Out-of-pocket-payments and the financial burden of 502 cancer patients of working age in Germany: results from a longitudinal study
Abstract
Purpose Cancer patients in Germany often face payments related to their disease or treatment which are not covered by their health insurance. The aim of this study was to analyze the amount of out-of-pocket payments (OOPPs) among cancer patients in Germany, to explore potential socioeconomic determinants of OOPPs, and to identify how cancer patients are burdened by these payments. Methods Cancer ptients were consecutively enrolled in 16 clinics in Leipzig, Germany. Data on OOPPs for the past 3 months and on socioeconomic status were obtained at the end of their hospital stay (t0) and 3 (t1) and 15 months (t2) after t0. Financial burden was calculated by dividing the monthly OOPPs by the midpoint of the income category, and the perceived burden was assessed by using the financial difficulties scale of the EORTC QLQ-C30. A two-part regression model was used to estimate the determinants of OOPPs. Results At baseline (t0), 502 cancer patients participated in the study and provided data on OOPPs and socioeconomic status. The mean 3-month OOPPs were the following: €205.8 at baseline, €179.2 at t1, and €148.1 at t2. Compared to the lowest income group ( Conclusion German cancer patients face relatively high OOPPs during their cancer journey. These payments may burden cancer patients, especially certain subgroups like low-income groups.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
Distress causes financial problems in patients with cancer.
“causes financial problems”
Distress results in a 4.4-fold higher risk of suicide compared with the general population in patients with cancer.
“results in a 4.4-fold higher risk of suicide compared with the general population.”
Distress leads to decreased quality of life in patients with cancer.
“leads to decreased quality of life”
In patients with cancer, distress strongly affects all aspects of their lives (eg, work-life, family life).
“In patients with cancer, distress strongly affects all aspects of their lives (eg, work–life, family life)”
Cites
Generalized modeling approaches to risk adjustment of skewed outcomes data
Manning, W. G., Basu, A., & Mullahy, J. (2005) · Journal of Health Economics · doi:10.1016/j.jhealeco.2004.09.011 · Cited by 760 · see citing works
Piette, J. D., Heisler, M., & Wagner, T. H. (2004) · American Journal of Public Health · doi:10.2105/ajph.94.10.1782 · Cited by 349 · see citing works
Singer, S., Szalai, C., Briest, S., Brown, A., Dietz, A., Einenkel, J., Jonas, S., Konnopka, A., Papsdorf, K., Langanke, D., et al. (2013) · Psycho-Oncology · doi:10.1002/pon.3282 · Cited by 87 · see citing works
Self-citationSinger, S., Meyer, A., Wienholz, S., Briest, S., Brown, A., Dietz, A., Binder, H., Jonas, S., Papsdorf, K., Stolzenburg, J., et al. (2014) · Cancer · doi:10.1002/cncr.28716 · Cited by 31 · see citing works
Self-citation
Flagged first, then by citations
Cited by
Sorted by citations
The Out-of-Pocket Cost Burden of Cancer Care—A Systematic Literature Review
Iragorri, N., de Oliveira, C., Fitzgerald, N., & Essue, B. M. (2021) · Current Oncology · doi:10.3390/curroncol28020117 · Cited by 209 · see citing works
“Finally, lower-income patients and households had a greater burden imposed by out-of-pocket expenses, as measured by the proportion of the household income spent in the form of out-of-pocket costs [31,34,47,68,69,74,86,87,90,92,108,116].”
BackgroundLongo, C. J., Fitch, M. I., Banfield, L., Hanly, P., Yabroff, K. R., & Sharp, L. (2020) · Supportive Care in Cancer · doi:10.1007/s00520-020-05620-9 · Cited by 133 · see citing works
Carrera, P., Curigliano, G., Santini, D., Sharp, L., Chan, R. J., Pisu, M., Perrone, F., Karjalainen, S., Numico, G., Cherny, N., et al. (2024) · ESMO Open · doi:10.1016/j.esmoop.2024.102992 · Cited by 70 · see citing works
“59 In comparison, transportation accounted for 38% and 62.8% at baseline and after 3 months.”
InfluentialThe patient-level effect of the cost of Cancer care – financial burden in German Cancer patients
Mehlis, K., Witte, J., Surmann, B., Kudlich, M., Apostolidis, L., Walther, J., Jäger, D., Greiner, W., & Winkler, E. (2020) · BMC Cancer · doi:10.1186/s12885-020-07028-4 · Cited by 64
Hueniken, K., Douglas, C. M., Jethwa, A. R., Mirshams, M., Eng, L., Hope, A. J., Chepeha, D. B., Goldstein, D. P., Ringash, J. G., Hansen, A. R., et al. (2020) · Cancer · doi:10.1002/cncr.33032 · Cited by 63 · see citing works
Leuteritz, K., Friedrich, M., Sender, A., Richter, D., Mehnert-Theuerkauf, A., Sauter, S., & Geue, K. (2020) · Journal of Adolescent and Young Adult Oncology · doi:10.1089/jayao.2020.0055 · Cited by 47 · see citing works
“The reasons for financial burdens can be manifold, even though in Germany, where most patients are covered by a statutory health care system 39 (no AYA-specific study): After 6 weeks of sickness, employees in Germany generally receive a paid sick leave of * 25% less than the last net salary.”
Schröder, S., Schumann, N., Fink, A., & Richter, M. (2019) · Supportive Care in Cancer · doi:10.1007/s00520-019-04915-w · Cited by 46 · see citing works
Pauge, S., Surmann, B., Mehlis, K., Zueger, A., Richter, L., Menold, N., Greiner, W., & Winkler, E. (2021) · Cancers · doi:10.3390/cancers13195015 · Cited by 45 · see citing works
“Six studies [16,38,50,54,60,62] did not statistically control for confounding variables regarding the outcome of financial distress.”
BackgroundResultFinancial toxicity in cancer patients treated with radiotherapy in Germany—a cross-sectional study
Fabian, A., Domschikowski, J., Greiner, W., Bockelmann, G., Karsten, E., Rühle, A., Nicolay, N. H., Grosu, A., Dunst, J., & Krug, D. A. (2022) · Strahlentherapie und Onkologie · doi:10.1007/s00066-022-01936-z · Cited by 41 · see citing works
“Furthermore, Büttner and colleagues followed cancer patients longitudinally that were hospitalized for treatment [19].”
BackgroundKong, Y.-C., Wong, L., Ng, C., Taib, N. A., Bhoo-Pathy, N., Yusof, M. M., Aziz, A., Yehgambaram, P., Ishak, W. Z. W., Yip, C., et al. (2020) · The Oncologist · doi:10.1634/theoncologist.2019-0426 · Cited by 39 · see citing works
Braun, I., Friedrich, M., Morgenstern, L., Sender, A., Geue, K., Mehnert, A., & Leuteritz, K. (2023) · European Journal of Oncology Nursing · doi:10.1016/j.ejon.2023.102329 · Cited by 40 · see citing works
Jiang, H., Lyu, J., Mou, W., Jiang, Q.-H., & Du, J.-L. (2022) · Asia-Pacific Journal of Clinical Oncology · doi:10.1111/ajco.13901 · Cited by 34 · see citing works
Büttner, M., Singer, S., Hentschel, L., Richter, S., Hohenberger, P., Kasper, B., Andreou, D., Pink, D., Taylor, K., Arndt, K., et al. (2021) · Supportive Care in Cancer · doi:10.1007/s00520-021-06406-3 · Cited by 33
Self-citationLueckmann, S. L., Schumann, N., Hoffmann, L., Roick, J., Kowalski, C., Dragano, N., & Richter, M. (2019) · Health and Social Care in the community · doi:10.1111/hsc.12907 · Cited by 27 · see citing works
Hernandez, D., & Schlander, M. (2021) · Cancer Medicine · doi:10.1002/cam4.3913 · Cited by 25
Cancer-associated financial burden in German head and neck cancer patients
Rast, J., Zebralla, V., Dietz, A., Wichmann, G., & Wiegand, S. (2024) · Frontiers in Oncology · doi:10.3389/fonc.2024.1329242 · Cited by 20
Self-citationThe Burden of Out-of-Pocket Expenditure Related to Gynaecological Cancer in Malaysia
Liew, C., Shabaruddin, F., & Dahlui, M. (2022) · Healthcare · doi:10.3390/healthcare10102099 · Cited by 19
“Additionally, future OOP expenditure studies can improve on the design of this study by conducting a prospective longitudinal study, which can thoroughly capture OOP expenditure without reliance on patient recall [45].”
BackgroundRiva, S., Bryce, J., Lorenzo, F. D., Campo, L. D. D., di Maio, M., Efficace, F., Frontini, L., Giannarelli, D., Gitto, L., Iannelli, E., et al. (2019) · BMJ Open · doi:10.1136/bmjopen-2019-031485 · Cited by 19 · see citing works
Finanzielle Toxizität einer Krebserkrankung
Lueckmann, S. L., Kowalski, C., & Schumann, N. (2021) · Der Onkologe · doi:10.1007/s00761-021-00931-w · Cited by 18 · see citing works
Research on the issue of financial toxicity in cancer: A systematic review of the literature
Sideris, L., Karampli, E., & Athanasakis, K. (2025) · Journal of Cancer Policy · doi:10.1016/j.jcpo.2025.100581 · Cited by 21 · see citing works
Tribius, S., Haladyn, S., Hanken, H., Busch, C., Krüll, A., Petersen, C., & Bergelt, C. (2020) · Strahlentherapie und Onkologie (Print) · doi:10.1007/s00066-020-01737-2 · Cited by 17
“In a recent study in a population of German cancer patients, the out-of-pocket payments in cancer patients were significant and the researchers concluded that these payments are an additional burden to cancer patients, especially in certain subgroups like low-income groups [61].”
BackgroundJones, S. M. W., Yi, J. C., Henrikson, N. B., Panattoni, L., & Shankaran, V. (2020) · Future Science OA · doi:10.2144/fsoa-2023-0229 · Cited by 17 · see citing works
Economic burden for retinoblastoma patients in China
Zhou, Y.-C., Cai, S.-Y., Jin, M., Jiang, C.-Y., Xu, N., Duan, C., Peng, X., Zhao, J.-Y., & Ma, X.-L. (2020) · Journal of Medical Economics · doi:10.1080/13696998.2020.1831518 · Cited by 16
Financial worry in people with cancer: Relationship to employment and outcomes
Jones, S. M. W. (2022) · Psycho-Oncology · doi:10.1002/pon.6034 · Cited by 14
Worry about debt is related to social loneliness in older adults in the Netherlands
Loibl, C., Drost, M., Huisman, M., Suanet, B., de Bruin, W. B., McNair, S., & Summers, B. (2021) · Ageing & Society · doi:10.1017/s0144686x21000325 · Cited by 14 · see citing works
“Evidence suggests that out-of-pocket medical expenses, limited access to jobs and rising costs of living contribute to the growing debt burden in older age (Joint Center for Housing Studies of Harvard University, 2016; Büttner et al., 2019).”
BackgroundBäuerle, A., Martus, P., Erim, Y., Schug, C., Heinen, J., Krakowczyk, J. B., Steinbach, J., Damerau, M., Bethge, W., Dinkel, A., et al. (2022) · BMJ Open · doi:10.1136/bmjopen-2021-056973 · Cited by 12 · see citing works
Bäuerle, A., Teufel, M., Schug, C., Skoda, E.-M., Beckmann, M., Schäffeler, N., Junne, F., Erim, Y., Zipfel, S., & Graf, J. (2020) · BMJ Open · doi:10.1136/bmjopen-2019-036466 · Cited by 11 · see citing works
Merollini, K. M. D., Gordon, L., Aitken, J., & Kimlin, M. (2020) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph17082831 · Cited by 11 · see citing works
Schneider, J., Hernández, D., CAESAR study group, Schlander, M., Arndt, V., & on behalf of the CEASAR study group (2022) · Journal of Cancer Survivorship · doi:10.1007/s11764-022-01293-x · Cited by 8 · see citing works
Dayan, D., Leinert, E., Singer, S., Janni, W., Kühn, T., Flock, F., Felberbaum, R., Herbert, S., Wöckel, A., & Schwentner, L. (2022) · Archives of Gynecology and Obstetrics · doi:10.1007/s00404-022-06604-2 · Cited by 10 · see citing works
Self-citationRiccetti, N., Felberbaum, R., Flock, F., Kühn, T., Leinert, E., Schwentner, L., Singer, S., Taylor, K., Wöckel, A., & Janni, W. (2022) · Supportive Care in Cancer · doi:10.1007/s00520-022-07074-7 · Cited by 10 · see citing works
“transportation costs [5]) and to the inability to work.”
BackgroundSelf-citationThe financial toll of cancer: uncovering the links between financial toxicity and symptom burden
Filetti, M., Lombardi, P., Gentile, G., Toccaceli, P., Fumi, G., Vacca, D., Colpani, E., Ravoni, G., Mazzuca, F., Daniele, G., et al. (2025) · The Oncologist · doi:10.1093/oncolo/oyaf131 · Cited by 9
Bergerot, C., Wang, A., Serpentini, S., Borgese, C., & Kim, Y. (2023) · Supportive Care in Cancer · doi:10.1007/s00520-023-07998-8 · Cited by 9 · see citing works
Economic burden of cancer treatment in India: an equity perspective
Behera, S., & Pradhan, J. (2023) · Journal of Social and Economic Development · doi:10.1007/s40847-023-00247-y · Cited by 8 · see citing works
Surmann, B., Lingnau, R., Witte, J., Walther, J., Mehlis, K., Winkler, E., & Greiner, W. (2021) · Zeitschrift fur Evidenz, Fortbildung und Qualitat im Gesundheitswesen · doi:10.1016/j.zefq.2021.02.006 · Cited by 8
[DNVF Memorandum Health Services Research in Oncology].
Kowalski, C., Albert, U., Baumann, W., Carl, E.-G., Ernstmann, N., Hermes-Moll, K., Fallenberg, E., Feick, G., Feiten, S., Härter, M., et al. (2020) · Das Gesundheitswesen · doi:10.1055/a-1191-3759 · Cited by 8
Singer, S., Danker, H., Meixensberger, J., Briest, S., Dietz, A., Kortmann, R., Stolzenburg, J., Kersting, A., & Roick, J. (2019) · Journal of Cancer Research and Clinical Oncology · doi:10.1007/s00432-019-03018-7 · Cited by 8 · see citing works
Self-citationEinkommenseinbußen nach Krebs – Ergebnisse aus Deutschland
Arndt, V., Hernandez, D., & Schlander, M. (2022) · Die Onkologie · doi:10.1007/s00761-022-01243-3 · Cited by 6
Parker, C., Berkovic, D. E., Wei, A. H., Zomer, E., Liew, D., & Ayton, D. (2021) · Health & Social Care in the Community · doi:10.1111/hsc.13642 · Cited by 6 · see citing works
Longo, C., & Fitch, M. (2021) · Current Opinion in Supportive and Palliative Care · doi:10.1097/spc.0000000000000561 · Cited by 6
“This occurs commonly in racialized groups [4,10,11,17,18 & ,19 & ,29,31,46], and also in the young [10,17,21,28]; in those with low education [17,28, 33,46], low income [1,11,21,28,46] or low socioeconomic status (SES) [4,26,28,32]; those who are underinsured [46]; those living in rural locations [18 & ] and those wit…”
BackgroundSelf-reported financial difficulties of colorectal cancer patients 1 year after start of treatment
Sibert, N. T., Breidenbach, C., Benz, S., Post, S., Seufferlein, T., Ackermann, C., Blossey, R., Böhm, G., Brennfleck, F., Bunse, J., et al. (2025) · ESMO Open · doi:10.1016/j.esmoop.2025.105078 · Cited by 5
Trenaman, L., Kaal, K. J., Laba, T., Safari, A., Aguiar, M., Burch, T., Beckett, J., Munro, S. B., Hudson, M., & Harrison, M. J. (2023) · CMAJ Open · doi:10.9778/cmajo.20220227 · Cited by 5 · see citing works
“21”
Finanzielle Toxizität bei Krebspatient*innen unter Strahlentherapie
Fabian, A., Rühle, A., Becker, J.-N., Bockelmann, E., Domschikowski, J., Boeke, S., Fink, C., Käsmann, L., Sonnhoff, M., Schneider, M., et al. (2022) · Forum · doi:10.1007/s12312-022-01097-1 · Cited by 4
Cancer treatment in the USA: a financially toxic cocktail
Gruber, K. (2020) · Nature Cancer · doi:10.1038/s43018-020-00157-6 · Cited by 4
Thong, M. S. Y., Doege, D., Weißer, L., Koch-Gallenkamp, L., Bertram, H., Eberle, A., Holleczek, B., Nennecke, A., Waldmann, A., Zeissig, S., et al. (2021) · Journal of Cancer Research and Clinical Oncology · doi:10.1007/s00432-021-03825-x · Cited by 3
Pham, P., Ubels, J., Eckford, R. D., & Schlander, M. (2025) · PharmacoEconomics - Open · doi:10.1007/s41669-025-00568-0 · Cited by 2
Smussi, D., Conti, C., Lorini, L., Mattavelli, D., Levaggi, R., Miniaci, R., Calza, S., Deganello, A., Paduano, C., Alberti, A., et al. (2025) · BMC Cancer · doi:10.1186/s12885-024-13230-5 · Cited by 2
“…the FIT questionnaire), which focuses on the costs not covered by the universal health care system and therefore paid by the patients (items 8, 9, 10, and 11); and loss of productivity (equal to the subdomain present in the FIT questionnaire), which investigates the impact on patient’s and…”
Krebs und die finanziellen Auswirkungen für Betroffene
Zuger, A., Richter, L., Pauge, S., Mehlis, K., & Winkler, E. C. (2024) · Forum · doi:10.1007/s12312-024-01296-y · Cited by 2 · see citing works
Die Messung der Kosten von Krebserkrankungen in Deutschland
Hernandez, D., Hernández-Villafuerte, K., & Schlander, M. (2021) · Forum · doi:10.1007/s12312-021-01026-8 · Cited by 2
“Zu diesem bis in die jüngste Vergangenheit weithin unterschätztenProblemfeld gibt es gerade für die westeuropäischen Wohlfahrtsstaaten einen großen Forschungsbedarf [19, 28], um robuste Daten über das wahre Ausmaß des Problems und vulnerable Patientengruppen zu generieren [1, 9, 21].”
Krebshilfe, S. D. (2020) · Forum · doi:10.1007/s12312-020-00800-4 · Cited by 2 · see citing works
Finanzielle Auswirkung von Krebserkrankungen und sozialethische Implikationen
Mehlis, K., Surmann, B., & Winkler, E. (2020) · Der Onkologe · doi:10.1007/s00761-020-00722-9 · Cited by 2
Patient-Reported Financial Burden in Head and Neck Cancer Undergoing Radiotherapy
Zahu, R., Chirila, M., Ciobanu, O., Sturzu, D., Ciobanu, A., Ciobanu, G., Besenyodi, N., Vesel-Pop, M., Coșer, F., Costache, R., et al. (2025) · Cancers · doi:10.3390/cancers18010003 · Cited by 1
Strampfer, L., Ellebrecht, N., Hasenburg, A., & Weis, J. (2025) · Prävention und Gesundheitsförderung · doi:10.1007/s11553-025-01278-5 · Cited by 1
„Financial toxicity“ – finanzielle Auswirkungen einer Krebserkrankung
Büttner, M. (2025) · Die Onkologie · doi:10.1007/s00761-024-01674-0 · Cited by 1 · see citing works
Self-citationBüttner, M. (2023) · Forum · doi:10.1007/s12312-023-01198-5 · Cited by 1
Self-citationPauge, S., Mehlis, K., Zueger, A., Richter, L., Surmann, B., Mathies, V., Ernst, T., Menold, N., Greiner, W., & Winkler, E. C. (2026) · Zeitschrift fur Evidenz, Fortbildung und Qualitat im Gesundheitswesen · doi:10.1016/j.zefq.2026.07.009
The financial burden resulting from complementary and alternative medicine in oncology care
Bagdonas, S., Schäfer, L., Wolf, C., & Hübner, J. (2026) · BMC Complementary Medicine and Therapies · doi:10.1186/s12906-026-05417-z
Pauge, S., Zuger, A., Richter, L., Mathies, V., Surmann, B., Ernst, T., Menold, N., Greiner, W., Winkler, E. C., & Mehlis, K. (2026) · Supportive Care in Cancer · doi:10.1007/s00520-026-10395-6
“Similarly, Buettner et al. (2019) [15] and Schneider et al. (2020) [16] have demonstrated that German cancer patients face relatively high out-of-pocket costs during the course of their illness.”
Hecht, E., Rückschloss, T., Steen, S., Bleymehl, M., Engel, M., Hoffmann, J., & Moratin, J. (2026) · Journal of cranio-maxillo-facial surgery : official publication of the European Association for Cranio-Maxillo-Facial Surgery · doi:10.1016/j.jcms.2026.104448
Tuo, B.-B., Zhao, H.-K., Hu, A., & Jiang, J.-N. (2025) · Risk Management and Healthcare Policy · doi:10.2147/rmhp.s527194
Tewes, M., Hosters, B., & Teufel, M. (2023) · Zeitschrift für Palliativmedizin · doi:10.1055/a-1997-8930
“[20] Büttner M, König HH, Löbner M et al.”
BackgroundArmut und Krebs: Zeit, den Teufelskreis zu durchbrechen!
Klein, F. (2023) · Die Onkologie · doi:10.1007/s00761-023-01319-8
soleman, S. (2021) · Jurnal Kebijakan Kesehatan Indonesia · doi:10.22146/jkki.69494
- Authors
- Büttner, M., König, H.-H., Löbner, M., Briest, S., Konnopka, A., Dietz, A., Riedel-Heller, S., & Singer, S.
- Affiliations
- University Medical Center of the Johannes Gutenberg University Mainz (DE)
- University Medical Center Hamburg-Eppendorf (DE)
- University Hospital Leipzig (DE)
- Corresponding author
- Büttner, Matthias
- ORCID
- Venue
- Supportive Care in Cancer
- Published
- 2018-10-12
- Volume
- 27
- Issue
- 6
- Pages
- 2221-2228
- ISSN
- 0941-4355 (ISSN-L)
- 1433-7339
- OpenAlex
- W2897409289
- Cited by
- 63
- References
- 0
- Citations by year
- 2026: 2 · 2025: 8 · 2024: 5 · 2023: 7 · 2022: 10 · 2021: 11 · 2020: 14 · 2019: 6
- FWCI
- 11.75
- Type
- journal article
- Language
- en
- Open access
- closed
- Licence
- www.springer.com/tdm (tdm)
- Locations
- Supportive Care in Cancer (publishedVersion)
- PubMed (publishedVersion)
- Funders
- German Pension Insurance (#8011-106-31/31.81)
- Topics
- Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Economic and Financial Impacts of Cancer
- Social Sciences › Economics, Econometrics and Finance › Finance › Healthcare Systems and Reforms
- Health Sciences › Medicine › Oncology › Cancer survivorship and care
- Keywords
- out-of-pocket costs, financial burden, cancer patients, socioeconomic status, income, health insurance coverage, EORTC QLQ-C30, low-income patients, Germany
- MeSH terms
- Adult, Health Expenditures, Female, Germany, Humans, Insurance, Health, Longitudinal Studies, Male, Middle Aged, Neoplasms, Young Adult
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
