Therapeutic and financial toxicity in the management of cancer in some tertiary health facilities

*Corresponding author: Timothy Olugbenga Ogundeko Copyright © 2025 Author(s) retain the copyright of this article. This article is published under the terms of the Creative Commons Attribution License 4.0. Therapeutic and financial toxicity in the management of cancer in some tertiary health facilities Dauda Adi Dangiwa 1, Esther Mrumun Hayab 2, Timothy Olugbenga Ogundeko 3, *, Emmanuel Anebi Ogbole 3, Binta Adamu Fwang’an 2, Nkiruka Philomina Okoye 3, Grace Musa Ebuga 2 and Steven Samuel Gyang 3 1 Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmaceutical Sciences, Jos, Nigeria. 2 Department of Pharmacy, Bingham University Teaching Hospital, Jos, Nigeria. 3 Department of Pharmacology and Therapeutics, College of Medical Sciences, Bingham University, Jos campus, Nigeria. World Journal of Biology Pharmacy and Health Sciences, 2025, 23(02), 150-160 Publication history: Received on 06 May 2025; revised on 05 August; accepted on 08 August 2025 Article DOI: https://doi.org/10.30574/wjbphs.2025.23.2.0595 Abstract Cancer remains a significant public health concern globally, with treatment-associated financial and therapeutic toxicity posing major challenges, particularly in lowand middle-income countries. This study evaluates the therapeutic and financial burdens of cancer care among patients receiving treatment at two tertiary health institutions in Jos, Nigeria. A retrospective cross-sectional review of medical records was conducted over a five-year period (March 2018 to July 2023) at Jos University Teaching Hospital (JUTH) and Bingham University Teaching Hospital (BhUTH). Data were analyzed using descriptive statistics and WHO prescribing indicators while, therapeutic and financial toxicity were assessed based on cancer type, drug regimens, and treatment-related side effects. Of the 228 patients studied, females constituted the majority (77.6%), with cervical (28.1%) and breast cancer (24.1%) being the most prevalent. Polypharmacy and high use of injectables were common. Frequently prescribed drugs included cisplatin, paclitaxel, and doxorubicin, all associated with significant side effects such as myelosuppression, nausea, and alopecia. Financial analysis revealed mean chemotherapy costs of ₦732,585 (JUTH) and ₦481,989 (BhUTH), with considerable variation depending on treatment type and duration. Most patients bore out-of-pocket expenses, underscoring limited insurance coverage and significant financial burden. Cancer treatment in the studied institutions is characterized by substantial therapeutic and financial toxicity. The need for affordable care, improved insurance coverage, and safer therapeutic options is critical to enhance cancer care outcomes in resource-limited settings. Keywords: Anticancer; Chemotherapy; Medical cost; Oncology; Toxicity; Jos-Nigeria 1. Introduction Financial toxicity generally refers to the damaging impact of the financial burden associated with cancer management on the patients, the family members and the society at large [1]. Although recent advances in cancer management are encouraging and cheering but this development becomes irrelevant when patients cannot afford the cost of the care. Affordability therefore has become the rate limiting step that determines the prognosis of cancer care [2]. The various advances and treatment options in the management of cancers such as immunotherapy, hormonal therapy, use of targeted agents, radiation therapy and surgery have greatly improved cancer treatment outcomes. However, these treatment options also come with the challenge of therapeutic toxicities [3]. The financial toxicity will however provide an overarching influence over the therapeutic toxicity. Cancer is a non-communicable disease reputed as a leading cause of death globally [4]. It constitutes one of the greatest global health challenges to mankind especially those less than the age of eighty-five years old [5]. The challenge posed by this disease can be minimized by early detection and management [6]. Drastic reduction of cancer mortality depends on prevention and early treatment strategies [7]. The World Journal of Biology Pharmacy and Health Sciences, 2025, 23(02), 150-160 151 most common cancer types are breast cancer, cervical cancer, prostate cancer and colon cancer and anorectal cancer. Medications for the treatment of cancers especially the new ones are expensive and affordability is a key challenge in resource limited countries [8]. A recent study revealed that oncology drugs are more expensive in low-income countries than in high income countries [9]. The ready availability of the latest and more effective chemotherapeutic agents is challenging especially in developing countries [10]. There are medicines for the management of different forms of cancers [11] and new ones with better activity are entering the market from day to day. Most developing countries don’t have a program that pays the bill for cancer patients. The resource challenged citizens of low-income countries cannot afford the anticancer drugs. Towards the realization of the goal of sustainable affordability and availability of anticancer medicines, the World Health Organization (WHO) provided a list of essential medicines including anticancer drugs. The list assists countries in making a selection of cost-effective, safe and therapeutically effective medicines [12]. The low-income countries are also plagued with lack of insurance program for the cancer patients thus limiting their access to the needed medicines [13]. The pharmaceutical sector in the developing countries is bedeviled with poor inventory control and management of medicines thus worsening the challenges faced by cancer patients [14]. In cancer chemotherapy, the drugs are required for a long duration of time and this reality contributes to the overall cost of care for this category of patients [15]. This study examined the financial and the therapeutic toxicity of cancer diseases in two tertiary health institutions in University Teaching Hospital (JUTH) and Bingham University Teaching Hospital (BhUTH) Jos Nigeria. 2. Materials and Methods 2.1. Study Design and Site A retrospective, cross-sectional study that captured four years hospital records (clinic register/admission records of both male and female in and out-patients who had been diagnosed of cancer and have been receiving treatment from Jos University Teaching Hospital (JUTH) and Bingham University Teaching Hospital (BhUTH) Jos Nigeria from March 2018 to July 2023. Figure 1 Google map location of BHUTH [16] Figure 2 Google map location of BHUTH [17] 2.2. Inclusion Criteria Out-patients and in-patients (males and females) irrespective of ages who had been diagnosed of cancer and receiving treatment from JUTH and BhUTH within the past five year. 2.3. Exclusion Criteria Patients not receiving cancer treatment in JUTH and BhUTH within the study period. 2.4. Financial Burden Considerations 2.4.1. Direct cost Include hospital bills, medication costs, laboratory tests and imaging studies 2.4.2. Indirect costs Include loss of income due to inability to work during treatment and cost associated with transportation to healthcare facilities World Journal of Biology Pharmacy and Health Sciences, 2025, 23(02), 150-160 152 2.4.3. Insurance coverage Many patients may not have adequate health insurance coverage, leading to higher out-of-pocket expenses 2.4.4. Socioeconomic factors Lower socioeconomic status can exacerbate the financial burden, as many patients may have limited access to resources for treatment 2.5. Data Analysis The data collected were analyzed using SPSS version 21 (IBM Corporation, Armonk, NY). The demographic and clinical characteristics, as well as the utilization of anticancer drugs and its indicators were analyzed using descriptive statistics; mean, standard deviation and frequency. Prescription pattern of anticancer medicines was determine using WHO core prescribing indicators for the number of prescriptions with polypharmacy, percent of prescriptions with injectables, percent of drugs prescribed with generic and brand names, percentage of antibiotics encountered. 3. Results and Discussion Table 1 Demographic characteristics (n=228) Age group Frequency Percentage (%) 4-23 9 4.0 24-43 68 29.8 44-63 111 48.6 64-83 38 16.7 84-103 2 0.9 Minimum age Maximum age Mean ± SD 4 95 49.80 ± 14.84 Sex Male 51 22.4 Female 177 77.6 The maximum age of patients with cancer was 95 years and the minimum age was 4 years and more females (177) had cancer compared to male subjects (51). Out of the different types of cancer encountered cervical cancer was the highest 64 and the lowest was liver and gastric cancer 1. World Journal of Biology Pharmacy and Health Sciences, 2025, 23(02), 150-160 153 Figure 3 Percentage Distribution for Cancer Types Out of the different types of cancer encountered cervical cancer was the highest 64 and the lowest was liver and gastric cancer 1. Table 2 Anticancer drugs prescribing patterns in BhUTH and JUTH Functional Classification Drug Name JUTH (n) JUTH (%) BhUTH (n) BhUTH (%) Alkylating agents Cyclophosphamide 26 6.2 15 14.4 Alkylating agents Dacarbazine 6 1.4 0 0 Alkylating agents Ifosphamide 9 2.1 0 0 Antibiotics Adriamycin 30 17.0 9 8.7 Antibiotics Bleomycin 2 0.5 0 0 Antibiotics Actinomycin 4 1.0 1 1.0 Antibiotics Epirubicin 2 0.5 2 1.9 Antimetabolites Capecitabine 6 1.4 3 2.9 Antimetabolites Gemcitabine 23 5.5 0 0 Antimetabolites 5-Fluorouracil 29 6.9 11 10.6 Antimetabolites Methotrexate 4 1.0 3 2.9 Monoclonal antibodies Bevacizumab 1 0.2 1 1.0 Monoclonal antibodies Rituximab 0 0 0 0 Platinum compounds Carboplatin 44 10.5 13 12.5 Platinum compounds Cisplatin 85 20.5 7 6.7 Platinum compounds Oxaliplatin 4 1.0 4 3.8 Taxanes Paclitaxel 82 19.6 15 14.4 World Journal of Biology Pharmacy and Health Sciences, 2025, 23(02), 150-160 154 Taxanes Docetaxel 39 9.3 14 13.5 Topoisomerase inhibitors Irinotecan 1 0.2 0 0 Topoisomerase inhibitors Etoposide 9 2.1 4 3.8 Vinca alkaloids Vincristine 6 1.4 2 1.9 Vinca alkaloids Vinblastine 7 1.7 0 0 Table 3 Prescription pattern of adjuvant drugs in BhUTH and JUTH Drug Class Drug Name BhUTH (n) BhUTH (%) JUTH (n) JUTH (%) Antiallergics Chlorpheniramine 0 0 163 13.0 Antiemetics Metoclopramide 60 22.6 3 0.2 Antiemetics Granisetron 0 0 163 13.0 Antiemetics Ondansetron 60 22.6 163 13.0 Anti-peptic ulcer drugs Cimetidine 0 0 2 0.2 Anti-peptic ulcer drugs Omeprazole 0 0 163 13.0 Antibiotics (non-antitumor) Ciprofloxacin 0 0 10 0.8 Antibiotics (non-antitumor) Ceftriaxone 3 1.1 21 1.7 Antibiotics (non-antitumor) Levofloxacin 0 0 13 1.0 Antibiotics (non-antitumor) Metronidazole 0 0 21 1.7 Analgesics Cocodamol 0 0 9 0.7 Analgesics Diclofenac 0 0 17 1.4 Analgesics Morphine 1 0.4 8 0.6 Analgesics Pentazocine 0 0 4 0.3 Anti-inflammatory (steroids) Dexamethasone 60 22.6 163 13.0 Anti-inflammatory (steroids) Hydrocortisone 60 22.6 163 13.0 Anti-inflammatory (steroids) Prednisolone 0 0 2 0.2 Antipyretic Paracetamol 3 1.1 9 0.7 Antiestrogen Tamoxifen 0 0 4 0.3 Antiresorptive (bisphosphonates) Zoledronic acid 1 0.4 9 0.7 Colony-stimulating factors Filgrastim 2 0.8 15 1.2 Diuretics Furosemide 7 2.6 85 6.8 Vitamins and minerals Vitamin B complex 0 0 7 0.6 Vitamins and minerals Vitamin C 2 0.8 10 0.8 Vitamins and minerals Fesolate 2 0.8 9 0.7 Vitamins and minerals Folinic acid 3 1.1 12 1.0 Others Goserelin 1 0.4 4 0.3 World Journal of Biology Pharmacy and Health Sciences, 2025, 23(02), 150-160 155 Table 4a Medical cost for JUTH Variable Cost Mean (SD) Median Range Investigations 4159600 25057.83±15031.05 22650 121700 Surgery 2489830 155614.38±223482.55 98540 936380 Chemotherapy 122341656 732584.76±1681469.16 498340 21567020 Consultation 502500 251250±202586.1 251250 286500 Total 129493586 1164507±2122569 870780 22911600 Table 4b Medical cost for BhUTH Variable Cost Mean (SD) Median Range Investigations 1168500 19155.74 ±7347.07 18000 24000 Chemotherapy 29401326.84 481988.96 ± 324152.35 463563 2058438 Consultation 95800 47900 ± 18526 47900 26200 Total 30569826.84 549044.7 ± 350025.4 529463 2108638 Table 5 Therapeutic toxicity profile of prescribed anticancer drugs Type of cancer drugs Side effects Therapeutic toxicity (%) Cisplatin Nausea and vomiting 70-80 Cisplatin Nephrotoxicity 25-30 Cisplatin Ototoxicity 10-15 Cisplatin Myelosuppression 10-15 Cyclophosphamide Nausea and vomiting 50-70 Cyclophosphamide Myelosuppression 30-50 Cyclophosphamide Hemorrhagic cystitis 5-10 Cyclophosphamide Alopecia 30-50 Doxorubicin (Adriamycin) Myelosuppression 30-50 Doxorubicin (Adriamycin) Cardiotoxicity 5-15 Doxorubicin (Adriamycin) Nausea and vomiting 60-70 Doxorubicin (Adriamycin) Alopecia 60-80 Methotrexate Myelosuppression 20-40 Methotrexate Mucositis 10-20 Methotrexate Hepatotoxicity 5-10 Methotrexate Renal toxicity 5-10 Paclitaxel Myelosuppression 20-30 Paclitaxel Peripheral neuropathy 10-20 Paclitaxel Hypersensitivity reactions 5-10 World Journal of Biology Pharmacy and Health Sciences, 2025, 23(02), 150-160 156 Paclitaxel Alopecia 60-80 Vincristine Peripheral neuropathy 40-50 Vincristine Constipation 20-30 Vincristine Myelosuppression (Less common) Vincristine Alopecia (less common) 5-Fluorouracil (5-FU) Myelosuppression 30-40 5-Fluorouracil (5-FU) Diarrhea 10-20 5-Fluorouracil (5-FU) Mucositis/Stomatitis 10-20 5-Fluorouracil (5-FU) Hand-foot syndrome 5-10 Tamoxifen Hot flashes 50-60 Tamoxifen Nausea 10-20 Tamoxifen Thromboembolic events 1-5 Tamoxifen Endometrial changes 1-5 Rituximab Infusion reactions 30-50 Rituximab Myelosuppression 10-20 Rituximab Infections 5-10 Rituximab Hepatitis reaction in chronic carriers Table 6 Cancer type, therapeutic regimen and common toxicity and financial profile Cancer Type Therapeutic Regimen Common Toxicities Financial Burden Breast cancer Surgery (lumpectomy or mastectomy) Myelosuppression (30– 50%) Surgery, chemotherapy, radiotherapy and supportive care. Out-of-pocket expenses and loss of income during treatment Surgery, chemotherapy, radiotherapy, and supportive care. Out-of-pocket expenses and loss of income during treatment. Breast cancer Chemotherapy (e.g., doxorubicin, cyclophosphamide, paclitaxel) Nausea and vomiting (60– 70%) Same as above Breast cancer Hormonal therapy (e.g., tamoxifen for hormone receptor-positive cases) Alopecia (60–80%); Cardiotoxicity with doxorubicin (5–15%) Same as above Cervical cancer Surgery (hysterectomy) Nausea and vomiting (50– 70%) Similar to breast cancer Cervical cancer Chemotherapy (e.g., cisplatin, 5-fluorouracil) Myelosuppression (20– 40%) Similar to breast cancer Cervical cancer Radiotherapy (often combined with chemotherapy) Fatigue (variable) Similar to breast cancer World Journal of Biology Pharmacy and Health Sciences, 2025, 23(02), 150-160 157 Prostate cancer Surgery (prostatectomy) Hot flashes with hormonal therapy (50–60%) Treatment can be costly due to surgery and long-term hormonal therapy. Access to medication may be limited by financial constraints Prostate cancer Hormonal therapy (e.g., LHRH agonist) Fatigue (variable) Same as above Prostate cancer Chemotherapy (e.g., docetaxel in advanced cases) Myelosuppression (20– 30%) Same as above Lymphomas (Hodgkin’s & NonHodgkin’s) Chemotherapy (e.g., CHOP regimen: cyclophosphamide, doxorubicin, vincristine, prednisone) Myelosuppression (30– 50%); Nausea and vomiting (60–70%); Peripheral neuropathy with vincristine (10–20%) Similar to other cancers, cost can accumulate from multiple cycles of chemotherapy and potential hospitalization for side effects Lymphomas (Hodgkin’s & NonHodgkin’s) Radiotherapy (in some cases) Fatigue (variable) Same as above Gastrointestinal cancers (e.g., colorectal cancer) Surgery Myelosuppression (20– 40%) Patients may face high cost of surgical procedures and ongoing chemotherapy, leading to financial strain Gastrointestinal cancers (e.g., colorectal cancer) Chemotherapy (e.g., 5fluorouracil, oxaliplatin) Diarrhea (10–20%); Mucositis/Stomatitis (10– 20%) Same as above Table 7 WHO Prescribing indicators as found in JUTH and BhUTH Prescribing Indicators (JUTH) (BhUTH) Average Antibiotic Per Prescription 1.57 2.50 Average Anticancer Drug Per Prescription 2.39 (3.50%) 2.36 (28.95%) Average Injection Per Prescription 2.45 (19.88%) 2.34 (27.72%) Average Generics 2.11 (3.90%) 1.07 (26.32%) Average brand 1.13 (22.13%) 1.12 (2.81%) Average Prescription 4.23 1.11 Number of Antibiotic 1.50 1.20 Prescriptions from Essential Drug List 100% 100% Despite the biomedical and technological advancement which have propelled the quality of cancer care and the treatment outcomes, the financial hardship experienced by the cancer patients and their family members has impacted negatively on cancer management [18], [19]. This is as a result of the inability of the patients to afford the associated cost of care required in the management of this disease condition. The economic burden thus negatively impacts the quality of care accessible to the patients and the eventual treatment outcomes and the quality of life of the patients. The financial burden is even worse in resource limited countries such as Nigeria where the majority of the people live on less than a dollar per day [20]. Cancer disease is a leading cause of death globally. It is characterized by continuous, uncontrolled multiplication of the cells of the body. The factors associated with the development of the disease are varied and they can be from environmental, dietary, lifestyle or radiation sources [21], [22]. The management of cancer has a heavy cost implication [23]. Chemotherapy is a key component required in the management and treatment of cancers [24]. Over the years, medications that brings about better treatment outcomes are being produced by the pharmaceutical industries. The medications are expensive and beyond the reach of the poor. The low-income countries World Journal of Biology Pharmacy and Health Sciences, 2025, 23(02), 150-160 158 are particularly challenged in the management of cancer as a result of financial constraints both at individual and governmental levels [25]. In this study, breast cancer (24%) and cervical cancer (28%) were the most common type of cancer found in the community under study. This is similar to the findings in a recent study that showed that breast cancer is the most common type of cancer [26]. The age bracket most affected by cancer plague is between 44-63 years of age. However, a recent study showed that there is no correlation between ageing and development of cancer disease [27]. The development of cancer has more to do with exposure to the predisposing factors than advancement in the age of an individual. The anticancer drugs mostly in use at the public hospital, JUTH and the faith based or private hospitals are the antimetabolites, the taxanes, alkylating agents and the platinum compounds. However, in another study, the most prescribed anticancer drugs were cisplatin, etoposide and cyclophosphamide [10]. It is noteworthy that new generation of anticancer drugs are available especially in the developed countries. The average cost for the treatment of cancer in a public hospital, JUTH is N1164507±2122569 or $1000 while the average cost of the same care in a missionbased hospital BhUTH is N549044.7±350025.4 or $460. This shows that treatment cost in a public hospital is significantly higher than in a missionary-based hospital or private hospital. On the contrary, a recent study showed that the treatment cost of cancer in a private hospital is significantly higher than in a public health institution or hospital [28]. Lack of affordability of the medicines will ultimately lead to abandonment of the treatment options and eventual poor outcome [29]. This study reveals the dual burden of therapeutic and financial toxicity among cancer patients in Nigerian tertiary health facilities. The findings highlight critical issues in oncology care in low-resource settings, where patients often contend with severe side effects from conventional chemotherapeutic agents alongside unsustainable treatment costs. Cervical and breast cancers, both prevalent in women, were the most commonly treated cancers in the cohort, aligning with national and global cancer epidemiology trends. The reliance on older cytotoxic agents—such as cisplatin, cyclophosphamide, and doxorubicin—though effective, is associated with high rates of adverse effects like myelosuppression, nausea, alopecia, and organ toxicity. These toxicities, especially when unmanaged, contribute to poor adherence, compromised quality of life, and increased hospitalization. Financial toxicity was equally alarming. Chemotherapy was the costliest component, with some regimens exceeding ₦2 million, especially in JUTH. Direct medical costs (investigations, surgery, and consultations) and indirect costs (lost income, transportation) further compound the burden. Patients at both institutions largely paid out-of-pocket, with negligible insurance support. This finding echoes other studies in sub-Saharan Africa where catastrophic health expenditures for cancer care are common and lead to treatment abandonment or delayed initiation. The WHO prescribing indicators showed concerning levels of polypharmacy and underuse of generic medications. In BhUTH, the use of generics was notably low (26.32%), potentially driving up treatment costs. The predominance of brand-name prescriptions, despite economic constraints, calls for improved drug procurement policies and adherence to essential medicine lists. Ultimately, the study emphasizes the need for systemic changes: subsidies for essential cancer treatments, expanded insurance coverage, and integration of less toxic and targeted therapies where feasible. Strategic interventions, including patient education and health system strengthening, are essential to mitigate the burdens identified and improve cancer care outcomes. 4. Conclusion Cancer treatment in the studied institutions is characterized by substantial therapeutic and financial toxicity. This suggests the level of burden associated with accessing cancer management in public, private/faith-based health facilities in Nigeria where generality of the members of the society live on less than a dollar per day. The need for affordable care, improved insurance coverage, and safer therapeutic options is critical to enhance cancer care outcomes in resource-limited setting. Compliance with ethical standards Acknowledgments We acknowledge the management of Bingham University Teaching Hospital Jos, Jos University Teaching Hospital Jos, Nigeria; and Centre of Excellence in Phytomedicines Research and Development, University of Jos, Nigeria, for their various assistance. Disclosure of conflict of interest The Authors declare no conflict of interest of any sort.