Economic Evaluations of Breast Cancer Care in Low- and Middle-Income Countries: A Scoping Review

Abstract

Background. Understanding the cost of delivering breast cancer (BC) care in low-and middle-income countries (LMICs) is critical to guide effective care delivery strategies. This scoping review summarizes the scope of literature on the costs of BC care in LMICs and characterizes the methodological approaches of these economic evaluations. Materials and Methods. A systematic literature search was performed in five databases and gray literature up to March 2020. Studies were screened to identify original articles that included a cost outcome for BC diagnosis or treatment in an LMIC. Two independent reviewers assessed articles for eligibility. Data related to study characteristics and methodology were extracted. Study quality was assessed using the Drummond et al. checklist.Results. Ninety-one articles across 38 countries were included. The majority (73%) of studies were published between 2013 and 2020. Low-income countries (2%) and countries in Sub-Saharan Africa (9%) were grossly underrepresented. The majority of studies (60%) used a health care system perspective. Time horizon was not reported in 30 studies (33%). Of the 33 studies that estimated the cost of multiple steps in the BC care pathway, the majority (73%) were of high quality, but studies varied in their inclusion of nonmedical direct and indirect costs. Conclusion.There has been substantial growth in the number of BC economic evaluations in LMICs in the past decade, but there remain limited data from low-income countries, especially those in Sub-Saharan Africa. BC economic evaluations should be prioritized in these countries. Use of existing frameworks for economic evaluations may help achieve comparable, transparent costing analyses. The Oncologist 2021;26:1-12 Implications for Practice: There has been substantial growth in the number of breast cancer economic evaluations in lowand middle-income countries (LMICs) in the past decade, but there remain limited data from low-income countries. Breast cancer economic evaluations should be prioritized in low-income countries and in Sub-Saharan Africa. Researchers should strive to use and report a costing perspective and time horizon that captures all costs relevant to the study objective, including those such as direct nonmedical and indirect costs. Use of existing frameworks for economic evaluations in LMICs may help achieve comparable, transparent costing analyses in order to guide breast cancer control strategies.

Economic Perspective of Cancer Care and Its Consequences for Vulnerable Groups

“…However, the published evidence targeting the economic perspective of LMICs is biased towards costs incurred by the healthcare sector, and direct nonmedical as well as indirect costs were often not included [52]. Therefore, transferring results between countries is critical, but a loss of available income due to cancer seems to be a worldwide thread and important disease-related financial risks for these patients [14].…”

“…These differences in diagnostic and treatment options, as determined by the given economic framework, are not limited to clinical availability but are furthermore related to participation in clinical research and access to innovation, respectively, due to financial limitations in these countries [95,96]. For example, in evaluations of breast cancer care, LMICs (2%) and Sub-Saharan Africa (9%) were grossly underrepresented [52]. However, access or acceptance bias in clinical research is also an issue in industrial countries, and vulnerable groups are likely disproportionately represented in cancer trials, resulting in severe selection as well as methodological bias.…”

Breast cancer molecular diagnostics in Rwanda: a cost-minimization study of immunohistochemistry versus a novel GeneXpert® mRNA expression assay

“… 15 Moreover, robust costing data for breast cancer diagnosis are lacking in sub-Saharan Africa, including for biomarker analysis; in a recent scoping review of breast cancer costing studies in low- and middle-income countries, only two studies were identified from sub-Saharan Africa. 16 These studies (from Kenya and Nigeria) only reported costs of histopathology, but not biomarker analysis. 17 , 18 A cost comparison of breast cancer biomarker analysis with STRAT4 and with immunochemistry could help to quantify the impact of STRAT4 adoption on hospital and government budgets.…”

Improving Adherence to Adjuvant Endocrine Therapy in Sub-Saharan Africa: Challenges and Innovative Nurse-Driven Solutions

“…Systematic assessment of intervention costs and cost-effectiveness compared with usual care are also important components that need to be incorporated into future trial, both to identify high-value components of intervention as well as to enhance the likelihood of uptake by care systems and policy makers. 19 …”