Attitude of Iranian Medical Oncologists Toward Economic Aspects, and Policy-making in Relation to New Cancer Drugs

Document Type : Original Article


1 Cancer Research Center, Cancer Institute of Iran, Tehran University of Medical Sciences, Tehran, Iran

2 Department of Health Economics and Management, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran

3 Hematology and Medical Oncology Department, Cancer Research Center, Cancer Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran

4 Cancer Model Research Center, Cancer Institute of Iran, Tehran University of Medical Sciences, Tehran, Iran


Although medical oncologists can have an important role in controlling the cost of cancer treatment, there is little information about their attitudes toward the cost of cancer treatment and the impact of cost on their treatment recommendations, especially in low- and middle-income countries (LMICs). In this study, we assessed the attitude of Iranian medical oncologists toward some economic aspects of new cancer drugs.
We translated a questionnaire that was used in similar studies in the United States and Canada into Persian and modified it according to the local setting in Iran. The face and content validity of the questionnaire were assessed by oncologists before being used in the survey. We distributed the questionnaire and collected the data from 80 oncologists who participated in the 13th Annual Congress of the Iranian Society of Medical Oncology and Hematology (ISMOH).
Fifty-two oncologists participated in our study (a response rate of 65%). The majority of oncologists stated that drug costs and patient out-of-pocket (OOP) costs influence their treatment recommendations (92% and 94%, respectively). Most oncologists (70%) felt that they are ready enough to use cost-effectiveness information in their treatment decisions, and 74% believed that patients should only have access to cancer treatments that are cost-effective. Most oncologists agree that the government should have control over drug prices, and more use of cost‐effectiveness data is required for decision-making about cancer drug coverage. Ninety-one percent of oncologists said that they always or frequently discuss cancer treatment costs with their patients. Oncologists believed that academic groups (research centers and scientific societies) (81%) and the Ministry of Health (MoH) (43%) are the most eligible groups for determining whether a drug provides good value.
Iranian medical oncologists are ready to participate in the health technology assessment and prioritysetting process. This situation creates a unique opportunity for the government to rely on scientific societies and find an appropriate solution for the improvement of patients’ access to high-quality care.


Main Subjects


    1. Rosamond T. The high cost of cancer drugs and what we can do about it. Paper presented at: Mayo Clinic Proceedings; 2013.
    2. Experts in Chronic Myeloid Leukemia. The price of drugs for chronic myeloid leukemia (CML) is a reflection of the unsustainable prices of cancer drugs: from the perspective of a large group of CML experts. Blood. 2013;121(22):4439-4442. doi:10.1182/blood-2013-03-490003
    3. Neumann PJ, Palmer JA, Nadler E, Fang C, Ubel P. Cancer therapy costs influence treatment: a national survey of oncologists. Health Affairs. 2010;29(1):196-202. doi:10.1377/hlthaff.2009.0077
    4. Meropol NJ, Schrag D, Smith TJ, et al. American Society of Clinical Oncology guidance statement: the cost of cancer care. J Clin Oncol. 2009;27(23):3868-3874. doi:10.1200/jco.2009.23.1183
    5. The World Bank Data. Country and Lending Groups. Accessed May 13, 2015.
    6. Marseille E, Larson B, Kazi DS, Kahnd JG, Rosenb S. Thresholds for the cost–effectiveness of interventions: alternative approaches. Bull World Health Organ. 2015;93(2):65-132.
    7. Kantarjian HM, Fojo T, Mathisen M, Zwelling LA. Cancer drugs in the United States: Justum Pretium—the just price. J Clin Oncol. 2013;31(28):3600-3604. doi:10.1200/jco.2013.49.1845
    8. Bullock AJ, Hofstatter EW, Yushak ML, Buss MK. Understanding patients' attitudes toward communication about the cost of cancer care. J Oncol Pract. 2012;8(4):e50-e58. doi:10.1200/jop.2011.000418
    9. Shih YCT, Halpern MT. Economic evaluations of medical care interventions for cancer patients: how, why, and what does it mean? CA: A Cancer Journal for Clinicians. 2008;58(4):231-244. doi:10.3322/ca.2008.0008
    10. Rouhollahi M, Mohamdnejad S, Harirchi I, et al. Recommendations for management of the Trastuzumab (Herceptin) among Iranian breast cancer patients, a policy brief. Basic & Clinical Cancer Research. 2014;6(2):27-34.
    11. Hajizadeh M, Nghiem HS. Out-of-pocket expenditures for hospital care in Iran: who is at risk of incurring catastrophic payments? Int J Health Care Finance Econ. 2011;11(4):267-285. doi:10.1007/s10754-011-9099-1
    12. Bazyar M, Pourreza A, Harirchi I, Akbari F, Mahmoudi M. Medical and non-medical direct costs of cancers in patients hospitalized in Imam Khomeini cancer institution - 2010. Hospital Journal. 2012;11 (1):39-50.
    13. Ministry of Health and Medical Education (MoHME), Internatinal Affairs Departement. Health Evolution Plan in the Islamic Republic of Iran. Accessed July 27, 2015.
    14. Alexander GC, Casalino LP, Tseng CW, McFadden D, Meltzer DO. Barriers to patient‐physician communication about out‐of‐pocket costs. J Gen Intern Med. 2004;19(8):856-860. doi:10.1111/j.1525-1497.2004.30249.x
    15. Pouragha B, Pourreza A, Jaafaripooyan E, et al. The effect of access and out of pocket payment on the utilization of physicians services. World Appl Sci J. 2013;22(1):104-112.
    16. Delavari H, Keshtkaran A, Setoudehzadeh F. Catastrophic health expenditures and coping strategies in households with cancer patients in Shiraz Namazi hospital. Middle East Journal of Cancer. 2014;5(1):13-22.
    17. Ansaripour A, Uyl-de Groot CA, Steenhoek A, Redekop WK. The drug reimbursement decision-making system in Iran. Value in Health Regional Issues. 2014;3:174-181.
    18. Drug Deputy of Iran Food and Drug Organization. The Drug Sales Statistics During 2014 (AmarNameh). Tehran, Iran: Ministry of Health and Medical Education; 2015.
    19. Ferlay J, Soerjomataram I, Dikshit R, et al. Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer. 2015;136(5):E359-E386. doi:10.1002/ijc.29210
    20. Berry SR, Hubay S, Soibelman H, Martin DK. The effect of priority setting decisions for new cancer drugs on medical oncologists' practice in Ontario: a qualitative study. BMC Health Serv Res. 2007;7(1):193. doi:10.1186/1472-6963-7-193
    21. de Kort SJ, Kenny N, van Dijk P, Gevers S, Richel DJ, Willems DL. Cost issues in new disease-modifying treatments for advanced cancer: In-depth interviews with physicians. Eur J Cancer. 2007;43(13):1983-1989. doi:10.1016/j.ejca.2007.05.017
    22. Berry SR, Bell CM, Ubel PA, et al. Continental divide? The attitudes of US and Canadian oncologists on the costs, cost-effectiveness, and health policies associated with new cancer drugs. J Clin Oncol. 2010;28(27):4149-4153. doi:10.1200/jco.2010.29.1625
    23. Nadler E, Eckert B, Neumann PJ. Do oncologists believe new cancer drugs offer good value? Oncologist. 2006;11(2):90-95.
    24. Schrag D, Hanger M. Medical oncologists' views on communicating with patients about chemotherapy costs: A pilot survey. J Clin Oncol. 2007;25(2):233-237. doi:10.1200/jco.2006.09.2437
    25. Thomson J, Schofield P, Mileshkin L, et al. Do oncologists discuss expensive anti-cancer drugs with their patients? Ann Oncol. 2006;17(4):702-708. doi:10.1093/annonc/mdj136
    26. Greenberg D, Hammerman A, Vinker S, Shani A, Yermiahu Y, Neumann PJ. Oncologists’ and family physicians’ views on value for money of cancer and congestive heart failure care. Isr J Health Policy Res. 2013;2:44. doi:10.1186/2045-4015-2-44
    27. Tangka FK, Trogdon JG, Richardson LC, Howard D, Sabatino SA, Finkelstein EA. Cancer treatment cost in the United States. Cancer. 2010;116(14):3477-3484. doi:10.1002/cncr.25150
    28. Schnipper LE, Davidson NE, Wollins DS, et al. American society of clinical oncology statement: a conceptual framework to assess the value of cancer treatment options. J Clin Oncol. 2015;33(23):2563-2577. doi:10.1200/JCO.2015.61.6706
    29. Kaser E, Shaw J, Marven M, Swinburne L, Boyle F. Communication about high-cost drugs in oncology—the patient view. Ann Oncol. 2010;21(9):1910-1914. doi:10.1093/annonc/mdq068
    30. Henrikson NB, Tuzzio L, Loggers ET, Miyoshi J, Buist DS. Patient and oncologist discussions about cancer care costs. Support Care Cancer. 2014;22(4):961-967. doi:10.1007/s00520-013-2050-x
    31. Hofstatter EW. Understanding patient perspectives on communication about the cost of cancer care: a review of the literature. J Oncol Pract. 2010;6(4):188-192. doi:10.1200/jop.777002
    32. Irwin B, Kimmick G, Altomare I, et al. Patient experience and attitudes toward addressing the cost of breast cancer care. Oncologist. 2014;19(11):1135-1140.  
    33. Bestvina CM, Zullig LL, Rushing C, et al. Patient-oncologist cost communication, financial distress, and medication adherence. J Oncol Pract. 2014;10(3):162-167. doi:10.1200/jop.2014.001406
    34. Rosenberg-Yunger ZR, Thorsteinsdóttir H, Daar AS, Martin DK. Stakeholder involvement in expensive drug recommendation decisions: an international perspective. Health Policy. 2012;105(2):226-235. doi:10.1016/j.healthpol.2011.12.002
    35. Pfister DG. The just price of cancer drugs and the growing cost of cancer care: Oncologists need to be part of the solution. J Clin Oncol. 2013;31(28):3487-3489. doi:10.1200/jco.2013.50.3466
    36. Baradaran-Seyed Z, Nedjat S, Yazdizadeh B, Nedjat S, Majdzadeh R. Barriers of clinical practice guidelines development and implementation in developing countries: a case study in iran. Int J Prev Med. 2013;4(3):340.