Cost of Treatment for Cervical Cancer in India

Toward a Framework to Assess the Financial and Economic Burden of Cervical Cancer in Low- and Middle-Income Countries: A Systematic Review

PURPOSE

To review the economic burden assessment of cervical cancer in low- and middle-income countries (LMICs) and use the findings to develop a pragmatic, standardized framework for such assessment.

METHODS

We first systematically reviewed articles indexed in scientific databases reporting the methodology for collecting and calculating costs related to the cervical cancer burden in LMICs. Data on study design, costing approach, cost perspective, costing period, and cost type (direct medical costs [DMC], direct nonmedical costs [DNMC], and indirect costs [IC]) were extracted. Finally, we summarized the reported limitations in the methodology and used the solutions to inform our framework.

RESULTS

Cervical cancer treatment costs across LMICs vary greatly and can be extremely expensive, up to 70,968 International US dollars. Economic and financial assessment methods also vary greatly across countries. Of the 28 reviewed articles, 25 studies reported DMC for cervical cancer treatment by extracting cost information from billing or insurance databases (eight studies), conducting surveys (five), and estimating the costs (12). Only 11 studies-mainly through surveys-reported DNMC and IC. The economic burden assessment framework includes health care/payer and societal perspectives (DMC, DNMC, IC, and human capital loss) across the cervical cancer screening and treatment continuum. To assess health care/payer costs, we recommend combining the predefined treatment standards with actual local treatment practices, multiplied by unit costs. To assess societal costs, we recommend conducting a cost survey in line with a standardized yet adaptable protocol.

CONCLUSION

Our standardized, pragmatic framework allows assessment of economic and financial burden of cervical cancer in LMICs despite the different levels of available resources across countries. This framework will facilitate global comparisons and monitoring and may also be applied to other cancers.

Burden of cervical cancer in India: estimates of years of life lost, years lived with disability and disability adjusted life years at national and subnational levels using the National Cancer Registry Programme data

BACKGROUND

Cervical cancer is ranked as the second most common cancer in India. This study aims to assess the cervical cancer burden at the national and subnational level in India, projecting it for the year 2025 in terms of years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life years (DALYs).

METHODS

Twenty-eight population based cancer registries within the National Cancer Registry Programme network contributed cancer incidence and mortality data for this analysis. The DisMod-II tool, WHO lifetables, disability weights, mortality to incidence ratio, sample registration system, and census data were used to estimate the burden of cervical cancer. The projection estimates for 2025 were performed using a negative binomial regression model.

RESULTS

In 2016, the cervical cancer burden in India was 223.8 DALYs per 100,000 women. The highest age-standardised DALYs were found in the northeast region (290.1 DALYs per 100,000 women) and the lowest in the eastern region (156.1 DALYs per 100,000 women). The states of Mizoram, Arunachal Pradesh, Karnataka, and Nagaland had a higher cervical cancer burden with DALYs exceeding 300 per 100,000 women. The projected cervical cancer burden for India in 2025 was estimated to be 1.5 million DALYs.

CONCLUSIONS

The study has found a significant cervical cancer burden across the regions of India, providing a baseline for monitoring impact of actions. Enhancing awareness of cervical cancer, advocating for the significance of screening, and promoting HPV vaccination among adolescents, families, and communities through informative communication campaigns are essential steps in managing and ultimately eliminating cervical cancer in India.

Catastrophic health expenditure and distress financing of breast cancer treatment in India: evidence from a longitudinal cohort study

OBJECTIVE

To estimate the catastrophic health expenditure and distress financing of breast cancer treatment in India.

METHODS

The unit data from a longitudinal survey that followed 500 breast cancer patients treated at Tata Memorial Centre (TMC), Mumbai from June 2019 to March 2022 were used. The catastrophic health expenditure (CHE) was estimated using households' capacity to pay and distress financing as selling assets or borrowing loans to meet cost of treatment. Bivariate and logistic regression models were used for analysis.

FINDINGS

The CHE of breast cancer was estimated at 84.2% (95% CI: 80.8,87.9%) and distress financing at 72.4% (95% CI: 67.8,76.6%). Higher prevalence of CHE and distress financing was found among rural, poor, agriculture dependent households and among patients from outside of Maharashtra. About 75% of breast cancer patients had some form of reimbursement but it reduced the incidence of catastrophic health expenditure by only 14%. Nearly 80% of the patients utilised multiple financing sources to meet the cost of treatment. The significant predictors of distress financing were catastrophic health expenditure, type of patient, educational attainment, main income source, health insurance, and state of residence.

CONCLUSION

In India, the CHE and distress financing of breast cancer treatment is very high. Most of the patients who had CHE were more likely to incur distress financing. Inclusion of direct non-medical cost such as accommodation, food and travel of patients and accompanying person in the ambit of reimbursement of breast cancer treatment can reduce the CHE. We suggest that city specific cancer care centre need to be strengthened under the aegis of PM-JAY to cater quality cancer care in their own states of residence.

TRIAL REGISTRATION

CTRI/2019/07/020142 on 10/07/2019.

The economic burden of cervical cancer on women in Uganda: Findings from a cross-sectional study conducted at two public cervical cancer clinics

There is limited research on how a cervical cancer diagnosis financially impacts women and their families in Uganda. This analysis aimed to describe the economic impact of cervical cancer treatment, including how it differs by socio-economic status (SES) in Uganda. We conducted a cross-sectional study from September 19, 2022 to January 17, 2023. Women were recruited from the Uganda Cancer Institute and Jinja Regional Referral Hospital, and were eligible if they were ≥ of 18 years and being treated for cervical cancer. Participants completed a survey that included questions about their out-of-pocket costs, unpaid labor, and family's economic situation. A wealth index was constructed to determine their SES. Descriptive statistics were reported. Of the 338 participants, 183 were from the lower SES. Women from the lower SES were significantly more likely to be older, have ≤ primary school education, and have a more advanced stage of cervical cancer. Over 90% of participants in both groups reported paying out-of-pocket for cervical cancer. Only 15 participants stopped treatment because they could not afford it. Women of a lower SES were significantly more likely to report borrowing money (higher SES n = 47, 30.5%; lower SES n = 84, 46.4%; p-value = 0.004) and selling possessions (higher SES n = 47, 30.5%; lower SES n = 90, 49.7%; p-value = 0.006) to pay for care. Both SES groups reported a decrease in the amount of time that they spent caring for their children since their cervical cancer diagnosis (higher SES n = 34, 31.2%; lower SES n = 36, 29.8%). Regardless of their SES, women in Uganda incur out-of-pocket costs related to their cervical cancer treatment. However, there are inequities as women from the lower SES groups were more likely to borrow funds to afford treatment. Alternative payment models and further economic support could help alleviate the financial burden of cervical cancer care in Uganda.

Geospatial mapping of public sentiment and infodemic on human papillomavirus vaccination in India: An indication to formulation of strategies for effective implementation

The implementation of Human Papillomavirus (HPV) vaccination is crucial for eliminating cervical cancer in India. The infodemic, characterised by misleading information, could hinder the successful implementation of the initiative. Misinformation related to the HPV vaccine, such as rumours, has been reported and circulated, contributing to an alarming pattern of vaccine hesitancy observed on social media. This study aimed to identify the public sentiment towards HPV vaccination based on the 'Behavioral and Social Drivers (BeSD)' framework through geospatial, content and sentiment analysis. A total of 1,487 tweets were extracted. After preprocessing, 1010 tweets were identified for sentiment and content analysis. The sentiments expressed towards the HPV vaccine are mixed, with a generally positive outlook on the vaccines. Within the population, there is a pervasive proliferation of misinformation, primarily focusing on vaccine safety and efficacy, contentious subjects, ethical considerations, and a prevalent sense of uncertainty in selecting the appropriate vaccine. These observations are crucial for developing targeted strategies to address public concerns and enhance vaccination rates. The insights gained from these results will guide policymakers, healthcare practitioners, and public health organisations to implement evidence-based interventions, thereby countering vaccine hesitancy and improving public health outcomes.

Estimation of economic burden throughout course of cervical squamous intraepithelial lesion and cervical cancer in China: A nationwide multicenter cross-sectional study

Objective

Cervical squamous intraepithelial lesion (SIL) and cervical cancer are major threats to females' health and life in China, and we aimed to estimate the economic burden associated with their diagnosis and treatment.

Methods

A nationwide multicenter, cross-sectional, hospital-based survey was conducted in 26 qualified hospitals across seven administrative regions of China. We investigated females who had been pathologically diagnosed with SIL and cervical cancer, and included five disease courses ("diagnosis", "initial treatment", "chemoradiotherapy", "follow-up" and "recurrence/progression/metastasis") to estimate the total costs. The median and interquartile range (IQR) of total costs (including direct medical, direct non-medical, and indirect costs), reimbursement rate by medical insurance, and catastrophic health expenditures in every clinical stage were calculated.

Results

A total of 3,471 patients in different clinical stages were analyzed, including low-grade SIL (LSIL) (n=549), high-grade SIL (HSIL) (n=803), cervical cancer stage IA (n=226), IB (n=610), IIA (n=487), IIB (n=282), III (n=452) and IV (n=62). In urban areas, the estimated total costs of LSIL and HSIL were [Formula: see text]1,637.7 (IQR: [Formula: see text]956.4-[Formula: see text]2,669.2) and [Formula: see text]2,467.1 (IQR: [Formula: see text]1,579.1-[Formula: see text]3,762.3), while in rural areas the costs were [Formula: see text]459.0 (IQR: [Formula: see text]167.7-[Formula: see text]1,330.3) and [Formula: see text]1,230.5 (IQR: [Formula: see text]560.6-[Formula: see text]2,104.5), respectively. For patients with cervical cancer stage IA, IB, IIA, IIB, and III-IV, the total costs were [Formula: see text]15,034.9 (IQR: [Formula: see text]11,083.4-[Formula: see text]21,632.4), [Formula: see text]19,438.6 (IQR: [Formula: see text]14,060.0-[Formula: see text]26,505.9), [Formula: see text]22,968.8 (IQR: [Formula: see text]16,068.8-[Formula: see text]34,615.9), [Formula: see text]26,936.0 (IQR: [Formula: see text]18,176.6-[Formula: see text]41,386.0) and [Formula: see text]27,332.6 (IQR: [Formula: see text]17,538.7-[Formula: see text]44,897.0), respectively. Medical insurance covered 43%-55% of direct medical costs for cervical cancer patients, while the coverage for SIL patients was 19%-43%. For most cervical cancer patients, the expense was catastrophic, and the extent of catastrophic health expenditure was about twice large for rural patients than that for urban patients in each stage.

Conclusions

The economic burden of SIL and cervical cancer in China is substantial, with a significant proportion of the costs being avoidable for patients with LSIL. Even for those with medical insurance, catastrophic health expenditures are also a major concern for patients with cervical cancer, particularly for those living in rural areas.

Cancer care and economic burden-A narrative review

Cancer care poses a significant economic burden in India, where noncommunicable diseases contribute to a large number of deaths and disability-adjusted life-years. Despite economic growth, equitable wealth distribution remains a challenge, leading to inequalities in healthcare access. India's healthcare system is primarily privatized, financed through out-of-pocket expenditure (OOPE), and lacks coverage for a majority of the population. As a result, individuals without financial means face catastrophic health consequences when seeking necessary healthcare. OOPE in India's healthcare system is a major concern, with medicines accounting for a significant portion of expenses, followed by diagnostic tests and consultation fees. Nonmedical expenses also contribute to the financial burden. Cancer care specifically faces substantial financial challenges, with high treatment costs, reduced workforce participation, and the need for distress financing. Cancer-related OOPE is predominantly borne by patients and their families, leading to significant financial strain. The lack of comprehensive health insurance coverage and limited access to publicly funded healthcare services exacerbate the problem. Catastrophic health expenditure (CHE) in cancer care is prevalent, pushing households into financial distress and potentially impoverishment. Efforts have been made to address this issue, such as increasing public spending on healthcare and implementing health insurance schemes. However, challenges remain in ensuring their effectiveness and reach. The role of family care physicians is crucial in supporting patients and their families during catastrophic health expenditures related to cancer-related palliative care. They coordinate care, provide advocacy, emotional support, symptom management, and facilitate end-of-life discussions. Comprehensive measures are needed to strengthen healthcare infrastructure, improve access to affordable cancer care, enhance health insurance coverage, and implement supportive measures for cancer patients. Additionally, promoting preventive measures and early detection can help reduce the need for expensive treatments and decrease the risk of catastrophic health expenditures.

Health and economic effects of introducing single-dose or two-dose human papillomavirus vaccination in India

BACKGROUND

Cervical cancer is a major public health problem in India, where access to prevention programmes is low. The WHO-Strategic Advisory Group of Experts recently updated their recommendation for human papillomavirus (HPV) vaccination to include a single-dose option in addition to the two-dose option, which could make HPV vaccination programmes easier to implement and more affordable.

METHODS

We combined projections from a type-specific HPV transmission model and a cancer progression model to assess the health and economic effects of HPV vaccination at national and state level in India. The models used national and state-specific Indian demographic, epidemiological and cost data, and single-dose vaccine efficacy and immunogenicity data from the International Agency for Research on Cancer India vaccine trial with 10-year follow-up. We compared single-dose and two-dose HPV vaccination for a range of plausible scenarios regarding single-dose vaccine protection, coverage and catch-up. We used a healthcare sector payer perspective with a time horizon of 100 years.

RESULTS

Under the base-case scenario of lifelong protection of single-dose vaccination in 10-year-old girls with 90% coverage, the discounted incremental cost-effectiveness ratio (ICER) of nationwide vaccination relative to no vaccination was US$406 (₹INR30 000) per DALY (disability-adjusted life-years) averted. This lay below an opportunity-cost-based threshold of 30% Indian gross domestic product per capita in each Indian state (state-specific ICER range: US$67-US$593 per DALY averted). The ICER of two-dose vaccination versus no vaccination vaccination was US$1404 (₹INR104 000). The ICER of two-dose vaccination versus single-dose vaccination, assuming lower initial efficacy and waning of single-dose vaccination, was at least US$2282 (₹INR169 000) per DALY averted.

CONCLUSIONS

Nationwide introduction of single-dose HPV vaccination at age 10 in India is highly likely to be cost-effective whereas extending the number of doses from one to two would have a less favourable profile.

Financial toxicity of cancer treatment in India: towards closing the cancer care gap

Background

The rising economic burden of cancer on patients is an important determinant of access to treatment initiation and adherence in India. Several publicly financed health insurance (PFHI) schemes have been launched in India, with treatment for cancer as an explicit inclusion in the health benefit packages (HBPs). Although, financial toxicity is widely acknowledged to be a potential consequence of costly cancer treatment, little is known about its prevalence and determinants among the Indian population. There is a need to determine the optimal strategy for clinicians and cancer care centers to address the issue of high costs of care in order to minimize the financial toxicity, promote access to high value care and reduce health disparities.

Methods

A total of 12,148 cancer patients were recruited at seven purposively selected cancer centres in India, to assess the out-of-pocket expenditure (OOPE) and financial toxicity among cancer patients. Mean OOPE incurred for outpatient treatment and hospitalization, was estimated by cancer site, stage, type of treatment and socio-demographic characteristics. Economic impact of cancer care on household financial risk protection was assessed using standard indicators of catastrophic health expenditures (CHE) and impoverishment, along with the determinants using logistic regression.

Results

Mean direct OOPE per outpatient consultation and per episode of hospitalization was estimated as ₹8,053 (US$ 101) and ₹39,085 (US$ 492) respectively. Per patient annual direct OOPE incurred on cancer treatment was estimated as ₹331,177 (US$ 4,171). Diagnostics (36.4%) and medicines (45%) are major contributors of OOPE for outpatient treatment and hospitalization, respectively. The overall prevalence of CHE and impoverishment was higher among patients seeking outpatient treatment (80.4% and 67%, respectively) than hospitalization (29.8% and 17.2%, respectively). The odds of incurring CHE was 7.4 times higher among poorer patients [Adjusted Odds Ratio (AOR): 7.414] than richest. Enrolment in PM-JAY (CHE AOR = 0.426, and impoverishment AOR = 0.395) or a state sponsored scheme (CHE AOR = 0.304 and impoverishment AOR = 0.371) resulted in a significant reduction in CHE and impoverishment for an episode of hospitalization. The prevalence of CHE and impoverishment was significantly higher with hospitalization in private hospitals and longer duration of hospital stay (p < 0.001). The extent of CHE and impoverishment due to direct costs incurred on outpatient treatment increased from 83% to 99.7% and, 63.9% to 97.1% after considering both direct and indirect costs borne by the patient and caregivers, respectively. In case of hospitalization, the extent of CHE increased from 23.6% (direct cost) to 59.4% (direct+ indirect costs) and impoverishment increased from 14.1% (direct cost) to 27% due to both direct and indirect cost of cancer treatment.

Conclusion

There is high economic burden on patients and their families due to cancer treatment. The increase in population and cancer services coverage of PFHI schemes, creating prepayment mechanisms like E-RUPI for outpatient diagnostic and staging services, and strengthening public hospitals can potentially reduce the financial burden among cancer patients in India. The disaggregated OOPE estimates could be useful input for future health technology analyses to determine cost-effective treatment strategies.

Efficacy and safety of EGFR inhibitor gefitinib in recurrent or metastatic cervical cancer: a preliminary report

There has been growing interest in the use of epidermal growth factor receptor inhibitors in various cancers. The study was conducted to evaluate the efficacy and safety of gefitinib as a monotherapy in patients with recurrent or metastatic cervical cancer. Patients with cervical carcinoma who experienced locoregional recurrence or distant metastases either at presentation or after definitive combined chemoradiotherapy or postoperative radiotherapy were enrolled. Gefitinib was administered orally at a dose of 250 mg/d to eligible patients. Treatment with Gefitinib was continued until disease progression, intolerable adverse effects were developed, or consent was withdrawn. Clinical and radiological investigations were used to verify the disease response. Toxicity was graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events version 5.0. The study enrolled 32 patients who met the eligibility criteria. Thirty patients were available for the analysis. The majority of the patients included in the analysis had FIGO stage IIIB disease at their initial presentation. The median follow-up time was 6 months (3-15 months). Two patients (7%) had a complete clinical response, 7 patients (23%) had a partial response, 5 patients (17%) showed a stable disease and 16 patients had progressive disease (53%). The disease control rate was 47%. The median PFS was noted to be 4.5 months and the 1-year PFS was 20%. None of the individuals experienced toxicity of grade 3 or higher. All toxicities were managed conservatively. The study suggests that gefitinib may be a promising therapeutic option for patients with advanced cervical cancer who have limited treatment alternatives.

Insurance status and access to cervical cancer treatment in a specialized cancer center in Mexico

To describe access to complete treatment in women with cervical cancer and state-sponsored insurance versus no insurance. We conducted a retrospective observational study. The source population consisted of women treated for cervical cancer from January 2000 to December 2015 in a tertiary care hospital. We included 411 women with state-sponsored insurance and 400 without insurance. We defined access to cervical cancer treatment as complete treatment (according NCCN/ESMO (National Comprehensive Cancer Network/European Society for Medical Oncology) standards) and timely initiation of treatment (less than 4 weeks). Clinical and sociodemographic characteristics were described and analyzed with logistic regression using complete treatment as the main outcome. A total of 811 subjects were included, the median age was 46 (IQR (Interquartile range) 42-50) years. Most of them were married (36.1%), unemployed (50.4%), and had completed primary school (44.0%). The most common clinical stages at diagnosis were II (38.2%) and III (24.7%). In the adjusted regression model, being married (OR (odds ratio): 4.3, 95% CI (confidence interval): 1.74-10.61) and having paid employment (OR: 2.79, 95% CI: 1.59-4.90) or state-sponsored insurance (OR: 1.54, 95% CI: 1.04-2.26) were positively associated with the possibility of having a complete treatment. Women with insurance were likely to be younger and receive timely treatment compared with uninsured women. Complete treatment was associated to insurance status and advanced stages of cervical cancer. State-sponsored insurance improves access to complete treatment. Government policies are needed to avoid social and economic inequity and provide better management of cervical cancer in our country.

The social and economic impacts of cervical cancer on women and children in low- and middle-income countries: A systematic review

BACKGROUND

There is limited knowledge on the social and economic impacts of a diagnosis of cervical cancer on women and children in low- and middle-income countries (LMICs).

OBJECTIVES

To determine the social and economic impacts associated with cervical cancer among women and children living in LMICs.

SEARCH STRATEGY

The MEDLINE, PsychInfo, CINAHL, Pais International, and CAB Global Health databases were systematically searched to retrieve studies up to June 2021.

SELECTION CRITERIA

Studies were included if they reported on either the social or economic impacts of women or children in a LMIC.

DATA COLLECTION AND ANALYSIS

Data was independently extracted by two co-authors. The authors performed a quality assessment on all included articles.

MAIN RESULTS

In all, 53 studies were included in the final review. Social impacts identified included social support, education, and independence. Economic impacts included employment and financial security. No study reported the economic impact on children. Studies that utilized quantitative methods typically reported more positive results than those that utilized qualitative methods.

CONCLUSIONS

Additional mixed-methods research is needed to further understand the social support needs of women with cervical cancer. Furthermore, research is needed on the impact of a mother's diagnosis of cervical cancer on her children.

Audio-Visual Training Improves Awareness and Willingness of Cervical Cancer Screening among Healthy Indian Women: Findings from a Survey

Priya GaneshkumarObjectives  We evaluated the impact of a standardized, simple audio-visual (AV) training video developed in regional languages on cervical cancer awareness among apparently healthy women and their willingness to undergo regular cervical cancer screening. Materials and Methods  This cross-sectional noninterventional multicentric survey was conducted in 69 centers across 14 states in India and one center in UAE among women aged between 18 and 88 years attending clinics for a variety of indications. Using a short questionnaire, cervical cancer awareness and willingness to undergo cervical cancer screening were assessed before and after the AV training. Statistical Analysis  In addition to descriptive analysis, improvement in awareness after the AV training was assessed using McNemar's test, and comparison of responses between subgroups was performed using Pearson chi-squared test. Results  The survey was completed by 3,188 apparently healthy women (mean age: 36.8 ± 11.3 years). Before AV training, correct answers were given to only 4/6 questions by majority of the participants; most participants were unaware about the main cause of cervical cancer (1,637/3,188, 51.4%), availability of cervical cancer screening tests (1,601/3,188, 50.2%), and cervical cancer vaccines (1,742/3,188, 54.6%). Only 576 women (18.1%) had undergone cervical cancer screening in the past. After the AV training, the proportion of women correctly responding to all six questions improved significantly (p < 0.05), and 84.4% (2691/3188) women showed willingness to undergo periodic cervical cancer screening. Compared to unmarried and professional women, although married women and home-makers had lower awareness scores, the latter subgroups had more often undergone previous cervical cancer screening. Conclusion  It is possible to improve cervical cancer awareness among healthy women, and to enhance their willingness to undergo regular cervical cancer screening tests using a simple, six minute-long, standardized AV training material.

CHSI costing study-Challenges and solutions for cost data collection in private hospitals in India

INTRODUCTION

Ayushman Bharat Pradhan Mantri Jan Aarogya Yojana (AB PM-JAY) has enabled the Government of India to become a strategic purchaser of health care services from private providers. To generate base cost evidence for evidence-based policymaking the Costing of Health Services in India (CHSI) study was commissioned in 2018 for the price setting of health benefit packages. This paper reports the findings of a process evaluation of the cost data collection in the private hospitals.

METHODS

The process evaluation of health system costing in private hospitals was an exploratory survey with mixed methods (quantitative and qualitative). We used three approaches-an online survey using a semi-structured questionnaire, in-depth interviews, and a review of monitoring data. The process of data collection was assessed in terms of time taken for different aspects, resources used, level and nature of difficulty encountered, challenges and solutions.

RESULTS

The mean time taken for data collection in a private hospital was 9.31 (± 1.0) person months including time for obtaining permissions, actual data collection and entry, and addressing queries for data completeness and quality. The longest time was taken to collect data on human resources (30%), while it took the least time for collecting information on building and space (5%). On a scale of 1 (lowest) to 10 (highest) difficulty levels, the data on human resources was the most difficult to collect. This included data on salaries (8), time allocation (5.5) and leaves (5).

DISCUSSION

Cost data from private hospitals is crucial for mixed health systems. Developing formal mechanisms of cost accounting data and data sharing as pre-requisites for empanelment under a national insurance scheme can significantly ease the process of cost data collection.

Catastrophic expenditure and treatment attrition in patients seeking comprehensive colorectal cancer treatment in India: A prospective multicentre study

BACKGROUND

Although colorectal cancer is increasing in India, the cost of comprehensive treatment and its consequences for patients and households are unknown. This study aimed to describe catastrophic expenditure and treatment attrition in patients with a treatment plan for colorectal cancer.

METHODS

A prospective, multicentre, cohort study was conducted in five tertiary hospitals in India from December 2020 to March 2022. Consecutive patients with a new treatment plan for colorectal cancer were followed-up for six months. The total cost of treatment was reported, including out-of-pocket payments (OOPP, paid by patients at the time-of-service use) and covered by third parties (insurance, public funds). The primary outcome was catastrophic expenditure, defined as OOPPs greater than 25% of patient's annual household income and the secondary outcome was treatment attrition, defined as unplanned interruption of the treatment course not recommended by the clinical team.

FINDINGS

Of 226 patients included, 20 died within six months of being offered a treatment plan and four were lost to follow-up. The median total cost of colorectal cancer treatment was 407,508 Indian Rupees (INR/5340 USD), to which the biggest contributor was the patient's OOPP (median 330,277 INR/4328 USD). Surgery and anaesthesia costs (median 85,944 INR/1126 USD) were higher than radiotherapy (median 55,525 INR/728 USD) and chemotherapy (median 14,780 INR/194 USD). The overall catastrophic expenditure rate was 90.1% (182/202) and the treatment attrition rate was 9.4% (19/202). Patients with treatment attrition made lower OOPPs than those who completed treatment (median 205,926 vs 349,398 INR, p < 0.01) but had a similar risk of catastrophic expenditure (OR 0.23, 95%CI 0.03-2.28, p = 0.186).

INTERPRETATION

Most treatment costs for colorectal cancer were paid out-of-pocket by patients and catastrophic expenditure was common. Treatment attrition rates at tertiary centres were low, suggesting greater attrition at previous stages of care. Better financial protection may allow more patients to receive comprehensive cancer treatment while avoiding household financial catastrophe.

FUNDING

This research was funded by the National Institute for Health Research (NIHR) (NIHR 16.136.79) using UK aid from the UK Government to support global health research, by the India Institute of the University of Birmingham and by the Global Challenges program of the University of Birmingham. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR or the UK government.

Cervical cancer elimination in indian context: Moving from barriers to facilitators

It has been 46 years since the launch of cancer control programs in India and yet the recent National Family Health Survey (fifth round, 2019-2021) has reported that just 1.9% of women aged 30-49 years have ever undergone cervical cancer screening. The cost of delayed diagnosis of cervical cancer and its treatment is overwhelming, and the rural population takes the worst hit. It is the need of the hour that the Indian health system and policymakers identify the barriers and facilitators for cervical cancer early detection and provide pragmatic solutions so that the targets of cervical cancer elimination can be achieved in a timely manner.

Cost of Surgical Care at Public Sector District Hospitals in India: Implications for Universal Health Coverage and Publicly Financed Health Insurance Schemes

BACKGROUND

In low- and middle-income countries (LMICs), provisioning for surgical care is a public health priority. Ayushman Bharat Pradhan Mantri-Jan Aarogya Yojana (AB PM-JAY) is India's largest national insurance scheme providing free surgical and medical care. In this paper, we present the costs of surgical health benefit packages (HBPs) for secondary care in public district hospitals.

METHODS

The costs were estimated using mixed (top-down and bottom-up) micro-costing methods. In phase II of the Costing of Health Services in India (CHSI) study, data were collected from a sample of 27 district hospitals from nine states of India. The district hospitals were selected using stratified random sampling based on the district's composite development score. We estimated unit costs for individual services-outpatient (OP) visit, per bed-day in inpatient (IP) and intensive care unit (ICU) stays, and surgical procedures. Together, this was used to estimate the cost of 250 AB PM-JAY HBPs.

RESULTS

At the current level of utilization, the mean cost per OP consultation varied from US$4.10 to US$2.60 among different surgical specialities. The mean unit cost per IP bed-day ranged from US$13.40 to US$35.60. For the ICU, the mean unit cost per bed-day was US$74. Further, the unit cost of HBPs varied from US$564 for bone tumour excision to US$49 for lid tear repair.

CONCLUSIONS

Data on the cost of delivering surgical care at the level of district hospitals is of critical value for evidence-based policymaking, price-setting for surgical care and planning to strengthen the availability of high quality and cost-effective surgical care in district hospitals.

Ensuring quality in contextualised cancer management guidelines for resource-constraint settings: using a systematic approach

To address the wide variation in access to cancer care in India requires strengthening of infrastructure, trained oncology workforce, and minimisation of out-of-pocket expenditures. However, even with major investments, it is unlikely to achieve the same level of infrastructure and expertise across the country. Therefore, a resource stratified approach driven by evidence-based and contextualised clinical guidelines is the need of the hour. The National Cancer Grid has been at the forefront of delivery of standardised cancer care through several of its initiatives, including the resource-stratified guidelines. Development of new guidelines is resource and time intensive, which may not be feasible and can delay the implementation. Adaptation of the existing standard guidelines using the transparent and well-documented methodology with involvement of all stakeholders can be one of the most reasonable pathways. However, the adaptation should be done keeping in mind the context, resource availability, budget impact, investment needed for implementation and acceptability by clinicians, patients, policymakers, and other stakeholders. The present paper provides the framework for systematically developing guidelines through adaptation and contextualisation. The process can be used for other health conditions in resource-constraint settings.

Cost Effectiveness of Ribociclib and Palbociclib in the Second-Line Treatment of Hormone Receptor-Positive, HER2-Negative Metastatic Breast Cancer in Post-Menopausal Indian Women

BACKGROUND

In this study, we evaluate the cost and outcomes of cyclin-dependent kinase 4/6 inhibitors (CDK4/6i) plus fulvestrant, fulvestrant alone, and conventional chemotherapy as the second-line therapy for hormone receptor-positive (HR+), human epidermal growth factor receptor 2-negative (HER2-) metastatic breast cancer (MBC) in India.

METHODS

Using a Markov model, the clinical effectiveness of managing HR+, HER2- MBC in postmenopausal women with either a CDK4/6i (either ribociclib or palbociclib) and fulvestrant, fulvestrant alone, and chemotherapy (single-agent paclitaxel or capecitabine) was measured in terms of quality-adjusted life-years (QALYs). The costs were estimated from two different points of view: scenario I, as per the prevailing market prices of the drugs; and scenario II, as per the reimbursement rates set up by the publicly financed national health insurance scheme. Incremental cost per QALY gained with a given treatment option was compared against the next best alternative and was assessed for cost effectiveness using a threshold of 1-time the per capita gross domestic product (GDP) in India from a societal perspective.

RESULTS

In scenario I, an MBC patient was found to incur a lifetime cost of Indian Rupees (₹) 2.54 million ($34,644), ₹2.53 million ($34,496), ₹512,598 ($6,984), ₹326,026 ($4,442) and ₹237,115 ($3,230) for the ribociclib and palbociclib combination arms, fulvestrant monotherapy, single-agent paclitaxel and the single-agent capecitabine treatment arms, respectively. The lifetime cost for CDK4/6i (ribociclib and palbociclib) combination therapy, fulvestrant monotherapy, paclitaxel, and capecitabine arms was estimated to be ₹1.94 million ($26,459), ₹1.92 million ($26,220), ₹315,387 ($4,296), ₹187,392 ($2,553) and ₹153,263 ($2,088), respectively, in scenario II. The mean QALYs lived per MBC patient with CDK4/6i (either ribociclib or palbociclib) combination therapy, fulvestrant, paclitaxel and capecitabine were estimated to be 1.4, 1.0, 0.9 and 0.7, respectively. None of the treatment arms are cost effective at current prices and reimbursement rates at a threshold of 1-time the per capita GDP of India. However, a 78% reduction in the current market price or a 72% reduction in the reimbursement rate of fulvestrant in the government-funded insurance program will make it a cost-effective treatment option for HR+, HER2- MBC patients in India.

CONCLUSION

CDK4/6i (ribociclib and palbociclib) therapy is not a cost-effective treatment option for MBC patients. A 72% reduction in the reimbursement rate for fulvestrant monotherapy will make it a cost-effective treatment option in the Indian context.

Cost Effectiveness of Bevacizumab Plus Chemotherapy for the Treatment of Advanced and Metastatic Cervical Cancer in India-A Model-Based Economic Analysis

PURPOSE

Patients with advanced and metastatic cervical cancer have a poor prognosis with a 1-year survival rate of 10%-15%. Recently, an antiangiogenic humanized monoclonal antibody bevacizumab has shown to improve the survival of these patients. This study was designed to assess the cost effectiveness of incorporating bevacizumab with standard chemotherapy for the treatment of patients with advanced and metastatic cervical cancer in India.

METHODS

Using a disaggregated societal perspective and lifetime horizon, a Markov model was developed for estimating the costs and health outcomes in a hypothetical cohort of 1,000 patients with advanced and metastatic cervical cancer treated with either standard chemotherapy alone or in combination with bevacizumab. Effectiveness data for each of the treatment regimen were assessed using estimates from Gynecologic Oncology Group 240 trial. Data on disease-specific mortality in metastatic cervical cancer, health system cost, and out-of-pocket expenditure were derived from Indian literature. Multivariable probabilistic sensitivity analysis was undertaken to account for parameter uncertainty.

RESULTS

Over the lifetime of one patient with advanced and metastatic cervical cancer, bevacizumab along with standard chemotherapy results in a gain of 0.275 (0.052-0.469) life-years (LY) and 0.129 (0.032-0.218) quality-adjusted life-years (QALY), at an additional cost of $3,816 US dollars (USD; 2,513-5,571) compared with standard chemotherapy alone. This resulted in an incremental cost of $19,080 USD (7,230-52,434) per LY gained and $34,744 USD (15,782-94,914) per QALY gained with the use of bevacizumab plus standard chemotherapy.

CONCLUSION

Addition of bevacizumab to the standard chemotherapy is not cost effective for the treatment of advanced and metastatic cervical cancer in India at a threshold of 1-time per-capita gross domestic product.

Financial toxicity in cancer care in India: a systematic review

Although financial toxicity is widely acknowledged to be a potential consequence of costly cancer treatment, little is known about its prevalence and outcome among the Indian population. In this study, we systematically reviewed the prevalence, determinants, and consequences of financial toxicity among patients with cancer in India. 22 studies were included in the systematic review. The determinants of financial toxicity include household income, type of health-care facility used, stage of disease, area of residence, age at the time of diagnosis, recurrent cancer, educational status, insurance coverage, and treatment modality. Financial toxicity was associated with poor quality of life, accumulation of debts, premature entry into the labour market, and non-compliance with therapy. Our findings emphasise the need for urgent strategies to mitigate financial toxicity among patients with cancer in India, especially in the most deprived sections of society. The qualitative evidence synthesised in this systematic review could provide a basis for the development of such interventions to reduce financial toxicity among patients with cancer.

Development of National Cancer Database for Cost and Quality of Life (CaDCQoL) in India: a protocol

INTRODUCTION

The rising economic burden of cancer on healthcare system and patients in India has led to the increased demand for evidence in order to inform policy decisions such as drug price regulation, setting reimbursement package rates under publicly financed health insurance schemes and prioritising available resources to maximise value of investments in health. Economic evaluations are an integral component of this important evidence. Lack of existing evidence on healthcare costs and health-related quality of life (HRQOL) makes conducting economic evaluations a very challenging task. Therefore, it is imperative to develop a national database for health expenditure and HRQOL for cancer.

METHODS AND ANALYSIS

The present study proposes to develop a National Cancer Database for Cost and Quality of Life (CaDCQoL) in India. The healthcare costs will be estimated using a patient perspective. A cross-sectional study will be conducted to assess the direct out-of-pocket expenditure (OOPE), indirect cost and HRQOL among cancer patients who will be recruited at seven leading cancer centres from six states in India. Mean OOPE and HRQOL scores will be estimated by cancer site, stage of disease and type of treatment. Economic impact of cancer care on household financial risk protection will be assessed by estimating prevalence of catastrophic health expenditures and impoverishment. The national database would serve as a unique open access data repository to derive estimates of cancer-related OOPE and HRQOL. These estimates would be useful in conducting future cost-effectiveness analyses of management strategies for value-based cancer care.

ETHICS AND DISSEMINATION

Approval was granted by Institutional Ethics Committee vide letter no. PGI/IEC-03/2020-1565 of Post Graduate Institute of Medical Education and Research, Chandigarh, India. The study results will be published in peer-reviewed journals and presented to the policymakers at national level.

Cost of scaling-up comprehensive primary health care in India: Implications for universal health coverage

India has announced the ambitious program to transform the current primary healthcare facilities to health and wellness centres (HWCs) for provision of comprehensive primary health care (CPHC). We undertook this study to assess the cost of this scale-up to inform decisions on budgetary allocation, as well as to set the norms for capitation-based payments. The scale-up cost was assessed from both a financial and an economic perspective. Primary data on resources used to provide services in 93 sub-health centres (SHCs) and 38 primary health care centres (PHCs) were obtained from the National Health System Cost Database. The cost of additional infrastructure and human resources was assessed against the normative guidelines of Indian Public Health Standards and the HWC. The cost of other inputs (drugs, consumables, etc.) was determined by undertaking the need estimation based on disease burden or programme guidelines, standard treatment guidelines and extent and pattern of care utilization from nationally representative sample surveys. The financial cost is reported in terms of the annual incremental cost at health facility level, as well as its implications at national level, given the planned scale-up path. Secondly, economic cost is assessed as the total annual as well as annual per capita cost of services at HWC level. Bootstrapping technique was undertaken to estimate 95% confidence intervals for cost estimations. Scaling to CPHC through HWC would require an additional ₹ 721 509 (US$10 178) million allocation of funds for primary healthcare >5 years from 2019 to 2023. The scale-up would imply an addition to Government of India's health budget of 2.5% in 2019 to 12.1% in 2023. Our findings suggest a scale-up cost of 0.15% of gross domestic product (GDP) for full provision of CPHC which compares with current public health spending of 1.28% of GDP and a commitment of 2.5% of GDP by 2025 in the National Health Policy. If a capitation-based payment system was used to pay providers, provision of CPHC would need to be paid at between ₹ 333 (US$4.70) and ₹ 253 (US$3.57) per person covered for SHC and PHC, respectively.