Abstract
INTRODUCTION: Since the ipilimumab's approval in 2011, immune checkpoint inhibitors (ICIs) have become an integral aspect of oncology practice, offering unparalleled survival benefits across various cancers. Financial toxicities associated with the high pricing of ICIs have put a major constraint on their incorporation into oncology practice. Financial barriers of ICIs are particularly more pronounced in low-middle-income countries (LMICs). AREAS COVERED: This review aimed to summarize financial barriers associated with the integration of immunotherapy into oncology practice, including dosing, pharmacoeconomic insufficiencies, flat-dosing overuse, out-of-pocket expenditures in LMICs, and structural barriers to access, such as limited reimbursement, and lack of biosimilars. We integrated evidence on dose optimization, de-escalation strategies, and health-care policies that can mitigate costs. Furthermore, we outlined the under-representation of LMICs in trials and the limited evidence on low-dose strategies from prospective data. LITERATURE SEARCH: We performed a comprehensive literature review on PubMed and Google Scholar for English-language studies published between 2014 and 2025 using terms related to "immunotherapy," "financial toxicity," "dose optimization," and 'low- and middle-income countries." COMMENTARY: Dose-optimization strategies can reduce costs without compromising clinical efficacy, especially where financial barriers threaten continuity of care. Priorities include, prospective trials validating reduced dosing and international partnerships to integrate LMICs into research.