cancers Systematic Review Patient-Reported Financial Distress in Cancer: A Systematic Review of Risk Factors in Universal Healthcare Systems Sophie Pauge 1, * ,† , Bastian Surmann 1,† , Katja Mehlis 2 , Andrea Zueger 2 , Luise Richter 3 , Natalja Menold 3 , Wolfgang Greiner 1 and Eva C. Winkler 2   Citation: Pauge, S.; Surmann, B.; Mehlis, K.; Zueger, A.; Richter, L.; Menold, N.; Greiner, W.; Winkler, E.C. Patient-Reported Financial Distress in Cancer: A Systematic Review of Risk Factors in Universal Healthcare Systems. Cancers 2021, 13, 5015. https://doi.org/10.3390/ cancers13195015 Academic Editor: Massimo Di Maio Received: 15 June 2021 Accepted: 4 October 2021 Published: 7 October 2021 Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affil- iations. Copyright: © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/). 1 Department for Health Economics and Health Care Management, School of Public Health, Bielefeld University, 33615 Bielefeld, Germany; bastian.surmann@uni-bielefeld.de (B.S.); wolfgang.greiner@uni-bielefeld.de (W.G.) 2 Section of Translational Medical Ethics, Department of Medical Oncology, National Center for Tumor Diseases (NCT), Heidelberg University Hospital, 69120 Heidelberg, Germany; katja.mehlis@med.uni-heidelberg.de (K.M.); andrea.zueger@med.uni-heidelberg.de (A.Z.); eva.winkler@med.uni-heidelberg.de (E.C.W.) 3 Methods in Empirical Social Research, Institute of Sociology, Faculty of Arts, Humanities and Social Science, Dresden University, 01062 Dresden, Germany; luise.richter4@tu-dresden.de (L.R.); natalja.menold@tu-dresden.de (N.M.) * Correspondence: sophie.pauge@uni-bielefeld.de; Tel.: +49-521-106-4331 † These authors contributed equally to this work. Simple Summary: A comprehensive understanding of risk factors associated with experiencing subjective financial distress is needed to inform the development of valid instruments and effective interventions to tackle financial toxicity. Several studies from the US indicate a strong correlation of the US-healthcare system’s systematic organisation and its particular socioeconomic risk factors for cancer patients experiencing financial toxicity. It is assumed that risk factors differ in other high- income countries due to the different structure of universal healthcare coverage. As an exhaustive analysis for other countries is lacking, this review aims to identify risk factors for subjective financial distress in universal healthcare systems. Abstract: Financial toxicity is a side effect of cancer that results from the perceived financial distress an individual may experience in the course of the disease. The purpose of this paper is to analyse underlying factors related to subjective financial distress in high-income countries with universal healthcare coverage. A systematic literature review was conducted to identify qualitative and quantitative studies of cancer patient-reported subjective financial distress by performing a search in the databases of PubMed, PsycINFO and CINAHL up to December 2020. A qualitative synthesis was performed linking the time-dependent occurrence of risk factors to derived categories of risk factors. Out of 4321 identified records, 30 quantitative and 16 qualitative studies were eligible. Classification of risk factors resulted in eight categories with a total of 34 subcategories. Subjective financial distress is primarily determined by pre-diagnosis sociodemographic- factors as well as financial and work factors that might change during the course of the disease. The design of healthcare and social security systems shapes the country-specific degree of subjective financial distress. Further research should focus on evolving multidisciplinary intervention schemes and multidimensional instruments for subjective financial distress to account for identified risk factors in universal healthcare systems more precisely. Keywords: cancer; financial toxicity; financial distress; universal healthcare coverage; risk factors 1. Introduction In recent years, the rising understanding of cancer as a chronic disease with lifelong individual consequences has shifted the awareness of potential side effects beyond clinical Cancers 2021, 13, 5015. https://doi.org/10.3390/cancers13195015 https://www.mdpi.com/journal/cancers