In Reply We thank Drs Ramagopalan and Sammon for their comments regarding our study on parking fees at National Cancer Institute-designated cancer centers 1 and want to underscore their point that financial toxicity driven by indirect costs is not isolated to the US. A study from Australia found that nonmedical costs for those in rural areas were primarily driven by travel and totaled more than $800 (US) in the first 6 months of cancer treatment. 2 Another study from Iran found that patients with cancer travel on average 282 miles (455 km) to receive care at the National Cancer Institute, which increases the burden on patients and caregivers. 3 Indirect costs of obtaining care, such as travel and parking, are not reimbursable by government or insurers and thus are universally costly. A study of patients with cancer conducted in Malaysia, a country with universal health coverage, found that catastrophic expenditures soared from 18% to 51% when nonmedical costs were taken into account. 4 In addition, a systematic review of financial toxicity found that in nations with publicly funded health care, out-of-pocket costs are smaller than in the US except for those related to lost income or travel, including parking fees. 5 Specifically, travel and accommodation costs ranged up to the equivalent of US $393 per month, highlighting that financial protection is inadequate even in countries with universal health care. As Ramagopalan and Sammon astutely point out, this burden is carried not just by the patient but the entire family.Altogether, these studies show that parking fees are a consistent concern regardless of health care delivery system typeall systems result in some degree of financial toxicity. Policies that address all forms of costs associated with obtaining high-quality care are necessary to ensure that patients and their caregivers are not eroding their financial welfare to receive care for their cancer. Gaps in coverage need to be addressed, as they lead to debilitating stress and strain on already vulnerable patients. We emphatically agree with Ramagopalan and Sammon; we need better documentation of costs incurred by patients and families. Similarly, we need more transparency from treating hospitals and cancer centers on indirect medical costs, such as parking, so that patients and families can better prepare for the true costs of treatment. The current system is essentially a tax on people who have a diagnosis of cancer.