Unbalanced Treatment Costs of Breast Cancer in China: Implications From the Direct Costs of Inpatient and Outpatient Care in Liaoning Province

Document Type : Original Article


1 Department of Health Service Management, China Medical University, Shenyang, China

2 The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China

3 School of Nursing, Capital Medical University, Beijing, China

4 Department of Biostatistics and Epidemiology, School of Public Health, China Medical University, Shenyang, China


The increasing incidence of breast cancer and its financial burden highlights the need for controlling treatment costs. This study aimed to assess the direct costs of inpatient and outpatient care for breast cancer patients in Liaoning Province to provide a policy reference for cost containment.

Based on the System of Health Accounts 2011 (SHA 2011), systematic data collection was conducted via multistage stratified cluster random sampling. A total of 1160 health institutions, including 83 hospitals, 16 public health institutions, 120 primary health institutions, and 941 outpatient institutions were enrolled in 2017. A database was established containing 20 035 patient-level medical records from the information system of these institutions. Curative care expenditure (CCE)was calculated, and generalized linear modeling was performed to determine cost-related factors.

In 2017, the CCE for breast cancer was approximately CNY 830.19 million (US$122.96 million) in Liaoning province (0.7% of the total health expenditure and 9.9% of cancer- related healthcare costs). Inpatient care costs were estimated to be CNY 617.27 million (US$91.42 million), accounting for 74.4% of the CCE for breast cancer, almost three times as large as outpatient costs (25.6%). The average inpatient and outpatient costs for breast cancer were estimated to be CNY 12 108 (US$1793) and CNY 829 (US$123) per visit. Medication cost was the main cost driver, which comprised 84.0% of the average outpatient cost and 37.2% of the mean inpatient cost.

Breast cancer imposes a large economic burden on patients and the social health insurance system. Results show an irrational cost pattern of inpatient and outpatient services, with patients relying excessively on inpatient services for treatment. Promoting outpatient care whenever relevant is conducive to cost containment and rational utilization of resources.


  1. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018;68(6):394-424. doi:10.3322/caac.21492
  2. Feng RM, Zong YN, Cao SM, Xu RH. Current cancer situation in China: good or bad news from the 2018 Global Cancer Statistics? Cancer Commun (Lond). 2019;39(1):22. doi:10.1186/s40880-019-0368-6
  3. Fan L, Strasser-Weippl K, Li JJ, et al. Breast cancer in China. Lancet Oncol. 2014;15(7):e279-289. doi:10.1016/s1470-2045(13)70567-9
  4. Hofmarcher T, Lindgren P, Wilking N, Jönsson B. The cost of cancer in Europe 2018. Eur J Cancer. 2020;129:41-49. doi:10.1016/j.ejca.2020.01.011
  5. The 2017 Statistical Bulletin of China's Health Development. National Health Commission of the People's Republic of China website. http://www.nhc.gov.cn/guihuaxxs/s10743/201806/44e3cdfe11fa4c7f928c879d435b6a18.shtml. Accessed October 23, 2020.
  6. Moses MW, Pedroza P, Baral R, et al. Funding and services needed to achieve universal health coverage: applications of global, regional, and national estimates of utilisation of outpatient visits and inpatient admissions from 1990 to 2016, and unit costs from 1995 to 2016. Lancet Public Health. 2019;4(1):e49-e73. doi:10.1016/s2468-2667(18)30213-5
  7. Lu JJ, Li HA, Xiong Y. Breast cancer inpatients undergoing mastectomy from a hospital in Guangzhou, China: a retrospective analysis 2004- 2013. Asian Pac J Cancer Prev. 2015;16(11):4577-4581. doi:10.7314/apjcp.2015.16.11.4577
  8. Li R, Zhang L, Yang J, et al. Analysis of inpatient payments of breast cancer patients with different medical insurance coverages in China (mainland) in 2011-2015. Chin J Cancer Res. 2017;29(5):419-425. doi:10.21147/j.issn.1000-9604.2017.05.06
  9. Liao XZ, Shi JF, Liu JS, et al. Medical and non-medical expenditure for breast cancer diagnosis and treatment in China: a multicenter cross-sectional study. Asia Pac J Clin Oncol. 2018;14(3):167-178. doi:10.1111/ajco.12703
  10. Organization for Economic Cooperation and Development, Eurostat, World Health Organization. A System of Health Accounts. Paris: OECD Publishing; 2011.
  11. Dieleman JL, Graves CM, Templin T, et al. Global health development assistance remained steady in 2013 but did not align with recipients' disease burden. Health Aff (Millwood). 2014;33(5):878-886. doi:10.1377/hlthaff.2013.1432
  12. Bui AL, Lavado RF, Johnson EK, et al. National health accounts data from 1996 to 2010: a systematic review. Bull World Health Organ. 2015;93(8):566-576d. doi:10.2471/blt.14.145235
  13. World Health Organizationn. Health accounts methodology. http://www.who.int/health-accounts/methodology/en/. Accessed October 23, 2020.
  14. Maeda A, Harrit M, Mabuchi S, Siadat B, Nagpal S. Creating Evidence for Better Health Financing Decisions: A Strategic Guide for the Institutionalization of National Health Accounts. Washington, DC: The World Bank; 2012.
  15. Mueller M, Morgan D. New insights into health financing: first results of the international data collection under the System of Health Accounts 2011 framework. Health Policy. 2017;121(7):764-769. doi:10.1016/j.healthpol.2017.04.008
  16. He J, Yin Z, Duan W, Wang Y, Wang X. Factors of hospitalization expenditure of the genitourinary system diseases in the aged based on "System of Health Account 2011" and neural network model. J Glob Health. 2018;8(2):020504. doi:10.7189/jogh.08.020504
  17. Fu W, Zhao S, Zhang Y, Chai P, Goss J. Research in health policy making in China: out-of-pocket payments in Healthy China 2030. BMJ. 2018;360:k234. doi:10.1136/bmj.k234
  18. Guo LW, Huang HY, Shi JF, et al. Medical expenditure for esophageal cancer in China: a 10-year multicenter retrospective survey (2002-2011). Chin J Cancer. 2017;36(1):73. doi:10.1186/s40880-017-0242-3
  19. Manning WG, Mullahy J. Estimating log models: to transform or not to transform? J Health Econ. 2001;20(4):461-494. doi:10.1016/s0167-6296(01)00086-8
  20. Luengo-Fernandez R, Leal J, Gray A, Sullivan R. Economic burden of cancer across the European Union: a population-based cost analysis. Lancet Oncol. 2013;14(12):1165-1174. doi:10.1016/s1470-2045(13)70442-x
  21. Allaire BT, Ekwueme DU, Guy GP Jr, et al. Medical care costs of breast cancer in privately insured women aged 18-44 years. Am J Prev Med. 2016;50(2):270-277. doi:10.1016/j.amepre.2015.08.035
  22. Bonastre J, Jan P, Barthe Y, Koscielny S. Metastatic breast cancer: we do need primary cost data. Breast. 2012;21(3):384-388. doi:10.1016/j.breast.2012.03.012
  23. Ekwueme DU, Allaire BT, Guy GP Jr, Arnold S, Trogdon JG. Treatment costs of breast cancer among younger women aged 19-44 years enrolled in Medicaid. Am J Prev Med. 2016;50(2):278-285. doi:10.1016/j.amepre.2015.10.017
  24. Zhang A, Nikoloski Z, Mossialos E. Does health insurance reduce out-of-pocket expenditure? Heterogeneity among China's middle-aged and elderly. Soc Sci Med. 2017;190:11-19. doi:10.1016/j.socscimed.2017.08.005
  25. Pathak R, Giri S, Aryal MR, Karmacharya P, Bhatt VR, Martin MG. Mortality, length of stay, and health care costs of febrile neutropenia-related hospitalizations among patients with breast cancer in the United States. Support Care Cancer. 2015;23(3):615-617. doi:10.1007/s00520-014-2553-0
  26. EUROSTAT. Cancer statistics. https://ec.europa.eu/eurostat/statistics-explained/index.php/Cancer_statistics_-_specific_cancers#Breast_cancer. Accessed August 21, 2020.
  27. McBride A, Campen CJ, Camamo J, et al. Implementation of a pharmacy-managed program for the transition of chemotherapy to the outpatient setting. Am J Health Syst Pharm. 2018;75(9):e246-e258. doi:10.2146/ajhp170138
  28. Joo EH, Rha SY, Ahn JB, Kang HY. Economic and patient-reported outcomes of outpatient home-based versus inpatient hospital-based chemotherapy for patients with colorectal cancer. Support Care Cancer. 2011;19(7):971-978. doi:10.1007/s00520-010-0917-7
  29. Sung H, Rosenberg PS, Chen WQ, et al. Female breast cancer incidence among Asian and Western populations: more similar than expected. J Natl Cancer Inst. 2015;107(7):djv107. doi:10.1093/jnci/djv107
  30. Yao N, Zhang N, Wang J, et al. Experiences with cancer survey in China. Cancer. 2019;125(17):3068-3078. doi:10.1002/cncr.32164
  31. Wang Z, Li X, Chen M, Si L. Social health insurance, healthcare utilization, and costs in middle-aged and elderly community-dwelling adults in China. Int J Equity Health. 2018;17(1):17. doi:10.1186/s12939-018-0733-0
  32. Meng Z, Ma Y, Song S, et al. Economic implications of Chinese diagnosis-related group-based payment systems for critically ill patients in ICUs. Crit Care Med. 2020;48(7):e565-e573. doi:10.1097/ccm.0000000000004355

Articles in Press, Corrected Proof
Available Online from 01 August 2021
  • Receive Date: 28 October 2020
  • Revise Date: 05 June 2021
  • Accept Date: 23 June 2021