The Financial Cost of Preventive and Curative Programs for Breast Cancer: A Case Study of Women in Shiraz-Iran

Background This cross-sectional study was conducted to compare the average costs of breast cancer screening and treatment among women with the age of 25 and over in Shiraz-Iran. Methods Three majors hospitals affiliated with Shiraz University of Medical Sciences (SUMS) were selected for data collection. Financial documents and interviews with the hospitals’ financial officers were used for data collection. Results Finding shows that the total cost of screening would be 5,847,544.96 US dollars for age groups of 25-34 and 35 and above, demonstrating the huge expense of screening programs. On the other hand, the average cost of breast cancer treatment for each patient would be 3,608.47, 996.89, and 311.47 US dollars for mastectomy, radiotherapy, and chemotherapy, respectively. In addition, the total average cost for treatment of 2217 patients would be 1,466,988.09 US dollars, which is much less than screening programs expenses. Conclusion It is concluded that although screening can be effective for improving quality of life and treatment effectiveness, considering the high costs of screening, it is not economical in Iran. Screening methods within suitable intervals, and also considering patients’ medical history have been recommended by the present study.


Introduction
Cancer is considered as a major issue concerning healthcare systems. Due to the global increases in cancer prevalence, and its attribution to more than 12% of the world's mortality, providing efficient policies for cancer screening and treatment is recognized as the leading priority of healthcare systems (1,2). According to the literature, five common factors that contribute to increasing cancer rates in both developed and developing countries include dietary changes, smoking, infections, occupational and agronomic problems, and environmental pollution. Among these, dietary factors and infections alone contributed to 4.4 out of 10 million cancers in 2002 (3,4). In Iran, cancer is the third leading cause of mortality, following accidents and heart disease. 30,000 individual deaths are attributed to cancer annually. Additionally, Iran experiences more than 70,000 new cancer cases annually, and this figure could potentially double in the next two decades due an aging population (4). Breast cancer is the most common cancer in women, and the second highest contributor to cancer mortality. It accounts for 20% of deaths in women aged 40 to 50 years (5), and 32% of women's cancers, and 19% of women's cancer deaths, are attributed to breast cancer (6). Considering the current inconclusive knowledge regarding the nature of cancers, cancer-management solutions should focus on prevention, early detection, control, and cure (7). According to World Health Organization (WHO) statistics, breast cancer prevalence rates presently increase by 1.8 to 2 yearly. Notably, 25% of all detected cases are in developed stages (5). Detection and preventive methods for breast cancer (breast sonography and mammography) are the most effective methods in the initial stages of breast cancer, otherwise increasingly complex treatments such as mastectomy, radiotherapy, and chemotherapy are utilised. However, such methods impose high costs for patients and hospitals (8). In developed countries, cancer screening is part of a national plan, which includes training for early detection, while in developing countries such as Iran, cancer screening is not yet institutionalized (8). A majority of cases in developed countries are detected and cured in stage 1, while in Iran many of cases are detected in the second or third stages, creating challenges for treatment (8). According to the above information, breast cancer bears a high prevalence rate, and is an important social and health issue (9). However the presently increasing population creates a strain on available resources, particularly in developing countries, which necessitate optimized utilization of financial resources (9). Thus, it is necessary for healthcare service managers and specialists to computation technology for effective health services in order to optimize resource assignment (10). Considering breast cancer prevalence in the Fars province and the necessity of mammography and sonography, this study has been conducted to show the financial cost of mammography and sonography screening program for preventive and curative procedures among women with the age of 25 and over in Shiraz-Iran.

Methods
This cross-sectional study has been conducted in 2007 (one year) in hospitals affiliated with Shiraz University of Medical Sciences (SUMS), including Shahid Faghihi, Hafez and Namazi hospitals. The study population includes two groups: 1) patients referred to Hafez hospital for sonography and mammography for breast cancer detection, and 2) patients referred to Shahid Faghihi hospital for mastectomy services, or to Namazi hospital for chemotherapy and radiotherapy services. Among the patients referred to Hafez hospital, 225 were referred for sonography and 494 were referred for mammography services. 196 cases were referred to Shahid Faghihi hospital for mastectomy; 190 and 1831 to Namazi hospital for radiotherapy and chemotherapy, respectively. It should be noted that all cases were selected in the sample, due to the limited numbers of patients. Data observation, financial documents and interviews with the hospitals' financial officers were used in data collection. Cost information was also based on the national tariff. For estimating the at-risk population requiring sonography and mammography, data related to women aged 25-34 years and above 35 years, respectively, was extracted from the statistical report of the Fars governmental programming deputy. Costs were then computed and compared in order to clarify the resource assignment process. Two costs, namely those related to cancer prevention actions and costs related to treatment were compared in this study.

Results
Findings show that the average costs of breast sonography and mammography per patient were 3.13 and 10.98 US dollars respectively for the hospital (the average cost was estimated based on the prime cost; Table 1). The average expense of breast sonography and mammography incurred by each patient was 4.45 and 11.70 US dollars respectively. This shows that hospitals do not incur any additional costs for these services, as the cost is covered by patients. Considering that mammography is the most suitable method for screening among women aged 35 years and over, sonography is generally used for patients under 35 years. Therefore, computations were completed in two different age groups to calculate the costs of screening, as follows: • In accordance with annual statistics (2005) (Table 3), which is much less than screening programs expenses.

Discussion and Conclusion
Cancer is considered as a global health imperative. It is predicted that cancer will become the leading cause of death by 2030 due to an aging population, relative control of infectious diseases, and increasing cancer risk factors such as pollution. Therefore providing efficient cancer-management techniques is essential in health systems (11). Breast cancer is one of the most prevalent cancers worldwide. Although breast cancer is common in both developed and developing countries, its prevalence is increasing in the developing world due to increased life expectancy, increased urbanization, and adoption of western lifestyles (5). In addition, these countries experience high case fatality rates, likely due to a lack of awareness of the benefits of detection and treatment, a scarcity of adequate facilities for detection and diagnosis, as well as poor access to primary treatment (5). Therefore, the necessity of using screening methods such as sonography and mammography for detecting and preventing this cancer is evident (12).  (14). Therefore, early detection is an important step towards reducing the physical and mental impacts of breast cancer. Evidence shows that general systematic invitations to breast imaging, for women aged 50-69 years, can reduce breast cancer risk up to 25% (14,15). In addition to planned screening, the quality and duration of screening are also important prevention/detection factors. Anderson et al. stated that systematic breast imaging every two years can help to detect the disease in its initial stages (13). Some evidence suggests that regular screening can reduce the risk of breast cancer by 30% in women aged over 50 years, as early detection allows more effective treatment, at lower costs (13). Lebovic (26). It is concluded that screening especially for women aged over 40 years can be considered an effective tool for improving quality of life and treatment effectiveness. However, considering the high costs of screening, it is not economical in most countries.

Limitations
One of the limitations of the present study is that the cost of screening programs is not certain and precise as sensitivity, specificity and negative and positive predictive value of screening programs (mammography and sonography) which could affect the overall cost was not calculated in this study. The second limitation is that the costs of breast cancer occur over time (during several years). Therefore looking at only one year might not indicate true cost of treatment.

Ethical issues
Ethical approval for this study was granted by the human research ethics committee of Shiraz University of Medical Sciences.

Implications for policy makers
In order to provide more cost-efficient services it is recommended to: • Perform screening methods within suitable intervals, and • Paying attention to the patients' medical history in order to help the necessity of screening programs.

Implications for public
In order to decrease the unnecessary referrals for breast cancer screening it is recommended to consider age and medical history. The necessity of breast cancer screening increases with the age particularly more than 40 and also individuals with high risk medical history. These systematic referrals could improve the cost-efficient of healthcare services for both patients and healthcare providers.