Introduction

The diagnosis of cancer causes physical and emotional suffering (1), which influences the lives of patients and their families, in addition to compromising multiple aspects of their lives, including financial ones. An American study (2) indicated that in 2018, in the United States of America, individuals diagnosed with cancer incurred approximately USD$5.6 billion in direct and indirect costs when undergoing treatment, a situation that can lead to or increase the onset of an adverse event in cancer treatment, known as “financial toxicity.”

Financial toxicity is defined as the subjective financial difficulty and objective financial burden resulting from medical care for high-cost diseases (3), such as cancer. The concept includes, in addition to the common costs of treatment, such as medication, appointments, and tests, all the expenses that patients did not have until the onset of the disease, i.e., transportation, special meals, the need for a caregiver, loss of income due to being absent from work, and concerns about their financial future.

Among the consequences stemming from the presence of financial toxicity are non-adherence to treatment (4), debt, unemployment, and a deterioration in health-related quality of life (HRQoL [5, 6]). A study (7) that assessed the impact of financial toxicity on the HRQoL and health behaviors of American patients found that greater financial toxicity was significantly associated with anxiety, fatigue, pain, functional capacity, and social aspects, indicating a relationship between both. HRQoL reflects the individual’s perception of the condition as well as its consequences and treatments, that is, how the disease influences their life. In nursing, HRQoL has a positive impact on the patient’s perception of health (8).

Although the World Health Organization and the Pan American Health Organization have studied HRQoL and the factors related to it, no research initiative by these agencies covering the theme of financial toxicity has been found. The studies available in the international literature were conducted by groups of researchers affiliated with universities. In Brazil, studies evaluating financial toxicity are incipient, but reveal the existence of challenges and suffering resulting from treatment costs, even with the existence of the Unified Health System (SUS, for its initials in Portuguese). A study (9) evaluating the financial toxicity experienced by cancer patients receiving care at both a public and a private institution showed the presence of this adverse event in both samples. However, this study was unable to find a correlation between financial toxicity and HRQoL.

Within this context where cancer patients have needs that can lead to more financial expenses and where the COVID-19 pandemic has led to an economic crisis, with increased unemployment, reduced purchasing power, and compromised daily life activities, all of which are conditions that impact HRQoL, present study aimed to correlate financial toxicity with the HRQoL of adults with cancer during the COVID-19 pandemic.

Materials and Methods

This was an observational, cross-sectional, and correlational study, which followed the Strobe (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines. It is part of a thematic project entitled “Financial toxicity in chronic illness,” performed by a group of researchers affiliated with the Nursing Department of the Federal University of Parana, Brazil.

This study was performed from September 2021 to December 2022, on two weekdays in the afternoon, with the following inclusion criteria for participation: to be an adult of either sex, aged 18 or over and to have started cancer treatment five months ago or more. This period of five months was adopted given that, at the start of treatment, patients may not have suffered economic impacts yet. People with difficulties in communication and/or cognitive limitations in their medical records were excluded.

The sample was scaled to 170 participants using Fisher’s z-test to compare a correlation with a reference value, based on the following parameters: A statistical significance level of 5 %, a statistical power of 80 %, a correlation coefficient of 0.44 (reference value [10]), and a correlation coefficient in the case of a null hypothesis of 0.25. The sample was selected based on convenience, and all patients who were present during the data collection period were invited; however, two of them refused to participate.

Of the 181 patients who were eligible to participate in the study, a total of 179 from two different units participated: from the hematology and oncology outpatient clinic (143) and the inpatient department (36), both belonging to a public teaching hospital, fully funded by the SUS, located in a capital city in southern Brazil.

Data collection was conducted in person and three printed questionnaires were used: a) a sociodemographic and clinical questionnaire, developed and used in other studies (9, 11) by the authors, consisting of 14 questions related to age, sex, race, marital status, education, financial situation, time since diagnosis, medication use, alcohol consumption, and smoking; b) the Comprehensive Score for Financial Toxicity (COST), consisting of 12 items relating to financial condition, treatment costs, financial concerns, among others; c) the Functional Assessment of Cancer Therapy-General (FACT-G), consisting of 27 items, which measures the HRQoL of cancer patients through the domains of “physical, social, emotional, and functional well-being.” Both have been translated and validated for the Brazilian context (11, 12).

To measure financial toxicity using the COST questionnaire, the FACIT guideline was followed (13). Questions 2, 3, 4, 5, 8, 9, and 10 were inverted and item 12 was disregarded. The score ranged from 0 to 44, and the higher the score, the greater the financial well-being and the lower the financial toxicity. The financial tox icity score was divided into grades according to a Japanese study (14). The grades (from 0 to 3) reflect the impact suffered by patients. This can range from no impact - grade 0 (score above 26), to mild impact - grade 1 (score 14-25), moderate impact - grade 2 (score 1-13), and high impact - grade 3 (score 0). To measure the FACT-G score, the scoring guidelines of the questionnaire were used (15), whose score is the sum of the points for each domain and can range from 0 to 108.

During the data collection period, the researchers talked to the potential participants and explained how the study would be conducted. Once they had accepted to participate, the informed consent form was read and signed in two printed copies (one was handed to the participants and the other remained with the researcher, who kept it on file). Subsequently, the three questionnaires were distributed and the need for help to read and complete them was identified.

The data was analyzed using descriptive (mean, standard deviation) and inferential (t-Student or Mann-Whitney tests) analyses. The absolute and relative frequencies of sociodemographic and clinical characteristics were presented for the sample as a whole and were stratified by data collection site. Statistical differences were assessed using Pearson’s chi-squared test. Means and standard deviations (SD), medians and interquartile ranges (IR) of the financial toxicity and HRQoL scores and their respective domains were presented for the sample as a whole and were stratified by data collection site.

The correlation between financial toxicity and HRQoL was measured using Spearman’s coefficient. All the analyses were performed using the Stata software (version 13.1) at a statistical significance level of 5 %.

This study was reviewed and approved by the Research Ethics Committee of the Hospital de Clínicas of the Universidade Federal do Paraná, under opinion number 3.957.590. The questionnaires used for data collection were authorized for this purpose.

Results

Of the 179 study participants (total sample), 114 (63.7 %) were female, 103 (57.5 %) were under age 60, 94 (52.5 %) were married or in a stable union, and 145 (81.1 %) had an income of up to three times the Brazilian minimum wage. In terms of clinical data, 99 (55.3 %) participants stated that they did not have any comorbidities; of those who did, a total of 41 (22.9 %), systemic arterial hypertension was the most common; 122 (68.2 %) of them reported being on continuous medication (Table 1).

Regarding the diagnosis of neoplasms, 50 (27.9 %) participants had breast cancer and 30 (16.7 %) had leukemia. As for lifestyle habits, 128 (71.5 %) participants stated they did not practice any physical activity, 78 (43.6 %) were smokers, and 28 (15.6 %) consumed alcoholic beverages (Table 1).

Regarding the financial toxicity of the total sample, the mean score obtained was 20.1/44 (17.8/44 for inpatients and 20.7/44 for outpatients, both with grade one financial toxicity). Concerning HRQoL, the mean score obtained for the total sample was 73.3/108 (74.6/108 for inpatients and 73/108 for outpatients). Table 2 shows the relationship between financial toxicity and HRQoL.

When relating financial toxicity to HRQoL, the Spearman correlation coefficient found in the total sample was 0.41 and the p-value was <0.001, which means there was positive significance. Considering the samples separately, the correlation in the inpatient sector was 0.33 with a p-value < 0.047 while in the outpatient sector, it was 0.43 with a p-value < 0.001.

Table 3 shows the correlation between the total HRQoL score and the domains that comprise it. The results show that, considering the three samples, the “emotional well-being” domain was significant and there was no correlation in the “social and family well-being” domain. In the inpatient sample, the “emotional well-being” domain was significant, while in the outpatient sample the “physical well-being”, “emotional well-being”, and “functional well-being” domains were significant.

Discussion

The present study describes the correlation between financial toxicity and HRQoL in adults with cancer during the COVID-19 pandemic. It was performed on the basis that cancer is among the chronic non-communicable diseases with the highest costs associated with treatment, which could lead to financial toxicity and influence HRQoL.

It was possible to note that the sociodemographic data of the total sample in this study was similar to the data from the outpatient information system in 2022, when 10732 chemotherapy treatments were performed on female patients and 7226 on male patients (16). This data showed that more women underwent the treatment or were more likely to adhere to it or seek treatment earlier in the course of the disease.

Regarding age, the results found in the present study differ from those found in a Japanese study (17) but are similar to those found in a study conducted in China (18), which assessed the levels of financial toxicity and related risk factors in 594 cancer patients. The study in question found a higher ratio of participants aged 45-59.

In Brazil, people in this age range are economically active and part of the workforce. According to a leading Brazilian institute (19), in 2022, more than 108 million people in Brazil would be of working age. The occurrence of cancer at this stage of life can reduce income and intensify financial toxicity.

In addition, the COVID-19 pandemic may have aggravated the consequences of financial toxicity for cancer patients. A renowned Brazilian foundation emphasized that the pandemic led to a crisis of unprecedented proportions, where the population faced social and economic vulnerability (20), combined with the threat of the collapse of the SUS (21), which resulted in a financial burden on patients to cover treatment costs. On top of these issues stemming from the pandemic and the lack of financial resources, the fear of being infected by the virus may have intensified depression and anxiety.

A Brazilian study (22) which aimed to understand the feelings experienced by women who had been diagnosed with breast cancer found that, upon receiving the diagnosis, they experienced feelings such as despair, concern for their family, closeness to and fear of death, sadness, denial, faith in a cure, and acceptance. These feelings can be intensified in working age due to the possible loss of income and increased expenses caused by treatment. A study (23) conducted in an outpatient mastology clinic in the countryside of the state of Sao Paulo, Brazil, found that the diagnosis of cancer at a working age led the sample studied to be concerned about their personal and family finances and changes in their lifestyle. This fear may be more evident in women who live alone with their children, as they are the ones who have to support the household.

Even before they are diagnosed, cancer patients incur unexpected expenses, such as exams, medication, transportation, special meals, the need for special food or a caregiver, and sometimes a reduction in income due to absence from work, all of which have an impact on the family finances and highlight financial toxicity. This indicates that even patients receiving care through the SUS who do not pay for the treatment themselves absorb costs and are affected by financial toxicity.

Regarding financial toxicity, the results obtained are similar to those found in international studies, such as a Chinese study (24) that analyzed the financial toxicity of patients with breast cancer and obtained a score of 21. Similarly, a study (25) that investigated financial toxicity in 539 patients with renal cell carcinoma from 14 different countries obtained a financial toxicity score of 21.5. Likewise, a study conducted in Canada (26) with patients with advanced lung cancer obtained a mean score of 21, while a 2022 Argentinian study (27) with patients with lung cancer obtained a mean score of 20 (mild impact of financial toxicity).

In contrast, a Brazilian study (9) that assessed the financial toxicity of cancer patients in the period prior to the pandemic obtained a financial toxicity score of 18.95, while a Mexican study (28) that explored and analyzed the financial burden of cancer among the elderly and their families and/or caregivers obtained a mean score of 16.4 (28). The result found in this study may be related to the support provided by the Brazilian government (29) during the global health crisis, which granted every citizen in a situation of vulnerability a monthly payment to cover their needs.

“Emergency aid” was a form of financial support provided during the pandemic to guarantee a minimum income for Brazilians, since some sectors of the economy were affected by the rules of isolation and social distancing. According to a Brazilian study (30) covering the pandemic and unemployment, the behavioral rules imposed during the pandemic have led to swift changes in the job market, with rigorous effects for 37.3 million people who lack formal employment and who do not have rights such as the Employment Guarantee Fund (better known by its acronym FGTS - Fundo de Garantia por Tempo de Serviço) and unemployment insurance, which are benefits intended to guarantee temporary financial assistance to workers who have been terminated without just cause.

Considering the samples in isolation and the financial toxicity scores, the results of the participants who received inpatient treatment may be related to financial concerns among them and the number of patients with an income of up to the minimum wage and those with no income in this sample.

A study (31) conducted in northern India that analyzed the financial toxicity and mental well-being of oral cancer survivors found that financial toxicity scores were lower among the unemployed. Also in this line of thought, a German study (32) that assessed whether financial toxicity was an issue for sarcoma patients, identifying the related risk factors, found that receiving a disability pension and being on sick leave were associated with higher odds of reporting financial toxicity.

The results of the correlation between financial toxicity and HRQoL indicate that the greater the financial well-being, the higher the HRQoL. These findings corroborate those found by an American study that measured financial toxicity and its association with quality of life in patients with advanced melanoma receiving immunotherapy and found a correlation of r = .44, p < 0.00133.

Similarly, a study (31) conducted in the United States, which measured the course of financial hardship at the start of treatment, at three and six months, and established the relationship with quality of life in cancer patients, found that less financial hardship was correlated with better HRQoL. In terms of the correlation between the total HRQoL score and the domains that comprise this construct, the results indicate that living together can be harmonious and beneficial regardless of the financial resources available.

The limitations of the present study lie in the size of the sample from the inpatient sector, which was restricted due to the limited turnover, as well as the lack of national literature to compare the findings in the various Brazilian regions.

Conclusion

Thus, it can be concluded that a grade one financial toxicity was found among adult inpatients and outpatients with cancer. In isolation, participants undergoing outpatient treatment had a higher financial toxicity score, which reflected greater financial well-being; in addition, the relationship between financial toxicity and HRQoL was significant, indicating that the lower the financial hardship, the higher the HRQoL. It is believed that the present study contributes to practice, as it highlights the presence of financial toxicity among patients receiving care from the SUS.

Furthermore, it is understood that knowing and recognizing financial toxicity as an adverse event of cancer treatment provides healthcare professionals and managers the conditions to devise a care plan that supports the patient.

Introdução

O diagnostico do cancer causa sofrimento fisico e emocional (1), que influencia a vida de pacientes e familiares, alem de comprometer multiplos aspectos, entre eles, o economico. Um estudo estadunidense (2) apontou que, em 2018, nos Estados Unidos da America, individuos diagnosticados com cancer empregaram aproximadamente USD$ 5,6 bilhoes em custos diretos e indiretos na realizacao do tratamento, situacao que pode gerar ou potencializar o surgimento de um evento adverso do tratamento do cancer, nominado como “toxicidade financeira”.

A toxicidade financeira e definida como a dificuldade financeira subjetiva e o onus financeiro objetivo dos cuidados medicos de doencas dispendiosas (3), como o cancer. O conceito inclui, alem dos custos comuns do tratamento, como medicamentos, consultas e exames, todas as despesas que o paciente nao tinha ate o momento do surgimento da doenca, ou seja, engloba transporte, alimentacao diferenciada, necessidade de cuidador, perda de renda devido a ausencias no trabalho e preocupacao com relacao ao futuro financeiro.

Entre as consequencias da presenca da toxicidade financeira, encontram- se a nao aderencia ao tratamento (4), o endividamento, o desemprego e a piora da qualidade de vida relacionada a saude (QVRS [5, 6]). Estudo (7) que verificou o impacto da toxicidade financeira na QVRS e nos comportamentos de saude de pacientes estadunidenses encontrou que maior toxicidade financeira foi significativamente associada com ansiedade, fadiga, dor, capacidade funcional e aspectos sociais, indicando relacao entre ambas.

A QVRS reflete a percepcao do individuo diante da enfermidade e as consequencias e os tratamentos referentes a ela, ou seja, como a doenca influencia em sua vida util. Na enfermagem, a QVRS demonstra um impacto positivo na percepcao de saude do paciente (8).

Embora a Organizacao Mundial de Saude e a Organizacao Pan-Americana de Saude estudem a QVRS e os fatores a ela relacionados, nao foram encontradas iniciativas de pesquisas sobre a toxicidade financeira por parte dessas agencias. Os estudos disponiveis na literatura mundial foram realizados por grupos de pesquisadores vinculados a universidades. No Brasil, estudos de avaliacao da toxicidade financeira sao incipientes, mas revelam a existencia de dificuldades e sofrimentos decorrentes dos custos do tratamento, mesmo na existencia do Sistema Unico de Saude (SUS). Estudo (9) que avaliou a toxicidade financeira de pacientes com cancer, atendidos por uma instituicao publica e outra privada, mostrou a presenca do evento adverso em ambas as amostras. No entanto, tal estudo nao verificou a correlacao entre a toxicidade financeira e a QVRS.

Dentro do contexto de que pacientes com cancer demandam necesidades que podem gerar mais gastos financeiros e que a pandemia da covid-19 originou uma crise economica, com aumento do desemprego, diminuicao do poder de compra e comprometimento das atividades da vida diaria, condicoes que impactam a QVRS, este estudo teve como objetivo correlacionar a toxicidade financeira com a QVRS de adultos com cancer durante a pandemia da covid-19.

Materiais e método

Trata-se de um estudo observacional, transversal e correlacional, que seguiu as recomendacoes do Strengthening the Reporting of Observational Studies in Epidemiology (Strobe). Ele integra o projeto tematico intitulado “A toxicidade financeira na doenca cronica”, desenvolvido por um grupo de pesquisadores vinculados ao Departamento de Enfermagem da Universidade Federal do Parana, Brasil.

A pesquisa foi conduzida entre setembro de 2021 e dezembro de 2022, durante dois dias da semana, em periodo vespertino, e teve os seguintes criterios de inclusao para a participacao: adultos de ambos os sexos, com idades iguais ou superiores a 18 anos, e ter iniciado tratamento de cancer ha cinco meses ou mais. Esse periodo de cinco meses foi considerado em virtude de que, no inicio do tratamento, o paciente pode nao ter sofrido com os impactos economicos. Foram excluidas pessoas com dificuldade na comunicacao e/ou limitacoes cognitivas registradas em prontuario.

A amostra foi dimensionada em 170 participantes com base no teste z de Fisher para a comparacao de uma correlacao com um valor de referencia, a partir dos seguintes parametros: nivel de significancia estatistica de 5 %, poder estatistico de 80 %, coeficiente de correlacao de 0,44 (valor de referencia [10]) e coeficiente de correlacao em caso de hipotese nula de 0,25.

A selecao da amostra foi por conveniencia, sendo convidados todos os pacientes que estivessem no local no momento da coleta de dados. Houve duas recusas em participar.

Dos 181 pacientes aptos a participar do estudo, participaram 179 de duas unidades distintas, a saber: ambulatorio de hematología e oncologia (143) e setor de internacao (36), ambos pertencentes a um hospital publico do tipo escola, totalmente financiado pelo SUS, localizado em uma capital do sul do Brasil.

A coleta de dados ocorreu de forma presencial e foram utilizados tres questionarios impressos: a) sociodemografico e clinico, desenvolvido e utilizado em outros estudos (9, 11) pelos autores, composto por 14 questoes relacionadas a idade, sexo, raca, estado civil, escolaridade, situacao financeira, tempo de diagnostico, uso de medicamentos, consumo de bebida alcoolica e tabagismo; b) COmprehensive Score for Financial Toxicity (COST), constituido por 12 itens, referentes a condicao financeira, custear o tratamento, preocupacoes financeiras, entre outros; c) Functional Assessment of Cancer Therapy-General (FACT-G), com 27 itens, o qual mensura a QVRS de pacientes com cancer por meio dos dominios “bem-estar fisico, social, emocional e funcional”. Ambos foram traduzidos e validados para a cultura brasileira (11, 12).

Para mensurar a toxicidade financeira a partir do questionario COST, seguiu-se o guideline do grupo norte-americano FACIT (13). Dessa forma, as questoes 2, 3, 4, 5, 8, 9 e 10 foram invertidas, e o item 12, desconsiderado. A pontuacao do escore variou de 0 a 44, sendo que, quanto mais alto, maior era o bem-estar financeiro e menor a toxicidade financeira. O escore de toxicidade financeira foi dividido em graus de acordo com o estudo japones (14). Os graus (de 0 a 3) refletem o impacto sofrido pelos pacientes. Este pode variar entre nenhum impacto - grau 0 (escore acima de 26), impacto leve - grau 1 (escore de 14-25), impacto moderado - grau 2 (escore de 1-13) e impacto alto - grau 3 (escore 0).

Para a mensuracao do escore do FACT-G, utilizou-se o scoring guidelines do questionario (15), cuja pontuacao e a soma dos pontos de cada dominio e pode variar de 0 a 108.

Na ocasiao da coleta de dados, os pesquisadores abordavam os possiveis participantes e explicavam como funcionaria a realizacao da pesquisa. Apos o aceite, o termo de consentimento livre e esclarecido era lido e assinado em duas vias impressas (uma era entregue ao participante e outra ficava com a pesquisadora, que a mantem arquivada). Posteriormente, eram entregues os tres questionarios e identificada a necessidade de ajuda para com a leitura e com o preenchimento.

A analise dos dados foi realizada com analise descritiva (media, desvio- padrao) e inferencial (testes de t-Student ou Mann-Whitney). A apresentacao de frequencias absolutas e relativas das características sociodemograficas e clinicas da amostra como um todo e estratificada por local de coleta de dados. Diferencas estatisticas foram avaliadas com o teste de qui-quadrado de Pearson. Foram apresentadas medias e desvios-padrao (DP), medianas e intervalos interquartis (IQ) do escore de toxicidade financeira, e do escore QVRS e de seus respectivos dominios para a amostra como um todo e estratificada por local de coleta de dados.

A correlacao entre a toxicidade financeira e a QVRS foi mensurada com o coeficiente de Spearman. Todas as analises foram realizadas no software Stata (versao 13.1) a um nivel de significancia estatistica de 5 %.

Este estudo foi apreciado e aprovado pelo Comite de Etica em Pesquisa do Hospital de Clinicas da Universidade Federal do Parana, parecer numero 3.957.590. Os questionarios utilizados na coleta de dados foram autorizados para tal fim.

Resultados

Dos 179 participantes do estudo (amostra total), 114 (63,7 %) eran do sexo feminino, 103 (57,5 %) tinham menos de 60 anos de idade, 94 (52,5 %) declararam-se casados ou em uniao estavel, 145 (81,1 %) tinham renda de ate 3 salarios-minimos brasileiros. Em se tratando de dados clinicos, 99 (55,3 %) participantes declararam nao possuir nenhuma comorbidade; daqueles que possuiam, a hipertensao arterial sistemica foi a mais comum, 41 (22,9 %); 122 (68,2 %) referiram utilizar medicacao continua (Tabela 1).

Com relacao ao diagnostico de neoplasias, 50 (27,9 %) participantes mtinham cancer de mama e 30 (16,7 %), leucemia. Quanto aos habitos de vida, 128 (71,5 %) participantes nao praticavam atividade fisica, 78 (43,6 %) fumavam e 28 (15,6 %) consumiam bebida alcoolica (Tabela 1).

No que diz respeito a toxicidade financeira da amostra total, o escore medio encontrado foi de 20,1/44 (17,8/44 para os participantes do setor de internacao e 20,7/44 para os participantes do ambulatorio, ambos com grau um de toxicidade financeira) Com relacao a QVRS, o escore medio encontrado na amostra total foi de 73,3/108 (74,6/108 para os participantes do setor de internacao e 73/108 para os participantes do ambulatorio). A Tabela 2 demonstra a relacao entre a toxicidade financeira e a QVRS.

Ao relacionar a toxicidade financeira a QVRS, o coeficiente de correlacao de Spearman encontrado na amostra total foi de 0,41 e o p-valor de < 0,001, ou seja, existe significancia positiva. Considerando as amostras separadamente, a correlacao no setor de internacao foi de 0,33 e o p-valor < 0,047 e no ambulatorio, 0,43 com p-valor < 0,001.

A Tabela 3 exibe a correlacao entre o escore total de QVRS e os dominios que a compoem. Os resultados revelam que, considerando as tres amostras, houve significancia no dominio “bem-estar emocional” e nao houve correlacao no dominio “bem-estar social e familiar”. Na amostra do setor de internacao, observou-se significancia no dominio “bem-estar emocional” e, na amostra do ambulatorio, nos dominios “bem-estar fisico”, “bem-estar emocional” e “bem-estar funcional”.

Discussão

Este estudo descreveu a correlacao entre a toxicidade financeira e a QVRS de adultos com cancer durante a pandemia da covid-19. Foi realizado por considerar que o cancer esta entre as doencas cronicas nao transmissiveis com maior custo associado ao tratamento, condicao que pode evidenciar a toxicidade financeira e influenciar a QVRS.

Foi possivel observar que os dados sociodemograficos da amostra total do presente estudo foram semelhantes aos dados do sistema de informacao ambulatorial no ano de 2022, quando foram realizadas 10732 quimioterapias em pacientes do sexo feminino e 7226 no sexo masculino (16). Esse dado revelou que mais mulheres realizaram o tratamento ou tiveram maior adesao a ele, ou procuram o servico mais precocemente a doenca.

Com relacao a idade, os resultados obtidos destoam dos encontrados em estudo japones (17), mas se assemelham aos de estudo desenvolvido na China (18), que investigou os niveis de toxicidade financeira e fatores de risco relacionados em 594 pacientes com cancer. O estudo em questao encontrou maior proporcao de participantes com idades entre 45-59 anos.

No Brasil, nessa faixa etaria, as pessoas encontram-se em idade economicamente ativa e inseridas no mercado de trabalho. De acordo com um importante instituto brasileiro (19), no ano de 2022, mais de 108 milhoes de pessoas no Brasil encontravam-se em faixa etaria apta a trabalhar. A ocorrencia do cancer nessa etapa da vida pode diminuir a renda e intensificar a toxicidade financeira.

Ademais, a pandemia da covid-19 pode ter agravado as consequencias da toxicidade financeira para os pacientes com cancer. Uma importante fundacao brasileira enfatizou que a pandemia criou uma crise de proporcoes ineditas, em que a populacao se encontrava em situacao de vulnerabilidade social e economica (20), somada a ameaca de colapso do SUS (21), o que resultou em sobrecarga financeira aos pacientes para o custeio de despesas do tratamento. Alem dessas questoes advindas da pandemia e da ausencia de condicoes financeiras, o medo de se infectar pelo virus pode ter acentuado quadros de depressao e ansiedade.

Estudo brasileiro (22) que buscou compreender os sentimientos vivenciados por mulheres que receberam o diagnostico de cancer de mama identificou que, ao receberem o diagnostico, foram encontrados sentimentos como desespero, preocupacao com a familia, proximidade e medo da morte, tristeza, negacao, fe na cura e aceitacao. Essas sensacoes podem ser intensificadas em idade produtiva devido a possivel perda de renda e ao aumento das despesas ocasionadas pelo tratamento.

Pesquisa (23) realizada em um ambulatorio de mastologia no interior de Sao Paulo, Brasil, encontrou que o diagnostico de cancer em idade produtiva gerou, na amostra estudada, preocupacao com o aporte financeiro pessoal e familiar, e mudanca no estilo de vida. Essa apreensao pode ser mais evidente em mulheres que vivem sozinhas com seus filhos, pois delas depende o sustento do lar.

Antes mesmo do diagnostico, o paciente com cancer passa a ter despesas nao previstas, como exames, medicacoes, transporte, alimentacao especial, necessidade de alimentacao diferenciada ou cuidador e, por vezes, diminuicao de renda em virtude de ausencias no trabalho, que impactam o orcamento familiar e evidenciam a toxicidade financeira. Isso indica que, mesmo os pacientes atendidos pelo SUS e que nao custeiam o tratamento em si, absorvem custos e sao acometidos pela toxicidade financeira.

Com relacao a toxicidade financeira, os resultados obtidos se assemelham ao encontrado por estudos internacionais, como pesquisa chinesa (24) que verificou a toxicidade financeira de pacientes com cancer de mama e obteve escore de 21. Da mesma forma, estudo (25) que investigou a toxicidade financeira em 539 pacientes com carcinoma de celulas renais de 14 paises distintos obteve escore 21,5 de toxicidade financeira. Igualmente, pesquisa realizada no Canada (26), entre pacientes com cancer avancado de pulmao, cuja pontuacao media foi de 21, e estudo argentino (27) realizado em 2022 com pacientes com cancer de pulmao, com escore medio de 20 (impacto leve de toxicidade financeira).

Diferentemente, pesquisa brasileira (9) que avaliou a toxicidade financeira de pacientes com cancer em periodo anterior a pandemia obteve escore de toxicidade financeira de 18,95, e estudo mexicano (28) que explorou e analisou o onus financeiro do cancer entre idosos e seus familiares e/ou cuidadores encontrou escore medio de 16,4 (28). O resultado encontrado por este estudo pode estar relacionado ao auxilio fornecido pelo governo brasileiro (29) durante a crise de saude mundial, que concedeu a todo cidadao em situacao de vulnerabilidade um valor mensal para o custeio de suas necessidades.

O auxilio emergencial foi um beneficio financeiro instituido durante a pandemia para garantir renda minima aos brasileiros, ja que alguns setores da economia foram prejudicados pelas regras de isolamento e distanciamento social. De acordo com um estudo brasileiro (30) sobre a pandemia e desemprego, as regras de comportamiento necessarias durante a pandemia promoveram rapidas mudancas no mercado de trabalho, com efeitos rigorosos para 37,3 milhoes de pessoas que nao possuem emprego formal e que nao possuem direitos como o Fundo de Garantia por Tempo de Servico (mais conhecido por sua sigla FGTS) e o seguro-desemprego, que sao beneficios com a finalidade de garantir assistencia financeira temporaria ao trabalhador dispensado sem justa causa.

Considerando as amostras isoladamente e os escores de toxicidade financeira, os resultados dos participantes que realizavam o tratamento internados podem estar relacionados a preocupacao financeira entre estes e a quantidade de pacientes com renda de ate um salario-minimo e sem renda nessa amostra.

Estudo (31) realizado ao norte da India que avaliou a toxicidade financeira e o bem-estar mental dos sobreviventes de cancer bucal encontrou escores menores de toxicidade financeira entre os desempregados. Ainda nessa vertente, pesquisa alema (32) que avaliou se a toxicidade financeira e um problema para pacientes com sarcoma e identificou os fatores de risco relacionados obteve que receber uma pensao por invalidez e estar de licenca medica estao associados a maiores chances de relatar toxicidade financeira.

Os resultados da correlacao entre a toxicidade financeira e a QVRS indicam que quanto maior o bem-estar financeiro maior e a QVRS. Esses achados corroboram com os encontrados por estudo norte-americano que mensurou a toxicidade financeira e a associacao com a qualidade de vida em pacientes com melanoma avancado tratados com imunoterapia, e encontrou correlacao de r = ,44, p < 0,00133.

Da mesma forma, estudo (31) norte-americano que mensurou a trajetoria do sofrimento financeiro no inicio do tratamento, aos tres e seis meses, e determinou a relacao com a qualidade de vida em pacientes com cancer encontrou que a menor dificuldade financeira estava correlacionada com melhor QVRS.

Em se tratando da correlacao do escore total de QVRS com os dominios que compoem o constructo, os resultados indicaram que o convivio pode ser harmonico e benefico independientemente dos recursos financeiros.

As limitacoes deste estudo se concentram no tamanho da amostra do setor de internacao que, devido a pequena rotatividade, ficou restrita, alem da ausencia de literatura nacional para comparar os achados nas diferentes regioes brasileiras.

Conclusão

Assim, conclui-se que houve toxicidade financeira de grau um entre pacientes adultos com cancer internados e em tratamento ambulatorial. Isoladamente, os participantes que realizavam tratamento ambulatorial tiveram escore mais alto de toxicidade financeira, o que revelou maior bem-estar financeiro; alem disso, houve significancia entre a toxicidade financeira e a QRVS, o que indica que quanto menor as dificuldades financeiras, maior e a QVRS.

Acredita-se que este estudo traz contribuicoes para a pratica, a medida que revela a presenca de toxicidade financeira entre os pacientes atendidos pelo SUS.

Ademais, entende-se que conhecer e reconhecer a toxicidade financeira como evento adverso do tratamento oncologico fornece aos profissionais de saude e aos gestores condicoes de elaborar um plano assistencial que ampare o paciente.