Estimating the Cancer Treatment Cost for 5 Common Types of Cancer with Separating Out-of-Pocket and Governmental Costs in Afghanistan, 2020

Dear Editor

The recently published article (Rohani et al., 2022) estimated the government and out-of-pocket treatment costs for five cancers (breast, esophagus, colorectal, stomach, and lung) in Afghanistan. We argue that some of the statements and findings expressed in this article are not consistent with the literature of the Ministry of Public Health (MoPH), nor is the methodology adequate to correctly measure the various components of treatment cost.

This article reported the out-of-pocket cost of cancer treatment as 13.97% (82,537.66) while the National Health Accounts (NHA) has consistently reported the out-of-pocket cost in health sector as more than 70% (National Health Accounts 2018, 2019). One of the reasons for this significant difference could be the inadequate use of the research methodology and inaccurate analysis of cost and expenses of various cancer care services in this study.

For example, the article mentioned that except for CT scan, MRI, and mammography, other services (Figure 3) were provided for free by the Cancer Center in Jamhuriat Hospital. Even though chemotherapy was administered for free, the National Cancer Control Program (NCCP) had not procured chemotherapeutic drugs but patients bought from pharmacies. Similarly, limited sonography services were provided to female patients only. Moreover, though the article mentioned the cost of biopsy procedure, it did not include the cost of cyto-histopathology examination. Therefore, if the costs of CT scan, MRI, mammography, and chemotherapy are added together, without even including the cost of cyto-histology and sonography, the out-of-pocket cost will increase from 13.9% to 43%.

Furthermore, the article mentioned that 2,180 patients were registered with the Cancer Center in 2020. Based on the Center’s report, however, 16,058 visits/consultations were recorded in 2020. Those consultations resulted in the admission of 3,200 patients to the medical and surgical oncology wards (IPD) and admission of 2,180 patients in the day-care unit (OPD). It is very likely that the article has analyzed only these 2,180 patients that were treated in the day-care unit while overlooking the other 3,200 patients from the IPD.

Also, the article stated that the possible causes of increased cancer prevalence were lack of awareness, late diagnosis, lack of access to medical services, and lack of financial resources. However, most of these factors are not associated with the increase in prevalence or incidence of cancer. These factors contribute to late diagnosis and subsequently premature deaths of cancer patients. In fact, the referenced article (Bhandari et al., 2021) implied that most of those factors were associated with low breast cancer screening intentions.

Besides, the article provided detailed information about the educational status of patients, and listed the educational status of patients into six groups such as two patients had master’s, 18 patients had bachelor’s, 12 patients graduated from 12th grade, one person each had primary and secondary level education, and 735 (96%) patients had no education (illiterate). How did the study acquire information on the educational status of these patients when the patients’ files at the Cancer Center do not contain such data?

Moreover, the article misidentified the Afghanistan Cancer Foundation (ACF) as Action Against Cancer Foundation. In the same paragraph, some other information is either incorrect or outdated. For example, the article stated that the NCCP was established in 2016 in Jamhuriat Hospital as Cancer Diagnosis and Treatment Project (CDTP). In fact, the CDTP and the NCCP were established in the MoPH in 2016 and 2017 respectively. On the other hand, it was the Cancer Center which was set up in Jamhuriat Hospital in 2016 by the CDTP.

Last but not least, the article mentioned that the study’s ethical approval was taken from the Afghanistan National Charity Organization for Special Diseases (ANCOSD), which is a small non-government organization (NGO). Based on the Ministry of Public Health’s regulations, the Institutional Review Board (IRB) of Afghanistan National Public Health Institute (ANPHI) has the authority to approve biomedical research proposals. Even though the Ministry of Higher Education and Kabul University have their respective IRBs, they are limited to the research work in their own institutions (Health Research Policy, 2012). Therefore, even they are not in a position to give approval to such research.

Given the above stated reasons, the article needs to be corrected. A well-designed and well-executed research is crucial to find out the economic cost of cancer, especially the catastrophic out-of-pocket cost of cancer treatment in Afghanistan.