Abstract
Introduction
Breast cancer is an evolving non-communicable disease and a global disease burden, which accounts for a momentous portion of worldwide mortality and morbidity with significant economic impacts. In low- and middle-income countries like Ethiopia, the most common problem with cancer treatment is scarcity of medical resources, and financial supply, for providing care, which includes expensive medical costs, cost of service provision, and medical equipment. In Ethiopia, the cost of breast cancer care increased and imposed an enormous financial burden on healthcare providers and the healthcare system. The study aimed to estimate the annual total direct medical cost of breast cancer and identify the cost drivers of breast cancer treatment at Jimma University Medical Center (JUMC).
Methods
A facility-based retrospective medical record review was employed using the provider’s perspective. Both mixed bottoms-up and top-down costing approaches were used to estimate the cost. Medical records of 130 breast cancer patients who were diagnosed between September 2022 and August 2023 were reviewed retrospectively.
Results
The mean age of patients was 41.9 (SD + 10.4) years. The total direct medical cost incurred at the hospital per patient to treat breast cancer across all stages was US$24,727 at JUMC. The total median cost per patient at the hospital to treat breast cancer at stages I, II, III, and IV could have been US$218.6, US$638.7, US$846.2, and US$753.4 respectively. At JUMC, the major cost drivers were the cost of drugs for chemotherapy accounts for 47.2%, followed by laboratory tests at 14.8%, and radiotherapy at 14.2%.
Conclusion
The hospital’s direct medical costs associated with breast cancer disease were extensive. The highest medical cost was incurred in stage III of the disease. The main cost drivers at JUMC were drugs for chemotherapy, laboratory tests, and radiotherapy (radiologic imaging) added higher direct medical costs followed by surgery and pathology. The stage-specific cost analysis study focused on cost identification and valuation that provides profound information related to the estimation of direct medical cost, and the main cost drivers of the disease, and helps to encourage the treatment and diagnosis of breast cancer at an early stage of the disease.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12962-025-00666-0.
Keywords: Direct medical cost, Breast cancer, Stage-specific, Retrospective analysis, Chemotherapy, JUMC, Ethiopia
Introduction
Breast cancer is a disease in which abnormal breast cells grow out of control and form tumors. It is a common type of cancer among women, although men can get the disease too, also, it is one of the leading causes of death worldwide. If left unchecked, the tumor can spread throughout the body and become fatal [1]. Breast cancer is an evolving non-communicable disease and a global disease burden, which accounts for a significant portion of mortality and morbidity worldwide with important economic impacts [2].
Globally, in 2020 there were 2.3 million women diagnosed and 685,000 died due to breast cancer. It disproportionately affects individuals in low- and middle-income countries. As of the end of 2020, there were 7.8 million women alive who were diagnosed with breast cancer in the past 5 years, making it the world’s most prevalent cancer [3].
Breast cancer is the leading diagnosed cancer and the second most common cause of cancer-related mortality in sub-Saharan African countries [4, 5]. The burden of cancer has increased in Sub-Saharan Africa (SSA), cancer death and incidence are rapidly increasing in the region, and cancer deaths are expected to rise by 77% between 2010 and 2030. In Ethiopia, breast cancer accounts for 30.2% of all cases, followed by cervical, 13.4%, and colorectal cancer (5.7%). The country’s annual cancer incidence is estimated to be around 60,960 cases, with an annual mortality of over 44,000 [5].
The major predictor of the cost of breast cancer treatment and resource utilization is the stage at which a breast cancer diagnosis is considered. Patients at the advanced stage need more intensive treatment and considerably higher consumption of health care resources and subsequently, higher costs associated with an early stage of breast cancer [6, 10]. At the initial stage, the disease is confined to a single organ, for which spreading prospects can be minimized through early treatment and reducing the cost of treatment. Since the treatment cost at later stages is considerably higher than the initial stages, various medical experts suggest that earlier diagnosis minimizes the issue related to health and financial resources [6].
In SSA countries, approximately 80% of breast cancer cases are detected at a late stage (stage III or IV), compared to 15% in developed countries. While choosing a treatment plan, the type of breast cancer and its stage should be considered. Consequently, studies from underdeveloped countries reported that stage I and II have 5-year survival rates of 90% and 65%, whereas stages III and IV have rates of only 33% and 6% respectively (8). The Five-Year National Cancer Control Plan of Ethiopia (2015–2020) indicated a need for US$ 93 million for activities related to cancer prevention, screening, diagnosis, and treatment [7, 11].
Methods and materials
Study area and setting
The study was conducted at Jimma University Medical Center (JUMC) and a medical record review was undertaken from April 25 to May 30, 2024. JUMC is found in Jimma City, Oromia state, southwest Ethiopia. Jimma town is located about 347 km, southwest of the center, Finfinnee. JUMC is one of the five teaching referral hospitals with a breast cancer oncology unit. The hospital serves as the only teaching and referral, government-owned hospital in southwest Ethiopia. In Ethiopia, a cancer treatment center was established in five teaching referral hospitals and JUMC is one of the national cancer control and treatment centers [13].
Study design
A facility-based retrospective medical record review was employed using the provider’s perspective.to estimate the annual total direct medical cost of breast cancer treatment using the provider’s perspective in the breast Cancer oncology unit at Jimma University Medical Center (JUMC). Both mixed bottoms-up and top-down costing approaches were used to calculate and estimate the unit and direct total cost of breast cancer at JUMC.
Cost estimation
A one-year retrospective selection of breast cancer patient’s medical records was used to obtain cost data from prescriptions and bills solely to extract the number of resources used to collect the number of laboratory tests, days of hospitalization, number of chemotherapy cycles from prescriptions whereas, the unit costs were obtained from JUMC finance office or administrative departments.
To estimate drug costs for chemotherapy, price lists were obtained from the pharmacy department at JUMC. In-patient hospitalization costs were calculated by identifying the duration of the patient’s hospitalization, the disease stage, and the allocated ward they stayed. Then, the finance and accounting departments were contacted to gather the patient’s financial records.
Hospitalization costs were estimated by multiplying the number of days with the per-day cost in the related ward. The cost of each patient’s surgery was also obtained from the finance and accounting department. Similarly, the list of prices for laboratory tests and radiology imaging (including X-ray and CT scans) was obtained through the laboratory and radiation departments. The cost of radiation therapy was further identified for each stage of breast cancer by the financial department, which helped to calculate the cost per patient by multiplying the number of radiotherapy sessions by the cost per session for each patient.
Valuation of cost items
Cost items can be valued using two approaches: the top-down or bottom-up costing method. The top-down approach relies on comprehensive sources, such as annual financial accounts, and divides aggregated costs by the total number of patients. Annual hospital expenditures on breast cancer prevention care drugs divided by the number of breast cancer prevention care patients leads to a cost estimate of drugs for the average patient. Bottom-up micro-costing requires patient utilization data such as the cost of drugs, surgery, radiotherapy, chemotherapy, and laboratory tests to be multiplied by unit prices, providing cost estimates for individual patients.
The top-down, or gross-costing approach was used to calculate personnel costs using, salaries, productive working hours, and minutes spent per patient. This approach was used to allocate the salary of doctors, nurses, and laboratory staff to healthcare service activities. Unit costs per hour were calculated by dividing their yearly salary by the number of productive working hours per year. Productive working hours were based on an average number of shifts per month and shift length, taking into account official leave days and the estimation of an annual number of sick days for nurses, doctors, and laboratory staff.
Patient medical record selection and sampling
In medical research, convenience sampling often involves selecting clinical cases or participants which are available around a particular location such as a hospital or a medical record database. Thus, this study essentially focused on the retrospective selection of medical records of breast cancer patients at the JUMC oncology department. The convenience sampling method for medical record selection comprises choosing the records that are readily accessible medical records of breast cancer patients at JUMC hospital oncology unit for one year were chosen retrospectively and reviewed for information extraction. Breast cancer patient’s medical record with complete sources of medical inputs, the number of resources used, and based on the distribution of patients at each stage of breast cancer was considered into (stage I, II, III, and IV) breast cancer patients who received treatment from September 2022 to August 2023 at JUMC were chosen retrospectively from patient’s medical records prescribed and information was extracted on the number of resources used.
Sampling method and sample size determination
The convenience sampling method was used to collect the medical records of breast cancer patients at the JUMC oncology department. Based on the International Classification of Diseases for Oncology (ICD-10). Medical records of breast cancer patients at JUMC who provided the service in the hospital or diagnosed, tested, took chemotherapy, radiotherapy, surgery, and patients registered with complete medical records at each stage for breast cancer treatment and resources utilized from September 2022 to August 2023 at JUMC were selected and included in the study.
To determine the sample of the study the single population formula was used, where δ = SD, Breast cancer patients spent on average with standard deviation (SD) of = $ 0.29.
d = Margin of error or degree of precision desired = 0.05.
z = the value of 95% CI = 1.96.
 |
Hence the final sample size was n = 130.
Finally, a total of (N = 130) breast cancer patients’ medical records from those who received treatment at JUMC with complete registry and their medical records were extracted between September 2022 and August 2023 and included in the study.
Data collection procedures, tools, and techniques
A retrospective review of breast cancer patient medical records at JUMC was employed to collect data on demographics (sex, age), resource utilization on stages of breast cancer treatment such as resource utilization for each stage of breast cancer e.g., number of chemotherapy cycles, radiation days, hospitalization days, surgical, and procedures, etc. as well as the unit cost of each service or input used in the analysis for an oncology unit at JUMC.
The data collected includes secondary data on patient demographics as well as information for each stage of breast cancer on diagnoses, drugs, chemotherapy regimens, surgical procedures, and radiation therapy. Besides, the medical records were used solely to extract the number of resources used e.g., number of laboratory tests, days of hospitalization, and number of chemotherapy cycles, whereas, the unit costs were obtained from Jimma University Medical Center pharmacy, radiation department, finance office, or administrative departments.
There is no interaction with research subjects, and thus, a retrospective method is only related to identifying subjects and extracting information from their medical records. Because of the methodological approach, the cost analysis includes only direct medical costs of breast cancer and the cost drivers at each stage, which were extracted and estimated from a healthcare provider’s perspective. Hence, the study did not include indirect and intangible costs.
A structured checklist was prepared to conduct a review of medical records at JUMC on the quantity of resources used by the breast cancer adult oncology department, and the unit cost information from hospital administration, pharmacy, radiation department, and finance office on cost per chemotherapy, radiotherapy, cost per day of hospitalization, salary of personnel, laboratory, and surgery costs. The tools were adapted from related literature, prepared in the English version, and modified for the context [9, 10, 14].
Considerations for provider perspective
Provider perspective mainly focuses on costs incurred by the hospital including medical supplies, equipment, personnel costs, and costs associated with different stages of care like different treatment, diagnosis, and follow-up of breast cancer treatment.
Data processing and analysis
Data entry was done using Microsoft Excel and exported to SPSS 22.0 for data analysis. Data cleaning was performed to check the accuracy, consistency, and validity. Microsoft Excel was also used for data analysis, cost calculation, and estimation of the direct cost of each stage of breast cancer and their cost drivers such as the cost of drugs, personnel, surgery, radiotherapy, chemotherapy, and laboratory tests. Data analysis was performed using percentage and frequency. A variety of descriptive statistics such as mean, median, and standard deviation (SD) were calculated and employed to determine the total direct medical cost of the hospital to treat breast cancer at different stages.
Cost analysis
Costs were categorized into cost components to conduct the analysis: cost of drugs, laboratory test, personnel cost, cost of surgery and cost of imaging, and their own cost drivers to estimate the 1- year direct medical cost of the hospital.
Descriptive cost analysis was performed using the mean, median, and standard deviation for cost components across each stage of breast cancer. Also, the statistical analysis was made on key characteristics of the providers to determine the relationship between stages of breast cancer and the cost driver to estimate the 1- year direct medical cost of the hospital. Because the non-normally distributed cost data (Shapiro -Wilk test, P- value < 0.001) was employed.
A quintile regression model was used to determine the relationship between stages of breast cancer and cost components. The major cost drivers were incorporated into the median regression model to determine the effect of the total direct medical cost. This study analyzed the median regression to estimate the difference between the stage of breast cancer and the cost components and the annual direct medical cost of the hospital. The median difference was presented between the stages with a P- value between < 0.05 and 95% CI. Differences between stages of breast cancer were statistically significant when the P- value was < 0.05. Costs were presented in US Dollars for comparison purposes. The exchange rate used was considering annual inflation in the nation. All costs estimated were explained by 2022/23 USD exchange with Ethiopian Birr (ETB) (1 USD = 51.94 ETB).
Results
Characteristics of study participants
A total of 135 breast cancer patient’s medical records were retrospectively reviewed at Jimma University Medical Center (JUMC) adult oncology unit and out of these 130 breast cancer patients’ medical records were selected, the quantity of resources used was extracted and included in the cost estimation analysis. Accordingly, five patients’ medical records were excluded from further study because of incomplete medical information and the healthcare professionals did not mention the stage of the disease, so, the stage was unknown.
The mean age of patients was 41.9 years, about (39.2%) of breast cancer patients treated at the medical center were less than or equal to 40 years old, the youngest patient was 20 years and the oldest patient was 70 years old. Out of (n = 130) breast cancer patients diagnosed; the most frequent age category was 30–39 years. The majority of breast cancer patients, 127 (97.7%), were women with a mean age of 41.9 (+ 10.4) years and 3(2.3%) were men. The largest proportion of breast cancer patients treated was at a younger age between the ages of 30–39 years, it constitutes 39.2% of all patients at each specific stage of the disease, followed by 30% of the age categories between 50 and 59 years (See Table 1).
Table 1.
Demographic characteristics of breast cancer patients at JUMC, September 2022 to August 2023
| Variable | N = 130 | Percentage (%) |
|---|---|---|
| Age (mean ± SD) | 41.9 + 10.4 | |
| Gender | ||
| Men | 3 | 2.3 |
| Women | 127 | 97.7 |
| Age in years during treatment | ||
| 20–29 | 10 | 7.7 |
| 30–39 | 51 | 39.2 |
| 40–49 | 27 | 20.8 |
| 50–59 | 39 | 30 |
| 60+ | 3 | 2.3 |
Direct medical cost across breast cancer stages
The median annual total direct medical cost spent by the hospital (JUMC) on breast cancer stages I, II, III, and IV were 9,670.2 ETB (US$186.2), 12,224.1 ETB (US$235.4), 10,602.6 ETB (US$204.1), and 10,458 ETB (US$201,4) respectively. While, the JUMC mean annual direct medical cost of breast cancer per patient from stage I to IV was 10,602.9 ETB (US$204.2), 13,598.6 ETB (US$261.8), 15,094.9 ETB (US$290.6) and 13,356.5 ETB (US$257.2) for stages I, II, III and IV respectively.
The mean annual direct medical cost of the hospital incurred on breast cancer at stage III on chemotherapeutic regimen alone in JUMC was 4,553.4 ETB (US$ 87.7) with a median cost of 4407.6 ETB (US$ 84.9), mainly drugs such as cyclophosphamide, paclitaxel, doxorubicin was the major cost contributors The proportion of drug cost and its contribution at an advanced level (stage III) from the whole cost drivers chemotherapy only contributed 30% of the total direct medical cost of all stages, followed by hospitalization cost (i.e. days stayed in hospital) 27.2%, surgery, and procedure cost 19.1%, radiologic imaging 9.4% (See Table 2).
Table 2.
The direct medical cost of breast cancer by stages of breast cancer at JUMC, 2022/23
| Cost components | Stages of Breast cancer | |||||||
|---|---|---|---|---|---|---|---|---|
| I | II | III | IV | |||||
| Mean (SD) | Median | Mean (SD) | Median | Mean (SD) | Median | Mean (SD) | Median | |
| Drugs (n = 130) | 3270.5 (93,18) | 2,801.2 | 3393.4 (376.3) | 3425 | 4553.4 (251.8) | 4407.6 | 3,661.0 (434.3) | 3466 |
| Radiotherapy (n = 49) | 1510.7 (35.6) | 1,357.5 | 4191 (530.6) | 3370.5 | 1,409.3 (477.3) | 1,220 | 1,117.1 (510.4) | 890 |
| Surgery (n = 37) | 2427.4 (90.5) | 2,450 | 2580.4 (838.8) | 2,778.6 | 2,938.9 | 0 | 2,939 (1475.5) | 2450 |
| Pathology (n = 130) | 442.9 (79.4) | 350 | 514.7 (876.1) | 350 | 4480 (940.9) | 3500 | 4,213.3 (761.7) | 3500 |
| Lab test (n = 130) | 1,090 (46.3) | 1,015 | 1453.5 (279.9) | 1,320 | 1,371.4 (224) | 1,475 | 1,374.1 (174.7) | 1430 |
| Personnel (n = 130) | 182.1 (59.8) | 0 | 182.1 (204.9) | 0 | 182.1 (274.7) | 0 | 182.1 (201.5) | 0 |
| Total cost in ETB | 10,602.9 | 9,670.2 | 13,598.6 | 12,224.1 | 15,094.9 | 10,602.6 | 13,356.5 | 10,458 |
| Total cost in US$ | $204.2 | $1862 | $261.8 | $235.4 | $290.6 | $204.1 | $257.2 | $201,4 |
Costs in USD
The total hospital spending on breast cancer disease treatment was higher due to the large number of patients who visited the hospital at an advanced stage relative to an early stage of breast cancer, stage III comprises 40.71% of the total spending compared to 31.75% of stage IV, 13.77%, and 10.8% for stage II, and stage I respectively. However, the total amount spent and the proportion for each stage of breast cancer would depend very much on the number of patients diagnosed at each stage.
Among 130 breast cancer patient’s medical records reviewed and assessed 14 (10.8%) patients visited the hospital at stages I, 17 (13.1%) stage II, 50 (38.5%) stage III, and 49 (37.6%) stage IV. Based on the stage of breast cancer at JUMC the patients suffering from the late stages III, and IV compared to early stages (I and II), this indicates that, at the hospital, the mean direct medical costs increased from early stage to late stage. The hospital’s one-year cost analysis for breast cancer at different stages showed 38.5% of the patients were diagnosed with metastasis stage III, 37.7% had stage IV, while, stage I and stage II accounted for 10.8% and 13.1%, of the patients treated at an early stage of the disease respectively (See Fig. 1).
Fig. 1.
Breast cancer patients diagnosed at each stage of the disease at JUMC adult oncology department from September 2022 to August 2023
Out of (n = 130) breast cancer patients whose medical records reviewed and visited the hospital 99 (76.6%) were received treatment at an advanced stage or metastasis stage (stage III and IV), however, chemotherapy, supportive medication, and laboratory tests were provided to all breast cancer patients at all stages. Another important predictor of the cost of breast cancer could be the stage of disease and treatment type required, for instance, chemotherapy, and radiotherapy show different trends at an advanced stage, and the cost of chemotherapy provided by the hospital was increased at stage III (38.5%) and decreased to 37.7% at stage IV, this is because of the limited treatment options at advanced stages of the disease. Although the total cost to the provider was higher for late-stage cancer, it was mainly due to the large number of patients in these stages. Cost per patient was at least 2.5 times higher in stages I and II compared to stages III and IV of the disease.
Breast cancer cost components
Among the major cost components of breast cancer at JUMC, the cost of breast cancer treatment was driven by chemotherapy, which costs US $6,073.6 and the commonly consumed drugs were cyclophosphamide, paclitaxel, and doxorubicin plus supportive medication to manage chemotherapy complication also cost US $3,755.7, the second cost driver in the hospital was laboratory test includes blood test (e.g. complete blood count or CBC), and laboratory, histopathology tests (a test of soft tissue e.g., RFT, and LFT) US $3,386, thirdly, breast cancer cost was driven by radiotherapy (radiologic imaging e.g. positron emission tomography, ultrasound images, and Computerized Tomography scan or CT- Scan) was US $3,237.9, followed by personnel cost (wage of healthcare professionals), hospitalization cost (i.e. days stayed in the hospital), cost of surgery, which accounted US $2836.9, US $2,519.3, US$1,805.8 respectively (See Fig. 2).
Fig. 2.
Breast cancer cost components and the direct medical cost drivers at JUMC
The direct medical cost of breast cancer at JUMC
The annual total direct medical cost incurred at JUMC on patients to treat breast cancer across all stages (n = 130) was US $24,727. From the patient’s medical record reviewed, who visited JUMC chemotherapy cycles can range from once a week to once every three weeks, with treatment durations typically being 3 to 6 months for early-stage breast cancer. Chemotherapy commonly used in early- stage of breast cancer should be Anthracyclines, doxorubicin, epirubicin, and at stage III chemotherapy and supportive drugs provided to the patients such as cyclophosphamide, doxorubicin, and paclitaxel for 8 cycles every 3 weeks, but for stage IV cyclophosphamide and doxorubicin for 6 cycles every 3 weeks. Drug cost showed the major cost component of the hospital accounted for (24.6%) of all breast cancer cost components and the largest cost driver at JUMC adult breast cancer oncology which spent on chemotherapeutic regimen, mainly, dominated by cost of Paclitaxel, carboplatin, cisplatin, cyclophosphamide, doxorubicin. The cost of supportive medication supplied by the hospital to treat complications of breast cancer, such as (antibiotics, analgesics, and antidiarrheal) during treatment of the disease was (15.2%), laboratory tests contributed (13.7%) and, radiotherapy imaging accounted for (13.1%) of the cost components of breast cancer at JUMC (See Table 3).
Table 3.
Annual total direct medical cost incurred on hospital due to breast cancer treatment at JUMC, September 2022 to August 2023
| Cost category | Total direct medical cost in ETB (US$) | Percentage (%) |
|---|---|---|
| Personnel | 147,348 ($2,836.9) | 11.5% |
| Drugs (medication) | 315,463.88 ($6,073.6) | 24.6% |
| Surgery and procedures | 93,791.69 ($1,805.8) | 7.3% |
| Radiotherapy | 168,175 ($3,237.9) | 13.1% |
| Pathology | 58,000($1,116.8) | 4.5% |
| Laboratory test | 175,870 ($3,386) | 13.7% |
| Supportive medication | 195,071.20 ($3,755.7) | 15.2% |
Moreover, drugs provided for chemotherapy at all stages were the prominent cost component at JUMC hospitals to provide necessary breast cancer treatment. However, at JUMC during the treatment of breast cancer patients at all stages of the disease, chemotherapy was the major cost driver (47.2%), followed by laboratory tests (14.8%), radiotherapy, and hospitalization 14.2% and 11% respectively (See Fig. 3).
Fig. 3.
Direct medical cost components of breast cancer disease at JUMC adult oncology from September 2022 to August 2023
Table 4 Showed that the stage of breast cancer was significant in terms of 1 year with the direct total cost of breast cancer treatment (p < 0.05). as indicated in further analysis of the relationship between direct medical cost components across stages of the disease revealed that breast cancer treatment increased with the stage from earlier stage to advanced stages.
Table 4.
Cost components of breast cancer treatment and their cost variance according to the stage of the disease at IUMC,2022/23
| Cost category | Median | Median difference | P- value | 95% CI |
|---|---|---|---|---|
| Chemotherapy cost | ||||
| Stage I | 218.6 | 0.0 | 0.054 | -78.74 -345.34 |
| Stage II | 638.7 | 214.2 | 0.002* | -21.87- 594.31 |
| Stage III | 846.2 | 528.4 | 0.001* | 266.5-574.23 |
| Stage IV | 753.4 | 431.7 | 0.001* | 217.54–422.32 |
| Cost of Lab test | ||||
| Stage I | 156.1 | 0.0 | 0.051 | -83.82–112.34 |
| Stage II | 173.4 | 112.4 | 0.001* | 82.67 -134.54 |
| Stage III | 522.6 | 128.7 | 0.001* | 457.34–435.12 |
| Stage IV | 409.4 | 219.5 | 0.001* | 437.22 -389.79 |
| Radiology cost | ||||
| Stage I | 755.3 | -566.8 | 0.001* | -354.6574 -804.54 |
| Stage II | 578.7 | -333.2 | 0.008 | -98.58 -596.45 |
| Stage III | 730.7 | 379.5 | 0.017 | 398.30–554.91 |
| Stage IV | 612.8 | 230.8 | 0.678 | 298.12–432.12 |
| Annual direct medical cost | ||||
| Stage I | 124.9 | 0.0 | 0.04* | 66.97- 160.43 |
| Stage II | 178.6 | 78.8 | 0.031* | 16.88–116.52 |
| Stage III | 245.2 | 134.5 | 0.001* | 3.39–102.39 |
| Stage IV | 189.8 | 98.6 | 0.003* | 53.73–70.73 |
Costs measured in US Dollars
*Significance level (p < 0.05)
The regression model analysis revealed that drug costs increased with the stage of breast cancer. The median cost of the hospital for chemotherapy in stages I, II, III, and IV were US$218.6, US$638.7, US$846.2, and US$753.4 respectively. As the median costs were different across the stage of breast cancer. At an advanced stage of the disease the treatment costs were also increased at the stage of the diagnosis and statistically significant (p < 0.05). By contrast, the cost of laboratory tests analysis showed that the hospital incurred a higher cost to treat breast cancer patients at an advanced stage and made the treatment even complex and difficult as a result of late visiting hospitals. The highest median cost incurred by the hospital was at stage III (US$830.7), followed by stage IV (US$612.8), and lower cost at stage I for laboratory test. The hospital incurred at stage I the highest median cost of (US$755.3) on radiotherapy and lower at stage II accounted for (US$578.7).
The hospital incurred the highest median cost for chemotherapy than other treatment options with (US$ 528.4) at stage III and (US$ 431.7 for stage IV to treat breast cancer disease. Nevertheless, the 1-year total median direct medical cost for JUMC to treat breast cancer patients at stage III and stage IV were accounted for (US$245.2) and (US$ 189.8) with (P-value = 0.001) and (0.003) respectively, while the treatment cost varies at an early stage (stages I and II) compared to treating at advanced stages. At earlier stages (stage I and II) the cost of breast cancer treatment became varied and lower indicating that the costs were not statistically significant (P > 0.05).
Discussion
This study provides a clear intimation of the distribution of costs and healthcare resources with stage-specific breast cancer treatment at Jimma University Medical Center (JUMC) adult oncology department. The study has provided insights on the estimation of direct medical of the hospital to treat breast cancer disease, and the analysis of the main cost driver of the stages of breast cancer, which are valuable in the allocation of healthcare resources and decision–making in the treatment of breast cancer disease.
A retrospective cost analysis made to estimate the hospital’s annual direct medical cost across the stage of breast cancer showed that the expanse required to treat breast cancer patients in 1 year was larger among patients treated at the advanced stage than providing treatment at the early stage. Thus, treating breast cancer at an early stage might be an opportunity to minimize the cost of treatment. Treatments made at advanced stages mean the cancer spreads to other parts of the body and is more likely to make more complex and difficult the treatment of the disease, which bears higher costs and declines the chance of patient survival.
Similar to studies done in low- and middle-income countries, this study suggests that breast cancer was common in younger women at the hospital. The mean age of patients who visited the hospital for treatment of breast cancer was 41.9 years, about (39.2%) of breast cancer patients treated at the medical center were less than or equal to 40 years old [15]. The result of this study has aligned with the studies done in different countries with similar study designs in Saud Arabia, Jordan, Italy, Canada, and different parts of Ethiopia showing that the mean annual medical cost of managing breast cancer disease was increased across the stages from (stage I- IV). The estimation of the total direct medical cost and the mean direct medical cost of this study was consistent with the studies done in different countries, as the disease progressed to advanced stages; the costs were pointedly higher at advanced stage of breast cancer disease [10, 12, 15, 16].
The finding of the study showed that the direct medical cost of the disease varies and significantly increases as the breast cancer disease stages advance, which showed a correlation between the disease stage and the cost of treatment, as the disease stage advances, more, it utilizes more healthcare resources and requires more intensive treatment at advanced stages than an early stage of the disease [10, 15]. This could be due to the high consumption of healthcare resources, trying to find other treatment options rather than chemotherapy, increased interest of patients to get treatment, even, in need of high tech-medications. Hence, this study suggests the significance of increasing awareness creation for healthcare providers and the general public, establishing and improving early screening, prevention, detection programs, and the use of minimal cost of managing the disease at an early stage of breast cancer disease [15, 17],
Consistent with other studies, the cost of chemotherapy at JUMC is stated as the main percentage of the total direct medical cost. The median cost of the hospital for chemotherapy in stages I, II, III, and IV were US$218.6, US$638.7, US$846.2, and US$753.4 respectively. This was due to the costly prices of new chemotherapeutic regimens, late visiting cancer clinics, lack of provision of essential drugs, and increased drug costs. However, targeted therapy was not a treatment option at JUMC, and the cost of expensive drugs such as trastuzumab alone or with a combination of pretuzumab was not supplied in the hospital which might have escalated the drug cost estimation considerably. Furthermore, the direct medical cost expenses incurred were higher in stages III and IV.
In contrast, the price of service provided to breast cancer patients in Ethiopia and other less developed countries was higher compared to the developed nations. Drug cost had the highest portion at JUMC to treat breast cancer patients, due to a shortage of foreign currency to import from abroad essential and costly drugs for timely treatment of breast cancer, additionally; most breast cancer patients were present and treated at advanced stage of the disease. At the later stages of the disease no treatment options other than chemotherapy, when compared with the cost of other categories and services provided, due to late diagnosis of breast cancer [10, 17, 18].
The overall increased annual mean cost of breast cancer is based on the stage of the disease, while the patients suffering from the illness are at the advanced stage of the disease and mainly experience a higher percentage of visiting cancer clinics, hospital stays, and home care. As a result of this, the advanced stage of the disease consumes more resources relative to the early stage of breast cancer disease [8]. In JUMC the highest percentage was stated at 38.5% in stage III and decreased to 37.7% for stage IV, because, at an advanced stage, there were limited treatment options for the patient. Moreover, the percentage further declined from 13.1% at stage II to 10.8% for stage I breast cancer patients treated in JUMC. The finding of the study showed that the mean annual direct medical cost of the hospital for breast cancer patient treatment was recognized to be higher and increasing from an early stage to advanced stages III and IV. Besides, when the disease stage progressed, the total cost of medicines was also higher, which accounted for 47.2% of the total direct medical cost of the hospital. Whereas, this study suggests that the direct annual medical cost was lower in stages I and II and higher for stages III and IV, the number of patients treated was much lower for stages I and II compared to stages III and IV [8, 18].
At JUMC the total direct medical cost of chemotherapeutic agents compared to laboratory tests and radiotherapy estimated for stage III and IV breast cancer disease was relatively higher, whereas, smaller at stage I and II, because of the treatment options and cost of treatment and number of patients. As a result of this, the treatment options were successful and less costly at an early stage of the disease than at the advanced stage of the disease. The majority of the breast cancer patients at JUMC were treated and diagnosed at the late stage of the disease, at stages III and IV than an early stage (stages I and II).
The finding of this study was in line with the study done at the University of Gonder Hospital Breast Cancer Center, Addis Ababa, Jordan, and Central Africa [8, 19–21]. In Africa specifically sub-Saharan countries, breast cancer patients including Ethiopia were visiting hospitals at the late stage of the disease. This might be a result of a lack of awareness about the disease, economic challenges of the community to access the service, high cost of treatment, absence of routine screening and detection programs, poor healthcare system shortage of oncology healthcare service and oncology professionals, and being not want to know and fearful to seen [8, 22].
As the study finding estimates the major cost driver of breast cancer disease at JUMC was the cost of chemotherapy which alone accounted (for 47.2%), followed by laboratory tests, radiotherapy, and hospitalization. Limited affordability of drugs plus the real cost of systemic treatment of the disease, added to the high cost of new chemotherapeutic regimens [10, 23, 24],
Among direct medical cost components at JUMC for the treatment of breast cancer across each stage, primarily it was driven by the cost of chemotherapy, cost of laboratory tests as the second, and radiotherapy took the third place, subsequently followed by the cost of hospitalization, surgery, procedures, and pathology, which had incurred higher direct medical cost. This study was contradicted by the study done in Ghana hospitalization cost was the 1st cost driver [24].
In this study, laboratory tests stand as the second cost driver of the hospital (for instance a complete blood count (CBC), Organ function test (OFT), and laboratory histopathology (i.e., a test of soft tissue) constituting (14.8%) of the total direct medical cost of breast cancer disease. This study is similar to the study conducted in Jordan, and Ghana, where laboratory cost stands as the second highest cost driver next to hospitalization [10, 24].
The study pinpointed that the cost of radiation therapy stands next to the cost of chemotherapy and lab tests, which was external beam radiation, a type of cancer treatment composed of high energy rays radiated through a machine to destroy cancer cells, at JUMC radiotherapy treatment as the third main cost driver accounted (14.2%) of the hospital share, mainly radiologic images (e.g., X-ray, Ultrasound, Computerized tomography (CT- scan) were used in the advanced stage of breast cancer.
Radiotherapy can minimize pain and diminish bone breakage when there are distant metastases in the bones. Patients receiving radiotherapy have significantly increased as the disease stage advanced (I, II, and III), but it declined in stage IV. When patients are diagnosed at a late stage, surgery has no role, and the primary treatment modality then becomes chemotherapy, hormonal therapy, and radiation [8, 10, 25].
Limitation
Some of the limitations considered in this study could be, similar to any retrospective cost analysis, secondary data was collected on the total direct medical cost of breast cancer treatment from the hospital database and breast cancer management, therefore, it does not include indirect and intangible cost for cost analysis and also restricted to breast cancer treatment of the specific teaching hospital. This study was not aimed to analyze and estimate indirect and intangible costs due to the retrospective methodology used and why this study was limited to only direct medical cost analysis.
Like other studies done with retrospective study design, in this study also some limitations must be considered while interpreting the result of secondary data collected from the hospital database and analyzed, therefore, the result of the study was limited and might not contain all data of interest to manage breast cancer. While reporting the patient’s medical record data, such as the prescribed drug costs might result in overestimation or underestimation of the costs. Since the study was restricted to a specific teaching hospital breast cancer patient the result of the study was limited. Patient screening and pre-detection costs were not included in the analysis, which was based on breast cancer stage-specific cost analysis after diagnosis of the disease. Also, the small sample size and retrospective cost analysis considered in this study suggest that future studies conducted should use a larger sample size and be prospectively done to minimize the shortage of cost analysis.
Conclusions
This study found that the annual direct medical cost of breast cancer at JUMC is substantial. Costs were significantly lower for patients diagnosed at stages I and II, notably higher for those in stages II and IV. Additionally, more patients were treated in the later stages than in the early ones. The primary cost drivers identified were chemotherapy, laboratory tests, and radiotherapy followed by hospitalization, surgery, and pathology services. These findings highlight the importance of early detection and prevention strategies, which could help reduce the overall treatment burden. This stage-specific cost analysis provides valuable insights into the economic impact of breast cancer at the hospital and supports healthcare informed resource allocation.
Data quality control
Before data collection, one-day training was given for 2 data collectors with a BSc nurse and one supervisor on how to review medical records and extract retrospectively secondary data from the patient registry. The daily collected data was checked by the supervisor and the principal investigator for completeness of the questionnaires and their consistencies. After data were collected data cleaning and validation were done on medical records and administrative cost data to ensure its accuracy and completeness. Assessing the cost data availability for its completeness and accessibility of patient medical records and administrative data including potential missing records and inconsistent data entry. The form was tested and assessed on its validity and data were collected through electronic and paper files.
Supplementary Information
Below is the link to the electronic supplementary material.
Acknowledgements
We would like to express my heartfelt appreciation to Jimma University Institute of health, staffs of Jimma University Medical center (JUMC), and department of health policy and management. Our special thanks go to data collectors and JUMC oncology department.
Author contributions
G.J.E. and K.A.K. were involved in drafting the proposal, data collection, wrot the main manuscript, study design, analysis and writing the initial draft of the manuscript. D.W.D. and A.J.E. were reviewed the manuscript and re analyzed the data and review the manuscript to get the final version. All authors read and approved the final manuscript.
Funding
The research was sponsored by Jimma University.
Data availability
The data generated and analyzed during the study were not publicly available due to the agreement made with the sponsored institute not to share the data with third parties and there are irremovable identifier data and are available with the corresponding author for reasonable request.
Declarations
Ethics approval and Consent to participate
Ethical clearance was taken from Jimma University Institute of Health Institutional Review Board and a letter of permission was obtained from Jimma University Medical Center. Written informed consent was given prior to the study. Name and other personal identifiers were not recorded for confidentiality purposes. All protocols were performed according to the regulations and guidelines.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The data generated and analyzed during the study were not publicly available due to the agreement made with the sponsored institute not to share the data with third parties and there are irremovable identifier data and are available with the corresponding author for reasonable request.