Dear Editor
The authors of this timely article rightly highlight the global neglect of palliative care as a healthcare priority.
However, based on over two decades of oncology practice in India, I believe the challenge in low- and middle-income countries (LMICs) is more layered. In these settings, palliative care often emerges not as a carefully chosen clinical pathway but as a default outcome shaped by financial limitations. This shift — though widespread — frequently remains unacknowledged, as it is framed within the language of “shared decision-making,” obscuring the influence of affordability on treatment decisions.
Palliative care should represent a considered and dignified option.
Yet, in many LMIC contexts, economic constraints subtly redirect patients toward it, even when curative therapies are technically feasible. For example, a patient with early-stage cervical or breast cancer may begin treatment under public schemes like India’s Ayushman Bharat (PMJAY), which offers approximately USD 6,000 per family annually, or through private insurance. These resources often support the initial phase—diagnosis, surgery, radiation, or chemotherapy. However, by the time patients reach maintenance or consolidation therapy, coverage limits are commonly exceeded.
At this point, patients are presented with treatment plans that are clinically sound but economically out of reach. When the cost of a single chemotherapy dose surpasses a household’s monthly income, clinical conversations begin to shift. Terms such as “aggressive treatment” are reframed as “impractical,” “maintenance therapy” becomes “watchful waiting,” and “curative intent” gradually transitions to a focus on “quality of life.” While cost may remain unspoken, its influence is significant—altering how options are discussed and ultimately limiting patient autonomy.
This constrained decision-making becomes particularly evident in cases requiring prolonged targeted therapy. In my clinical experience, families have sold vehicles or livestock to afford just a few cycles of trastuzumab, a standard maintenance drug for HER2-positive breast cancer. A patient may receive her first dose under insurance coverage, only to learn that subsequent doses—each costing roughly USD 240—must be paid out of pocket. When resources run out, treatment halts. Disease progression follows—not due to tumor biology, but because care was interrupted.
Such patterns reflect what might be described as institutionalised attrition: treatment plans begin with curative intent but quietly devolve into palliation when financial resources are depleted. This is not a rare occurrence; it represents a systemic challenge. The broader LMIC context — including limited healthcare infrastructure, shortage of oncology specialists, and indirect costs such as travel and income loss — only intensifies these barriers.
While public insurance schemes and corporate coverage play a vital role in improving access, they are often structured to support initiation rather than completion of treatment. Particularly for complex, multi-phase protocols or expensive maintenance regimens, this design flaw creates a gap between what is accessible and what is sustainable. That distinction —between access and equity — is critical. Entry into the healthcare system is not equivalent to receiving the full standard of care.
To address this, three practical steps may help ensure that palliative care in LMICs is chosen for the right reasons:
1. Incorporate cost transparency into informed consent, allowing patients to make decisions based on both clinical and financial considerations.
2. Recognize financial toxicity as a clinical risk factor, on par with organ dysfunction or frailty, to inform realistic treatment planning.
3. Shift policy focus from initiation to continuity, ensuring that once treatment starts, there is a viable path to completion.
Without such structural changes, palliative care may continue to reflect economic limitation rather than clinical appropriateness. Acknowledging this dynamic is essential if we aim to strengthen both ethical practice and equitable oncology care.
“In the absence of financial continuity, even the best-intentioned care plans dissolve—until palliation is not what we choose, but what remains.”
