even use pensions or borrowing, creating a long-term debt cycle [44]. The mental health of minor children may be impaired due to family economic pressure, especially children in single-parent families whose mothers have cancer are more prone to behavioral problems [44].

Early implementation of universal screening serves as the initial step towards alleviating the financial burden encountered by cancer patients. Prior to commencing formal treatment, patients may be unaware of the potential fiscal distress. Hence, early assessment of FT is of paramount importance in facilitating patient comprehension and adaptation to plausible financial challenges. Screening plays a critical role in identifying high-risk individuals at an early stage, including patients with low income, patients requiring systemic treatment, and those with inadequate insurance coverage. Patients with ovarian cancer demonstrate a relatively lower incidence of FT compared to those with types of GO, which may be attributed to the establishment of standardized treatment pathways [22]. A meta-analysis indicated that the incidence of FT was 35.3% (95% CI: 27.3%–44.4%) in high-income countries, compared to 78.8% (95% CI: 60.4%–90.0%) in low- and middle-income countries, highlighting the importance of the economic environment on screening requirements [54]. However, the optimal frequency and duration of FT screening in GO patients remains uncertain. A study involving 120 patients initiating a new therapy for gynecological tumors found no statistically significant alteration in FT, as assessed by the COST score at 6 months, even when stratified according to the presence or absence of FT at baseline [20]. Additionally, a study of 220 patients with recurrent ovarian cancer revealed that those with low FT at baseline experienced a significant increase in FT over the course of 12 months, while those who had high FT at baseline showed slight improvement [55]. This implies that the potential emergence or exacerbation of financial distress during follow-up should not be disregarded, even in the absence of apparent issues at the initial stage. Consequently, early screening for FT should be incorporated into the development of intervention programs, with repeat evaluations scheduled for the intended follow-up period. More targeted and effective intervention strategies can be devised by examining changes in FT level in patients with gynecological tumors at different stages, and by integrating dynamic indicators such as treatment duration, mode transformation, and complications. The incorporation of FT screening and management into quality indicators for oncology practice can enhance awareness of these issues in the field, thereby empowering healthcare professionals to take a more proactive approach towards mitigating financial risks for patients.

The utilization of deductibles, copays, and multi-tiered formulary sets in employer-based insurance plans continues to rise annually, meaning that cancer patients bear the majority of healthcare expenses due to the high costs of specialty cancer drugs. In view of the prolonged treatment duration required for cancer care, patients are accountable for over half of the total cost burden. They lack the opportunity to reduce treatment services without compromising the level of care [56]. FT can be effectively mitigated during the early stage of treatment if patients purchase major accident insurance, various supplementary insurance and medical assistance programs, and make reasonable use of various financial assistance resources [57]. A prospective cohort study demonstrated that an increased rate of trastuzumab use among human epidermal growth factor receptor 2 (HER2)-positive breast cancer patients who received financial support, resulting in a significantly improved 5-year survival rate (HR = 0.62, p 0.01) [58]. A study conducted in China revealed that patients who lacked commercial insurance or relied solely on urban and rural resident medical insurance faced a higher risk of FT (OR = 2.1, p 0.001), whereas those having insurance for critical illness substantially reduced catastrophic medical expenses [59]. Leopold et al. [60] indicated that patients enrolled in high-deductible health plans (HDHP) experienced elevated out-of-pocket expenses, which in turn increased the likelihood of treatment delays (OR = 1.8, 95% CI: 1.3–2.5). The Seattle-based non-profit organization Northwest Hope & Healing provided immediate economic relief to GO patients, leading to fewer treatment interruptions among those receiving aid. Health insurance plans with high cost-sharing markedly exacerbate the economic risks and treatment delays for cancer patients. The systematic integration of supplementary insurance, critical illness coverage, and targeted economic assistance can significantly alleviate FT, enhance treatment adherence, and improve survival outcomes.

In a breast cancer study, 44% of patients reported at least moderate financial distress, although only 14% engaged in discussions regarding treatment costs with their physicians [61]. Another study found that 35% of GO patients expressed a preference for pre-treatment cost disclosure [62]. Previous research has demonstrated that patients who engaged in discussions regarding anticipated treatment expenses could effectively mitigate out-of-pocket burdens [57]. Moreover, 60% of individuals undergoing cancer treatment exhibited a favorable disposition towards open communication about costs with their oncologist [63]. World Health Organization (WHO) recommends a stepwise implementation of cancer prevention and control strategies, with early screening and palliative care being more cost-effective. The “screening-treatment” strategy of human papillomavirus (HPV) primary screening combined with thermal ablation therapy can reduce the treatment cost of cervical cancer by 7.5%–12.5%, with an additional quality-adjusted life year (QALY) cost of 1383 euros [64]. In 2021, China included 17 anti-tumor drugs in the medical insurance directory, thus reducing the out-of-pocket payment ratio of patients by 30% to 50%. In 2009, the American Society of Clinical Oncology (ASCO) established guidelines for cancer treatment that emphasized the significance of doctor-patient communication concerning treatment expenses as an integral aspect of delivering high-quality care [65]. The assessment of treatment value for a patient should be based on the clinical benefits, toxicity profile, and cost-effectiveness. Additionally, it is essential to propose an alternative treatment plan or strategy to mitigate the economic burden during discussion of the patient’s treatment approach [66]. Healthcare providers should also identify uninsured or underinsured patients who are at significant risk of experiencing FT. They can subsequently offer financial assistance programs, evaluate the patients’ level of financial literacy, and help to improve their financial skills. This includes assessment of the patients’ financial situation, creation of a budget, guidance with adapting to changed economic circumstances, establishing creditworthiness, and managing debt. Patient-centered care facilitates discussion and management of the financial burden associated with cancer treatment. In addition to policy and insurance reforms aimed at enhancing affordability, institutional-level strategies may include universal screening for FT, provision of hospital parking subsidies, and the promotion of drug equity through the prescription of generic or biosimilar chemotherapy and hormone therapies that are effectively equivalent and appropriate [63]. The Financial Navigation program minimizes out-of-pocket patient expenses and mitigates hospital write-offs through the optimization of health insurance plans. This ensures that patients develop the most effective cancer diagnosis plan, often resulting in higher premiums, but reduced out-of-pocket costs, and improved coverage [67].