Research on the Economics of Cancer-Related Health Care: An Overview of the Review Literature

Abstract

We reviewed current literature reviews regarding economics of cancer-related health care to identify focus areas and gaps. We searched PubMed for systematic and other reviews with the Medical Subject Headings “neoplasms” and “economics” published between January 1, 2010, and April 1, 2020, identifying 164 reviews. Review characteristics were abstracted and described. The majority (70.7%) of reviews focused on cost-effectiveness or cost-utility analyses. Few reviews addressed other types of cancer health economic studies. More than two-thirds of the reviews examined cancer treatments, followed by screening (15.9%) and survivorship or end-of-life (13.4%). The plurality of reviews (28.7%) cut across cancer site, followed by breast (20.7%), colorectal (11.6%), and gynecologic (8.5%) cancers. Specific topics addressed cancer screening modalities, novel therapies, pain management, or exercise interventions during survivorship. The results indicate that reviews do not regularly cover other phases of care or topics including financial hardship, policy, and measurement and methods.

Cancer health economics is the application of health economics to the delivery of care across the cancer control continuum, from prevention and screening to diagnosis, treatment, survivorship, and end-of-life care and is a recognized interest of the Healthcare Delivery Research Program in the National Cancer Institute’s Division of Cancer Control and Population Sciences, (https://healthcaredelivery.cancer.gov/cancer-health/). Health economics is the application of economic theory, models, and empirical techniques to the analysis of decision making by people, health-care providers, and governments with respect to health and health care (1). Cancer health economics research may examine factors associated with organization, production, delivery, and demand for cancer-related health care across the cancer control continuum, as well as outcomes such as type, quantity, quality, and cost of care faced by the patient, family, insurer or public payer, and society (2). An important dimension of health economics research generally is to assess cost-effectiveness, cost-utility, or cost benefit associated with existing and new treatments, technologies, or interventions, including public programs. Cancer health economics may also incorporate development of data, measures, and analytic methods specifically geared to support this research. The field of cancer health economics is uniquely poised to address many aspects of cancer control with important economic implications. Some of the most notable research issues that can be examined using an economic framework include the following:

• The role of expected direct medical, nonmedical, and indirect costs on initial and ongoing cancer treatment decisions

• The role of public policy, such as expansion of publicly subsidized insurance benefits, coverage mandates, and other aspects of insurance benefit design, on cancer prevention, screening, and treatment

• The role of individual income and assets, as well as social determinants of health, on access to cancer screening, cancer care, and ability to complete recommended cancer treatment

• The effect of provider reimbursement incentives, including experimental payment models, on cancer care provided, location, and cost to payers

• Evaluation of cost-effectiveness or cost-utility of new technology or pharmaceuticals used for cancer screening, diagnosis, treatment, or supportive care

Given this broad potential scope of cancer economics research, we sought to characterize recent literature primarily related to cancer-related health-care delivery and identify where there are gaps in reviews of the literature contributing to the knowledge base. Given the potential breadth and depth of this literature, we examined relatively recent review articles and describe their areas of focus.

Methods

We used the PubMed database to identify review articles on topics within the economics of cancer health care published in English between 2010 and 2020. The search was conducted on April 1, 2020. Our search strategy combined medical subject headings for “neoplasms” and “economics” and resulted in the selection of 352 abstracts. Two reviewers (AJD, KA, and/or MTH) independently assessed the titles and abstracts of these articles for eligibility. Included studies were required to review published literature, including systematic reviews using the PRISMA, PICO, or PICOS frameworks; meta-analysis; scoping review; narrative review; or other manuscripts summarizing findings from at least 2 previously published studies. The studies were required to fall within topics of interest to the authors addressing 1) economics of supply and demand for cancer-related health care, including insurance coverage, coverage design, coverage mandates, benefit design, including cost sharing, and provider payment incentives, including bundled payment models; 2) economic outcomes, including utilization, medical and nonmedical direct cost of health care, indirect costs including employment, out-of-pocket cost, financial burden, and cost-effectiveness; or 3) methods used in cancer-related economic studies, including but not limited to cost measurement, cost-effectiveness or cost-utility analysis, and analysis of treatment or policy effects (for example, the Affordable Care Act, or ACA) using difference-in-difference analysis or other techniques. A detailed list of potential topic areas is included in the Supplementary Materials (available online). We excluded studies conducted outside the United States unless they included at least 2 articles assessing economics from the perspective of the US health-care delivery environment. We also excluded reviews focused on primary health behavior changes, for example, smoking cessation or exercise interventions, where reduced cancer risk is one of several potential health outcomes and often not the principal outcome of interest. We included reviews of prevention specifically connected to cancer risk reduction, including human papillomavirus vaccines, as well as secondary health behavior interventions in cancer survivors. We also excluded reviews that considered studies only concerning person-level characteristics such as race, ethnicity, income, education or insurance, and reviews related to efficacy or effectiveness that were used primarily to populate cost-effectiveness or cost-utility simulation models. We note that our criteria preclude inclusion of empirical studies that have extensive literature reviews in support of the empirical question, if they are not identified as review articles. Questions about article eligibility were resolved by consensus. Following abstract review, 164 met the full inclusion criteria (46.6% of identified publications). A PRISMA flow diagram is included in the Supplementary Materials (available online).

Data Abstraction

Data were collected from the paper abstract, if sufficiently informative; otherwise, we reviewed the full article. Information was abstracted on review paper characteristics, including type of economic studies reviewed, cancer type and stage, component of the cancer control continuum (prevention, screening, treatment, survivorship, and end-of-life care), and population. (Additional details are provided in the Supplementary Materials, available online). Information was gathered concerning all cancers specifically mentioned; if the topic was not limited to specific cancers, for example, studies of financial toxicity associated with advanced solid tumors, we assigned them to the category cross-cutting. Similarly, we gathered information on the phase of the cancer control continuum, identifying a specific phase, or using the term cross-cutting if the review included studies relevant to more than 1 phase.

Results

The number of reviews increased over time, with the plurality published in 2016 (n = 27; 16.5%) (3-29) but only 5 (3.0%) published in each of 2010 (30-34) and 2011 (35-39). Two addressed treatment for children (40,41), and 1 examined economic burden to parents of children with cancer (42); the remainder addressed issues for adults or were not age specific. The overwhelming majority (n = 128; 70.7%) of reviews focused on cost-effectiveness or cost-utility analyses (3–7,9,11,13,14,16–21,24,26–32,34,36,39–41,43-131), followed by cost-of-care reviews (n = 70; 42.7%) (3,5,6,8,10–12,15,22,25,30,31,33,35,37,38,40,42,50,51,55,58,64,70,71,75,76,79,87–89,93,95,97,101,107,109,119,128–130,132–160). There were relatively few reviews that covered other types of cancer health economic studies (Figure 1).

Figure 1.

Percentage distribution of literature reviews by type of cancer health economic studies. Percentages may sum to >100% if reviews fit more than 1 category. CBA = cost-benefit analysis; CEA = cost-effectiveness analysis; CUA = cost-utility analysis.

More than two-thirds (n = 112; 68.3%) of the reviews focused on cancer treatments, followed by reviews of screening (n = 26; 15.9%) (20,21,46,48,65,66,69,71,74,75,79,84,85,90,100,104,106,110,114,116,120,125,126,144,161,162) and survivorship or end-of-life (n = 22; 13.4%) (22,42,45,52,69,73,75,76,83,86,87,133,134,136,152,156,158,159,163–165) (Figure 2). With respect to cancer site, we found that the plurality (n = 47; 28.7%) of reviews addressed topics that were cross-cutting, without mention of any specific cancer. This was followed by breast (n = 34; 20.7%) (5,13,16,18,23,29,35,56,62,68,73,74,76,88,89,92,96-99,106,117,120,121,125,127,128,130,131,133,136,138,144,153), colorectal (n = 19; 11.6%) (11,15,33,61,66,71,72,75,78,80,85,100,108,110,112,113,126,146), and gynecologic (n = 14; 8.5%) (5,66,84,90,98,101,109,116,126,142-145,161) cancers (Figure 3).

Figure 2.

Percentage distribution of literature reviews by phase of the cancer-control continuum. Percentages may sum to >100% if reviews fit more than 1 category. EoL = end-of-life.

Figure 3.

Percentage distribution of literature reviews by cancer type. The category of female gynecologic cancers includes ovarian, uterine, and cervical cancers. Percentages may sum to >100% if reviews fit more than 1 category. Gyn = gynecologic; HPV = human papillomavirus.

Figure 4 reports a sample of more detailed topical areas. For example, within the prevention and screening phases of the cancer control continuum, the reviews focused on colorectal, breast, and prostate cancer screening; examining colonoscopy (110,160); mammography (106,120); and prostate-specific antigen assessment (104), respectively. Additional reviews addressed human papillomavirus vaccines (66), low-dose computed tomography lung cancer screening (20,21,114), and a variety of genetic risk assessment issues (56,98,112,113). Within the treatment phase, several reviews focused on what were novel therapies at the time, including targeted therapies (57,91,92,96,101,108,111,137,151,166,167), monoclonal antibodies (78), immunotherapy and chimeric antigen receptor T cells (41,67), and transplant (30). Relatively few addressed care delivery approaches for these treatments; 1 review examined use of home intravenous therapy (134). Topical areas during survivorship reflected the heterogeneity of that phase of the cancer control continuum, with reviews examining supportive care (45,60,83) and symptom management (168), rehabilitation (73,169), exercise (73), and end-of-life planning discussions (152).

Figure 4.

Sample topics of individual literature reviews, by phase of the cancer-control continuum. CAR-T = chimeric antigen receptor T-cell therapy; CT = computerized tomography; EoL = end-of-life; HPV = human papillomavirus; IV = intravenous; PT = physical therapy.

Discussion

In this paper summarizing the review literature on the economics of cancer care, we identified review articles published between 2010 and the first quarter of 2020 and described the topical focus of studies reviewed. We found that the majority of reviews examined the treatment phase of the cancer control continuum and examined cost-effectiveness or cost-utility of various interventions, with limited emphasis on other phases of care or economic study types. The results indicate that reviews do not regularly cover other phases of care or topics including financial hardship, policy, and measurement and methods.

The most common disease focus was on topics that cut across cancer sites, followed by reviews examining care related to breast, colorectal, and female gynecologic cancers. The cross-cutting reviews focused on treatments that are common across cancers, for example, radiation therapy, or survivorship care that is agnostic to type of cancer or treatment, such as management of bone metastases or pain. Among the cancer-specific reviews, the emphasis did not reflect disease incidence; rather it may reflect public awareness of the cancer, perhaps because of publicity associated with screening (as in the case of breast or colorectal cancers) or disease prevalence. Further, review papers may be stimulated by release of new results from randomized controlled trials or the need to update treatment guidelines.

The reviews selected showed a surprising lack of focus on health policy, in an era where there were dramatic changes likely to affect cancer care. For example, the ACA, passed in 2010, included major insurance expansions implemented in 2014. Since implementation, there have been a plethora of individual studies examining the effects of the ACA on insurance eligibility, insurance coverage, cancer screening, diagnosis stage, treatment, out-of-pocket expenditures, and survival outcomes. However, it took several years after implementation for the literature to be sufficiently mature to review. At least 3 such reviews were published in 2020 (170–172) but after the period covered by our literature search. This scenario highlights a general limitation of literature reviews. By design, they are backward-looking, in that they report the results of studies during an earlier period rather than describing ongoing research or even completed research that has not yet been disseminated. Further, there must be enough studies to review, which may further delay the time frame, particularly if the topic of interest is complex or narrowly focused. In the case of the ACA, the intervention and the subsequent literature needed to mature sufficiently to undertake a meaningful review.

In addition to lags in reviewing the literature, it is important to note that the topics reviewed are not selected systematically. In other words, there is no objective indicator triggering a literature review once a minimum number of high-quality studies have been published. The literature reviewed reflects both the state of the underlying published articles and the research interests or policy agenda of the extramural research community and various other stakeholders. In addition, preparation and successful submission of high-quality review manuscripts (particularly systematic reviews) can be a time-consuming process; researchers may choose to focus on publishing manuscripts that highlight their original research rather than reviews. As a result, reviews of the literature may not be representative of the body of knowledge around a specific topic. Although we did not catalogue funding source or authorship affiliation, we expect that these factors may drive some of the focus on cost-effectiveness or utility analysis related to cancer treatments. Further research is needed to examine this and related issues.

Our overview of literature reviews has some limitations. We only searched PubMed to identify relevant articles, as it provides the broadest collection of citations. Other sources, for example, EMBASE or the Cumulative Index to Nursing and Allied Health, tend to overlap PubMed and are otherwise more specialized in areas of lesser interest for purposes of our review. We used somewhat global terms for the search and required Medical Subject Headings (MESH) for both neoplasm and economics. As a result, we may have missed some topics that are not directly focused on economics of cancer-related health care but have implications for cancer incidence, for example, economic interventions to encourage exercise or smoking cessation, or are associated with acute or chronic conditions more generally but also are relevant for individuals with cancer. For example, literature related to health shocks and employment or access to and cost of palliative or end-of-life care may be highly relevant to individuals diagnosed and treated for cancer but may not have the relevant MESH headings. In addition, by selecting general MESH search terms (economics and neoplasm), we may have missed literature of potential interest, such as health insurance or payment models that are ultimately associated with health-related behaviors or health outcomes or market structure and consolidation that may affect access and costs of care, if they were not listed under the “economics” MESH heading. Finally, we excluded literature that focused on individual characteristics such as race and ethnicity and rural residence. There has been a substantial focus on these individual characteristics as they relate to disparities across the cancer control continuum; we chose to highlight topics not otherwise described. We note that by limiting our search to articles identified as systematic or other review, we did not capture empirical studies, commonly published in economics or health economics journals or even working papers posted by the National Bureau of Economic Research. These papers often include robust reviews of literature as background for the empirical analysis. Researchers or policy makers seeking information on specific topics may benefit from including these types of papers in their own literature searches.

There is a large and growing literature examining economic issues related to cancer health care. Our review of review articles that met our topical and content criteria tended to concentrate on cost or cost-effectiveness of cancer treatments. The results indicate gaps related to other phases of care and other areas of focus, including financial hardship, policy, structure and efficiency of cancer care markets, and measurement and methods.

Funding

No funding was used for this study.

Notes

Role of the funder: Not applicable.

Disclosures: AJD received consulting income from Amgen, and a family member received advisory board income from Abbvie. Neither AK or MTH reported any disclosures.

Author contributions: AJD and MTH were responsible for study design; AJD, KA, and MTH were responsible for data collection and analysis; AJD was responsible for drafting the manuscript, and KA and MTH made critical editorial input and revisions.

Disclaimer: The views expressed in this article are those of the authors, and no official endorsement by the National Cancer Institute, National Institutes of Health, or the Department of Health and Human Services is intended or should be inferred.

Prior presentations: Preliminary results were presented virtually at the National Cancer Institute’s Conference on the Future of Cancer Health Economics Research, December 2, 2020.

Data Availability

An electronic spreadsheet listing the articles reviewed and the attributes abstracted is avavailable from the authors on request.