Financial toxicity and its association with quality of life and psychological distress among patients with gynecologic cancers receiving radiotherapy in China: a multicenter cross-sectional study

Background Financial toxicity is increasingly recognized as a consequential dimension of cancer care, yet multicenter evidence in China remains limited for patients with gynecologic cancers undergoing radiotherapy, a treatment pathway that often entails repeated visits and substantial non-medical costs. This study estimated the prevalence and severity of financial toxicity and examined its association with quality of life and psychological distress. Methods A multicenter cross-sectional survey was conducted in three tertiary hospitals in China, led by West China Second University Hospital, Sichuan University. Adult patients with gynecologic cancers receiving external beam radiotherapy and or brachytherapy with definitive, adjuvant, or curative-intent salvage or consolidation intent were consecutively recruited. Financial toxicity was assessed using the COmprehensive Score for financial Toxicity (COST, 0 to 44; lower scores indicate worse toxicity). Quality of life was measured using the EORTC QLQ-C30, and psychological distress using the Distress Thermometer (DT, 0 to 10; clinically significant distress defined as DT ≥ 4). Multivariable regression models included hospital fixed effects to account for measured differences across centers and adjusted for sociodemographic, access-burden, and clinical covariates. Results Among 1,533 returned questionnaires, 1,303 were valid and analyzed (85.0%). Mean COST score was 21.6 (SD 7.4); 17.5% had severe financial toxicity (COST ≤ 14), 48.0% moderate (15 to 24), and 34.5% mild (≥25). Mean QLQ-C30 global health status was 61.3 (SD 14.2). Mean DT score was 4.3 (SD 2.1), and 65.2% met criteria for clinically significant distress. In adjusted analyses, each 5-point decrease in COST was associated with lower global health status (β −4.17, 95% CI −4.62 to −3.72), lower emotional functioning (β −4.68, 95% CI −5.20 to −4.16), higher fatigue (β 4.47, 95% CI 3.93 to 5.01), and higher DT score (β 0.32, 95% CI 0.23 to 0.40), all p < 0.001. Each 5-point decrease in COST was associated with higher odds of clinically significant distress (OR 1.34, 95% CI 1.22 to 1.47; p < 0.001). Conclusion Financial toxicity was common among gynecologic radiotherapy patients in China and was independently associated with poorer quality of life and higher psychological distress. Integrating financial toxicity screening with supportive care pathways during radiotherapy may help identify high-risk patients and guide targeted assistance.