ImportanceFinancial toxicity (FT) is the negative impact of cost of care on financial well-being. Patients with breast cancer are at risk for incurring high out-of-pocket costs given the long-term need for multidisciplinary care and expensive treatments.ObjectiveTo quantify the FT rate of patients with breast cancer and identify particularly vulnerable patient populations nationally and internationally.Data SourcesA systematic review and meta-analysis were conducted. Four databases—Embase, PubMed, Global Index Medicus, and Global Health (EBSCO)—were queried from inception to February 2021. Data analysis was performed from March to December 2022.Study SelectionA comprehensive database search was performed for full-text, English-language articles reporting FT among patients with breast cancer. Two independent reviewers conducted study screening and selection; 462 articles underwent full-text review.Data Extraction and SynthesisA standardized data extraction tool was developed and validated by 2 independent authors; study quality was also assessed. Variables assessed included race, income, insurance status, education status, employment, urban or rural status, and cancer stage and treatment. Pooled estimates of FT rates and their 95% CIs were obtained using the random-effects model.Main Outcomes and MeasuresFT was the primary outcome and was evaluated using quantitative FT measures, including rate of patients experiencing FT, and qualitative FT measures, including patient-reported outcome measures or patient-reported severity and interviews. The rates of patients in high-income, middle-income, and low-income countries who incurred FT according to out-of-pocket cost, income, or patient-reported impact of expenditures during breast cancer diagnosis and treatment were reported as a meta-analysis.ResultsOf the 11 086 articles retrieved, 34 were included in the study. Most studies were from high-income countries (24 studies), and the rest were from low- and middle-income countries (10 studies). The sample size of included studies ranged from 5 to 2445 people. There was significant heterogeneity in the definition of FT. FT rate was pooled from 18 articles. The pooled FT rate was 35.3% (95% CI, 27.3%-44.4%) in high-income countries and 78.8% (95% CI, 60.4%-90.0%) in low- and middle-income countries.Conclusions and RelevanceSubstantial FT is associated with breast cancer treatment worldwide. Although the FT rate was higher in low- and middle-income countries, more than 30% of patients in high-income countries also incurred FT. Policies designed to offset the burden of direct medical and nonmedical costs are required to improve the financial health of vulnerable patients with breast cancer.

Objective: We sought to describe the current Medicaid coverage landscape for gender-affirming surgery across the U.S. at the procedure level and identify factors associated with coverage. Summary Background Data: Medicaid coverage for gender-affirming surgery differs by state, despite a federal ban on gender identity-based discrimination in health insurance. States that cover gender-affirming surgery also differ in which procedures are included in Medicaid coverage, leading to confusion among patients and clinicians. Methods: State Medicaid policies in 2021 for gender-affirming surgery were queried for each of the 50 states, and District of Columbia (D.C.). State partisanship, state-level Medicaid protections, and coverage of gender-affirming procedures in 2021 were recorded. Linear correlation between electorate partisanship and total procedures covered was assessed. Pairwise t-tests were used to compare coverage based on state partisanship and presence of absence of state-level Medicaid protections. Results: Medicaid coverage for gender-affirming surgery was covered in 30 states and Washington D.C. The most commonly covered procedures were genital surgeries and mastectomy (n=31), followed by breast augmentation (n=21), facial feminization (n=12), and voice modification surgery (n=4). More procedures were covered in Democrat-controlled or leaning states, as well as in states with explicit protections for gender-affirming care in Medicaid coverage. Conclusion: Medicaid coverage for gender-affirming surgery is patchwork across the United States and is especially poor for facial and voice surgeries. Our study provides a convenient reference for patients and surgeons detailing which gender-affirming surgical procedures are covered by Medicaid within each state.