Highlights
Financial toxicity (FT) is significantly associated with lower satisfaction with life (SWL) among patients receiving ambulatory cancer care (r = -0.34, P < .001).
Hopefulness and perceived social support serve as critical mediators of the relationship between financial burden and psychological well-being.
The study supports a multimodal intervention strategy that combines direct financial assistance with programs designed to strengthen psychosocial resilience factors.
Background and Disease Burden
In the modern oncological landscape, the efficacy of novel therapeutics is frequently overshadowed by the escalating costs of care. Financial toxicity—a term describing the objective financial burden and subjective distress resulting from cancer treatment—has emerged as a major adverse effect of clinical management. Beyond the immediate impact on treatment adherence and clinical outcomes, financial toxicity deeply penetrates the patient’s psychological core, affecting their overall satisfaction with life (SWL).
While previous research has established the link between financial strain and poor health-related quality of life, the mechanisms through which economic stress translates into reduced life satisfaction remain under-explored. Identifying these mediators is essential for clinicians and policy makers to move beyond simplistic financial aid models toward a more holistic approach to patient resilience. This study specifically examines hopefulness and social support as potential buffers that may mitigate the downstream psychological impacts of financial toxicity.
Study Design and Methodology
This cross-sectional analysis utilized baseline data from the Economic Strain and Resilience in Cancer-II (ENRICh-II) study, a prospective, multisite investigation conducted between August 2020 and December 2022. The study cohort included 519 adults receiving ambulatory care for various malignant neoplasms, including breast, gastrointestinal, and hematologic cancers, across six diverse clinical settings including academic centers and federally qualified health centers.
The researchers employed the ENRICh instrument to quantify financial toxicity across three subdomains: material burden, coping mechanisms, and psychological distress. The primary outcome, Satisfaction with Life, was measured using the validated Satisfaction with Life Scale (SWLS). To investigate the underlying pathways, the team assessed hopefulness via the State Hope Scale and social support through the Medical Outcomes Study Social Support Survey. A bootstrapping approach to multiple mediation was applied, controlling for key demographic and clinical variables such as age, race, and cancer stage.
Key Findings
The participant pool (mean age 52.0 years; 67.2% female) represented a clinically diverse population, with breast cancer (38.9%) and colorectal cancer (21.4%) being the most prevalent diagnoses. The study yielded several critical insights into the interplay of economic and psychological health.
The Magnitude of Financial Toxicity
Higher levels of financial toxicity were strongly correlated with lower satisfaction with life (r = -0.34, P < .001). This association was robust across all subdomains of the ENRICh instrument, indicating that whether the strain was material (e.g., medical debt) or psychological (e.g., worry about future costs), the impact on patient well-being remained significant.
The Role of Mediators
The mediation analysis revealed that the relationship between financial toxicity and SWL is not entirely direct. Instead, it is partially channeled through psychosocial factors:
- Social Support: Perceived social support significantly mediated the association (-0.03 [95% CI, -0.06 to -0.01]), suggesting that financial strain may erode a patient’s sense of connection or that strong support networks can provide a buffer against the stress of cost.
- Hopefulness: Hopefulness was a more potent mediator (-0.08 [95% CI, -0.12 to -0.03]), indicating that financial toxicity often saps a patient’s goal-oriented thinking and agency, which in turn diminishes life satisfaction.
The combined multiple mediation path (including both hope and social support) was statistically significant (-0.02 [95% CI, -0.04 to -0.01]). These findings suggest that approximately one-third of the impact of financial toxicity on life satisfaction is explained by these two resilience factors.
Expert Commentary
The results of this study underscore the multifaceted nature of financial toxicity in oncology. From a clinical perspective, these data suggest that simply addressing the ‘material’ side of financial toxicity—such as through co-pay assistance or grants—may be insufficient if the ‘psychological’ and ‘coping’ components are neglected. The significant role of hope as a mediator is particularly noteworthy. In oncology, hope is not merely optimism; it is a cognitive process involving the perceived capacity to derive pathways to desired goals and the motivation to use those pathways.
Clinicians should recognize that financial strain often acts as a ‘hope-depleting’ agent. When patients feel they cannot afford their care, they may lose the sense of agency required to navigate their treatment journey. Furthermore, the erosion of social support suggests that financial stress can isolate patients, potentially due to the stigma of debt or the inability to participate in social activities. Therefore, interventions must be integrated, involving social workers, financial navigators, and mental health professionals to build a safety net that is both economic and emotional.
Conclusion
This multisite study demonstrates that financial toxicity is a profound determinant of life satisfaction in cancer patients, mediated by hope and social support. While systemic changes to reduce the cost of cancer care remain the ultimate goal, current clinical practice should evolve to include resilience-building strategies. By screening for financial toxicity early and providing targeted support to bolster a patient’s hope and social network, healthcare providers can better protect the psychological well-being of those undergoing cancer treatment.
Funding and References
This research was supported by the Economic Strain and Resilience in Cancer-II (ENRICh-II) study. Detailed funding information can be found in the original publication.
Reference: Smith GL, Feldman DB, Ma H, et al. Financial Toxicity, Hope, and Satisfaction With Life in Patients Receiving Ambulatory Cancer Care. JAMA Netw Open. 2026;9(2):e2557328. doi:10.1001/jamanetworkopen.2025.57328.
