Introduction
Health care is informed first and foremost by scientific and medical understanding of how to treat and prevent disease. Economics can, however, provide useful insights to inform policy in the design and implementation of the systems to provide health care, as well as in the process of prioritizing interventions to make the best use of scarce resources. Treating a single cancer patient may require the coordination of many inputs and may cost tens or even hundreds of thousands of dollars in high-income countries (HICs). Ongoing population cancer screening and early detection also require considerable coordination, including treatment for cases detected, and costs. Finally, although knowledge of cancer prevention is inadequate, prevention can be a costly endeavor—as demonstrated by the large sums spent on behavior change promotion (such as smoking cessation) or on vaccines to prevent cancer, such as against human papilloma virus to prevent cervical cancer and hepatitis B virus to prevent liver cancer—and economics can be informative.
The second section of this chapter reviews how the availability of resources for cancer care varies by economic status, using the World Bank’s categories of low-income countries (LICs), middle-income countries (MICs) (comprising lower-middle-income countries and upper-middle-income countries), and HICs. At the same time, economy is not destiny. Countries at the same level of economic development differ because other factors intervene. Urbanization affects the patterns of cancer and the ability to access care. Local champions, governmental political leadership, and international partnerships can all loosen the constraints of local economic resources. Conversely, some countries are underachievers in cancer care despite their income level, perhaps because of leadership failures.
The third section reviews the cost-effectiveness of interventions for cancer care, where care is here defined to include prevention. The cost-effectiveness of interventions has been well studied in HICs, but much less so in low- and middle-income countries (LMICs). This section summarizes the literature on the economics of cancer care in LMICs; the section also draws on the literature from HICs, particularly for cancer treatment, in areas where reliable studies for LMICs are particularly scarce. It may be possible to make inferences for one country using results from another country; the validity of these inferences rises with the extent of the similarities in the two countries. Where possible, we separate out the findings for high-income economies in Asia, since they are likely to be more relevant for LMICs in this region than the results from North America or Western Europe.
We use the resource grouping suggested by Anderson and others (see chapter 3) for the Breast Health Global Initiative and apply this to other cancers. In this framework, facility resource environments fall into four categories of resource availability:
Basic
Limited
Enhanced
Maximal
These categories are correlated with the World Bank income groupings. LICs have a preponderance of Basic facilities, rural areas in MICs have more facilities with Limited capabilities, urban areas in MICs have more facilities with Enhanced capabilities, and much of the population in HICs has access to facilities with Maximal capabilities. The implications for the availability of resources specific to cancer care are described. This section requires some interpolation on the authors’ part because of the paucity of previous work in the area and is subject to further validation by experts.
The fourth and final section contains conclusions, consisting of summary recommendations of packages of cancer care appropriate for each of the four resource environments, as well as priority areas where further research is required. The appropriateness of a package is defined by feasibility (those resources can be expected to exist or could exist with reasonable investments) and by likely cost-effectiveness (within the limits of available data). Although there are internationally validated resource-specific care guidelines for breast cancer (the Breast Health Global Initiative), no such guidelines are available as yet for other cancers. The packages presented here have been validated in consultation with the chapter authors of this volume (chapters 3 through 8), but need to be further refined by expert consultation.
Availability of Cancer Care Resources Across Countries
Patterns of cancer vary across countries of different income levels (chapter 2 in this volume). Countries also have different capabilities for cancer care, depending on resource availability. Some of the resources for cancer care are specific to individual cancers, for example, the availability of a specific drug or test kit. Other resources are specific to cancer in general, for example, radiation therapy or the need for specialized medical personnel trained in oncology. Still others are not specific to cancer but affect many kinds of medical care, including imaging facilities, surgical facilities, pathology, and laboratory medicine services. Finally, there are broader factors that affect health care generally, such as the availability of health insurance (public, private, or mixed) and general administrative capability for the requisite health care systems.
LMICs generally have inadequate resources for health care, which conditions what is available specifically for cancer care and, hence, mortality rates. From a policy perspective, it is important to identify the priorities for investment to make maximum health gains with the available budgetary resources. We use cost-effectiveness analysis to provide some guidelines, for areas where additional recurrent expenditures would benefit care (such as buying additional drugs) and for areas where large investments in fixed costs are required (such as setting up a specialized cancer hospital).
Some resource constraints can be overcome. Even low-income Sub-Saharan African countries can acquire and maintain radiation facilities, although ensuring access for patients from remote rural areas may be difficult. It is more challenging, however, to advocate treatments that require sophisticated pathology and laboratory facilities. Such facilities are important for a wide range of medical conditions, for which cancer forms only a small percent, and they require a much larger effort and investment to set up and maintain, particularly the training of skilled personnel. It may be completely infeasible in such countries to consider certain types of organized screening if no insurance system is in place to finance the screening costs, much less the treatment of the cases diagnosed.
provides examples of availability, by income grouping, of some specific resources relevant to cancer treatment; each resource is discussed in turn. Information about the availability of radiation therapy and cancer registries is available elsewhere (and not included in the table); quantitative data on the availability of skilled personnel and laboratories are not easily obtained.
Resource Availability Affecting Cancer Care by Country Income Groups.
Surgery
Surgery is the cornerstone of treatment for many solid tumors. The level of surgical skill and associated resources required varies by type of cancer. Surgery for earlier stage colon cancer or mastectomy for early-stage breast cancer can be undertaken at reasonably well-equipped first-level hospitals. More sophisticated facilities and skills are required for such procedures as breast-conserving surgery and rectal surgery. Surgery for certain precancerous conditions may be possible at lower-level facilities; cryotherapy for cervical cancer, for example, can be undertaken in clinics. shows that HICs have more than 12 times as many operating theaters per capita as LICs (chapter 13 in this volume). Countries may face difficult choices as to how much surgical capacity to utilize for palliation for patients for whom there is no chance of cure, compared with those for whom there is the possibility of cure.
Radiotherapy
Radiotherapy is a key to improving survival for certain cancers. In Afghanistan, Iraq, and Sub-Saharan Africa, 25 countries lack any radiation unit; other countries have one unit per five million people (IAEA 2013). Clearly, the radiation unit alone is not the only constraint; sufficient trained staff members are also required. Not surprisingly, greater availability of radiotherapy is correlated with country income. Low-income countries can provide radiotherapy, but the main issue is that the capacity in many countries is completely insufficient to meet the need. Typically, facilities need, at a minimum, the Limited level of resources to be able to provide radiotherapy.
Medications
Pharmaceuticals of various kinds are vital to improve cancer survival rates, yet country income is associated with the availability of these agents. Access to tamoxifen for breast cancer is limited in LICs, as is access to pain control using oral morphine (, using survey data from WHO 2012). The case is similar for chemotherapy agents, although no quantitative data were readily available. The budget constraints in LICs and rural areas of MICs often mean that these areas can only afford the lowest cost (usually older, off-patent) regimens. In addition to the cost of the agents, chemotherapy requires multiple visits to a health facility each month to obtain the supporting blood chemistry. Facilities need the Limited level of resources to support chemotherapy, effectively restricting its use to MICs and HICs.
Some effective but modest-cost cancer medications should be available, even from Basic level facilities. As long as a single laboratory test can be undertaken per patient to determine hormone receptor status, tamoxifen can be used, even in rural areas and LICs. Pain control medication, including morphine, should be available in all environments as long as access can be controlled.
Laboratories
Laboratories are an essential component of screening, diagnosis, and treatment options. They are required for rapid, accurate results from cytology or biopsies, or from the analysis of blood chemistry for chemotherapy. These services are typically not available in Basic, or even Limited, facilities. Although it is possible to send specimens collected from rural residents to a major city, the results are often not obtained in a sufficiently timely manner to provide optimal treatment. Hence, treatments involving extensive laboratory support are often not feasible in settings without facilities with Enhanced resources, as in urban areas of MICs (see Fleming in DCP3 volume 9, Disease Control Priorities).
Cancer Registries
Cancer registries, which form the basis for understanding and documenting patterns of cancer, are a basic tool in health care service provision. In LMICs, the percentage of the population covered by a high-quality registry, such as those in the International Agency for Research on Cancer’s series on Cancer Incidence in Five Continents (Curado and others 2007), is in the single digits; this level rises to double digits in Europe; it is 80 percent or more only in Australia, New Zealand, and North America. Although it is not essential to have 100 percent population coverage, country planning and policy setting are much more difficult in the absence of a cancer registry of reasonable quality that covers at least one region.
Skilled Medical Personnel
The lack of adequate numbers of skilled medical personnel in LICs affects the ability to screen for, as well as to treat, cancer. LICs have few oncologists and oncology nurses, which limits treatment ability. Although some of the tests involved in cancer screening are often deceptively low-technology interventions (for example, Pap smears, clinical breast exams, and fecal occult blood tests), the organizational skills and infrastructure to conduct them successfully at scale and ensure appropriate referral make screening a high-technology intervention. Accordingly, organized screening programs become feasible in urban areas of MICs. Opportunistic screening, however, can occur in countries at all levels, provided that the screening test involved is not too demanding; clinical breast examination, visual inspection with acetic acid of the cervix, and the rapid DNA test for human papillomavirus (HPV) in low-resource environments are all possibilities. Campaign-style screening has been successfully used in LMICs, for example, in the Arab Republic of Egypt for breast cancer and in India for oral cancer; a rapid DNA test for cervical cancer is being piloted in low-resource provinces in China. In a campaign, the effort is made to screen a large number of the vulnerable groups in a short period of time, sometimes in local health facilities and sometimes using outreach, for example, using mobile facilities.
Health Insurance
Health insurance conditions access to all services, including treatment and screening. Individuals, who often underinvest in preventive health measures, may not see the value of paying for screening tests, particularly if they cannot afford treatment if they are subsequently diagnosed. The proportion of the population covered by health insurance typically increases with the level of development. In the poorer countries, only those people working in the formal sector or for the government may be covered; coverage in rural areas is minimal. Out-of-pocket spending on health constituted 48.1 percent of health expenditures in LICs, 52.8 percent in lower-middle income countries, 33.3 percent in upper-middle income countries, and only 13.7 percent in HICs (, using data for the most recent years available from World Bank 2013). Expansion of insurance coverage in Mexico since 2003 through Seguro Popular—the scheme that covers those working outside the formal sector—was accompanied by an increase in coverage of cervical cancer screening and a reduction in the proportion of those abandoning breast cancer treatment (Knaul and others 2012). Chapter 17 elaborates further on the role of health financing in cancer care.
Although the importance of country resource levels for the inputs required for different aspects of cancer care has been documented, some countries underperform despite relatively high levels of income. The dislocation of public health systems in the Russian Federation following the economic system change, combined with adverse risk factors that include the relatively high consumption of fat, tobacco, and alcohol, is associated with high rates of incidence as well as overall cancer mortality. For example, 25 percent of the cases of colon cancer are diagnosed at stage 4 and 33 percent of newly diagnosed patients die within a year of diagnosis (Avksentyeva 2010). Many of those diagnosed are not eligible to receive reimbursement for drugs; of those who are eligible, drug supply problems inhibit the success of treatment. A cancer registry has existed since 1939 and, in theory, screening programs exist for at least five cancers. In practice, however, the lack of resourcing and lack of political will are associated with poor outcomes in cancer care (Avksentyeva 2010).
International Partnerships
Local champions can enable countries to outperform others at similar income levels. Local champions—key individuals willing to exert their influence in advocacy and/or leadership—can draw on substantial international resources that can make a difference, whether through partnership with a single other country or hospital or through membership in international networks. Partnerships have been used extensively for pediatric cancer in particular (Sloan and Gelband 2007, chapter 7). Although international financial resources can be important in saving lives, such as the radiation facilities provided by the International Atomic Energy Authority (IAEA) to selected Sub-Saharan African countries, the true value of these resources lies in access to expertise and support for developing guidelines and systems.
Cancer care works best in the context of a national cancer plan, and political leadership and the will to provide the funding for the plan are keys. The World Health Organization reports that, although increasing numbers of countries surveyed have developed cancer plans over the past decade, many countries still have not dedicated resources to fund these plans (WHO 2012).
The role of partnerships with or membership in international networks matters at all levels, including the following examples:
For training: IAEA’s support of radiation personnel training in eight LICs and MICs through its Programme of Action for Cancer Therapy model demonstration sites project,
http://cancer.iaea.org/pmds.asp
Partnerships between institutions, such as twinning arrangements between cancer hospitals, serve a similar function.
Cost-Effectiveness
Cost-Effectiveness Methods
Cost-effectiveness methods are described in standard texts (such as Drummond and others 2005); these methods have been applied widely in LMICs for infectious disease, for example, where there are large flows of international assistance. These methods have been much less well used for cancer interventions in LMICs, with the exception of vaccines for hepatitis B (HBV) and HPV and new DNA tests for HPV.
For this volume, a systematic literature search was undertaken to identify studies from LMICs for all aspects of care for six cancers; the literature on tobacco control is addressed separately in chapter 10. The search covered English language articles contained in PubMed and EconLit from 2000 to 2013. The detailed search terms, inclusion criteria, and full table of results are available in annex 16A. The articles are also graded for quality using a checklist based on Drummond and others (2005).
Fewer than 15 articles were found for the cost-effectiveness of interventions for breast, colon, liver, oral, and pediatric cancers in LMICs—including four for HBV. In contrast, 16 articles were found that satisfied the inclusion criteria for the cost-effectiveness of vaccination and/or screening for cervical cancer. This result may reflect the fact that international funding has been available to investigate and promote the vaccines, principally through Gavi, the Vaccine Alliance. An additional six articles for breast and colon cancer were found for HICs in Asia. These six were included, since they may provide some guidance for MICs in this region.
Another reason that may explain the thin literature is that there are very few articles (whether for LMICs or HICs) on the cost-effectiveness of surgery, the cornerstone of cancer treatment. The effectiveness of basic surgery was established long before economic cost-effectiveness methods were developed and surgery became “usual care.”
Given the lack of cost-effectiveness data for LMICs, the literature from other countries might prove helpful. The literature from HICs may provide guidance and the literature from HICs in Asia may be useful for other countries in the region. The cost-effectiveness literature has to be used cautiously, since the greater the difference in context (including disease patterns, prevalence, usual care alternatives, costs, and comorbidities), the less reliable the comparison is likely to be. We utilized cost-effectiveness findings from HICs from the web appendix of Greenberg and others (2010). Greenberg and colleagues undertook a systematic review of interventions for several cancers in HICs. Their approach yielded some useful studies, primarily for breast cancer, that have relevance for LMICs.
In through , we indicate generally whether an intervention is “very cost-effective,” “cost-effective,” or “not cost-effective” in a given study. A few countries have set their own decision criteria, for example, the National Institute for Health and Care Excellence in the United Kingdom. In a comprehensive study of cost-effectiveness in Australia, Vos and others (2010) categorize interventions that cost less than US$10,000 per quality-adjusted life year (QALY) as very cost-effective; those interventions between US$10,000 and US$50,000 per QALY are cost-effective; and those over $50,000 per QALY are not cost-effective. A similar limit (US$50,000) is often used in the United States as the dividing line between what is and is not cost-effective. For countries that have not established their own threshold, the Commission on Macroeconomics and Health (2001) suggests that interventions costing less than one times the per capita gross national product per DALY averted are very cost-effective and those between one and three times per capita gross national product are cost-effective.
Breast Cancer: Summary of Feasibility and Likely Cost-Effectiveness of Interventions, by Resource Level.
Pediatric Cancer: Summary of Likely Cost-Effectiveness of Interventions, by Experience Level.
What is very cost-effective in HICs might merit consideration in LICs and what is cost-effective in HICs might be considered in MICs. This approach presupposes that the underlying model is similar, namely, the interventions are similar and the “no intervention” or “standard care” alternative scenarios are also similar, as are other key parameters. Country-specific data would be better in the future to guide policy.
The results summarized in the following section draw on the cost-effectiveness analyses in other chapters of this volume: Anderson and others (chapter 3), Denny and others (chapter 4), Sankaranarayanan and others (chapter 5), Rabeneck and others (chapter 6), Gupta and others (chapter 7), and Gelband and others (chapter 8). These analyses, in turn, utilize systematic literature surveys for the LMICs described in annex 16A.
Cost-Effectiveness Results
summarizes the specific resources likely to be available at each of the four facility environments: Basic, Limited, Enhanced, and Maximal. Cancer care feasible in facilities with Basic resources is likely to be the norm in LICs, care feasible in facilities with Limited resources predominates for the rural population in MICs, care feasible in facilities with Enhanced resources is likely to be available for urban populations in MICs, and facilities with Maximal resources are broadly available only in some HICs. Almost all countries, irrespective of income, have some facilities with Maximal resources to which a minority of the population has access or can be referred.
Cancer Care Tools in Four Resource Environments.
These resource categories are used as an organizing framework for five of the six major cancers covered. The exception is pediatric cancer, which has a similar ranking of feasibility but is determined differently. Patients with pediatric cancers, which are relatively rare, are often referred to specialized facilities. Specialized facilities with the least expertise can successfully treat a limited range of pediatric cancers; the range increases as experience grows.
through summarize by resource environment the feasibility of various interventions for the six cancers considered: breast, cervical, colorectal, liver, oral, and pediatric. The cost-effectiveness evidence is provided where it exists, along with the country context in which the data were obtained. For surgery, the cost-effectiveness data are virtually nonexistent, even for HICs, except for new techniques, such as laparoscopic surgery. Data are most abundant for pharmaceuticals, since these data are often required in HICs as part of the approval process for new drugs.
Cervical Cancer: Summary of Feasibility and Likely Cost-Effectiveness of Interventions, by Resource Level.
Colorectal Cancer: Summary of Feasibility and Cost-Effectiveness of Interventions, by Resource Level.
Liver Cancer: Summary of Feasibility and Likely Cost-Effectiveness of Interventions, by Resource Level.
Oral Cancer: Summary of Feasibility and Likely Cost-Effectiveness of Interventions, by Resource Level.
Interventions listed as options in the Basic environment are limited to those that the evidence suggests are very cost-effective in HICS or cost-effective in LMICs. The range of options is broadened a little in the Limited environment to include items that are “close to being very cost-effective” in HICs, or “possibly cost-effective in LMICs,” and the greater feasibility of radiation and chemotherapy options broadens the range for consideration.
In the Enhanced environment, more interventions are feasible because of the greater availability of resources and because a larger percent of the population is located in urban areas and able to undertake treatments that require regular visits, for example, for preoperative radiotherapy, or require more intensive follow-up, for example, for organized screening. Options that are not recommended in this environment are those that are not cost-effective even in HICs.
Finally, in the Maximal environment, an even broader range of options is available, some of which are cost-effective in those environments. Those that are currently not cost-effective—for example, some new chemotherapy agents—may well eventually become cost-effective once they no longer have patent protection.
Conclusions
Feasibility and cost-effectiveness data suggest that cancer care can and should be expanded in LMICs. summarizes the interventions, by cancer and by resource level, which are supported by feasibility and cost-effectiveness data, noting that virtually no cost-effectiveness data are available for surgery. The interventions provide suggestions to policy makers as to the sequence in which to add publicly funded interventions as country income increases, as part of a cancer plan.
Summary Recommendations Based on Feasibility and Cost-Effectiveness, by Resource Level.
suggests that LMICs have cost-effective options in cancer control. More can be done in all countries in prevention, particularly tobacco control, and expansion of HPV vaccine and DNA testing for cervical cancer, provided that the costs can be reduced sufficiently. There are methods to reduce the risk of liver cancer. The large expansion of HBV vaccination is a success story in preventing cancer.
The cost-effectiveness results suggest that a sustained expansion of cancer treatment is appropriate in all LMICs. The expansion of capacity for surgery and radiation is a priority throughout. The use of tamoxifen is feasible and cost-effective for breast cancer in LICs, and newer hormone treatments can be cost-effective in MICs. In MICs, the use of classical chemotherapy regimens for breast and cervical cancer is cost-effective; in areas where Enhanced facilities predominate. Chemotherapy can be expanded to include newer regimens for breast and cervical cancers and chemotherapy regimens for colon and oral cancers.
As treatment is scaled up, screening is more important to stage-shift treatment. LICs with largely Basic facilities are not readily able to undertake organized screening. Opportunistic screening in LICs and organized screening in MICs can help to identify cancer earlier to increase the chance of a cure. In LICs, cost-effective screening choices include clinical breast examination, visual inspection of the cervix with acetic acid, and visual inspection for oral cancer in high-prevalence countries, with rapid DNA test-and-treat for cervical cancer potentially feasible as country income increases or the cost of the test falls. Urban areas in MICs can consider mammography and fecal immunochemical testing for colon cancer, where prevalence patterns dictate. MICs can screen in rural areas for liver flukes, if prevalent.
For the common pediatric cancers, a case can be made for centralizing treatment, either in-country or in-region. Evidence suggests that many pediatric cancers can be treated cost-effectively, even in LMICs, and scale-up is feasible.
To support countries as they develop cancer plans, more work on costing is needed. Experience with other global health concerns facing LMICs (for example, HIV-AIDS and nutrition) suggests that credible estimates of total costs are important. These estimates can help to convince the international community that action is possible and may motivate the substantial mobilization of resources required. Estimating resource requirements will be a key next step for the global fight against cancer.
Further research is needed to validate the recommendations for cervical, colorectal, liver, oral, and pediatric cancer made in , including expert consultations and updating of the systematic literature reviews. The literature search was conducted only in English, but groups are undertaking cost-effectiveness studies in Brazil and China, and some literature is not yet categorized in PubMed. also does not include studies after 2007 for HICs, except for breast cancer.
It is clear that the literature on cost-effectiveness in LMICs is thin. More studies need to be done using best practice methodology, such that findings can be compared across countries. Multi-country studies with common assumptions are valuable to help identify the types of situations where a particular intervention is cost-effective. For screening, there are good multi-country studies for cervical cancer using a common model, but almost none for the other cancers. Although the WHO’s Choosing Interventions That Are Cost-Effective multi-country work has been done for cervical, breast, and colon cancer screening (for example, Ginsberg and others 2012), this needs to be updated using state-of-the-art models similar to the large ones used in HICs. Future economics work on cancer is to cost out the ingredients required for the priority interventions, such that costs of resource-appropriate care can be estimated in individual countries. This approach can help countries to plan for and mobilize the resources needed to implement a cancer plan.
Acknowledgments
The authors thank Hellen Gelband, Carol Levin, Joe Lipscomb, and Rachel Nugent for helpful suggestions on earlier drafts, and Benjamin Anderson, Craig Earle, Surendra Shastri, and Rengaswamy Sankaranarayanan for useful inputs regarding specific cancers.
Note
World Bank income classifications as of July 2014 are as follows, based on estimates of gross national income per capita for 2013:
Low-income countries: US$1,045 or less
Middle-income countries:
Lower-middle-income: US$1,046–US$4,125
Upper-middle-income: US$4,126–US$12,745
High-income countries: US$12,746 or more
References
Aballéa S, Boler A, Craig A, Wasan H. 2007. “An economic evaluation of oxaliplatin for the Adjuvant Treatment of Colon Cancer in the United Kingdom.” European Journal of Cancer
43 (11): 1687–93. [
PubMed: 17587564]
Armstrong K, Chen T M, Albert D, Randall T C, Schwartz J S. 2001. “Cost-Effectiveness of Raloxifene and Hormone Replacement Therapy in Postmenopausal Women: Impact of Breast Cancer Risk.” Obstetrics Gynecology
98 (6): 996–1003. [
PubMed: 11755544]
Avksentyeva M.
2010. “Colorectal Cancer in Russia.” European Journal of Health Economics
1: S91–S98. [
PubMed: 20012132]
Beutels P.
2001. “Economic Evaluations of Hepatitis B Immunization: A Global Review of Recent Studies (1994–2000).” Health Economics
10
751–74. [
PubMed: 11747055]
Bhakta N, Martiniuk A L C, Gupta S, Howard S C. 2013. “The Cost-Effectiveness of Treating Paediatric Cancer in Low-Income and Middle-Income Countries: A Case-Study Approach Using Acute Lymphocytic Leukaemia in Brazil and Burkitt Lymphoma in Malawi.” Archives of Disease in Children
98 (2): 155–60. [
PubMed: 23201550]
Cameron D A, Camidge D R, Oyee J, Hirsch M. 2008. “Economic Evaluation of Fulvestrant as an Extra Step in the Treatment Sequence for ER-Positive Advanced Breast Cancer.” British Journal of Cancer
99 (12): 1984–90. [
PMC free article: PMC2607221] [
PubMed: 19018261]
Campos N G, Kim J J, Castle P E, Ortendahl J, O’Shea M. others. 2012. “Health and Economic Impact of HPV 16/18 Vaccination and Cervical Cancer Screening in Eastern Africa.” International Journal of Cancer
130 (11): 2672–84. [
PMC free article: PMC3314721] [
PubMed: 21717458]
Curado M P, Edwards B, Shim H R, Storm H, Ferlay J. others, eds. 2007. Cancer Incidence in Five Continents, vol. IX. Scientific Publications 160. Lyon: International Agency for Research on Cancer.
de Lima Lopes G.
2011. “Societal Costs and Benefits of Treatment with Trastuzumab in Patients with Early HER2neu-Overexpressing Breast Cancer in Singapore.” BMC Cancer
11
178–85. [
PMC free article: PMC3118893] [
PubMed: 21586176]
de Verteuil R M, Hernández R A, Vale L. 2007. “Economic Evaluation of Laparoscopic Surgery for Colorectal Cancer.” International Journal of Technology Assessment in Health Care
23 (4): 464–72. [
PubMed: 17937835]
Dedhia R C, Smith K J, Johnson J T, Roberts M. 2011. “The Cost-Effectiveness of Community-Based Screening for Oral Cancer in High-Risk Males in the United States: A Markov Decision Analysis Approach.” Laryngoscope
121 (5): 952–60. [
PMC free article: PMC3082601] [
PubMed: 21384383]
Delea T E, Karnon J, Sofrygin O, Thomas S K, Papo N L, Barghout V. 2007. “Cost-effectiveness of Letrozole versus Tamoxifen as Initial Adjuvant Therapy in Hormone-receptor-positive Postmenopausal Women with Early-stage Breast Cancer.” Clinical Breast Cancer
7 (8): 608–18. [
PubMed: 17592673]
Desch C E, Hillner B E, Smith T J, Retchin S M. 1993. “Should the Elderly Receive Chemotherapy for Node-Negative Breast Cancer? A Cost-Effectiveness Analysis Examining Total and Active Life-Expectancy Outcomes.” Journal of Clinical Oncology
11 (4): 777–82. [
PubMed: 8478671]
Dranitsaris G, Verma S, Trudeau M. 2003. “Cost Utility Analysis of First-line Hormonal Therapy in Advanced Breast Cancer: Comparison of Two Aromatase Inhibitors to Tamoxifen.” American Journal of Clinical Oncology
26(3):289–96. [
PubMed: 12796603]
Drummond M F, Schulpher M J, Torrance G W, O’Brien D J, Stoddart G L. 2005. Methods for the Economic Evaluation of Health Care Programmes. 3rd edition. New York: Oxford University Press.
Essers B A, Seferina S C, Tjan-Heijnen V C, Severens J L, Novák A. others. 2010. “Transferability of Model-Based Economic Evaluations: The Case of Trastuzumab for the Adjuvant Treatment of HER2-Positive Early Breast Cancer in the Netherlands.” Value in Health
13 (4): 375–80. [
PubMed: 20088894]
Fonseca M, Araújo G T B, Saad E D. 2009. “Cost-Effectiveness of Anastrozole, in Comparison with Tamoxifen, in the Adjuvant Treatment of Early Breast Cancer in Brazil.” Revista Da Associação Medica Brasileira
55
410–15. [
PubMed: 19750307]
Funk L M, Weiser T G, Berry W R, Lipsitz S R, Merry A F. others. 2010. “Global Operating Theatre Distribution and Pulse Oximetry Supply: An Estimation from Reported Data.” Lancet
376 (9746): 1055–61. [
PubMed: 20598365]
Gil J M, Rubio-Terres C, Del C A, Gonzalez P, Canorea F. 2006. “Pharmacoeconomic Analysis of Adjuvant Therapy with Exemestane, Anastrozole, Letrozole or Tamoxifen in Postmenopausal Women with Operable and Estrogen Receptor-Positive Breast Cancer” Clinical Transl Oncology
8 (5): 339–48. [
PubMed: 16760009]
Ginsberg G M, Lauer J A, Zelle S, Baetan S, Baltussen R. 2012. “Cost Effectiveness of Strategies to Combat Breast, Cervical, and Colorectal Cancer in sub-Saharan Africa and South East Asia: Mathematical Modelling Study.” British Medical Journal
344: eb14. doi:10.1136/bmj.e614. [
PMC free article: PMC3292522] [
PubMed: 22389347]
Goldie S J, Gaffikin L, Goldhaber-Fiebert J D, Gordillo-Tobar A, Levin C. others. 2005. “Cost-Effectiveness of Cervical-Cancer Screening in Five Developing Countries.” New England Journal of Medicine
353
2158–68. [
PubMed: 16291985]
Greenberg D, Earle C, Fang C H, Eldar-Lissai A, Neumann P J. 2010. “When Is Cancer Care Cost-Effective? A Systematic Overview of Cost-Utility Analyses in Oncology.” Journal of the National Cancer Institute
102 (2): 82–88. [
PMC free article: PMC2808348] [
PubMed: 20056956]
Hayes J L, Hansen P. 2007. “Is Laparoscopic Colectomy for Cancer Cost-Effective Relative to Open Colectomy?” Australia and New Zealand Journal of Surgery
77 (9): 782–86. [
PubMed: 17685959]
Hedden L, O’Reilly S, Lohrisch C, Chia S, Speers C. others. 2012. “Assessing the Real-World Cost-Effectiveness of Adjuvant Trastuzumab in HER-2/neu Positive Breast Cancer.” Oncologist
17 (2): 164–71. [
PMC free article: PMC3286164] [
PubMed: 22302231]
Hillner B E, Smith T J. 1991. “Efficacy and Cost Effectiveness of Adjuvant Chemotherapy in Women with Node-Negative Breast Cancer. A Decision-Analysis Model.” New England Journal of Medicine
324 (3): 160–68. [
PubMed: 1898533]
Hillner B E, Smith T J. 1993. “Assessing the Cost Effectiveness of Adjuvant Therapies in Early Breast Cancer Using a Decision Analysis Model.” Breast Cancer Research and Treatment
25 (2): 97–105. [
PubMed: 8347850]
IAEA (International Atomic Energy Authority). 2013. “Radiotherapy Availability.” Programme of Action for Cancer Therapy (PACT), Programme Office.
http://cancer.iaea.org/agart.asp.
Ishiguro H, Kondo M, Hoshi S L, Takada M, Nakamura S. others. 2010. “Economic Evaluation of Intensive Chemotherapy with Prophylactic Granulocyte Colony-Stimulating Factor for Patients with High-Risk Early Breast Cancer in Japan.” Clinical Therapeutics
32 (2): 11–26. [
PubMed: 20206789]
Karnon J, Delea R, Johnston S R, Smith R, Brandman J, Sung J. others 2003. “Cost-effectiveness of Extended Adjuvant Letrozole in Postmenopausal Women after Adjuvant Tamoxifen Therapy: the UK Perspective. Pharmacoeconomics
24 (3): 237–50. [
PubMed: 16519546]
Kim J J, Kobus K E, Diaz M, Van Minh V, Goldie S J. 2008. “Exploring the Cost-Effectiveness of HPV Vaccination in Vietnam: Insights for Evidence-Based Cervical Cancer Prevention Policy.” Vaccine
26
4015–24. [
PubMed: 18602731]
Khlangwiset P, Wu F. 2010. “Costs and Efficacy of Public Health Interventions to Reduce Aflatoxin-induced Human Disease.” Food Additives and Contaminants Part A Chemical Analysis, Control of Exposure and Risk Assessment
27(7): 998–1014. [
PMC free article: PMC2885555] [
PubMed: 20419532]
Knaul F M, González-Pier E E, Gómez-Dantés O, García-Junco D, Arreola-Ornelas H. others. 2012. “The Quest for Universal Health Coverage: Achieving Social Protection for All in Mexico.” Lancet
350
1259–79. [
PubMed: 22901864]
Lee S Y, Jeong S H, Kim Y N, Kim J, Kang D R. others. 2009. “Cost-Effective Mammography Screening in Korea: High Incidence of Breast Cancer in Young Women.” Cancer Science
100: 1105–1111. [
PubMed: 19320639]
Levin C E, Sellors J, Shi J -F, Ma L, Qiao Y -L, Ortendahl J, O’Shea M K H, Goldie S J. 2010. “Cost-effectiveness Analysis of Cervical Cancer Prevention based on a Rapid Human Papillomavirus Screening Test in a High-Risk Region of China.” International Journal of Cancer
127
1404–11. [
PubMed: 20049838]
Liberato N L, Marchetti M, Barosi G. 2007. “Cost-Effectiveness of Adjuvant Trastuzumab in Human Epidermal Growth Factor Receptor 2-Positive Breast Cancer.” Journal of Clinical Oncology. 25(6):625–33. [
PubMed: 17308267]
Luo X Q, Ke Z Y, Huang L B, Guan X Q, Zhang Y C. others. 2009. “Improved Outcome for Chinese Children with Acute Promyelocytic Leukemia: A Comparison of Two Protocols.” Pediatric Blood and Cancer
53
325–28. [
PubMed: 19422024]
Malin J L, Keeler E, Wang C, Brook R. 2002. “Using Cost-Effectiveness Analysis to Define a Breast Cancer Benefits Package for the Uninsured.” Breast Cancer Research and Treatment
74 (2): 143–53. [
PubMed: 12186375]
Montero A J, Avancha K, Glück S, Lopes G. 2012. “A Cost-Benefit Analysis of Bevacizumab in Combination with Paclitaxel in the First-Line Treatment of Patients with Metastatic Breast Cancer.” Breast Cancer Research and Treatment
132 (2): 747–51. [
PubMed: 22200867]
Naeim A, Keeler E B. 2005. “Is Adjuvant Therapy for Older Patients with Node (-) Early Breast Cancer Cost-Effective?” Critical Reviews in Oncology/Hematology
53 (1): 81–89. [
PubMed: 15607936]
Nguyen L H, Laohasiriwong W, Stewart J F, Wright P, Nguyen Y T B, Coyte P C. 2013. “Cost-effectiveness Analysis of a Screening Program for Breast Cancer in Vietnam.” Value in Health Regional Issues
2
21–28. [
PubMed: 29702847]
Norum J, Angelsen V, Wist E, Olsen J A. 1996. “Treatment Costs in Hodgkin’s Disease: A Cost-Utility Analysis.” European Journal of Cancer
32A (9):1510–17. [
PubMed: 8911110]
Norum J, Olsen J A, Wist E A. 1997. “Lumpectomy or mastectomy? Is breast conserving surgery too expensive?” Breast Cancer Research and Treatment
45 (1): 7–14. [
PubMed: 9285112]
Okonkwo Q L, Draisma G, der Kinderen A, Brown M L, de Koning H J. 2008. “Breast Cancer Screening Policies in Developing Countries: A Cost-Effectiveness Analysis for India.” Journal of the National Cancer Institute
100 (18): 1290–1300. [
PubMed: 18780864]
Ozawa S, Mirelman A, Stacka M L, Walker D G, Levine O S. 2012. “Cost-Effectiveness and Economic Benefits of Vaccines in Low- and Middle-Income Countries: A Systematic Review.” Vaccine
31
108–96. [
PubMed: 23142307]
Park S M, Yun Y H, Kwon S. 2005. “Feasible Economic Strategies to Improve Screening Compliance for Colorectal Cancer in Korea.” World Journal of Gastroenterology
11
1587–93. [
PMC free article: PMC4305936] [
PubMed: 15786532]
Pignone M, Russell L, Wagner J. eds. 2005. Economic Models of Colorectal Cancer Screening in Average-Risk Adults. Washington, DC: National Academies Press. [
PubMed: 22379648]
Praditsitthikorn N, Teerawattananon Y, Tantivess S, Limwattananon S, Riewpaiboon A. others. 2011. “Economic Evaluation of Policy Options for Prevention and Control of Cervical Cancer in Thailand.” Pharmacoeconomics
29 (9): 781–806. [
PubMed: 21838332]
Ramsey S D, Liu Z, Boer R, Sullivan S D, Malin J. others. 2009. “Cost-Effectiveness of Primary versus Secondary Prophylaxis with Pegfilgrastim in Women with Early-Stage Breast Cancer Receiving Chemotherapy.” Value in Health
12 (2): 217–25. [
PubMed: 18673353]
Reid S.
2012. “Estimating the Burden of Disease from Unsafe Injections in India: A Cost-Benefit Assessment of the Auto-Disable Syringe in a Country with Low Blood-Borne Virus Prevalence.” Indian Journal of Community Medicine
37 (2): 89–94. doi:10.4103/0970-0218.96093. [
PMC free article: PMC3361807] [
PubMed: 22654281]
Rodgers M, Soares M, Epstein D, Yang H, Fox D. others. 2011. “Bevacizumab in Combination with a Taxane for the First-Line Treatment of HER2-Negative Metastatic Breast Cancer.” Health Technology Assessment
1
1–12. [
PubMed: 21609648]
Salomon J A, Carvalho N, Gutiérrez-Delgado C, Orozco R, Mancuso A. others. 2012. “Intervention Strategies to Reduce the Burden of Non-Communicable Diseases in Mexico: Cost Effectiveness Analysis.” British Medical Journal
344: e355. [
PMC free article: PMC3292518] [
PubMed: 22389335]
Sloan F A, Gelband H. eds. 2007. Opportunities for Cancer Control in Low- and Middle-Income Countries. Washington, DC: National Academies Press. [
PubMed: 21595106]
Smith R D, Hall J, Gurney H, Harnett P R. 1993. “A Cost-Utility Approach to the Use of 5-Fluorouracil and Levamisole as Adjuvant Chemotherapy for Dukes’ C Colonic Carcinoma.” Medical Journal of Australia
158 (5): 319–22. [
PubMed: 8474372]
Speight P M, Palmer S, Moles D R, Downer M C, Smith D H. others. 2006. “The Cost-Effectiveness of Screening for Oral Cancer in Primary Care.” Health Technology Assessment
10 (14): 1–144. [
PubMed: 16707071]
Starling N, Tilden D, White J, Cunningham D. 2007. “Cost-Effectiveness Analysis of Cetuximab/Irinotecan vs Active/Best Supportive Care for the Treatment of Metastatic Colorectal Cancer Patients Who Have Failed Previous Chemotherapy Treatment.” British Journal of Cancer
96 (2): 206–12. [
PMC free article: PMC2359988] [
PubMed: 17242694]
Subramanian S, Sankaranarayanan R, Bapat B, Somanathan T, Thomas G. others. 2009. “Cost-Effectiveness of Oral Cancer Screening: Results from a Cluster Randomized Controlled Trial in India.” Bulletin of the World Health Organization
87 (3): 200–06. [
PMC free article: PMC2654641] [
PubMed: 19377716]
Tappenden P, Jones R, Paisley S, Carroll C. 2007. “The Cost-Effectiveness of Bevacizumab in the First-Line Treatment of Metastatic Colorectal Cancer in England and Wales.” European Journal of Cancer
17 (2487): 2494. [
PubMed: 17910914]
Tsoi K K F, Ng S S M, Leung M C M, Sung J J Y. 2008. “Cost-Effectiveness Analysis on Screening for Colorectal Neoplasm and Management of Colorectal Cancer in Asia.” Alimentary Pharmacology and Therapeutics
28 (3): 353–63. [
PubMed: 18638075]
van den Brink M, van den Hout W B, Stiggelbout A M, Klein Kranenbarg E, Marijnen C A. others. 2004. “Cost-Utility Analysis of Preoperative Radiotherapy in Patients with Rectal Cancer Undergoing Total Mesorectal Excision: A Study of the Dutch Colorectal Cancer Group.” Journal of Clinical Oncology
22 (2): 244–53. [
PubMed: 14665610]
van der Meij E H, Bezemer P D, van der Waal I. 2002. “Cost-Effectiveness of Screening for the Possible Development of Cancer in Patients with Oral Lichen Planus.” Community Dentistry and Oral Epidemiology
30 (5): 342–52. [
PubMed: 12236825]
van Litsenburg R R, Uyl-de Groot C A, Raat H, Kaspers G J, Gemke R J. 2011. “Cost-Effectiveness of Treatment of Childhood Acute Lymphoblastic Leukemia with Chemotherapy Only: The Influence of New Medication and Diagnostic Technology.” Pediatric Blood and Cancer
57 (6): 1005–10. [
PubMed: 21618420]
van Vlaenderen I, Canon J L, Cocquyt V, Jerusalem G, Machiels J P. others. 2009. “Trastuzumab Treatment of Early Stage Breast Cancer Is Cost-Effective from the Perspective of the Belgian Health Care Authorities.” Acta Clinica Belgica
64 (2): 100–12. [
PubMed: 19432022]
Vos T, Carter R, Barendregt J, Mihalopoulos C, Veerman L, Magnus A, Cobiac L, Bertram M, Wallace A. 2010. Assessing Cost-Effectiveness in Prevention: Final Report. University of Queensland, Brisbane and Deakin University, Melbourne.
WHO (World Health Organization). 2012. Assessing National Capacity for the Prevention and Control of Noncommunicable Diseases: Report of the 2010 Global Survey. Geneva: WHO.
Wong I O L, Kuntz K M, Cowling B J, Lam C L K, Leung G M. 2007. “Cost Effectiveness of Mammography Screening for Chinese Women.” Cancer
110 (885): 895. [
PubMed: 17607668]
Wong S S, Leong A P K, Leong T Z. 2004. “Cost-Effectiveness Analysis of Colorectal Cancer Screening Strategies in Singapore: A Dynamic Decision Analytic Approach.” Studies in Health Technology Information
107 (Pt 1):104–10. [
PubMed: 15360784]
Wu G H -M, Wang Y -M, Yen A M -F, Wong J -M, Lai H -C. others. 2006. “Cost-Effectiveness Analysis of Colorectal Cancer Screening with Stool DNA Testing in Intermediate-Incidence Countries.” BMC Cancer
6
136–48. [
PMC free article: PMC1525200] [
PubMed: 16723013]
Yang J J, Park S K, Cho L Y, Han W, Park B. others. 2010. “Cost-Effectiveness Analysis of 5 Years of Postoperative Adjuvant Tamoxifen Therapy for Korean Women with Breast Cancer: Retrospective Cohort Study of the Korean Breast Cancer Society Database.” Clinical Therapeutics
32
1122–38. [
PubMed: 20637966]
Zelle S G, Nyarko K M, Bosu W K, Aikins M, Niëns L M. others. 2012. “Costs, Effects and Cost-Effectiveness of Breast Cancer Control in Ghana.” Tropical Medicine and International Health
17
1031–43. [
PubMed: 22809238]
