Revisiting the EMPATICC trial in low- and middle-income countries

This commentary refers to ‘Heart failure therapy in patients with advanced cancer receiving specialized palliative care: the EMPATICC trial’, by M.S. Anker et al., https://doi.org/10.1093/eurheartj/ehaf705 and the discussion piece ‘The EMPATICC-trial – should location shape therapy?’, by M.S. Anker et al., https://doi.org/10.1093/eurheartj/ehag009. Cancer diagnosis and treatment lead to substantial financial burden for both patients and their families worldwide. Beyond the profound psychological and physical toll, cancer care can be both emotionally and financially exhausting. Studies indicate that approximately 47% of patients in middle- and high-income countries experience catastrophic healthcare expenditures related to cancer treatment, whereas this figure rises to 74.4% in low-income countries.1 The magnitude of this challenge is particularly pronounced in Pakistan, where an estimated 180 000 new cancer cases are diagnosed annually2 representing a significant demand that outpaces the nation’s scarce healthcare resources. Financial hardship is pervasive in Pakistan, as approximately 45% of the population lives below the global poverty line, with an average daily income of ∼4 USD, as reported by the World Bank.3 This systemic poverty translates directly to the financial toxicity endemic to this region. A local study in Pakistan’s tertiary care hospital assessed 100% of participants lacking sufficient savings to fund their cancer treatment expenses. Moreover, 84% reported difficulty meeting basic living expenses.4