Catastrophic health expenditure and 12-month mortality associated with cancer in Southeast Asia: results from a longitudinal study in eight countries

The relationships of unmet needs with quality of life and characteristics of Indonesian gynecologic cancer survivors

Gynecologic cancer survivors' complex needs are too often overlooked. This study aimed to identify the associations between unmet needs and quality of life, and selected characteristics of Indonesian gynecologic cancer survivors. This study was a cross-sectional, correlation study. A total of 298 participants completed the Cancer Survivor Unmet Needs (CaSUN), EORTC QLQ-C30, and demographic and clinical-related questionnaires. A higher level of unmet needs was linked to lower perceived quality of life. Higher levels of unmet needs were associated with younger age, lower income, higher educational background, shorter time since diagnosis, more advanced cancer stage, and having combination therapies (p < 0.05). The most frequently reported unmet need of the Indonesian gynecologic cancer survivors was financial support (70.5%). The gynecologic cancer survivors who had completed primary treatment need continuous comprehensive cancer care to help them cope with the lingering or emerging problems related to cancer and its treatment.

Estimating cost-effectiveness of screening for colorectal cancer in Vietnam

Background:Presently, there are no national screening programs for cancer in Vietnam. This study aimed to analyze the cost-effectiveness of an annual colorectal cancer (CRC) screening program from the healthcare service provider's perspective for the Vietnamese population.Methods:The economic model consisted of adecision tree and aMarkov model. Adecision tree was constructed for comparing two strategies, including ascreening group with aguaiac-based fecal occult blood test (gFOBT) and ano-screening group in general populations, aged 50 years and above. The Markov model projected outcomes over a25-year horizon. The cost-effectiveness outcome was the incremental cost-effectiveness ratio (ICER) represented by costs per quality-adjusted life-years (QALYs).Results:When compared with no screening, ICER was $1,388per QALY with an increased cost of $ 43.98 and again of 0.032 QALY (Willingness to pay $2,590). The uptake rate of gFOBT, cost of colonoscopy, and the total cost of screening contributed to the largest impact on the ICER. PSA showed that results were robust to variation in parameter estimates, with annual screening remaining cost-effective compared with no screening.Conclusion:Our screening strategy could be considered cost-effective compared to ano screening strategy. Our findings could be potentially used to develop aCRC national screening program.

The minimum standard of care for managing malignant pleural mesothelioma in developing nations within the Asia-Pacific Region

Malignant pleural mesothelioma (MPM) is an incurable malignancy associated with high symptom burden and poor prognosis. The relationship between asbestos exposure and MPM incidence is well-established. The incidence rate of MPM in Australia and New Zealand is among the highest globally. Matching the experience of other nations with legal restrictions on asbestos, incidence is expected to fall. In contrast, the incidence of MPM is rising in the developing nations of the Asia-Pacific as consumption and mining (albeit to a lesser extent) of asbestos continues. The incidence of MPM in these nations is currently low or unknown, reflecting insufficient latency periods since industrial use of asbestos, deficient resources for accurate diagnosis, and lack of occupational disease or cancer registries. The landscape of treatment for MPM is rapidly changing with combination immunotherapy now demonstrating improved survival in the first-line setting. Considering vast global inequity in access to anticancer treatments, establishing minimum standard of care for MPM in developing nations is of greater significance. Here, we review the evidence that form the basis of our minimum-standard recommendations for diagnosis, systemic treatment, management of recurrent pleural effusions, and symptom management. We also briefly review evidence-based treatment that may be considered for those with access.

Out-of-Pocket Costs of Complementary Medicine Following Cancer and the Financial Impact in a Setting With Universal Health Coverage: Findings From a Prospective Cohort Study

PURPOSE

To determine household spending patterns on complementary medicine following cancer and the financial impact in a setting with universal health coverage.

METHODS

Country-specific data from a multinational prospective cohort study, Association of Southeast Asian Nations Costs in Oncology Study, comprising 1,249 cancer survivors were included. Household costs of complementary medicine (healthcare practices or products that are not considered as part of conventional medicine) throughout the first year after cancer diagnosis were measured using cost diaries. Study outcomes comprised (1) shares of household expenditures on complementary medicine from total out-of-pocket costs and health costs that were respectively incurred in relation to cancer, (2) incidence of financial catastrophe (out-of-pocket costs related to cancer ≥ 30% of annual household income), and (3) economic hardship (inability to pay for essential household items or services).

RESULTS

One third of patients reported out-of-pocket household expenditures on complementary medicine in the immediate year after cancer diagnosis, accounting to 20% of the total out-of-pocket costs and 35% of the health costs. Risk of financial catastrophe was higher in households reporting out-of-pocket expenditures on complementary medicine (adjusted odds ratio: 1.39 [95% CI, 1.05 to 1.86]). Corresponding odds ratio within patients from low-income households showed that they were substantially more vulnerable: 2.28 (95% CI, 1.41 to 3.68). Expenditures on complementary medicine were, however, not associated with economic hardship in the immediate year after cancer diagnosis.

CONCLUSION

In settings with universal health coverage, integration of subsidized evidence-based complementary medicine into mainstream cancer care may alleviate catastrophic expenditures. However, this must go hand in hand with interventions to reduce the use of nonevidence-based complementary therapies following cancer.

New Frontiers for Fairer Breast Cancer Care in a Globalized World

In early 2020, the book "Breast cancer: Global Quality Care" was published by Oxford University Press. In the year since then, publications, interviews (by ecancer), presentations, webinars, and virtual congress have been organized to disseminate further the main message of the project: "A call for Fairer Breast Cancer Care for all Women in a Globalized World." Special attention is paid to increasing the "value-based healthcare" putting the patient in the center of the care pathway and sharing information on high-quality integrated breast cancer care. Specific recommendations are made considering the local resource facilities. The multidisciplinary breast conference is considered "the jewel in the crown" of the integrated practice unit, connecting multiple specializations and functions concerned with patients with breast cancer. Management and coordination of medical expertise, facilities, and their interfaces are highly recommended. The participation of two world-leading cancer research programs, the CONCORD program and Breast Health Global Initiative, in this project has been particularly important. The project is continuously under review with feedback from the faculty. The future plan is to arrive at an openaccess publication that is freely available to all interested people. This project is designed to help ease the burden and suffering of women with breast cancer across the globe.

Australian Experiences of Out-of-Pocket Costs and Financial Burden Following a Cancer Diagnosis: A Systematic Review

(1) Background: This systematic review was conducted to identify cancer patient experiences, and the impact of out-of-pocket costs and financial burden in Australia. (2) Methods: A systematic review, following the Preferring Reporting Items for Systematic Reviews and Meta-Analyses, was conducted. Cumulative Index of Nursing and Allied Health Literature and PubMed were searched. The primary outcome was financial burden among cancer patients and their families in Australia. The secondary outcome was out-of-pocket costs associated with cancer care and treatment within the population sample, and the impact of financial burden. (3) Results: Nineteen studies were included, covering more than 70,000 Australians affected by cancer. Out-of-pocket costs varied by cancer type and ranged from an average of AUD 977 for breast cancer and lymphoedema patients to AUD 11,077 for prostate cancer patients. Younger aged patients (≤65 years), Aboriginal and Torres Strait Islander people, people in rural and/or remote areas, households with low income, those who were unemployed and people with private health insurance were at increased risk of experiencing out-of-pocket costs, financial burden or a combination of both. (4) Conclusions: Australians diagnosed with cancer frequently experience financial burden, and the health and financial consequences are significant. Focusing efforts on the costs of care and options about where to have care within the context of informed decisions about cancer care is necessary.

The Global Landscape of Treatment Standards for Breast Cancer

Background

Breast cancer (BC) is a leading cause of morbidity, mortality, and disability for women worldwide. There is substantial variation in treatment outcomes, which is function of multiple variables, including access to treatment. Treatment standards can promote quality and improve survival; thus, their development should be a priority for the cancer-control planning.

Methods

We extracted the guidelines for the treatment of BC from a systematic review of the literature. We evaluated the development process, the methodology, and the recommendations formulated and surveyed the country resource stratification. Metrics of health-system capacity were selected to study the guidelines context appropriateness.

Results

We analyzed 49 distinct guidelines for BC, mostly in English language (n = 23), developed in upper-middle and high-income countries of the European and American regions (n = 39). A resource-stratified approach was identified in a quarter of the guidelines (n = 11), mostly from resource-constrained settings. Only one-half of the guidelines reached a gender balance of the authorship, and 10.2% were based on a multidisciplinary steering committee. A number of efforts and solutions of resource adaptations were recognized, mostly in low- and middle-income countries. Overall, the national guidelines appeared not sensitive enough of the local health-system capacity in formulating recommendations, with possible exception for the radiation therapy availability.

Conclusion

This global landscape of treatment standards for BC demonstrates that the majority is not context appropriate. Research on the formulation of cancer treatment standards is highly warranted, along with novel platforms for developing and disseminating resource-appropriate guidance.

The challenge of the implementation and evaluation of hospital-based cancer registry in Indonesia’s national referral hospital

BACKGROUND To lower the burden caused by cancer, the Ministry of Health of the republic of Indonesia requires valid data collection to plan and evaluate cancer programs. This study aimed to evaluate the challenge of developing a cancer registry (CanReg) in Cipto Mangunkusumo Hospital. METHODS This was an observational study on the implementation of cancer registration from the initial licensing until the creation of valid and accurate data, also the challenges in implementing hospital-based cancer registry (HBCR) in Cipto Mangunkusumo Hospital. RESULTS Cancer registry was developed in 2016 using the 2013 Indonesian version of CanReg5 program called SriKandI. We identified some problems in this registry implementation, such as legal and human resources, medical records, electronic health records, and the CanReg5 program. Moreover, this team processed 886,086 raw patients’ data with fairly good topography and age data completeness. CONCLUSIONS Several obstacles were encountered upon the establishment of HBCR at Cipto Mangunkusumo Hospital from program to bureaucracy and resources. Nevertheless, CanReg data can be used as a basis for decision making by stakeholders.

The Direct and Indirect Costs of Colorectal Cancer in Vietnam: An Economic Analysis from a Social Perspective

The incidence and mortality of colorectal cancer (CRC) has increased rapidly in Vietnam, but the economic burden of this disease has never been estimated. We estimate the direct and indirect cost of CRC patients in Vietnam in 2018 using a prevalence-based approach and human capital method. The total economic cost of CRC was VND 3041.88 billion (~$132.9 million), representing 0.055% of the 2018 gross domestic product. Notably, indirect costs comprised 83.58 % of the total cost, 82.61% of which is future income loss, because CRC occurs during productive years. The economic burden of CRC in Vietnam is substantial. The medical cost for CRC diagnosis and treatment is higher for younger patients and for those in advanced stages. Strategies to decrease the economic burden of CRC at the patient and national level, such as screening programs, should be developed and implemented in Vietnam.

Quantifying the Effect of Financial Burden on Health-Related Quality of Life among Patients with Non-Hodgkin's Lymphomas

Simple Summary

Financial burdens result from the growing out-of-pocket costs associated with cancer care to help patients regain physical and psychological health-related quality of life (HRQoL) are dramatically intensified. The aim of our study was to assess the association of HRQoL with financial burden using both subjective and objective methods among patients with non-Hodgkin’s lymphoma (NHL) in China. A majority of the patients reported suffering moderate to high financial burdens. A significant relationship between increased financial burden and reduced HRQoL was identified. Patients tended to report a poorer HRQoL when using objective method than using subjective method to estimate financial burden. Medical professionals should involve patients and their families into the clinical decision making and provide them cost-effective plans.

Abstract

Objective: This study aimed to assess the association of health-related quality of life (HRQoL) with financial burden among patients with non-Hodgkin’s lymphoma (NHL) in China. Methods: The data used for the analyses came from a nationwide survey to investigate the health status of patients with lymphomas in China. The EQ-5D and EORTC QLQ-C30 were used to assess the patients’ HRQoL. The financial burden was calculated using both subjective and objective methods. The chi-squared test, Kruskal–Wallis one-way analysis of variance, ordinal least squared model, and Tobit regression model were used to estimate the relationship between financial burden and HRQoL. Results: Data from 1549 patients who reported living with 11 subtypes of NHL were elicited for our analysis. Approximately 60% of respondents reported suffering moderate to high financial burdens. A significant relationship between increased financial burden and reduced HRQoL scores, including the EQ-Index, physical, emotional, and social functioning, was identified. Compared with using an objective method to measure financial burden, patients with NHL indicated a poorer HRQoL when using a subjective method to measure financial burden. Conclusion: Medical professionals should select highly cost-effective treatments and ensure that patients understand the potential financial consequences of those treatments.

Cancer and COVID-19: economic impact on households in Southeast Asia

The ongoing COVID-19 pandemic may worsen the existing financial vulnerabilities of cancer survivors who may be experiencing a double financial hit, both from cancer-induced financial toxicity as well as economic strains arising from loss of income and prolonged unemployment following the pandemic. The impact of the pandemic is likely to be more pronounced on cancer survivors living in resource-limited settings, such as in Southeast Asia. As health care systems in the region try to streamline resources and accommodate the influx of patients from COVID-19, many in the cancer community have experienced severe disruptions in their care. The delays and disruption of timely access to cancer care could lead to patients presenting with worsened conditions and at more advanced cancer stages in which treatment options tended to be costlier. Similar to countries around the world, the various forms of movement restrictions that were enforced have aggravated the rates of unemployment, loss of wages and the limited access to support from family or friends around Southeast Asia. The economic impact of COVID-19 hits even harder on the large proportion of the population in the region that works in the informal sector, who are often one paycheque or one episode of illness away from financial catastrophe. More worryingly, the lack of a robust social security system in many Southeast Asian countries, especially in terms of income protection, could ultimately force many cancer survivors to choose between paying for their treatments, or to forego treatments, and feed their families. Early identification of cancer patients experiencing financial toxicity following the pandemic will enable timely and appropriate interventions to be undertaken by various stakeholders, potentially averting a cascade of other economic fallouts that may last for years after cancer treatment.

Cost of Treatment for Cervical Cancer in India

INTRODUCTION

Cervical cancer is a major public health problem in India leading to high economic burden, which is disproportionately borne by the patients as out-of-pocket expenditure (OOPE). Several publicly financed health insurance schemes (PFHIs) in India cover the treatment for cervical cancer. However, the provider payment rates for health benefit packages (HBP) under these PFHIs are not based on scientific evidence. We undertook this study to estimate the cost of services provided for treatment of cervical cancer and  cost of the package of care for cervical cancer in India.

METHODS

The study was undertaken at a large public tertiary hospital in North India. The health system cost was assessed using a mixed micro-costing approach. The data were collected for all the resources utilized during service delivery for cervical cancer patients. To evaluate the OOPE, randomly selected 248 patients were interviewed following the cost of illness approach. Logistic regression was used to assess the factors associated with catastrophic health expenditure (CHE).

RESULTS

Health system cost for different cervical cancer treatment modalities i.e. radiotherapy, brachytherapy, chemotherapy and surgery, ranges from INR 19,494 to 41,388 (USD 291 - 617). Furthermore, patients spent INR 4,042 to 23,453 ( USD 60 - 350) as OOPE. Nearly 62% patients incurred CHE, and 30% reported distress financing. The odds of CHE (OR: 25.39, p-value: <0.001) and distress financing (OR: 15.37, p-value: 0.001) were significantly higher in poorest-income quintile. The HBP cost varies from INR 45,364 to 64,422 (USD 676 - 960) for brachytherapy and radiotherapy respectively.

CONCLUSION

Cervical cancer treatment leads to high OOPE in India, which imposes financial hardship, especially for the poorest. The coverage of risk pooling mechanisms like PHFIs should be enhanced. The findings of our study should be used to set the reimbursement rates of providing cervical cancer treatment under PFHI schemes.

Catastrophic health expenditures of households living with pediatric leukemia in China

Background

Leukemia can create a significant economic burden on the patients and their families. The objective of this study is to assess the medical expenditure and compensation of pediatric leukemia, and to explore the incidence and determinants of catastrophic health expenditure (CHE) among households with pediatric leukemia patients in China.

Methods

A cross‐sectional interview was conducted among households living with pediatric leukemia using a questionnaire in two tertiary hospitals. CHE was defined as out‐of‐pocket (OOP) payments that were greater than or equal to 40% of a household's capacity to pay (CTP). Chi‐square tests and logistic regression analysis were performed to identify the determinants of CHE.

Results

Among 242 households living with pediatric leukemia, the mean OOP payment for pediatric leukemia healthcare was $9860, which accounted for approximately 35.7% of the mean household's CTP. The overall incidence of CHE was 43.4% and showed a downward trend with the lowest income group at 69.0% to the highest income group at 16.1%. The logistic regression model found that medical insurance, frequency of hospital admissions, charity assistance, and income level were significant predictors of CHE.

Conclusion

The results revealed that pediatric leukemia had a significant catastrophic effect on families, especially those with lower economic status. The occurrence of CHE in households living with pediatric leukemia could be reduced by addressing income disparity. In addition, extending coverage and improving compensation from medical insurance could also alleviate CHE. Some other measures that can be implemented are to address the barriers of charity assistance for vulnerable groups.

Catastrophic healthcare expenditure and coping strategies among patients attending cancer treatment services in Addis Ababa, Ethiopia

BACKGROUND

With the rapid increase in magnitude and mortality of cancer, which is costly disease to manage, several patients particularly in developing countries are facing a huge financial burden. The study aimed to examine the incidence of catastrophic health expenditure (CHE), identify associated factors and coping strategies among patients attending cancer treatment services in Addis Ababa, Ethiopia.

METHODS

A hospital-based cross-sectional survey of patients with cancer was conducted in public and private hospitals between January and March 2018. Data was collected using a structured questionnaire. All direct medical and nonmedical expenditures were measured and reported as expenditure (US$) per patient (1US$ equivalent to 23.41 Ethiopian Birr). The CHE was estimated using a threshold of 10% of annual household income.

RESULTS

A total of 352 (response rate of 87.1%) participants were interviewed. Majority (73.3%) of the respondents were females; most (94%) from public hospitals and their mean (±SD) age was 48 ± 13.2 years. Vast majority (74.4%) of patients experienced CHE with mean overall expenditure of $2366 per patient (median: $1708). Medical expenditure shared the highest overall expenditure (83.6%) with mean medical and nonmedical costs of $1978 (median: $1394) and $388 (median: $222), respectively. Patients who took greater than six cycles of chemotherapy (AOR: 3.64; 95% CI: 1.11-11.92), and age (AOR: 1.03; 95% CI: 1.01-1.06) were significantly associated with CHE. Household saving (85.5%) followed by financial support received (43.0%) was the main coping strategy.

CONCLUSION

A substantial number of patients with cancer were exposed to CHE with a considerable medical expenditure. Hence, in addition to the popularization of the already introduced health insurance scheme, other better prepayment or insurance mechanisms should also be considered to ensure financial risk protection and realize universal health coverage for patients with cancer.

Financial toxicity and its associated patient and cancer factors among women with breast cancer: a single-center analysis of low-middle income region in China

PURPOSE

To assess the financial toxicity (FT) and to investigate patients and cancer characteristic that associated with it in patients admitted in a tertiary hospital in central China.

METHODS

This was a cross-sectional study of 166 patients from 188 with stage 0-III women breast cancer admitted in Bethune hospital in Taiyuan, Shanxi province during January-May 2019. FT was self-reported using of financial Toxicity Comprehensive Rating Scale (COST-FACIT). Patients' sociodemographic factors, clinical examination, and cancer treatment were collected from questionnaire and hospital record. The financial concern and coping strategy was self-reported. Factors associated with FT were identified using linear regression analysis.

RESULTS

Of the 166 completed the survey, the COST score ranged 0-40 with a mean of 21.2 (median 22.5, standard deviation 8.1). On multivariate linear regression analysis, older age (β coefficient: 0.20, 95% CI 0.11-0.29, p < 0.001), higher household income (β coefficient: 3000-5000 Yuan: 7.88, 95% CI 4.74-11.01, p < 0.001; ≥ 5000 Yuan: 12.81, 95% CI 9.54-16.08, p < 0.001) were positively associated with COST scores. Advanced cancer stage was the strongest predictor of FT among the cancer characteristics (β coefficient: - 4.52, 95% CI - 7.13-1.92, p = 0.001). To cope with the FT, 131 (78.8%) patients decreased non-medical expenses, and 56 (33.7%) reduced or quitted treatment.

CONCLUSIONS

FT was significantly associated with patient's age, income, and cancer stage. Women having financial concerns after diagnosis were more likely to reduce their non-medical expenses and even quit treatments. Clinicians should take into account the FT levels in all patients and work out appropriate treatment strategies for optimal clinical outcome.

Study protocol for a single-centre observational study of household wellbeing and poverty status following a diagnosis of advanced cancer in Blantyre, Malawi - 'Safeguarding the Family' study

Background: Many households in low-and-middle income countries face the additional burden of crippling out-of-pocket expenditure when faced with a diagnosis of life-limiting illness. Available evidence suggests that receipt of palliative care supports cost-savings for cancer-affected households. This study will explore the relationship between receipt of palliative care, total household out-of-pocket expenditure on health and wellbeing following a first-time diagnosis of advanced cancer at Queen Elizabeth Central Hospital in Blantyre, Malawi.

Protocol: Patients and their primary family caregivers will be recruited at the time of cancer diagnosis.  Data on healthcare utilisation, related costs, coping strategies and wellbeing will be gathered using new and existing questionnaires (the Patient-and-Carer Cancer Cost Survey, EQ-5D-3L and the Integrated Palliative Care Outcome Score). Surveys will be repeated at one, three and six months after diagnosis. In the event of the patient’s death, a brief five-item questionnaire on funeral costs will be administered to caregivers not less than two weeks following the date of death. Descriptive and Poisson regression analyses will assess the relationship between exposure to palliative care and total household expenditure from baseline to six months. A sample size of 138 households has been calculated in order to detect a medium effect (as determined by Cohen’s f ²=0.15) of receipt of palliative care in a regression model for change in total household out-of-pocket expenditure as a proportion of annual household income.

Ethics and dissemination: The study has received ethical approval. Results will be reported using STROBE guidelines and disseminated through scientific meetings, open access publications and a national stakeholder meeting. 

Conclusions: This study will provide data on expenditure for healthcare by households affected by advanced cancer in Malawi. We also explore whether receipt of palliative care is associated with a reduction in out-of-pocket expenditure at household level.

Understanding the Financial Needs Following Diagnosis of Breast Cancer in a Setting with Universal Health Coverage

BACKGROUND

A diagnosis of cancer negatively impacts the financial wellbeing of affected individuals as well as their households. We aimed to gain an in-depth understanding of the financial needs following diagnosis of breast cancer in a middle-income setting with universal health coverage.

MATERIALS AND METHODS

Twelve focus group discussions (n = 64) were conducted with women with breast cancer from two public and three private hospitals. This study specifically focused on (a) health costs, (b) nonhealth costs, (c) employment and earnings, and (d) financial assistance. Thematic analysis was used.

RESULTS

Financial needs related to cancer treatment and health care varied according to the participant's socioeconomic background and type of medical insurance. Although having medical insurance alleviated cancer treatment-related financial difficulties, limited policy coverage for cancer care and suboptimal reimbursement policies were common complaints. Nonhealth expenditures were also cited as an important source of financial distress; patients from low-income households reported transport and parking costs as troublesome, with some struggling to afford basic necessities, whereas participants from higher-income households mentioned hired help, special food and/or supplements and appliances as expensive needs following cancer. Needy patients had a hard time navigating through the complex system to obtain financial support. Irrespective of socioeconomic status, reductions in household income due to loss of employment and/or earnings were a major source of economic hardship.

CONCLUSION

There are many unmet financial needs following a diagnosis of (breast) cancer even in settings with universal health coverage. Health care professionals may only be able to fulfill these unmet needs through multisectoral collaborations, catalyzed by strong political will.

IMPLICATIONS FOR PRACTICE

As unmet financial needs exist among patients with cancer across all socioeconomic groups, including for patients with medical insurance, financial navigation should be prioritized as an important component of cancer survivorship services, including in the low- and middle-income settings. Apart from assisting survivors to understand the costs of cancer care, navigate the complex system to obtain financial assistance, or file health insurance claims, any planned patient navigation program should also provide support to deal with employment-related challenges and navigate return to work. It is also echoed that costs for essential personal items (e.g., breast prostheses) should be covered by health insurance or subsidized by the government.

Study protocol for a single-centre observational study of household wellbeing and poverty status following a diagnosis of advanced cancer in Blantyre, Malawi - ‘Safeguarding the Family’ study

Background: Many households in low-and-middle income countries face the additional burden of crippling out-of-pocket expenditure when faced with a diagnosis of life-limiting illness. Available evidence suggests that receipt of palliative care supports cost-savings for cancer-affected households. This study will explore the relationship between receipt of palliative care, total household out-of-pocket expenditure on health and wellbeing following a first-time diagnosis of advanced cancer at Queen Elizabeth Central Hospital in Blantyre, Malawi. Protocol: Patients and their primary family caregivers will be recruited at the time of cancer diagnosis.  Data on healthcare utilisation, related costs, coping strategies and wellbeing will be gathered using new and existing questionnaires (the Patient-and-Carer Cancer Cost Survey, EQ-5D-3L and the Integrated Palliative Care Outcome Score). Surveys will be repeated at one, three and six months after diagnosis. In the event of the patient’s death, a brief five-item questionnaire on funeral costs will be administered to caregivers not less than two weeks following the date of death. Descriptive and Poisson regression analyses will assess the relationship between exposure to palliative care and total household expenditure from baseline to six months. A sample size of 138 households has been calculated in order to detect a medium effect (as determined by Cohen’s f2=0.15) of receipt of palliative care in a regression model for change in total household out-of-pocket expenditure as a proportion of annual household income. Ethics and dissemination: The study has received ethical approval. Results will be reported using STROBE guidelines and disseminated through scientific meetings, open access publications and a national stakeholder meeting.  Conclusions: This study will provide data on expenditure for healthcare by households affected by cancer in Malawi. We also explore whether receipt of palliative care is associated with a reduction in out-of-pocket expenditure at household level.

Incidence and Intensity of Catastrophic Health-care Expenditure for Type 2 Diabetes Mellitus Care in Iran: Determinants and Inequality

BACKGROUND

The present study aimed to assess the prevalence and intensity of catastrophic health-care expenditures (CHE) relating to type 2 diabetes mellitus care and inequality in facing such expenditures in Iran.

METHODS

A total of 1065 type 2 diabetes patients were included in this cross-sectional study. A multistage sampling method was used to select the samples. Data on sociodemographic characteristics, economic status, health and diabetic costs were collected using a self-constructed questionnaire. We used capacity to pay (CTP) of households to calculate the incidence of CHE due to diabetic care at four different thresholds. The mean positive overshoot (MPO) and overshoot were used to assess the intensity of CHE. The relative concentration index and slope index of inequality (SII) were used to measure socioeconomic-related inequalities in incidences of CHE. In addition, decomposition methods were used to identify the main factors affecting observed inequality in CHE.

RESULTS

The incidence of CHE at the 10, 20, 30, and 40% of CTP thresholds for type 2 diabetes mellitus care was 57.5, 28.9, 16.5, and 11.4%, respectively. The results of CI and SII indices for CHE due to diabetic care indicated that the incidence of CHE was more prevalent among patients with lower socioeconomic groups. The decomposition analysis showed that the socioeconomic status, marital status and gender of patients were the main factors contributing to socioeconomic inequality in incidence of CHE among the poor.

CONCLUSION

Our study demonstrated that the incidence and intensity of CHE due to diabetic care were relatively high, particularly among socioeconomically disadvantaged patients. Modification to the present health care financing strategies is recommended in order to protect lower socioeconomic groups against the financial burden of diabetic care.

Catastrophic health expenditure and health-related quality of life among older adults in China

Older adults have more health-care needs and higher financial burdens but fewer income resources compared to other age groups in China. Meanwhile, substantial inequalities exist between rural and urban older adults in terms of welfare benefits level, access to health care, quality of care and financial resources to pay for health-care services. Using 2011–2013 panel data from the China Health and Retirement Longitudinal Study and a difference-in-differences methodology, this study examined the association between the incidence of catastrophic health expenditure (CHE) and health-related quality of life among older adults in China. To distinguish the dynamic of CHE and generate rigorous estimates, we categorised the older adults into four groups: CHE entry group, non-CHE group, CHE exit group and CHE persistent group. Overall, we found that entry into CHE was associated with poorer physical and mental health for both rural and urban older adults, but this association was more consistent and robust for physical than for mental health. Exiting CHE was found to have a weak and sporadic positive association with physical and mental health across rural and urban areas. The results suggest that financial resources and social services are needed in China to support older adults who experience CHE persistently or periodically to help improve their health outcomes.

Systematic comparison of plasma EBV DNA, anti-EBV antibodies and miRNA levels for early detection and prognosis of nasopharyngeal carcinoma

Nasopharyngeal carcinoma (NPC) is originated from the epithelial cells of nasopharynx, Epstein–Barr virus (EBV)‐associated and has the highest incidence and mortality rates in Southeast Asia. Late presentation is a common issue and early detection could be the key to reduce the disease burden. Sensitivity of plasma EBV DNA, an established NPC biomarker, for Stage I NPC is controversial. Most newly reported NPC biomarkers have neither been externally validated nor compared to the established ones. This causes difficulty in planning for cost‐effective early detection strategies. Our study systematically evaluated six established and four new biomarkers in NPC cases, population controls and hospital controls. We showed that BamHI‐W 76 bp remains the most sensitive plasma biomarker, with 96.7% (29/30), 96.7% (58/60) and 97.4% (226/232) sensitivity to detect Stage I, early stage and all NPC, respectively. Its specificity was 94.2% (113/120) against population controls and 90.4% (113/125) against hospital controls. Diagnostic accuracy of BamHI‐W 121 bp and ebv‐miR‐BART7‐3p were validated. Hsa‐miR‐29a‐3p and hsa‐miR‐103a‐3p were not, possibly due to lower number of advanced stage NPC cases included in this subset. Decision tree modeling suggested that combination of BamHI‐W 76 bp and VCA IgA or EA IgG may increase the specificity or sensitivity to detect NPC. EBNA1 99 bp could identify NPC patients with poor prognosis in early and advanced stage NPC. Our findings provided evidence for improvement in NPC screening strategies, covering considerations of opportunistic screening, combining biomarkers to increase sensitivity or specificity and testing biomarkers from single sampled specimen to avoid logistic problems of resampling.

What's new?

Plasma Epstein–Barr virus (EBV) DNA is an established nasopharyngeal carcinoma (NPC) biomarker, but not all cases are associated with EBV and its sensitivity for stage I NPC remains controversial. Meanwhile, most newly‐reported NPC biomarkers have neither been externally validated nor compared to established biomarkers. This study systematically evaluates six established and four new biomarkers in NPC cases, population controls, and hospital controls. The findings provide evidence to policymakers for improvement in NPC screening and monitoring strategies, covering considerations of opportunistic screening, combining biomarkers to increase sensitivity/specificity, and testing multiple biomarkers on single specimens to avoid the logistic problems of resampling.

Cancer Attributable to Tobacco Smoking in Member Countries of Association of Southeast Asian Nations (ASEAN) in Year 2018

South East Asia is one of the world's largest tobacco epidemic regions which tobacco smoking is known increase the risk of various diseases, including cancer. As data from GLOBOCAN 2018 has had released on September 2018, the aim of this study are to calculate the estimated burden of several types of cancer attributable to tobacco smoking in Association of Southeast Asian Nations (ASEAN) 2018 and compare it with established result data in 2012. So it can be highlight what has been achieved and what it needs to be addressed by member countries of ASEAN to strengthen cancer prevention against tobacco smoking. This study was using descriptive epidemiological incidence and prevalence-based research design to estimate the burden of 14 types of cancer attributable to tobacco smoking in member countries of ASEAN, in term of incidence and mortality. The cancer incidence and mortality data gained from GLOBOCAN 2018. According to the estimation, tobacco smoking was responsible for 121,849 new cancer cases in 2018 (106,858 male and 14,991 female cases) in ASEAN 2018. Our findings are mostly lower than previous study in 2012, both for cancer incidence and mortality in male and female. It seems more ASEAN member states are adopting effective policies in the MPOWER suite of interventions such as raising taxes on tobacco, establishing smoke-free areas and implementing graphic health warnings in decreasing number of tobacco smoking. Therefore, ASEAN member countries are strongly encouraged to strengthen the existing tobacco control measure in order to effectively gain a significant decline of tobacco smoking related cancer in the future.

Catastrophic health expenditure and its determinants in households with gastrointestinal cancer patients: evidence from new health system reform in Iran

Purpose

The right to health for all people means that everyone should have access to the needed healthcare services without suffering from severe financial hardship. The purpose of this paper is to investigate the prevalence as well as the effective factors on facing catastrophic health expenditures (CHE) among gastrointestinal cancer patients and families in Kurdistan province in west of Iran after the implementation of Health Transformation Plan (HTP).

Design/methodology/approach

A cross-sectional study was carried out on 189 households with gastrointestinal cancer patients in Kurdistan province in 2018. Data were collected using World Health Survey questionnaire. A method developed by World Health Organization with the threshold of 40 percent household’s capacity to pay was used in order to measure the proportion of households facing CHE. Also, logistic regression was applied for identifying the effective factors on household’s exposure to CHE. Data were analyzed using STATA version 13.

Findings

Almost 73 percent (72.7 percent) of the households (n=117) faced the CHE. Not having supplementary health insurance (adjusted odds ratio (AOR): 3.8; 95% confidence interval: 1.3–10.8 (and having low socio-economic status (AOR: 7.1; 95% CI: 1.8–28.1) were the significant factors affecting the households’ exposure to CHE. In total, 57 and 1 percent of the studied households reported that having a gastrointestinal cancer patient at home had a significant effect on refraining from using health services by other family members.

Originality/value

The proportion of the studied households facing CHE was very high. This may indicate the weakness of health system as well as health insurance or the weakness of HTP in financial protection of fragile population.

Depression and health-related quality of life among Cambodian patients with cancer

BACKGROUND

Symptom assessment and quality of life (QoL) are considered two of the most important factors in the overall care of cancer patients. Although cancer is one of the leading causes of death after communicable disease in Cambodia, the QoL of Cambodian cancer patients has not been examined previously. This study aimed to describe the QoL of cancer patients in Cambodia.

METHODS

A cross-sectional study was conducted with cancer patients who visited Khmer-Soviet Friendship Hospital in Phnom Penh. Two hundred patients participated in this study. The inventory comprised two previously validated scales: the Center for Epidemiological Studies Depression Scale-10 (CESD-10) and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30. Descriptive analyses, independent samples t-tests, and Pearson's correlation analysis were performed to examine the differences and relationship between study variables.

RESULTS

The mean global health score was 51.62, and 58.5% of the participants had depressive symptom. The global health score was statistically significantly lower in depressive patients. The QoL was negatively correlated with depression, but positively and significant correlated with physical function, role function, emotional function, cognitive function, and social function.

CONCLUSION

This study is the first to describe the QoL of Cambodian cancer patients. Our findings suggest that more attention should be paid to psychological concerns and symptom management in Cambodian cancer patients. Appropriate management could be effective in improving the QoL of cancer patients.

Inequities in breast cancer treatment in sub-Saharan Africa: findings from a prospective multi-country observational study

BACKGROUND

Improving breast cancer survival in sub-Saharan Africa (SSA) is urgently needed, requiring early diagnosis and improved access to treatment. However, data on the types of and barriers to receiving breast cancer therapy in this region are limited and have not been compared between different SSA countries and treatment settings.

METHODS

In different health care settings across Uganda, Nigeria and Namibian sites of the prospective African Breast Cancer - Disparities in Outcomes cohort study, we assessed the percentage of newly diagnosed breast cancer patients who received treatment (systemic, surgery and/or radiotherapy) for cancer and their socio-demographic and clinical determinants. Treatment data were systematically extracted from medical records, as well as self-reported by women during 6-month follow-up interviews, and were used to generate a binary indicator of treatment received within 12 months of diagnosis (yes/no), which was analysed via logistic regression.

RESULTS

Of 1325 women, cancer treatment had not been initiated treatment within 1 year of diagnosis for 227 (17%) women and 185 (14%) of women with stage I-III disease. Untreated percentages were highest in two Nigerian regional hospitals where 38% of 314 women were not treated (32% among stage I-III). At a national referral hospital in Uganda, 18% of 430 women were not treated (15% among stage I-III). In contrast, at a cancer care centre in Windhoek, Namibia, where treatment is provided free to the patient, all non-black (100%) and almost all (98.7%) black women had initiated treatment. Percentages of untreated women were higher in women from lower socio-economic groups, women who believed in traditional medicine and, in Uganda, in HIV+ women. Self-reported treatment barriers confirmed treatment costs and treatment refusal as contributors to not receiving treatment.

CONCLUSIONS

Financial support to ensure treatment access and education of treatment benefits are needed to improve treatment access for breast cancer patients across sub-Saharan Africa, especially at regional treatment centres, for lower socio-economic groups, and for the HIV-positive woman with breast cancer.

Understanding financial toxicity in head and neck cancer survivors

OBJECTIVES

(1) Describe financial toxicity (FT) in head and neck cancer (HNC) survivors and assess its association with personal/health characteristics and health-related quality of life (HRQOL); (2) examine financial coping mechanisms (savings/loans); (3) assess relationship between COmprehensive Score for financial Toxicity (COST) and Financial Distress Questionnaire (FDQ).

PATIENTS AND METHODS

Cross-sectional survey from January - April 2018 of insured patients at a tertiary multidisciplinary HNC survivorship clinic who completed primary treatment for squamous cell carcinoma of the oral cavity, oropharynx, or larynx/hypopharynx.

RESULTS

Of 104 survivors, 30 (40.5%) demonstrated high FT. Patients with worse FT were more likely (1) not married (COST, 25.33 ± 1.87 vs. 30.61 ± 1.34, p = 0.008); (2) of lower education levels (COST, 26.12 ± 1.47 vs. 34.14 ± 1.47, p < 0.001); and (3) with larynx/hypopharynx primaries (COST, 22.86 ± 2.28 vs. 30.27 ± 1.50 vs. 32.72 ± 1.98, p = 0.005). Younger age (4.23, 95%CI 2.20 to 6.26, p < 0.001), lower earnings at diagnosis (1.17, 95%CI 0.76 to 1.58, p < 0.001), and loss in earnings (-1.80, 95%CI -2.43 to -1.16, p < 0.001) were associated with worse FT. COST was associated with HRQOL (0.08, p = 0.03). Most survivors (63/102, 60%) reported using savings and/or loans. Worse FT was associated with increased likelihood of using more mechanisms (COST, OR1.06, 95%CI 1.02 to 1.10, p = 0.004). Similar results were found with FDQ.

CONCLUSIONS

We found differences in FT by primary site, with worst FT in larynx/hypopharynx patients. This finding illuminates potential site-specific factors, e.g. workplace discrimination or inability to return to work, that may contribute to increased risk. FDQ correlates strongly with COST, encouraging further exploration as a clinically-meaningful screening tool.

Estimating the Direct Cost of Cancer in Nepal: A Cross-Sectional Study in a Tertiary Cancer Hospital

Background: The increasing prevalence of cancer and lack of strong health financing system in low income countries like Nepal is exerting an enormous financial burden on cancer patients. However, there is scant information relating to the amount of expenditure on health services for cancer treatments in Nepal. Therefore, this study aimed to estimate the direct cost associated with the treatment of cancer on the patients attending a tertiary cancer treatment center in Nepal. Methods: A quantitative cross-sectional study was carried out on 294 cancer patients who were receiving treatment from Bhaktapur Cancer Hospital between 17th November 2016 and 13th February 2017. Direct medical cost and non-medical costs borne by the patients were calculated based on the cost of illness methodology. Medical cost included the cost of consultation, diagnosis and treatment while non-medical cost comprised the cost occurred out of the health facility such as the cost of food, travel, and accommodation. Result: Of those 294, 169 (57.5%) were female and 125 (42.5%) were male. The median (IQR) age was 54 (19) years. Cancer of the lung was present in 19.39%, breast cancer in 15.65% and cervical cancer in 14.29%. Mean (SD) and Median (IQR) direct cost of cancer was NRs 387.5 (196.8) and 346.1 (260.5) thousand. Medical cost contributed to 80.91% of the total direct cost. Almost everyone relied on out-of-pocket (OOP) payment for cancer treatment, where 253 (86.1%) participants reported that they were experiencing financial hardship, 230 (78.2%) took a loan, and 140 (47.6%) sold their property to manage the OOP. Both medical and non-medical costs varied significantly with age, socio-economic status, types of cancer and the treatment. Conclusion: Medical cost contributed the most to the direct cost. OOP was dominant payment mechanism to utilize health services. Average direct cost of cancer was higher than the average income of patients, sufficient to cause financial catastrophe. This implies the need of improved health financing strategy to protect people from the financial hazards of health service utilization for cancer in Nepal.

The social and economic toll of cancer survivorship: a complex web of financial sacrifice

PURPOSE

To assess the financial outcomes and associated social and economic effects on cancer survivors and their families.

METHODS

We assessed the responses of 1656 cancer survivors to a survey with both closed- and open-ended questions about cancer-related financial sacrifices they and their family experienced and evaluated differences in financial sacrifice by reported levels of cancer-related debt.

RESULTS

The most commonly reported financial sacrifices included cutbacks on household budgets, challenges with health care insurance and costs, career/self-advancement constraints, reduction/depletion of assets, and inability to pay bills. Survivors who incurred $10,000 or more in debt were significantly more likely to report social and economic impacts, including housing concerns and strained relationships.

CONCLUSIONS

Our analysis demonstrates both the frequency with which cancer survivors and families must make financial sacrifices as a result of their cancer, and the variety of forms that this sacrifice can take, even for individuals who have health insurance. The many types of financial hardship create challenges that are unique to each survivor and family.

IMPLICATIONS FOR CANCER SURVIVORS

Interventions that allow for personalized assistance with the specific financial and social needs of cancer survivors and their families have the potential to address a critical aspect of the long-term wellbeing of this important population.

Catastrophic health expenditure of cancer patients at the end-of-life: a retrospective observational study in China

Background

Cancer is the second leading cause of death globally, causing a substantial economic burden on cancer suffers and their families. The aim of this study is to explore the prevalence, determinants and consequences of catastrophic health expenditure (CHE) among urban and rural end-of-life (EOF) cancer patients in China.

Methods

Using respondent-driven sampling and face-to-face interviews, field research was conducted with a specialist questionnaire. Data were collected on 792 cancer patients who died between June 2013 and June 2016 in China. The determinants of household catastrophic expenditure were identified by multivariate logistic regression.

Findings

It is found that more than 80% of cancer patients received life-extending treatment. Extremely high rates of CHE were identified among EOL cancer patients, at 94.3% for urban families and 96.1% for rural families. After spending for health, 84.1% of urban and 91.1% rural EOL cancer patient households were impoverished, falling below the poverty line. For both urban and rural households, income was the most significant factor associated with catastrophic health expenditure (CHE). Health insurance did not adequately compensate for CHE. Rural families experienced higher CHE, lower levels of health care utilization, a different mix of health care access and higher rates of borrowing for out-of-pocket (OOP) health care expenditures than urban families. Both urban and rural households suffered long-term economic disadvantage due to CHE and borrowing for OOP medical care expenses.

Conclusions

EOL cancer patients experienced severe CHE, with families forced into poverty. With only about 1% of EOL cancer patients receiving palliative care, developing palliative care services and expanding the acceptance of palliative care in China is both urgent and essential. To help address impoverishment due to CHE, China should also develop targeted programs to reduce income inequality, especially rural-urban inequalities; increase access to health care; and accelerate health reform. Increasing the retirement age would provide households with more savings and wealth to withstand CHE.

Financial Toxicity After Cancer in a Setting With Universal Health Coverage: A Call for Urgent Action

BACKGROUND

Financial toxicity negatively affects the well-being of cancer survivors. We examined the incidence, cost drivers, and factors associated with financial toxicity after cancer in an upper-middle-income country with universal health coverage.

METHODS

Through the Association of Southeast Asian Nations Costs in Oncology study, 1,294 newly diagnosed patients with cancer (Ministry of Health [MOH] hospitals [n = 577], a public university hospital [n = 642], private hospitals [n = 75]) were observed in Malaysia. Cost diaries and questionnaires were used to measure incidence of financial toxicity, encompassing financial catastrophe (FC; out-of-pocket costs ≥ 30% of annual household income), medical impoverishment (decrease in household income from above the national poverty line to below that line after subtraction of cancer-related costs), and economic hardship (inability to make necessary household payments). Predictors of financial toxicity were determined using multivariable analyses.

RESULTS

One fifth of patients had private health insurance. Incidence of FC at 1 year was 51% (MOH hospitals, 33%; public university hospital, 65%; private hospitals, 72%). Thirty-three percent of households were impoverished at 1 year. Economic hardship was reported by 47% of families. Risk of FC attributed to conventional medical care alone was 18% (MOH hospitals, 5%; public university hospital, 24%; private hospitals, 67%). Inclusion of expenditures on nonmedical goods and services inflated the risk of financial toxicity in public hospitals. Low-income status, type of hospital, and lack of health insurance were strong predictors of FC.

CONCLUSION

Patients with cancer may not be fully protected against financial hardships, even in settings with universal health coverage. Nonmedical costs also contribute as important drivers of financial toxicity in these settings.

Ethics of cancer care: beyond biology and medicine

Treatable cancers are on the rise due to improved early diagnosis and more innovative treatments, and preventative strategies against cancer are becoming a global concern. With the rapidly increasing complexity of cancer treatment, a clear definition of what constitutes ethical cancer care has become a matter of great debate. This situation is more complex in a developing country where healthcare resources are limited. Doctors, nurses and public health professionals engaged in the prevention, screening, diagnosis, treatment and research of cancers are often posed with ethical dilemmas while making complex choices. With a special focus on low- and middle-income countries, this paper is intended to highlight these real-world ethical concerns facing those involved in the management of cancer patients. While taking a neutral view, this paper has adopted a theme-wise approach to discuss barriers in cancer care.

Incidence and Mortality of Cancers Related to Secondhand Smoking in Southeast Asia Countries

Background: Secondhand smoke has been a big problem for human being worldwide as it is well-established risk factors for cancers. ASEAN (Association of Southeast Asian Nations) bear high burden of cancers since the high prevalence of secondhand smoke. The objective of this study is to estimate the burden of cancer attributable to secondhand smoking in ASEAN. Methods: This research was using descriptive epidemiological incidence and prevalence-based research design, with cancers incidence and mortality data gained from GLOBOCAN 2012. Secondhand smoke attributable fractions (SAFs) of six cancers (lung, bladder, colorectal, stomach, pancreas and larynx) were estimated and burden of cancers caused by secondhand smoking in ASEAN were calculated in term of incidence and mortality. Results: Secondhand smoking estimated for 453,562 cancer cases and 323,284 of total cancer mortality in 2012. The number of incidence and death of lung cancer attributable to secondhand smoking show the highest number compared with other type of cancers. Furthermore, we found that the number of cancer cases and cancer deaths attributable to secondhand smoking varied by each countries due to differences in size of population, various background risk of the cancer, and prevalence of secondhand smoking in each country. Conclusion: Secondhand smoking has been a risk factor for about two-fifth of cancer incidence and mortality in ASEAN. Therefore, ASEAN member countries are strongly encouraged to put in place stronger tobacco control policies and to strengthen the existing tobacco control measure in order to decrease the number of secondhand smokers and more effectively control cancers.

Cancer-related financial hardship among head and neck cancer survivors: Risk factors and associations with health-related quality of life

OBJECTIVE

Cancer survivors are susceptible to financial hardship. In head and neck cancer (HNC) survivors, we investigated (a) predictors for cancer-related financial hardship and (b) associations between financial hardship and health-related quality of life (HRQoL).

METHODS

We conducted a cross-sectional study in HNC survivors identified from the National Cancer Registry Ireland. HRQoL was based on the Functional Assessment for Cancer Therapy General (FACT-G) plus Head and Neck Module (FACT-HN). Objective cancer-related financial hardship (financial stress) was assessed as household ability to make ends meet due to cancer and subjective financial hardship (financial strain) as feelings about household financial situation due to cancer. Modified Poisson regression was used to identify predictors for financial hardship. Bootstrap linear regression was used to estimate associations between hardship and FACT domain scores.

RESULTS

Pre-diagnosis retirement (relative risk [RR] 0.50, 95% confidence interval [CI] 0.37-0.67), pre-diagnosis financial stress (RR 1.85, 95% CI 1.58-2.15), and treatment were significantly associated with objective financial hardship. Predictors of subjective financial hardship were similar: aged greater than or equal to 65 years, pre-diagnosis financial stress, and treatment. Participants with objective financial hardship reported significantly lower physical (coefficient -3.45, 95% CI -4.39 to -2.44), emotional (-2.01, 95% CI -2.83 to -1.24), functional (-2.56, 95% CI -3.77 to -1.33) and HN-specific HRQoL (-3.55, 95% CI -5.04 to -2.23). Physical, emotional, and functional HN-specific HRQoL were also significantly lower in participants with subjective financial hardship.

CONCLUSION

Cancer-related financial hardship is common and associated with worse HRQoL among HNC survivors. This supports the need for services and supports to address financial concerns among HNC survivors.

The effect of community based health insurance on catastrophic health expenditure in Northeast Ethiopia: A cross sectional study

INTRODUCTION

Moving towards the goal of universal health coverage requires strengthening service delivery and overcoming significant financial barriers. The Government of Ethiopia is rolling out community based health insurance to protect the rural community from high out of pocket health expenditure and improve health service utilization. We investigated the effect of community based health insurance on catastrophic health expenditure in Northeast Ethiopia.

METHODS

A community based cross sectional study was conducted. A Multi stage sampling technique was used to get a total of 454 (224 insured and 230 uninsured) households. The data were entered using EPI info version 7 and analyzed using SPSS version 20 and STATA version 13 for binary logistic regression analysis and propensity score matching analysis respectively. Wealth status of the households was computed by Principal Component Analysis (PCA). A multivariable logistic regression analysis was done to identify the predictors of catastrophic health expenditure. Propensity score matching analysis was used to determine the effect of community based health insurance on catastrophic health expenditure. The average treatment effect on the treated (ATT) was calculated to compare the means of outcomes across insured and uninsured households.

RESULTS

A total of 454 household heads were included in the study, making a response rate of 91.2%.The total level of catastrophic health expenditure was found to be 20%. Among the households with catastrophic health expenditure, 4.41% were insured, whereas the remaining 15.64% were noninsured. Insured households (AOR = 0.19, 95% CI: 0.11-0.34), rich households (AOR = 1.98; 95% CI: 1.07-3.66), having member with chronic illness (AOR = 2.13, 95% CI: 1.01-4.51) and having member encountered any illness during the past 3 months (AOR = 2.44, 95% CI: 1.35-4.40) were statistically associated with catastrophic health expenditure. Community based health insurance contributed to 23.2% (t = -5.94) (95% CI: -0.31_-0.15) reduction of catastrophic health expenditure.

CONCLUSION

The overall level of catastrophic health expenditure was high among noninsured households. Community based health insurance has significant financial protection from catastrophic health expenditure in northeast Ethiopia. Thus, the government need to scale up community based health insurance to protect the noninsured households from catastrophic health expenditure.

How great is current curative expenditure and catastrophic health expenditure among patients with cancer in China? A research based on "System of Health Account 2011"

In recent years, the incidence and mortality of cancer have witnessed a dramatic increase. Cancer has already caused severe economic burdens on society, especially in developing countries and has become a major public health concern. This study evaluates the medical economic burden, including total current curative expenditure (CCE) and catastrophic health expenditure (CHE) on cancer in Liaoning Province, China. A total of 252 medical institutions were investigated with multistage stratified cluster random sampling. We established a standardized database of 3 532 517 samples. “System of Health Account 2011”, a new internationally recognized accounting system, was established to analyze the CCE on six most common cancers. CHE were estimated from the extracted 1344 patients with cancer, which performed a cross‐sectional study. The association of individual and contextual factors with CHE was evaluated using logistic regression models. CCE for all the patients with the six types of cancer was 2801.38 million CNY in Liaoning Province, the highest of which was lung cancer. The incidence of CHE was 42.78%, while the threshold was 40%. The average and relative distance were 10.41% and 24.32%, respectively. Influencing factors were length of stay, type of health insurance, location of household, etc. Our findings highlight the need to address medical economic burden in the cancer population. Households with the cancer are more likely to incur CHE. Financial intervention to prevent it should target on poor households. We provide suggestions in aspects of health insurance and health service management to reduce CHE.

Private health insurance and catastrophic health expenditures of households with cancer patients in South Korea

This study examines the effects of private health insurance (PHI) on the incidence of catastrophic health expenditures (CHE) for households with a patient with cancer. This study uses 1-year data from 2013 and households with cancer patients as the unit of research rather than individual household members. The sample thus includes 468 households with members with cancer who also used emergency, outpatient and hospitalisation services. Households with PHI had a lower incidence of CHE for all thresholds than those without did. At the 10% threshold, the incidence became significantly lower, by 0.59 and 0.60 times, respectively, if householders had higher education and income levels. Moreover, the incidence of CHE was higher by 8.71 times if the householders are female, and lower by 0.84 times if the householders did not have a spouse at the 20% threshold. From the analysis of households with cancer patients that hold PHI as the key variable, these households showed a lower incidence of CHE than the others did. PHI provides healthcare payments not secured through national health insurance (NHI) and protects households from health expenditures, thereby complementing NHI to a certain degree.

Impact of Osteoarthritis on Household Catastrophic Health Expenditures in Korea

BACKGROUND

Osteoarthritis (OA) is a disease of old age whose prevalence is increasing. This study explored the impact of OA on household catastrophic health expenditure (CHE) in Korea.

METHODS

We used data on 5,200 households from the Korea Health Panel Survey in 2013 and estimated annual living expenses and out-of-pocket (OOP) payments. Household CHE was defined when a household's total OOP health payments exceeded 10%, 20%, 30%, or 40% of the household's capacity to pay. To compare the OOP payments of households with OA individuals and those without OA, OA households were matched 1:1 with households containing a member with other chronic disease such as neoplasm, hypertension, heart disease, cerebrovascular disease, diabetes, or osteoporosis. The impact of OA on CHE was determined by multivariable logistic analysis.

RESULTS

A total of 1,289 households were included, and households with and without OA patients paid mean annual OOP payments of $2,789 and $2,607, respectively. The prevalence of household CHE at thresholds of 10%, 20%, 30%, and 40% were higher in households with OA patients than in those without OA patients (P < 0.001). The presence of OA patients in each household contributed significantly to CHE at thresholds of 10% (odds ratio [OR], 1.48; 95% confidence interval [CI], 1.16-1.87), 20% (OR, 1.29; 95% CI, 1.01-1.66), and 30% (OR, 1.37; 95% CI, 1.05-1.78), but not of 40% (OR, 1.17; 95% CI, 0.87-1.57).

CONCLUSION

The presence of OA patients in Korean households is significantly related to CHE. Policy makers should try to reduce OOP payments in households with OA patients.

Tackling socioeconomic inequalities and non-communicable diseases in low-income and middle-income countries under the Sustainable Development agenda

Five Sustainable Development Goals (SDGs) set targets that relate to the reduction of health inequalities nationally and worldwide. These targets are poverty reduction, health and wellbeing for all, equitable education, gender equality, and reduction of inequalities within and between countries. The interaction between inequalities and health is complex: better economic and educational outcomes for households enhance health, low socioeconomic status leads to chronic ill health, and non-communicable diseases (NCDs) reduce income status of households. NCDs account for most causes of early death and disability worldwide, so it is alarming that strong scientific evidence suggests an increase in the clustering of non-communicable conditions with low socioeconomic status in low-income and middle-income countries since 2000, as previously seen in high-income settings. These conditions include tobacco use, obesity, hypertension, cancer, and diabetes. Strong evidence from 283 studies overwhelmingly supports a positive association between low-income, low socioeconomic status, or low educational status and NCDs. The associations have been differentiated by sex in only four studies. Health is a key driver in the SDGs, and reduction of health inequalities and NCDs should become key in the promotion of the overall SDG agenda. A sustained reduction of general inequalities in income status, education, and gender within and between countries would enhance worldwide equality in health. To end poverty through elimination of its causes, NCD programmes should be included in the development agenda. National programmes should mitigate social and health shocks to protect the poor from events that worsen their frail socioeconomic condition and health status. Programmes related to universal health coverage of NCDs should specifically target susceptible populations, such as elderly people, who are most at risk. Growing inequalities in access to resources for prevention and treatment need to be addressed through improved international regulations across jurisdictions that eliminate the legal and practical barriers in the implementation of non-communicable disease control.

Action to address the household economic burden of non-communicable diseases

The economic burden on households of non-communicable diseases (NCDs), including cardiovascular diseases, cancer, respiratory diseases, and diabetes, poses major challenges to global poverty alleviation efforts. For patients with NCDs, being uninsured is associated with 2-7-fold higher odds of catastrophic levels of out-of-pocket costs; however, the protection offered by health insurance is often incomplete. To enable coverage of the predictable and long-term costs of treatment, national programmes to extend financial protection should be based on schemes that entail compulsory enrolment or be financed through taxation. Priority should be given to eliminating financial barriers to the uptake of and adherence to interventions that are cost-effective and are designed to help the poor. In concert with programmes to strengthen national health systems and governance arrangements, comprehensive financial protection against the growing burden of NCDs is crucial in meeting the UN's Sustainable Development Goals.

Determinants of catastrophic healthcare expenditure in Peru

The aims of this study were to assess factors associated with catastrophic healthcare expenditure (CHE) and the burden of out-of-pocket (OOP) payments for specific healthcare services in Peru. We used data from 30,966 households that participated in the 2016 National Household Survey (Encuesta Nacional de Hogares, ENAHO). Participants reported household characteristics and expenditure on ten healthcare services. CHE was defined as healthcare spending equal to or higher than 40% of the household's capacity to pay. The associations of various household characteristics and OOP payments for specific healthcare services with CHE were assessed in logistic regression models. Poorer, rural and smaller households as well as those with older adults and individuals with chronic conditions had greater odds of facing CHE. According to the estimates from the adjusted regression model, healthcare services could be grouped into three groups. Medical tests, surgery and medication were in the first group with odds ratios (ORs) between 6.43 and 4.72. Hospitalisation, outpatient, dental and eye care were in the second group with ORs between 2.61 and 1.46. Child care, maternity care and other healthcare services (such as contraceptives, rehabilitation, etc.) were in the third group with non-significant ORs. Many Peruvian households are forced to finance their healthcare through OOP payments, burdening their finances to the extent of affecting their living standards.

UICC-ARO Symposium at the UICC 2016 World Cancer Congress How Can We Mobilize Action to Realize UHC in Asia?

The 2016 World Cancer Congress, organised by UICC, was held in Paris in November 2016, under the theme “Mobilizing action – Inspiring Change.” As part of Track 4 presentations on the theme of “Strengthening cancer control: optimizing outcomes of health systems,” UICC-Asian Regional Office (UICC-ARO) held a symposium to discuss the issue of mobilizing action to realize UHC in Asia. Introducing the symposium, Hideyuki Akaza noted that universal health coverage (UHC) is included in the Sustainable Development Goals and one of the key issues for achieving UHC will be how to balance patient needs with the economic burden of cancer. Speakers from Japan and Indonesia addressed various issues, including the current status and challenges for medical economic evaluation in Asia, the importance of resource stratification, prospects for precision medicine, and the outlook for cancer control and UHC in developing and emerging countries in Asia. Key issues raised included how to respond to the rising costs of treating cancer as new and increasingly expensive drugs come to the market. Speakers and participants noted that health technology assessment programs are being developed around Asia in order to evaluate the cost-effectiveness of drugs in the face of budgetary constraints within increasingly pressurized national health systems. The importance of screening and early detection was also noted as effective means that have the potential to reduce reliance on expensive drugs for advanced cancers. The symposium was chaired jointly by Hideyuki Akaza and Shinjiro Nozaki (WHO Kobe Centre).

Financial Toxicity among Patients with Bladder Cancer: Reasons for Delay in Care and Effect on Quality of Life

PURPOSE

Costly surveillance and treatment of bladder cancer can lead to financial toxicity, a treatment related financial burden. Our objective was to define the prevalence of financial toxicity among patients with bladder cancer and identify delays in care and its effect on health related quality of life.

MATERIALS AND METHODS

We identified patients with bladder cancer in the University of North Carolina Health Registry/Cancer Survivorship Cohort. Financial toxicity was defined as agreement with having "to pay more for medical care than you can afford." Health related quality of life was measured using general and cancer specific validated questionnaires. Statistical analyses were performed using the Fisher exact test and the Student t-test.

RESULTS

A total of 138 patients with bladder cancer were evaluated. Median age was 66.9 years, 75% of the patients were male and 89% were white. Of the participants 33 (24%) endorsed financial toxicity. Participants who were younger (p = 0.02), black (p = 0.01), reported less than a college degree (p = 0.01) and had noninvasive disease (p = 0.04) were more likely to report financial toxicity. On multivariable analysis only age was a significant predictor of financial toxicity. Patients who endorsed financial toxicity were more likely to report delaying care (39% vs 23%, p = 0.07) due to the inability to take time off work or afford general expenses. On general health related quality of life questionnaires patients with financial toxicity reported worse physical and mental health (p = 0.03 and <0.01, respectively), and lower cancer specific health related quality of life (p = 0.01), physical well-being (p = 0.01) and functional well-being (p = 0.05).

CONCLUSIONS

Financial toxicity is a major concern among patients with bladder cancer. Younger patients were more likely to experience financial toxicity. Those who endorsed financial toxicity experienced delays in care and poorer health related quality of life, suggesting that treatment costs should have an important role in medical decision making.

Catastrophic Health Expenditure Among Colorectal Cancer Patients and Families: A Case of Malaysia

This study aimed to estimate the cost of colorectal cancer (CRC) management and to explore the prevalence and determinants of catastrophic health expenditure (CHE) among CRC patients and their families arising from the costs of CRC management. Data were collected prospectively from 138 CRC patients. Patients were interviewed by using a structured questionnaire at the time of the diagnosis, then at 6 months and 12 months following diagnosis. Simple descriptive methods and multivariate binary logistic regression were used in the analysis. The mean cost of managing CRC was RM8306.9 (US$2595.9), and 47.8% of patients’ families experienced CHE. The main determinants of CHE were the economic status of the family and the likelihood of the patient undergoing surgery. The results of this study strongly suggest that stakeholders and policy makers should provide individuals with financial protection against the consequences of cancer, a costly illness that often requires prolonged treatment.