Prevalence of and factors associated with financial toxicity among gastrointestinal cancer patients in Pakistan.

Background: Financial toxicity (FT) impacts cancer care in low- and middle-income countries (LMICs), affecting treatment adherence and quality of life. This study assesses FT prevalence and associated factors among gastrointestinal (GI) cancer patients across distinct healthcare systems in Pakistan. Methods: A cross-sectional study was conducted across three tertiary care centers in Karachi: Aga Khan University Hospital (AKUH, private, fee-for-service), Jinnah Postgraduate Medical Center (JPMC, public, free), and Cancer Foundation Hospital (CFH, private-philanthropy, subsidized). FT was assessed using the Urdu version of the Comprehensive Score for Financial Toxicity–Functional Assessment of Chronic Illness Therapy (COST-FACIT). Multivariable negative binomial regression identified factors linked to high FT. Results: Of 375 patients, 44.5% were from AKUH, 33.6% from JPMC, and 21.9% from CFH. Mean age was 50.8 ± 14.4 years, with 62.4% males. Only 8.3% had health insurance, and the median International Wealth Index (IWI) was 79.9 (IQR: 57.1–95.1). Catastrophic healthcare expenditure affected 41.7%. The mean COST-FACIT score was 16.0 ± 7.4, with 46.1% experiencing mild FT (score: 14–26) and 41.9% moderate FT (score: ≤14). Patients delaying or forgoing care had higher FT (p < 0.001). Borrowing money, selling assets, or cutting essential expenses were strongly associated with increased FT (p < 0.001). Patients at AKUH reported higher FT than JPMC (IRR = 0.84, 95% CI: 0.74–0.97). Younger patients (21–50 years) (IRR = 0.66, 95% CI: 0.46–0.95) and those receiving chemotherapy (IRR = 0.89, 95% CI: 0.81–0.98) experienced higher FT. Females (IRR = 1.36, 95% CI: 1.17–1.58) and higher socioeconomic status (IRR = 1.39, 95% CI: 1.06–1.83) were associated with lower FT. Conclusions: Nearly 85% of GI cancer patients faced FT. Younger age, male gender, lower socioeconomic status, and systemic therapy were associated with higher FT. Subsidized care, financial support, and institution-specific strategies are critical to mitigating FT in LMIC healthcare systems.