Background: Uterine cervical cancer (UCC) represents a public health problem in many part of the world. The use of new technologies is leading to increased treatment costs, resulting in a substantial economic impact worldwide. Standardization of economic evaluation methods is needed to improve comparisons between jurisdictions. Objective: To identify the methods used to measure the cost of treating invasive UCC, and to search for correlations between cancer treatment expenditures and local economies. Methods: We searched articles in MEDLINE, LILACS, and SciELO with no language restrictions, and included publications from January 01, 2007 to December 31, 2016. Studies were included if they described the annual direct cost of invasive cervical cancer and detailed the costing method. Complete economic evaluations were excluded. Results were described in 2016 international dollars. Results: Of 1581 studies initially reviewed, 13 articles were included in the analysis. Six articles used a bottom-up ; six used a top-down approach and one used both. Annual cost per patient varied from I$ 2146.22 (Poland) to 34,351.54 (Sweden). Middle-income countries (MIC) spent median 72. 52% of its GDP per capita on the treatment of invasive cervical cancer, while high-income countries (HIC) spent median 30.12% (p = 0.032). No significant difference was found when separated by costing method. Conclusions: We found that, for the treatment costs of invasive UCC, the percentages of GDP per capita were statistically higher in MIC than in HIC. However, no significant difference was found between costing methods, and the top-down approach could be used.
Uterine cervical cancer (UCC) is the fourth most common malignant neoplasia in women worldwide [
Since resources are limited, economic evaluation has emerged as an important tool in evaluating healthcare [
Costs refer to all expenditures related to an intervention, including the treatment itself, adverse effects, and acute or late complications [
The cost of an intervention can be estimated by means of a top-down (TD) or a bottom-up (BU) method. In a TD approach, an adequate population is identified and their aggregated economic or resource costs of a particular health intervention are extracted from the health services billing data. It is then adjusted by cost to charge ratios. In a BU method, estimates are obtained in a two-step process. First, the utilization frequency of individual resources is obtained, after which the frequencies are multiplied by each unit’s cost and summed to yield a total cost. A full assessment of the costs is described by some as micro costing, where details of additional costs are provided―such as the contribution of the care provided by health workers, supplies, or ancillary services [
Conducting cost description studies may be a difficult task, mainly for low and middle-income countries. Another major point of discussion is transferability of health economic data between jurisdictions; the results of cost evaluations may vary from place to place because of differences in the severity of the disease, the availability of health care resources, clinical practice patterns, and prices [
All over the world, especially in developing countries, strong economic health policies are necessary and economic evaluation studies are essential in order to identify the best action for each situation. Thus, the aim of this review is to identify the methods used to measure the cost of treating invasive UCC, and to search for correlations between cancer treatment expenditures and local economies, in articles published in the last ten years.
This systematic review incorporated studies where costing methods of invasive UCC treatment costs were described.
Studies were identified by searching MEDLINE, LILACS, and SciELO from January 01, 2007 to December 31, 2016. The search strategy included the descriptors: “uterine cervical neoplasms” or “cervical cancer” were combined with: “costs and cost analysis”, “drug costs”, “cost of illness”, “cost-benefit analysis”, “economics”, “direct service costs” and “hospital costs”. A free search was also conducted in the references of studies considered relevant. No language restriction was applied.
Studies were included if they met the following criteria: 1) was primary research; 2) described the annual direct cost of invasive UCC; and 3) described a detailed costing method. An initial selection of titles and abstracts was conducted by two independent researchers. Discordant cases were evaluated at a consensus meeting. Thereafter, articles were read in full to ensure that they met the inclusion criteria. Complete economic evaluations, which comprised “cost-effectiveness, cost-benefit, and cost-utility analysis”, were excluded.
Data were collected using a spreadsheet that contained information about the author, location, year of publication, costing method, total annual cost, and annual cost per patient. For comparison, we searched economic and demographic data referent to each country discussed in this analysis. Based on their GNI, countries were divided into MIC (between US$1026 and US$12,475) and high-income countries (HIC) (more than US$12,476) [
All costs were inflated for 2016 and then converted to 2016 International dollar (I$) using purchasing power parities (PPP) from the World Bank consumer prices (
In order to test the differences in costs between MIC and HIC, statistical analysis was done using a non-parametric Kruskal-Wallis test in STATA, version 12.1 SE. A p value < 0.05 was considered statistically significant.
This project was approved by the Ethics Committee at IMIP (document
Country | Inflation rate per year (%) | ||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|
2006 | 2007 | 2008 | 2009 | 2010 | 2011 | 2012 | 2013 | 2014 | 2015 | 2016 | |
Belgium | 4.487 | 5.345 | 8.95 | 3.044 | 3.513 | 5.000 | 3.852 | 2.784 | 2.762 | 1.595 | 1.614 |
Brazil | 4.184 | 3.637 | 5.663 | 4.886 | 5.038 | 6.636 | 5.402 | 6.202 | 6.332 | 9.028 | 8.739 |
Canada | 2.002 | 2.138 | 2.370 | 0.299 | 1.777 | 2.912 | 1.516 | 0.938 | 1.907 | 1.125 | 1.429 |
Italy | 2.070 | 1.821 | 3.375 | 0.750 | 1.540 | 2.741 | 3.041 | 1.220 | 0.241 | 0.039 | -0.100 |
Japan | 0.249 | 0.060 | 1.380 | −1.353 | −0.720 | −0.268 | −0.052 | 0.346 | 2.762 | 0.790 | −0.117 |
Mexico | 3.629 | 3.967 | 5.125 | 5.297 | 4.157 | 3.407 | 4.112 | 3.806 | 4.019 | 2.721 | 2.821 |
Morocco | 3.285 | 2.042 | 3.707 | 0.995 | 0.987 | 0.922 | 1.279 | 1.888 | 0.435 | 1.558 | 1.635 |
Poland | 1.115 | 2.388 | 4.349 | 3.826 | 2.707 | 4.258 | 3.557 | 1.034 | 0.107 | −0.991 | −0.610 |
Sweden | 1.360 | 2.212 | 3.437 | −0.494 | 1.158 | 2.961 | 0.888 | −0.044 | −0.18 | −0.047 | 0.984 |
Tunisia | 4.491 | 3.417 | 4.921 | 3.525 | 4.416 | 3.544 | 5.138 | 5.799 | 4.938 | 4.857 | 3.711 |
USA | 3.226 | 2.853 | 3.839 | −0.356 | 1.640 | 3.157 | 2.069 | 1.465 | 1.622 | 0.119 | 1.262 |
*Source: The World Bank, 2017 [
number 4026-14). As secondary published data were analyzed, no informed consent was needed.
The selection algorithm is described in
The initial search retrieved 1581 references. Among these, 1546 articles were excluded by title and another 22 were excluded because of eligibility criteria. The remaining 13 articles were included in the analysis.
The economic characteristics of the countries referred to in this review are outlined in
Ten studies used the payer perspective and included only direct costs. Four studies used the societal perspective, where direct and indirect costs were calculated. For these articles, indirect costs represented between 14.11% (only morbidity costs) and 80.50% (morbidity and mortality costs included) of the total costs. Nine studies did not name the costing method, although they detailed how costs were derived. In this review, the costing method (CM) of each article was classified into TD and BU; these methodologies were used in seven articles each, with one article using both (see
The annual per patient invasive UCC treatment cost, considering only direct costs, were inflated to the 2016 local currency and then converted to International dollar (I$). Results varied from I$2146.22 (Poland) to 34351.54 (Sweden), mean of I$16390.15 (±9566.20). For comparison, we obtained the ratio between gross domestic product (GDP) per capita (in 2016 I$) and the annual cost per
Local | GDP (2016) (USD million) [ | GDP (2016) per capita USD [ | GDP (2016) per capita I$ [ | GNI per capita in USD (2011) [ | Local currency | PPP (2016) [ |
---|---|---|---|---|---|---|
Belgium | 466365.73 | 41096.20 | 46383.20 | 47070.00 | EUR | 0.80 |
Tunisia | 42062.55 | 3688.6 | 11598.50 | 3690.00 | TND | 0.68 |
Morocco | 101445.00 | 2832.40 | 7837.90 | 3000.00 | MAD | 3.54 |
Brazil | 1796186.59 | 8649.90 | 15127.80 | 11010.00 | BRL | 1.99 |
Japan | 4939383.91 | 38894.50 | 41469.90 | 46880.00 | JPY | 102.04 |
Canada | 1529760.49 | 42157.90 | 44025.20 | 47060.00 | CND | 1.27 |
Sweden | 510999.80 | 51599.90 | 49174.90 | 55660.00 | SEK | 8.98 |
Italy | 1849970.46 | 30527.30 | 38160.70 | 37680.00 | EUR | 0.72 |
USA | 18569100.00 | 57466.80 | 57466.80 | 50460.00 | USD | 1 |
Poland | 469508.68 | 12372.40 | 27810.50 | 12900.00 | PLN | 1.75 |
Mexico | 1045998.07 | 8201.30 | 17861.60 | 9170.00 | MXN | 8.57 |
GDP: Gross Domestic Product; GNI: Gross National Income; PPP: Purchasing Power Parity; USD: United States Dollar (US$); I$: International Dollar; EUR: Euro (?; TND: Tunisian dinar; MAD: Moroccan dirham; BRL: Real (R$); JPY: Yen (¥); CND: Canadian Dollar; SEK: Swedish Krona; PLN: Zloty; MXN: Mexican Peso.
Author | Location/Year | Perspective | CM by author | CM by reviewer | Annual cost total | Indirect and total costs rate (%) |
---|---|---|---|---|---|---|
Annemans et al. [ | Belgium/2008 | Payer & Societal | NN | TD | 8.4 million - 12.3 million (total costs) 6.5 million (5.8 million - 7.9 million) (direct costs) (EUR) | 33.82 |
Ben Gobrane et al. [ | Tunisia/2009 | Payer | NN | BU | 486847.00 (EUR) | NA |
Berraho et al. [ | Morocco/2012 | Payer | NN | BU | 13589360.00 (USD) | NA |
Cheikh et al. [ | Morocco/2016 | Payer | Micro-costing | BU & TD | 1429673.00 (USD) | NA |
Fonseca et al. [ | Roraima (Brazil)/2010 | Payer | NN | BU | 609782.00 (BRL) | NA |
Hayata et al. [ | Japan/2015 | Societal | Cost of illness | TD | 159000000000.00 (total costs) 31000000000.00 (direct costs) (JPY) | 80.50 |
Liu et al. [ | Ontario (Canada)/2016 | Payer | Cost of illness | BU | 62888000.00 (CND)# | NA |
Novaes et al. [ | Brazil/2015 | Societal | Gross-costing | TD | 82768409.00 (total costs) 71086509.00 (direct costs) (USD) | 14.11 |
Östensson et al. [ | Sweden/2015 | Societal | NN | TD | 15830004.00 (total costs) 12220541.00 (direct costs) (EUR) | 22.80 |
Ricciardi et al. [ | Italy/2009 | Payer | NN | BU | 19210075.00 (EUR) | NA |
Insinga et al. [ | USA/2008 | Payer | NN | TD | 129038950.00 (USD)# | NA |
Holecki et al. [ | Poland/2015 | Payer | NN | TD | 8766547.00 (PLN) | NA |
Sanchez-Roman et al. [ | Mexico/2012 | Payer | NN | BU | 5190800.00 (MXN) | NA |
CM: Costing Method; NN: Not Named; TD: Top-Down; EUR: Euro; BU: Bottom-Up; NA: Not Applicable; USD: United States Dollars; JPY: Yen; CND: Canadian Dollar; PLN: Zloty; MXN: Mexican Peso. #Not described in the article, value calculated by this reviewer based on data in the article.
patient, results ranged from 7.71% to 241.63% (median 61.36%). Final costs are outlined in
Based on 2011 per capita GNI, Tunisia, Morocco, Brazil, and Mexico are defined as MIC by the World Bank [
However, when separated by costing method, no difference was found (p = 0.522) (
This review compared results by relating the adjusted cost of invasive UCC in 2016 I$ in different countries with each country’s GDP per capita, thus accommodating for the huge economic differences across jurisdictions.
Most studies used the payer perspective, where only direct costs were included. Indirect costs were described when the societal perspective was used.
Local/Year | Annual cost per patient extracted in the article | Annual cost per patient in local currency inflated to 2016 | GDP per capita I$ 2016 [ | Annual cost per patient in 2016 I$ | ICC treatment cost and GDP rate (%) |
---|---|---|---|---|---|
Belgium/2008 | 9716.00 (EUR) | 14777.35 (EUR) | 46383.20 | 18471.69 | 39.82 |
Tunisia/2009 | 1766.00 (EUR) | 5120.71 (TND) | 11598.50 | 7530.45 | 64.93 |
Morocco/2012 | 6899.91(EUR)* | 67043.51 (MAD) | 7837.90 | 18938.84 | 241.63 |
Morocco/2016 | 2599.00 (USD) | 25022.68 (MAD) | 7837.90 | 7068.55 | 90.18 |
Roraima (Brazil)/2010 | 8711.00 (BRL) | 14441.25 (BRL) | 15127.80 | 7256.91 | 47.97 |
Japan/2015 | 3165203.19 (JPY) | 3275312.27 (JPY) | 41469.90 | 32098.32 | 77.40 |
Ontario (Canada)/2016 | 15722.00 (CND) | 16839.21 (CND) | 44025.20 | 13259.22 | 30.12 |
Brazil/2015 | 4559.75 (USD)* | 18472.94 (BRL) | 15127.80 | 9282.88 | 61.36 |
Sweden/2013 | 27710.98 (EUR)* | 308476.87 (SEK) | 49174.90 | 34351.54 | 69.86 |
Italy/2009 | 6536.06 (EUR) | 7177.92 (EUR) | 38160.70 | 9969.33 | 26.12 |
USA/2008 | 11573.00 (USD) | 15441.89 (USD) | 57466.80 | 15441.89 | 26.87 |
Poland/2015 | 3408.46 (PLN)* | 3755.88 (PLN) | 27810.50 | 2146.22 | 7.72 |
Mexico/2012 | 91064.00 (MXN) | 122624.74 (MXN) | 17861.60 | 14308.60 | 80.11 |
*Not explicit in the article; data were calculated by the reviewer using data from the article. GDP: Gross Domestic Product; GNI: Gross National Income; PPP: Purchasing Power Parity; USD: United States Dollar (US$); I$: International Dollar; EUR: Euro (?; TND: Tunisian Dinar; MAD: Moroccan Dirham; BRL: Real (R$); JPY: Yen (¥); CND: Canadian Dollar; SEK: Swedish Krona; PLN: Zloty; MXN: Mexican Peso.
Although the societal perspective has the stronger claim to be the basis for comparison across studies [
We found no significant difference in the results derived by different costing methods. Actually, most articles did not name the costing method. However, they did describe how costs were calculated, and could therefore be separated into studies using TD and BU methods. Although BU is the theoretically correct way to estimate service cost, this approach may not be practical in all cases; the resources required for the BU costing could outweigh the benefit of more accurate costing [
In this review, MIC had a relatively higher expenditure as percentage of per capita GDP than HIC on the treatment of invasive UCC. This is in some respects different from what was demonstrated in earlier studies, where Latin America spent 7.7% of its GDP on health, while the USA and Canada spent approximately 18% and 12%, respectively [
This study has limitations. First, only four studies specified that the treatment costs were related to the first year after diagnosis. It has been demonstrated that costs may change depending on the time since diagnosis, and costs are the lowest in the period between the initial and end-of-life phase, following a “U-shaped” curve [
However, because all costs were adjusted to one common currency and correlated to each country’s GDP, we were able to determine the cost of invasive UCC treatment relative to the health budget of each evaluated country. Economic evaluations are important tools to guide decision makers with respect to appropriate resource allocation. The methodology of these studies is heterogeneous, but forms of equivalency should always be sought.
Although we recognize many caveats, this is to our knowledge the only study that has tried to determine a parallel between invasive UCC treatment costs across different regions. The intent is that this would contribute to the continued efforts of policy makers to standardize and develop reproducible economic studies, especially in low and middle-income counties.
We found that, for the treatment costs of invasive UCC, the percentages of GDP per capita were statistically higher in MIC than in HIC. However, no significant difference was found between costing methods, and the top-down approach could be used.
The authors declare no conflicts of interest regarding the publication of this paper.
de Araújo Lima Santos, C.A., Souza, A.I. and Vidal, S.A. (2019) Techniques for Determining the Treatment Costs of Cervical Cancer: A Systematic Review. Open Journal of Obstetrics and Gynecology, 9, 117-128. https://doi.org/10.4236/ojog.2019.92012