Associations of Financial Toxicity with Employment Concerns and Cancer-Related Distress: A Cross-Sectional Survey among Korean Working-Age Cancer Survivors

Hyun-Ju Seo; Dal-Lae Jin; Young Ae Kim; Su Jung Lee; Seok-Jun Yoon

doi:10.4143/crt.2024.090

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Original Article General Associations of Financial Toxicity with Employment Concerns and Cancer-Related Distress: A Cross-Sectional Survey among Korean Working-Age Cancer Survivors: Hyun-Ju Seo¹, Dal-Lae Jin^2,3, Young Ae Kim⁴, Su Jung Lee⁵, Seok-Jun Yoon^6,7; Cancer Research and Treatment : Official Journal of Korean Cancer Association 2025;57(3):659-668.
DOI: https://doi.org/10.4143/crt.2024.090
Published online: December 3, 2024

¹College of Nursing, Chungnam National University, Daejeon, Korea

²Department of Public Health, Graduate School of Korea University, Seoul, Korea

³Transdisciplinary Major in Learning Health Systems, Graduate School, Korea University, Seoul, Korea

⁴Division of Cancer Control and Policy, National Cancer Center, Goyang, Korea

⁵College of Nursing, Institute of Health Science Research, and Inje Institute of Hospice & Palliative Care, Inje University, Busan, Korea

⁶Department of Preventive Medicine, Korea University College of Medicine, Seoul, Korea

⁷Institute for Future Public Health, Graduate School of Public Health, Korea University, Seoul, Korea

Correspondence: Seok-Jun Yoon, Department of Preventive Medicine, Korea University College of Medicine, 73 Goryeodae-ro, Seongbuk-gu, Seoul 02841, Korea
Tel: 82-2-2286-1347 E-mail: yoonsj02@korea.ac.kr

• Received: January 24, 2024 • Accepted: December 2, 2024

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Abstract

Purpose
Although South Korea’s health insurance has a co-payment-decreasing policy for cancer survivors, information on the extent of financial toxicity and its related factors is limited. We assessed the level of financial toxicity and the association of high levels of financial toxicity with employment concerns after diagnosis and cancer-related distress in working-age cancer survivors.
Materials and Methods
A cross-sectional study was conducted. Study participants were recruited from the National Cancer Survivorship Center between November and December 2022. Financial burden was assessed using the Korean version of the Comprehensive Score for Financial Toxicity, and cancer-related distress was measured using the National Comprehensive Cancer Network Distress Thermometer. Multivariate logistic regression analyses were used to explore the associations between high financial toxicity, cancer-related distress, and changes in employment status after cancer diagnosis.
Results
Of 1,403 working-age cancer survivors, approximately 62% reported high levels of financial distress. Survivors reporting early retirement and taking time off work with the intent to return were more likely to report high financial toxicity (adjusted odds ratio [OR], 1.69; 95% confidence interval [CI], 1.14 to 2.5; and adjusted OR, 2.82; 95% CI, 1.24 to 6.43, respectively) than those with a full-time or part-time job. Moreover, cancer survivors with high distress levels were more likely to report high financial toxicity than those with low distress levels (adjusted OR, 4.36; 95% CI, 3.17 to 5.99).
Conclusion
High financial toxicity is associated with adverse employment concerns and cancer-related distress among working-age cancer survivors. Therefore, developing cancer survivorship interventions within the healthcare system is necessary to ensure improvements in financial well-being.
Key words: Cancer survivors, Financial toxicity, Psychological distress, Survivorship, Cross-sectional studies

Introduction

Cancer is a significant public health concern worldwide [1] and is the leading cause of death in South Korea [2]. The incidence of cancer is increasing, with an estimated 19.3 million new cases worldwide [3]. However, cancer survival rates have also increased globally, with an estimated 53.5 million survivors [4]. Similarly, the number of cancer survivors in South Korea surpassed 2.5 million in 2018, owing to a 70.3% 5-year relative survival rate between 2014 and 2018 [5].

The financial burden of cancer arises from medical costs, including treatment and follow-up care-related expenses, travel and transportation costs to attend visits and treatments, and wage loss owing to changes in employment status [6,7], regardless of South Korea’s decreasing co-payment policy, in which patients’ out-of-pocket payments comprise only 5% of the reimbursement costs during a 5-year follow-up [8]. Although co-payments for cancer fees are at 5% compared to 20%-30% for other diseases, out-of-pocket spending remains high at 34% of the healthcare expenditure [9]. One-third of the cancer survivors in South Korea experience financial toxicity [10]. Financial toxicity, a crucial patient-reported outcome measure, may worsen cancer outcomes such as mortality and quality of life (QOL) among survivors [11]. As approximately half of Korean cancer survivors are of working age [5], these survivors and their families have potentially experienced financial hardships owing to employment disruptions and loss of household income [12]. Therefore, understanding the financial hardships experienced by working-age cancer survivors during follow-up care after cancer diagnosis is essential.

Recent studies have reported the considerable impact of cancer survivors’ treatment on their employment status and financial well-being [13-15]. Despite the high prevalence of cancer-related distress [16,17] and financial burden [15], most studies have explored the association between cancer-related distress and employment status according to the level of financial toxicity among cancer survivors [6,18-21]. Moreover, most studies included only one type of cancer [22,23], patients with cancer undergoing acute treatment [23], or acute care settings rather than transitional care or survivorship settings [10,24,25].

Therefore, we aimed to identify the level of financial toxicity and the relationship among financial toxicity, cancer-related distress, and employment status among working-age cancer survivors diagnosed with various types of cancer using data from the universal National Health Insurance system of South Korea. We hypothesized that a high level of financial toxicity would be negatively associated with changes in employment status and positively associated with cancer-related distress after cancer diagnosis while controlling for sociodemographic and clinical characteristics. Additionally, the impact of high financial distress associated with employment concerns and cancer-related distress over time after cancer diagnosis, sex, and cancer site were investigated.

Materials and Methods

1. Setting and design

This cross-sectional online survey included working-age South Korean cancer survivors from the economically active population. This survey was a segment of a more extensive study conducted in the “Development of the Healthcare Reimbursement System for Cancer Survivors in South Korea” project supported by the Ministry of Health and Welfare. This study was registered with the Clinical Research Information Service (https://www.cris.cdc.go.kr; registration number: KCT0008641). Community-dwelling working-age cancer survivors completed a survey on cancer-related distress, employment status, and financial toxicity.

2. Study population and survey administration

Convenience sampling of the cancer survivors was performed at the National Cancer Survivorship Center in South Korea. The sample size for a cross-sectional survey of an estimated 2.5 million population of cancer survivors with a margin of error of 3%, was a minimum of 1,067 respondents [26]. The inclusion criteria for this study were economically active cancer survivors aged 18-64 years [27], cancer survivors who had completed acute cancer treatment, including chemotherapy, radiotherapy, or surgery [28,29], and those who could communicate without cognitive impairment. The exclusion criteria were patients with cancer undergoing acute treatment, those who received hospice and palliative care, and cancer survivors at end-of-life stages. Considering the inclusion of the main types of cancer, such as gastric, breast, colorectal, liver, cervical, lung, and prostate cancers, in South Korea [30], the required effective sample size was 1,448 [31]. After excluding the incomplete responses, the final number of respondents was 1,403 (dropout rate of 3.1%).

3. Dependent variables

Personal financial burden, which has been validated in disease-free breast cancer survivors, was measured using the Korean version of the Comprehensive Score for Financial Toxicity (COST-K) [32]. The original version of the COST has been validated in patients with advanced cancer in the United States [33]. This questionnaire comprises 11 questions on a 4-point Likert scale categorized into three dimensions: (1) two resource items, (2) one financial item, and (3) eight effect items questioning the subjective financial distress due to cancer care. The score ranges between 0 and 44; the lower the score, the worse the financial toxicity [32]. A COST-K threshold score of 21 was set, as used by De Souza et al. [34]. The total scores on the 11-item COST were divided into high and low financial toxicity groups using this threshold.

4. Independent variables

This study includes two independent variables of interest. Employment concerns, such as changes in work status, were obtained from individuals who were employed at the time of diagnosis. Employment concerns included maintaining a full-time or part-time job, transitioning to a part-time or less demanding job, career change, retiring earlier than planned, taking paid time off, and planning to return to work [35].

The National Comprehensive Cancer Network distress thermometer (DT) was used to assess psychological distress on a scale of 0 (no distress) to 10 (great distress), and a score of 4 was determined as the cut-off value for moderate psychological distress and the trigger for psychological assistance referral [36].

5. Covariates

Sociodemographic information (age, sex, education level, marital status, insurance type, employment status at the time of diagnosis, type of work at the time of diagnosis, and monthly household income) and cancer-related clinical characteristics (time since diagnosis, cancer stage, cancer site, presence of comorbidities, and type of cancer treatment received) were gathered from all respondents at the time of the survey [37-39]. Survey data were collected using web-or mobile-based online surveys between November and December 2022, owing to social distancing during the coronavirus disease 2019 pandemic. The time to complete the self-report questionnaire was approximately 10-15 minutes; and the participants were presented with a $10 reward upon completion.

6. Statistical analysis

Descriptive analyses were performed using Student’s t test, Pearson’s chi-square test, or Fisher’s exact test to compare participants’ characteristics by dependent variable (Table 1); multivariable logistic regression analyses was used to examine the associations between high financial toxicity, change in employment status after cancer diagnosis, and cancer-related distress, adjusted for sociodemographic and clinical characteristics.

Significant variables were entered into the multivariate analysis. The multicollinearity of the model variables was assessed using tests for covariance, variance inflation factor, and tolerance. Using these same variables, we then examined the differences in odds ratios (ORs) having high financial toxicity by sex (male vs. female), cancer site (grouped into prevalent cancer types of participants namely, the stomach, breast, colorectal, and others), and duration of cancer survival based on a 5-year survival rate [38] (≤ 5 years vs. > 5 years) using multivariable logistic regressions, adjusted for significant variables in multivariate analysis. ORs and the associated 95% confidence intervals (CIs) were calculated using multivariate logistic regression models. All analyses and data management were performed using SAS ver. 9.4 (SAS Institute Inc.). Statistical tests were two-sided, with p < 0.05 considered statistically significant.

Results

1. Characteristics of the participants

The characteristics of the study population (n=1,403) by financial toxicity (high and low financial toxicity) is presented in Table 1. The response rate was 96.9%. Approximately two-thirds (62.4%) of the participants reported high financial toxicity. Significant differences in financial toxicity were observed according to age, education, marital status, insurance type, employment status at the time of diagnosis, employment concerns after diagnosis, DT score, household income, time since diagnosis, and cancer site.

2. Association of financial toxicity with employment concerns and cancer-related distress

The association between high financial toxicity, employment concerns, and cancer-related distress following cancer diagnosis is presented in Table 2. Data from 1,085 of the 1,403 respondents (excluding 318 who did not have an employment status at the time of diagnosis) were included. Participants reporting adverse employment after a cancer diagnosis were more probable to report high financial distress than the reference group maintaining full-time or part-time jobs.

Individuals reporting early retirement and those who were taking time off work with plans to return were more probable to report high financial toxicity following a cancer diagnosis (adjusted OR, 1.69; 95% CI, 1.14 to 2.5; and adjusted OR, 2.82; 95% CI, 1.24 to 6.43, respectively) after controlling for age, education, marital status, insurance type, employment status at the time of diagnosis, DT score, household income, time since diagnosis, and cancer site.

Respondents with high distress levels have a significantly higher probability of reporting high financial toxicity following a cancer diagnosis than those with low cancer-related distress levels. The odds of reporting high financial toxicity were approximately 4.4 times higher among those reporting high distress than those reporting low distress (adjusted OR, 4.36; 95% CI, 3.17 to 5.99) (Table 2).

3. Financial toxicity by employment concerns and cancer-related distress according to time since cancer diagnosis

The ORs and 95% CIs from the multivariate logistic regression analysis of the associations of high financial toxicity with employment concerns and cancer-related distress according to the time since cancer diagnosis (< 5 years vs. > 5 years) are presented in Table 3. As expected, among participants with < 5 years since their diagnosis, individuals entering early retirement (adjusted OR, 2.14; 95% CI, 1.27 to 3.62) and taking time off from work with the intent to return (adjusted OR, 3.95; 95% CI, 1.43 to 10.9) had significantly increased odds of having high financial toxicity than those maintaining a full- or part-time job after cancer diagnosis. However, compared with those reporting low cancer-related distress levels, respondents with high distress levels had a significantly increased probability of reporting high financial toxicity, regardless of the time since cancer diagnosis (Table 3).

Additionally, regarding the association of high financial toxicity with employment concerns and cancer-related distress according to sex and cancer site, women entering early retirement (adjusted OR, 1.89; 95% CI, 1.17 to 3.05) and taking time off from work with the intent to return (adjusted OR, 2.79; 95% CI, 1.09 to 7.16) had significantly increased odds of high financial toxicity. Moreover, women cancer survivors with high distress levels had approximately two-fold higher ORs reporting high financial toxicity than men (adjusted OR, 5.78; 95% CI, 3.81 to 8.79 in women and adjusted OR, 2.89; 95% CI, 1.7 to 4.9 in men, respectively) (S1 Table).

Consistent with the results in S2 Table, breast cancer survivors reporting early retirement were highly probable of having high financial toxicity than those who maintained their job after cancer diagnosis (adjusted OR, 2.17; 95% CI, 1.14 to 4.12). Survivors reporting high levels of distress, regardless of the cancer site, were reported to have significantly increased odds of high financial toxicity compared to those with low levels of cancer-related distress (S2 Table).

Discussion

This study used data from a cross-sectional survey of working-age cancer survivors to explore the extent of financial toxicity and the association among financial toxicity, employment concerns, and psychological distress following a cancer diagnosis. We observed that 62.4% of the 1,403 working-age cancer survivors experienced high levels of financial toxicity. According to a survey of 727 working-age cancer survivors in Korea between 2017 and 2018, 31% reported experiencing financial toxicity, and 12% and 26% of the survivors reported having an objective financial burden and subjective financial distress, respectively [10]. A previous systematic review reported that 12%-62% of survivors were in debt because of treatment, and 47%-49% of cancer survivors experienced financial hardship [40]. Another systematic review noted that 14.8%-78.8% of cancer survivors experienced financial harm, particularly in low-income populations [41]. Our results are marginally higher than those reported in previous studies. These differences may be due to the convenience sampling of patients with cancer at a single medical institution. However, as employment is the primary source of health insurance for working-age cancer survivors [42], the risk of cancer-related financial hardship may be higher among individuals of working-age with a cancer history than those without a cancer history [43] or cancer survivors aged ≥ 65 years [38]. Therefore, policymakers and healthcare systems must focus on reducing the financial burden, as it threatens the sustainability of access to care, adherence to treatment, clinical outcomes, and health-related QOL in this population [38,44].

The prevalence of financial toxicity varies according to the scale used, and the population studied [40]. Despite Korea’s special medical insurance coverage paying 5% of their copayment for 5 years [45], cancer survivors experience subjective financial distress owing to out-of-pocket payments and other indirect cancer treatment costs [10]. Out-of-pocket payments, including over-the-counter drugs, additional room charges during hospitalization, and services provided by specially designated physicians, can be burdensome and cause financial toxicity in cancer survivors [46]. Given that cancer survivors in South Korea bear many uninsured medical benefit payments, the financial distress level of the current working-age cancer survivor population was demonstrated to be high in our study.

In this study, high financial toxicity was revealed to be associated with employment status. Patients who reported early retirement and taking time off work with the intent to return were more likely to report high financial toxicity following cancer diagnosis. This result was similar to that of a previous study, which reported that a job change (extended leave or switching to part-time) causes more material financial hardship (49.1%) than being employed and not making these changes (20.2%) or not being employed at the time of diagnosis (17.3%) [32]. In the regression analysis, among participants reporting less than 5 years since their cancer diagnosis, those who reported “early retirement” and “taking time off work with the intent to return” had a significantly increased probability of poor financial health than those who reported “maintain full-time/part-time jobs” after cancer diagnosis. These results are in line with those of previous studies, revealing that illness uncertainty has a strong association with “subjective financial toxicity.” Moreover, rising uncertainty owing to changes in employment status has led to difficulties in coping with cancer survivorship [47]. A previous Korean study reported that financial toxicity is associated with uncertainty, fear of cancer recurrence, loss of hope, and loss of purpose among working-age cancer survivors. For example, compared with those with “objective financial burden,” survivors with “subjective financial toxicity” were 8.8 times more probable to experience a “fear of cancer recurrence.” [10]. Survivors worry about the future costs of recurrence, making it challenging to plan their daily life and thereby increasing their sense of uncertainty [10]. Another qualitative study has reported that “uncertainty” encompasses many issues for survivors, such as employment and financial burdens [48]. Building on this previous study, our results suggest that for survivors in the “took paid time off from work and planned to return to work” category, uncertainty about returning to work has a more significant effect on “lower financial toxicity” than those in the “retire earlier than planned” category. Therefore, this study confirms that the impact of “high financial toxicity” differs according to occupational status after cancer diagnosis. Future studies should conduct prospective cohort studies to demonstrate the effects of “high financial toxicity” on job uncertainty and status.

Furthermore, this study reveals that “high financial toxicity” is significantly associated with psychological distress. Cancer survivors with high psychological distress levels were 4.36 times more likely to report “high financial distress” than those who reported low levels of cancer-related distress. Additionally, cancer survivors with increased psychological distress were significantly more likely to report high financial toxicity regardless of the time since cancer diagnosis. These results are consistent with those of previous studies reporting that financial problems predict distress in patients with cancer [19,49,50]. In other studies, distress in cancer survivors or patients was related to health-related QOL [10] and financial well-being [32]. Therefore, to improve the QOL related to working-age cancer survivors’ distress, we suggest introducing a reimbursement system for transitional care to reduce the economic burden of the survivorship journey following acute cancer treatment. From the perspective of supportive care in cancer, cancer survivors suggest various transitional care needs, such as the expansion of health insurance coverage to ensure a patient-centered aftercare system to improve the continuity of survivorship care [51]. Healthcare professionals also highlight establishing a healthcare reimbursement system for the provision of comprehensive cancer survivorship care (e.g., cancer treatment summaries, consultation, psychological counseling, education, and surveillance for recurrence) [51,52]. In other words, during the transitional care phase, ongoing care costs, including periodic screening tests, medications, colostomy products, and hospital visits, are incurred, which may affect the financial toxicity of cancer survivors.

This study also found that women survivors with high distress levels, including breast cancer survivors, were significantly more likely to report high levels of financial distress after their cancer diagnosis. In a previous study, 63.1% of breast cancer survivors reported severe distress in emotional domains such as fear, anxiety, sadness, and depression [53]. Until now, South Korean breast cancer survivors have been considered to suffer less financial toxicity than cancer survivors in other countries because of the relatively low medical costs in South Korea, owing to the co-payment decreasing policy [32]. Our study results also demonstrated that breast cancer had a lower impact on financial toxicity than other cancers; however, breast cancer survivors who experienced high levels of distress were more probable to experience high levels of cancer-related financial distress. Therefore, it is necessary to provide social support to mitigate the financial distress caused by direct and indirect cancer treatment costs for low-income working-age cancer survivors.

This study had several limitations. First, data were collected through convenience sampling using a self-report questionnaire with an online survey, and not through medical records. Therefore, we could not estimate the nationwide prevalence of financial toxicity among Korean working-age cancer survivors. Additionally, responses such as cancer diagnoses could not be validated because the data were de-identified. However, cancer survivors’ diagnoses were entered directly to reduce transcriptional errors. Although some participants may have overreported or underreported financial toxicity or cancer-related distress, we used validated measurement instruments to minimize potential bias [54]. Second, as this survey relied on retrospective participant reporting, there is a risk of recall bias. For example, survivors who have lost their jobs were more likely to remember work-related distress than those who have not. However, we attempted to collect diverse data, including data on patients with various cancer types, ages, job statuses, and cancer survivors living in the community to ensure representativeness.

Despite these limitations, the present finding of significant associations between “employment status” and “high financial toxicity” has critical implications for working-age cancer survivors. This study explicitly confirms that cancer survivors’ distress regarding their return to work, anxiety, and uncertainty about job changes upon returning to work significantly affect their financial toxicity. Previous studies have confirmed that financial distress in working-age cancer survivors affects their QOL [10] and that those without a job have a lower QOL than those with a job [55]. This study builds on these previous studies to identify the impact of uncertain job status upon returning to work and highlight the financial burden of working-age cancer survivors. Moreover, women (or breast cancer) survivors with high levels of distress were more likely to report high levels of financial distress. Based on these results, this study suggests that healthcare professionals, including oncologists, should better assess the factors affecting high financial toxicity. They should also provide relevant coping strategies to relieve financial toxicity, such as education, counseling, and helping survivors return to work and manage their psychosocial distress. Moreover, it is necessary to develop and test cancer survivorship interventions to ensure improvements in financial well-being by considering health insurance payments and social support systems. This study may be crucial for transitional care of working-age cancer survivors.

Electronic Supplementary Material

Supplementary materials are available at Cancer Research and Treatment website (https://www.e-crt.org).

crt-2024-090_S1_Table.pdf

crt-2024-090_S2_Table.pdf

NOTES

Ethical Statement

All participants were provided with a thorough explanation of the This study was approved by the Institutional Review Board of the National Cancer Center (IRB number: NCC2022-0326). Informed consent was obtained from all the participants. All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and were conducted in accordance with the principles of the Declaration of Helsinki.

Author Contributions

Conceived and designed the analysis: Yoon SJ, Seo HJ.

Collected the data: Kim YA, Jin DR.

Contributed data or analysis tools: Jin DR.

Performed the analysis: Jin DR.

Wrote the paper: Seo HJ, Lee SJ.

Supervision: Yoon SJ.

Conflict of Interest

Conflict of interest relevant to this article was not reported.

Funding

This work was supported by the National Cancer Center of South Korea (grant number: HA21C0206).

Table 1.

Characteristics of the study participants based on financial toxicity (n=1,403)

Characteristic	Total	High financial distress	Low financial distress	p-value
Total	1,403 (100)	876 (62.4)	527 (37.6)
Sex
Male	462 (32.9)	287 (62.1)	175 (37.9)	0.864
Female	941 (67.1)	589 (62.6)	352 (37.4)
Age at diagnosis (yr)
Mean±SD	44.87±9.41	43.88±9.10	46.52±9.96	< 0.001
Education
≤ High school	273 (19.4)	150 (54.9)	123 (45.0)	0.004
≥ Any college	1,130 (80.5)	726 (64.2)	404 (35.8)
Marital status
Married	1,066 (76)	638 (59.8)	428 (40.2)	0.001
Divorced/Separated/Widowed	68 (4.8)	45 (66.2)	23 (33.8)
Never married	726 (51.7)	193 (26.6)	76 (10.5)
Insurance type
National Health Insurance	1,316 (93.8)	813 (61.8)	503 (38.2)	0.001
Medical Aid	48 (3.4)	34 (70.8)	14 (29.2)
No/Do not know	39 (2.8)	29 (74.4)	10 (25.6)
Employment status at the time of diagnosis
Yes	1,085 (77.3)	701 (64.6)	384 (35.4)	0.002
No	318 (22.7)	175 (55.0)	143 (45.0)
Type of work at the time of diagnosis^a)
Professional, managerial	242 (17.2)	144 (59.5)	98 (40.5)	0.271
Office work, service, salesperson	744 (53)	492 (66.1)	252 (33.9)
Skilled, blue-collar worker	39 (2.8)	27 (69.2)	12 (30.8)
Simple laborer, others	60 (4.3)	38 (63.3)	22 (36.7)
Employment concerns after diagnosis^a)	1,085 (100)	701 (64.6)	384 (35.4)	< 0.001
Maintain full-time/Part-time job	420 (38.7)	232 (55.2)	188 (44.8)
Change to working a part-time or less demanding job	107 (9.9)	77 (72.0)	30 (28.0)
Move from the prior work	236 (21.8)	156 (66.1)	80 (33.9)
Retire earlier than planned	269 (24.8)	192 (71.4)	77 (28.6)
Took paid time off from work and plan to return to work	53 (4.9)	44 (83.0)	9 (17.0)
Distress thermometer score
Mean±SD	5.21±2.09	5.78±1.94	4.29±2.01	< 0.001
Low (< 4)	522 (37.2)	236 (45.2)	286 (54.8)	< 0.001
High (≥ 4)	881 (62.8)	640 (72.6)	241 (27.4)
Household income (USD/mo)
< 833	57 (4.1)	45 (78.9)	12 (21.1)	< 0.001
833-2,500	284 (20.2)	198 (69.7)	86 (30.3)
2,500-4,167	813 (57.9)	517 (63.6)	296 (36.4)
> 4,167	249 (17.7)	116 (46.6)	133 (53.4)
Time since diagnosis (yr)
Median (IQR)	4 (2-6)	4 (2-6)	4 (2-7)
< 3	37 (2.6)	21 (56.8)	16 (43.2)	0.007
3-5	759 (54.1)	498 (65.6)	261 (34.4)
> 5 and < 10	476 (33.9)	291 (61.1)	185 (38.9)
≥ 10	131 (9.3)	66 (50.4)	65 (49.6)
Cancer stage
Stage 0	78 (5.6)	49 (62.8)	29 (37.2)	0.631
Stage I	684 (48.8)	393 (57.5)	255 (37.3)
Stage II	484 (34.5)	305 (63.0)	233 (48.1)
Stage III/IV	164 (11.7)	54 (32.9)	10 (6.1)
Do not know	29 (2.1)	19 (65.5)	10 (34.5)
Cancer site
Stomach	273 (19.5)	170 (62.3)	103 (37.7)	0.015
Breast	498 (35.5)	293 (58.8)	205 (41.2)
Colorectal	232 (16.5)	138 (59.5)	94 (40.5)
Others^b)	400 (28.5)	275 (68.8)	125 (31.3)
Comorbidities under treatment
Yes	309 (22.0)	207 (67.0)	102 (33.0)	0.061
No	1,094 (78.0)	669 (61.2)	425 (38.8)
Cancer treatment^c)
Surgery	143 (10.2)	90 (62.9)	53 (37.1)
Chemotherapy	922 (65.7)	574 (62.3)	348 (37.7)
Radiotherapy	912 (65)	564 (61.8)	348 (38.2)
Other cancer treatment	639 (45.5)	393 (61.5)	246 (38.5)

Values are presented as number (%). IQR, interquartile range; SD, standard deviation.

^a) n=1,085,

^b) Ovarian cancer, blood cancer, lymphoma, cervical cancer, prostate cancer, pancreatic cancer, kidney cancer, etc.,

^c) p-value cannot be presented due to multiple responses.

Table 2.

Multivariable logistic regression models of high financial toxicity, adjusted for sociodemographic and clinical characteristics (n=1,085)

	OR (95% CI)
Employment concerns
Maintain full-time/Part-time job	1.0
Change to working a part-time or less demanding job	1.46 (0.89-2.42)
Engaged in economic activities elsewhere	1.21 (0.82-1.78)
Retire earlier than planned	1.69 (1.14-2.5)
Took paid time off from work and plan to return to work	2.82 (1.24-6.43)
Distress thermometer score
Low (< 4)	1.0
High (≥ 4)	4.36 (3.17-5.99)

Odds ratios (ORs) were adjusted for age, education level, marital status, insurance type, household income, time since diagnosis, and cancer site. CI, confidence interval.

Table 3.

Multivariable logistic regression models of high financial toxicity, adjusted for sociodemographic and clinical characteristics based on time since cancer diagnosis (n=1,085)

	OR (95% CI)
	≤ 5 years	> 5 years
Employment concerns
Maintain full-time/Part-time job	1.0	1.0
Change to working a part-time or less demanding job	1.36 (0.66-2.82)	1.51 (0.74-3.08)
Engaged in economic activities elsewhere	1.56 (0.87-2.81)	0.93 (0.54-1.59)
Retire earlier than planned	2.14 (1.27-3.62)	1.19 (0.64-2.22)
Took paid time off from work and plan to return to work	3.95 (1.43-10.9)	2.18 (0.44-10.76)
Distress thermometer score
Low (< 4)	1.0	1.0
High (≥ 4)	4.36 (2.74-6.94)	4.61 (2.93-7.25)

Odds ratios (ORs) were adjusted for age, education level, marital status, insurance type, household income, time since diagnosis, and cancer site. CI, confidence interval.

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Associations of Financial Toxicity with Employment Concerns and Cancer-Related Distress: A Cross-Sectional Survey among Korean Working-Age Cancer Survivors

Cancer Res Treat. 2025;57(3):659-668. Published online December 3, 2024

DOI: https://doi.org/10.4143/crt.2024.090

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Abstract
Introduction
Materials and Methods
Results
Discussion
Electronic Supplementary Material
NOTES
REFERENCES

Associations of Financial Toxicity with Employment Concerns and Cancer-Related Distress: A Cross-Sectional Survey among Korean Working-Age Cancer Survivors

Characteristic	Total	High financial distress	Low financial distress	p-value
Total	1,403 (100)	876 (62.4)	527 (37.6)
Sex
Male	462 (32.9)	287 (62.1)	175 (37.9)	0.864
Female	941 (67.1)	589 (62.6)	352 (37.4)
Age at diagnosis (yr)
Mean±SD	44.87±9.41	43.88±9.10	46.52±9.96	< 0.001
Education
≤ High school	273 (19.4)	150 (54.9)	123 (45.0)	0.004
≥ Any college	1,130 (80.5)	726 (64.2)	404 (35.8)
Marital status
Married	1,066 (76)	638 (59.8)	428 (40.2)	0.001
Divorced/Separated/Widowed	68 (4.8)	45 (66.2)	23 (33.8)
Never married	726 (51.7)	193 (26.6)	76 (10.5)
Insurance type
National Health Insurance	1,316 (93.8)	813 (61.8)	503 (38.2)	0.001
Medical Aid	48 (3.4)	34 (70.8)	14 (29.2)
No/Do not know	39 (2.8)	29 (74.4)	10 (25.6)
Employment status at the time of diagnosis
Yes	1,085 (77.3)	701 (64.6)	384 (35.4)	0.002
No	318 (22.7)	175 (55.0)	143 (45.0)
Type of work at the time of diagnosis^a)
Professional, managerial	242 (17.2)	144 (59.5)	98 (40.5)	0.271
Office work, service, salesperson	744 (53)	492 (66.1)	252 (33.9)
Skilled, blue-collar worker	39 (2.8)	27 (69.2)	12 (30.8)
Simple laborer, others	60 (4.3)	38 (63.3)	22 (36.7)
Employment concerns after diagnosis^a)	1,085 (100)	701 (64.6)	384 (35.4)	< 0.001
Maintain full-time/Part-time job	420 (38.7)	232 (55.2)	188 (44.8)
Change to working a part-time or less demanding job	107 (9.9)	77 (72.0)	30 (28.0)
Move from the prior work	236 (21.8)	156 (66.1)	80 (33.9)
Retire earlier than planned	269 (24.8)	192 (71.4)	77 (28.6)
Took paid time off from work and plan to return to work	53 (4.9)	44 (83.0)	9 (17.0)
Distress thermometer score
Mean±SD	5.21±2.09	5.78±1.94	4.29±2.01	< 0.001
Low (< 4)	522 (37.2)	236 (45.2)	286 (54.8)	< 0.001
High (≥ 4)	881 (62.8)	640 (72.6)	241 (27.4)
Household income (USD/mo)
< 833	57 (4.1)	45 (78.9)	12 (21.1)	< 0.001
833-2,500	284 (20.2)	198 (69.7)	86 (30.3)
2,500-4,167	813 (57.9)	517 (63.6)	296 (36.4)
> 4,167	249 (17.7)	116 (46.6)	133 (53.4)
Time since diagnosis (yr)
Median (IQR)	4 (2-6)	4 (2-6)	4 (2-7)
< 3	37 (2.6)	21 (56.8)	16 (43.2)	0.007
3-5	759 (54.1)	498 (65.6)	261 (34.4)
> 5 and < 10	476 (33.9)	291 (61.1)	185 (38.9)
≥ 10	131 (9.3)	66 (50.4)	65 (49.6)
Cancer stage
Stage 0	78 (5.6)	49 (62.8)	29 (37.2)	0.631
Stage I	684 (48.8)	393 (57.5)	255 (37.3)
Stage II	484 (34.5)	305 (63.0)	233 (48.1)
Stage III/IV	164 (11.7)	54 (32.9)	10 (6.1)
Do not know	29 (2.1)	19 (65.5)	10 (34.5)
Cancer site
Stomach	273 (19.5)	170 (62.3)	103 (37.7)	0.015
Breast	498 (35.5)	293 (58.8)	205 (41.2)
Colorectal	232 (16.5)	138 (59.5)	94 (40.5)
Others^b)	400 (28.5)	275 (68.8)	125 (31.3)
Comorbidities under treatment
Yes	309 (22.0)	207 (67.0)	102 (33.0)	0.061
No	1,094 (78.0)	669 (61.2)	425 (38.8)
Cancer treatment^c)
Surgery	143 (10.2)	90 (62.9)	53 (37.1)
Chemotherapy	922 (65.7)	574 (62.3)	348 (37.7)
Radiotherapy	912 (65)	564 (61.8)	348 (38.2)
Other cancer treatment	639 (45.5)	393 (61.5)	246 (38.5)

	OR (95% CI)
Employment concerns
Maintain full-time/Part-time job	1.0
Change to working a part-time or less demanding job	1.46 (0.89-2.42)
Engaged in economic activities elsewhere	1.21 (0.82-1.78)
Retire earlier than planned	1.69 (1.14-2.5)
Took paid time off from work and plan to return to work	2.82 (1.24-6.43)
Distress thermometer score
Low (< 4)	1.0
High (≥ 4)	4.36 (3.17-5.99)

	OR (95% CI)
	≤ 5 years	> 5 years
Employment concerns
Maintain full-time/Part-time job	1.0	1.0
Change to working a part-time or less demanding job	1.36 (0.66-2.82)	1.51 (0.74-3.08)
Engaged in economic activities elsewhere	1.56 (0.87-2.81)	0.93 (0.54-1.59)
Retire earlier than planned	2.14 (1.27-3.62)	1.19 (0.64-2.22)
Took paid time off from work and plan to return to work	3.95 (1.43-10.9)	2.18 (0.44-10.76)
Distress thermometer score
Low (< 4)	1.0	1.0
High (≥ 4)	4.36 (2.74-6.94)	4.61 (2.93-7.25)

Table 1. Characteristics of the study participants based on financial toxicity (n=1,403)

Values are presented as number (%). IQR, interquartile range; SD, standard deviation.

n=1,085,

Ovarian cancer, blood cancer, lymphoma, cervical cancer, prostate cancer, pancreatic cancer, kidney cancer, etc.,

p-value cannot be presented due to multiple responses.

Table 2. Multivariable logistic regression models of high financial toxicity, adjusted for sociodemographic and clinical characteristics (n=1,085)

Odds ratios (ORs) were adjusted for age, education level, marital status, insurance type, household income, time since diagnosis, and cancer site. CI, confidence interval.

Table 3. Multivariable logistic regression models of high financial toxicity, adjusted for sociodemographic and clinical characteristics based on time since cancer diagnosis (n=1,085)

Odds ratios (ORs) were adjusted for age, education level, marital status, insurance type, household income, time since diagnosis, and cancer site. CI, confidence interval.