EPICOST breast cancer
Patterns of care and cost profles of women with breast cancer in Italy: EPICOST study based on real world data
This paper represents the first attempt in Italy to estimate the economic burden of cancer at population level taking into account the entire disease pathway and using multiple current health care databases. A combination of cross-sectional approach and a threephase of care decomposition model with initial, continuing and fnal phases-of-care defned according to time occurred since diagnosis and disease outcome is adopted. Direct estimation of cancer-related costs is obtained.
This study involved 8 population-based cancer registries (CRs) with at least 8 years of registration: (3 out of 21 Local Health Units of) Veneto, Friuli Venezia Giulia (FVG) and Milano in Northern Italy; Umbria, Firenze-Prato (Fi-Prato) and Latina in Central Italy; Napoli and Palermo in Southern Italy. These CRs belong to eight diferent regions and overall they cover about 5.3 million subjects, corresponding to 17% of the Italian female population. The study cohort is cross-sectional and included women diagnosed with malignant breast cancer (ICD-X C50). Each CR contributes to the study with patients who have been diagnosed in the 8 years prior to prevalence date, who are still alive on prevalence date (prevalence cohort). The CRs entered the study with the most up-to-date data at the time of case extraction: dates of prevalence span between January 1st 2009 and January 1st 2013.
Data on patients provided by CR are linked at individual level with data on health-care services and corresponding claims from administrative databases.
Each patient contributed to the study with a 12-month time interval and we defned three mutually exclusive phases of care: initial (the frst 12 months following diagnosis), continuing (the time between the initial and the fnal phase of care) and fnal (the fnal 12 months of life).
Costs were expressed in Euros and were defned as the direct expenditure paid by the Regional Health Authority to the health care providers (hospitals, ambulatories, pharmacies) as reimbursement of the services provided to a breast cancer patient. These costs are computed by phase of care and/or by type of health care service
42% of the resources were absorbed by patients in the initial phase of care, 44% of the resources for patients in the continuous phase and 14% of the resources in the last year of life.
Hospitalization was the most important cost factor, especially in the initial phase, accounting for over 55% of total costs followed by outpatient services (29%) and pharmaceutical costs (16%).
The following figures illustrate the monthly cost profiles (in euros) by type of health service in the group of CRs selected. The vertical axis represents the patient's (a) and outpatient (b) monthly hospitalization costs. The horizontal axis represents time in months, in each phase of the cure: Initial phase (12 months from diagnosis), Continuous (time between initial and final), Final (last 12 months before death for cancer).
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The results, confirmed by the literature [Mariotto, A.B. et al., Natl Cancer Inst. 2011; Laudicella, M. et al., Br J Cancer 2016; Yabroff, KRet al., Natl Cancer Inst 2008], show that costs are not evenly distributed along the disease path, but follow a U-shape with higher costs concentrated in the first months, when diagnosis and treatment are provided of the main therapeutic path, and in the last year of life, when palliative care is provided.
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Outpatient costs were on average higher in the first and last stages of treatment. This trend seems consistent with the care pathway: diagnostic tests are administered in the clinic in the first month, followed by surgery in the hospital and subsequently by chemotherapy in the clinic.
At the aggregate level, 80% of patients are in the continuous phase and their total annual costs represent 44% of the total expenditure. This percentage is expected to increase, as the prevalence of breast cancer is rapidly increasing in Italy [Guzzinati, S., BMC Cancer 2018].
The stage at diagnosis is the main determinant of the annual cost, albeit with rather variable discrepancies between RT: advanced patients (III and IV) absorb on average about 10,000 euros compared to patients diagnosed with low stage (I and II) who absorb between 6000 and 7800 euros. The Epicost study confirms the economic benefit of early detection of breast cancer, therefore suggests supportive measures to increase the spread and adherence to organized screening programs, especially aimed at women residing in the southern regions.
In the initial phase, elderly patients absorb half of the total costs and 1/5 in the last year of life compared to younger patients. These findings are likely due to different clinical approaches: young patients tolerate more aggressive (and more expensive) treatments better and are more likely to survive longer if treated aggressively than older patients who are more comorbid and likely needy. nursing care, the costs of which were not included in our data.
This approach can be used by health care managers to forecast breast cancer burden in the near future according to specific interventions and corresponding scenarios. The analysis model proposed here is replicable to Italian regions and other countries with different health conditions and health care systems, provided that individual health and administrative information is available.
For example, in the ongoing European Commission funded innovative partnership for action against cancer (iPAAC), the methodology has been proposed for application to other European countries, such as Belgium, Spain, Norway and Poland (WP7 iPAAC).
Written by Sandra Mallone CNaPPS - Istituto Superiore Sanità