The Costs of Cancer
Each year 27,000 new cases of cancer are diagnosed in Finland, divided roughly evenly between the sexes. The most common form of cancer among women is breast cancer. Among men it is prostate cancer. The number of cancers is about twice that of the 1960s. The age level of the onset of most cancers has not however changed so dramatically. What has changed is the prevalence of different cancers. Stomach, cancers of the oesophagus, lip and throat have declined overall. Lung cancer among men has declined due to the drop in smoking, while among women it has increased from the opposite reason. The increase in the prevalence of prostate and bladder cancer among men is in part due to improved diagnostics. Among women breast cancer has steadily become more prevalent, as have skin melanomas and cancers of the central nervous system.
It is reckoned that in 2015 there will be 30,000 new cancer cases a year. Cancer trends are expected to follow those already recognised, with intestinal cancers, lymphomas and brain and central nervous system tumours increasing among men and women. Breast cancer in women and prostate cancer in men is expected to continue to increase so that by 2015 they comprise over a third of all new cases of cancer. The increased prevalence of cancer is almost wholly linked to population ageing. A second main factor of change is the shift in people’s lifestyles, with the drop in smoking being the clearest example in the fall in smoking related cancers. But while the prevalence of cancer is being found to increase each year, the death rate has declined by about a third than it was in the 1950s. This is due to more accurate and timely diagnostics and the tremendous developments in treatment in recent decades. At the same time, cancers with poor prognoses have tended to diminish whereas those with good prognoses have prevailed. This means that increasingly more people survive cancer even though the disease has become more usual.
The costs incurred by cancer overall can be split into three groups: healthcare costs, productivity costs and out-of-pocket costs, or the expenses patients have to shoulder themselves. In practice, there are other groups of costs, such as direct and indirect ones and psychosocial costs. Direct costs include prevention, diagnostics, treatment, rehabilitation and costs accompanying healthcare resources and other expenses related directly to cancer and its treatment. These also comprise such things as patients’ travel expenses, home renovation costs or even those of moving home, as well as home or family care. Indirect costs are incurred by the time taken up by treatment, lower productivity due to diminished working capacity, sick leave, early retirement and premature death.
Psychosocial costs are to do with the weakened quality of life and its consequences due to cancer, and include such things as dealing with pain, having to relocate, limited functional capacity, social exclusion, depression and anxiety. These are hard to put into financial costs, which means that they are excluded from much cost research. This report considers the calculation of cancer treatment costs for the healthcare system, which means inpatient and outpatient costs, drug reimbursements, rehabilitation and screening. It also considers productivity costs, meaning absenteeism due to illness and work disability pensions. Costs borne by patients are not covered because of the lack of reliable data.
Cancer patients use healthcare services more than other patients, though this varies greatly among the types of cancers involved. Chang et al (2004, 3526) estimate that cancer patients use on average 4.1 outpatient visits and 3.5 hospital ward days more non-cancer patients. Cancer treatment costs are highest immediately after diagnosis as well as shortly before death. The costs between these two points are fairly low. Estimates of overall cancer treatment costs for one patient are about 30,000€. Some 86% of treatment costs cover inpatient care, while outpatient care make up 14%. Sasser et al (2005) estimate that the healthcare costs for one breast cancer patient amount to nearly 14,000 USD.
Cancer impacts in many ways on patients’ ability to work. In addition to the disease, its treatment can be debilitating, undermining working capacity and on top of that treatment and recovery take up time. Chang et al (2004, 3527) find that cancer patients are off work many times more than non-cancer patients, on average 5.2 days a month compared to 0.2 days. Breast cancer patients have 2.7 times more sickness absenteeism compared to others in their age groups. The family members of cancer patients also have to take more days off work than others. There are also costs in time due to waiting for treatment and transportation, for instance amounting to a fifth of the cost the treatment of intestinal cancer in the initial phase (4,500 USD) and two fifths of the final stage (2,800 USD), according to one study. Resources used in rehabilitative care have only been sparsely researched.
Research on the costs of cancer for 1996-2004 is based on data drawn from different registers, and the report presents information from different sub-regions and sources. In 2004 cancer costs were over 520€ million and the figure for 1996 was 330€ million, a 60% increase. The average cost increase per hospital bed was about 6%. Inpatient care accounts for the majority of costs, though the proportion of this gets smaller over the period covered. In 1996 inpatient care was 50% of all costs and in 2004 about 45%. Over the same period outpatient care increased from 16% to 20% of overall costs. Working incapacity and sickness benefit comprised about a fifth of all cancer costs and they increased in similar proportion to overall costs. Rehabilitation accounted for the smallest portion of costs, less than 1%. Screening costs amounted to just over 2%.
The impact on costs in the future depends greatly on how the prevalence of cancer develops. In 2004 there were 25,661 new cases of the disease. The forecast for 2015 is 30,199, an 18% increase. The report bases its parameter on those cancers diagnosed within the last five years. This predicts a 35% increase by 2015.
The diagnosis of cancer is developing quickly, especially in the use of imaging. Computer tomography and magnetic imaging are more widely used in detecting tumours and determining the health of the tissue surrounding them. The use of PET as a clinical instrument started to increase at the end of the last century. The development of digital technology enables accurate definition of tumours without over encumbering patients. Examination methods are nevertheless expensive, so their use should be linked to correct patient selection. Screening technology is nowadays able to determine tumour development more exactly, instead of only diagnoses as in the past.
Operations are nowadays increasingly less invasive, but their cost has not been properly researched. Research is being carried out on cryotherapy in treating prostate cancer to avoid removing the entire gland. The development of robotics will enable fully automated surgery that will better preserve surrounding tissue. The expenses incurred by more intricate surgical equipment and disposable instruments in the future will devolve increasingly on service supply.
With new technology areas of the body that need treating can be defined three-dimensionally, enabling increasingly more accurate treatment plans. Radiotherapy technology allows for pinpoint accuracy and the intensity of rays can be altered during treatment. Advances in molecular biology allow for the faster synthesis of drug combinations especially to affect the deviant molecular mechanisms of cancer cells. 2005-2010 is reckoned to be a crucial time for research in molecular biology. Other promising treatments include antiangiogenic treatment and gene therapy. The former concerns drugs that prevent the growth of blood vessels, the first of which are now in use.
New diagnostic and treatment methods enable the earlier start to treatment and impact favourably on the costs associated with diminished working capacity by patients. Long periods of sick leave or early retirement need not in the future be the necessary for the majority of cancer patients. Screening is being used in an effort to reduce the cancer death rate, for instance with the mass screening for colorectal cancer started in some municipalities in Finland in 2004. The aim is to expand such screening by 2015 to all people between the ages of 60-69.
The aim of healthcare is to combine cancer treatment and its related support treatment in a more integrated manner that is holistic and patient-centred. There will also be more emphasis in the future on parallel treatment and care. Experts forecast that the treatment of cancer will be given more emphasis in primary outpatient healthcare. Outpatient treatment is increasing, in particular in radiotherapy and chemotherapy, and the overall increase in outpatient treatment, both in primary healthcare and hospital care, is expected to double by 2015. The cost of drugs and new technology will also inevitably rise.
Using different models for cost prediction, experts estimate that the overall annual cost increase of cancer will by 2015 reach 1,028€ million. The maximum scenario envisages an annual increase to about 1.5€ billion. This is based on the exponential model that assumes that costs will increase each year by a percentage that will vary only slightly. The basic, regression model, envisages an increase to about 850€ million. The accuracy of the expert’s model posited in the report hinges in part on the attention given to new drugs and methods of treatment.