Asian American individuals compose a diverse race and ethnic group representing 8% of the US population, among whom 60% are recent immigrants.¹ Cancer is the leading cause of death among many Asian American groups, who experience heterogeneous cancer risk, incidence, and outcomes, including on average low screening rates.¹ Asian American individuals face numerous and often overlooked health equity gaps, including financial toxicity of cancer.

Financial toxicity鈥攖he financial challenges that cancer survivors face related to the costs of care鈥攊s driven by direct and indirect costs and can have negative downstream effects including limitations in access to care, lower treatment adherence, and psychosocial distress.² The national costs of cancer are projected to reach $246 billion by 2030 compared with $183 billion in 2015. Overall, 47% of individuals with a breast cancer diagnosis experienced catastrophic financial burden鈥攖he most prevalent cancer subtype among Asian American women.^1,3 Psychological distress related to financial toxicity may also be higher among Asian American cancer survivors compared to non-Hispanic White patients.² In this Viewpoint, we highlight financial toxicity specific to Asian American individuals and present steps forward within the framework of the social ecological model of health, considering individual, interpersonal, community, and policy-level dimensions.

At the community and policy levels, socioeconomic status contributes to financial toxicity among Asian American cancer survivors. Misconceptions regarding Asian American individuals as the 鈥渕odel minority鈥� mask upstream disparities in determinants of health and financial toxicity. Despite Asian American individuals on average having higher median household income compared with White individuals in the US, significant heterogeneity exists; for example, 24% of Burmese American individuals live at or below the poverty level compared with 6% of Indian American individuals.¹ Additionally, insurance coverage alone may not be sufficient to protect patients from financial toxicity. Out-of-pocket (OOP) costs pose a significant financial burden; patients with employer-sponsored insurance incurred upwards of $3600 in OOP costs in the first year postdiagnosis alone,³ likely disproportionately affecting the most vulnerable groups.

At the interpersonal level, many Asian cultures have a family-centric approach when making health care decisions that require family deliberation, which is not always aligned with the Western focus on patient autonomy. The ripple effect of financial toxicity affects family caregivers as well. Caregiving is associated with physiological burdens, such as anxiety and stress; family caregivers may also delay or forgo their own needed medical care due to costs.⁴ These negative effects are further exacerbated by cultural stigma surrounding mental health treatment in many Asian cultures.

Evidence from Asian American immigrants鈥� countries of origin demonstrate the far-reaching sequelae of financial toxicity, likely with parallels in cultural approaches to cancer among Asian American individuals. In China, the costs incurred by cancer care have led half of all households surveyed to face catastrophic health expenditures. To cope with financial toxicity, many have to borrow money, reduce family expenses on basic necessities, and rely on immediate and extended family.⁴ The strong emphasis on filial piety in many Asian cultures leads to financial stress on the families of their children. Although little is known about financial toxicity specific to South Asian American individuals, financial toxicity in parts of India and other similarly resourced settings can manifest as children discontinuing their education to care for family members with cancer, highlighting the intergenerational impacts of financial toxicity on families.

At the individual level, one consequence of financial toxicity among Asian American immigrants is delaying or forgoing care due to the cost. Cultural stoicism is common among many Asian American cultures, manifesting in patients not wanting to place an emotional or financial burden on family members, leading to treatment delays and worse health outcomes. One study of primarily first-generation Chinese American women with breast cancer found that many attested to delaying Western therapies in lieu of traditional Chinese therapies to conserve money and time, providing one rationale for the trend of many Asian American groups experiencing longer time intervals to treatment for cancer care compared with White patients.⁵

Delays in care can result in later stages of cancer at presentation; more advanced disease is associated with increased OOP costs across breast, cervical, colorectal, lung, ovarian, and prostate cancers.³ Notably, Asian American individuals often present with later stages of many cancer types, likely contributing significantly to financial toxicity.¹

All interventions to reduce the burden of financial toxicity on Asian American cancer survivors must carefully consider the cultural (often including linguistic) needs of these tremendously diverse groups. At the policy level, we must promote efforts to lower the cost of cancer care in the US. While the Medicare Drug Price Negotiation Program in the Inflation Reduction Act is a promising first step to lowering the cost of prescription drugs, only one of the initial 10 drugs selected for price negotiation (Imbruvica [ibrutinib]) is an oncology drug. Given the skyrocketing cost of cancer care largely driven by prescription drug prices, the Cancer Moonshot 2020 coalition should support the development of a value-based assessment agency for newly approved drugs, like the health technology assessment agencies of several countries, to inform Medicare price negotiations for more cancer drugs.

Beyond national policy changes, we can address the gaps in cancer screening among many Asian American subgroups to promote earlier diagnosis at the community level, which is associated with lower medical expenditures and improved outcomes at the individual level. While private insurance covers preventive services to beneficiaries under the Affordable Care Act, many Asian American individuals cited lack of insurance coverage, the cost of seeing a physician, and not feeling the need to see a physician as the top 3 individual-level barriers to screening, suggesting that Asian American individuals may lack coverage or knowledge of free-of-cost screening.⁶ Culturally tailored, community-wide screening programs that increase awareness of the importance, cost-effectiveness, and accessibility of screening can promote higher rates of cancer screening, especially for the most financially vulnerable Asian American populations.

At the interpersonal level, the incorporation of bilingual financial navigators has seen success in several pilot studies. The incorporation of financial navigation staff is associated with higher quality of life, improved physical and mental health scores, and lower risk of death, as has been shown among patients with hematological malignant neoplasms.⁷ As financial navigation services are expanded, we must improve the currently limited cultural and linguistic diversity among financial navigation staff. When bilingual navigators are not available, consistent interpreter services must be provided free of charge for patients and their families. Access to psychosocial, supportive, and palliative care informed by cultural humility must also be facilitated, including lowering OOP costs.

Lastly, further disaggregated and intersectional research focusing on financial toxicity among Asian American individuals is necessary to inform interventions moving forward. The dearth of literature on certain disaggregated groups, such as Asian American individuals of South Asian descent, warrants further research into this understudied population. Such work should incorporate financial toxicity as a function of linguistic barriers, psychosocial concerns, cancer epidemiology, and implications for patients鈥� families.

Despite limited research on the unique impacts of financial toxicity on Asian American cancer survivors, socioeconomic status, insurance coverage, family-centric care, and treatment delays are among the factors that lead to financial toxicity among Asian American cancer survivors. Given the heterogeneity of the Asian American population in the US, we must prioritize disaggregated research to identify the unmet financial needs of cancer survivors among different Asian American subgroups to inform tailored interventions. Addressing these issues through changes in Medicare drug negotiation policies, accessible screening programs, and bilingual financial navigators is essential to reduce the disparities and ensure equitable care.

Corresponding Author: Edward Christopher Dee, MD, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065 (deee1@mskcc.org).

Published Online: November 7, 2024. doi:10.1001/jamaoncol.2024.5016

Conflict of Interest Disclosures: Drs Chino and Dee reported are funded in part from the National Cancer Institute Support Grant P30 CA008748. No other disclosures were reported.