Background: Travel burden is an under-recognised but highly actionable modifiable driver of cancer inequities. As oncology services are commonly centralised, travel burden becomes a critical barrier towards equitable cancer care access.

Objectives: Using nationally sampled patient-level data from Malaysia, an upper-middle income setting with centralised and highly subsidized cancer care, we quantified travel distance, time and out-of-pocket travel costs incurred when accessing cancer care and demonstrate their impact on financial toxicity (FT) and quality of life (QOL).

Methods: Between 2021-2022, 1,190 individuals with cancer were recruited across Malaysia. Malaysia’s combination of high cancer treatment subsidies, centralised cancer services, and stark socioeconomic and urban-rural disparities across two geographically-separated regions make it a stringent test case to assess travel burden in cancer care access. This structural framework is broadly applicable across health and social systems across low- and middle-income countries (LMICs) and high-income countries (HICs) and extends beyond oncology to other chronic conditions that rely on centralised services. Travel burden examined included number of trips, time, distance, and out-of-pocket cost incurred to access cancer care over the past month. Travel cost-to-income ratios were determined, with ≥10% deemed catastrophic. Linear regression models were used to assess the associations between travel burden with FT, psychological distress, and QOL.

Results: One in five participants (20.8%) incurred catastrophic travel expenditures when accessing cancer care in the past month. Low-income and rural households bore disproportionately heavier travel burdens; travel distance and time were at least three-fold higher among Non-Central Peninsular residents compared to Central Peninsular residents, while travel cost-to-income ratios were nine-fold higher among low-income households compared to their wealthier counterparts (p=0.0001, respectively). Men, older individuals, those with advanced stage at diagnosis, head and neck cancers, or with ongoing radiotherapy were also more likely to report higher travel burden. Greater travel burden was significantly associated with increased FT and poorer QOL.

Conclusions: Even in subsidised health systems, cancer-related travel burden can become an “access tax” that disproportionately affect rural and lower-income households. Alongside reducing direct medical costs, targeted transport subsidies, decentralised care, and multisectoral partnerships should be prioritized interventions aiming to improve access to cancer care and reduce the financial impact of cancer. Addressing travel burden will require multisectoral, community-based, and policy-level interventions that extend beyond traditional service delivery and funding models.

Implications: Our findings emphatically illustrate that “free” healthcare is not really “free” for vulnerable populations, where travel expenditure remains one of the most visible costs that highlights gaps in universal health coverage (UHC). Specifically, our findings provide compelling evidence that centralised care for complex, chronic conditions (including oncology) shifts costs to patients, widening inequities despite subsidised treatment. Health systems should measure distance, time and out-of-pocket travel expenses and include these indicators into national UHC monitoring and benefit package design.