Financial catastrophe, treatment discontinuation and death associated with surgically operable cancer in South-East Asia: Results from the ACTION Study The ACTION Study Group*
Background. This study assessed the extent to which individuals with surgically operable cancer in Southeast Asia experience financially catastrophic out-of-pocket costs, discontinuation of treatment, or death. Methods. The ACTION study is a prospective, 8-country, cohort study of adult patients recruited consecutively with an initial diagnosis of cancer from public and private hospitals. Participants were interviewed at baseline and 3 months. In this paper, we identified 4,584 participants in whom surgery was indicated in initial treatment plans and assessed the following competing outcomes: death, financial catastrophe (out-of-pocket costs of >30% of annual household income), treatment discontinuation, and hospitalization without financial catastrophe incurred. We then analyzed a range of predictors using a multinomial regression model. Results. Of the participants, 72% were female and 44% had health insurance at baseline. At 3 months, 31% of participants incurred financial catastrophe, 8% had died, 23% had discontinued treatment, and 38% were hospitalized but avoided financial catastrophe. Health insurance status was found to be associated with lower odds of treatment discontinuation (odds ratio [OR], 0.60; 95% CI, 0.47–0.77) relative to hospitalization without financial catastrophe. Women had greater odds of financial catastrophe than men (OR, 1.35; 95% CI, 1.05–1.74), whereas lower socioeconomic status (range of indicators) was generally found to be associated with higher odds of death, treatment discontinuation, and financial catastrophe. Conclusion. Priority should be given to measures such as programs to extend social health insurance to offset the out-of-pocket costs associated with surgery for cancer faced in particular by women, the uninsured, and individuals of low socioeconomic status in Southeast Asia. (Surgery 2015;157:971-82.)
IN THE ASSOCIATION OF SOUTH-EAST ASIAN NATIONS (ASEAN), with a population of approximately 600 million, there were >700,000 new cases of cancer and 500,000 cancer deaths in 2008.1 This burden will rise with the expected increase in the *Refers to Appendix 3. Funding: Unrestricted educational grant from Roche Asia Pacific. S.J. is the recipient of an Australian National Health and Medical Research Council (NHMRC) Senior Research Fellowship and M.W. is the recipient of an NHMRC Principal Research Fellowship. Accepted for publication February 28, 2015. Reprint requests: Stephen Jan, PhD, The George Institute for Global Health, PO Box M201, Missenden Road, Camperdown, Sydney, NSW 2050, Australia. Email: [email protected] 0039-6060/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.surg.2015.02.012
number of new cases in Asia over the next decade.2 The treatment of most cancers requires some combination of surgery, radiotherapy, and systemic chemotherapy.3 However, the cost associated with surgery can represent a substantial and unexpected economic burden for households, particularly among the poor and underinsured. As a consequence, many patients diagnosed with operable cancer in Asia and around the world face the prospect of financial ruin. Noncommunicable diseases such as cancer have been found to impose significant household economic burden in low- and middle-income countries.4-6 This financial burden is commonly defined in terms of incidence of financial catastrophe, where out-of-pocket expenditure for health care exceeds a defined threshold proportion of annual income, usually 30% of annual household income7-9 or 40% of nonfood expenditure or SURGERY 971
972 The ACTION Study Group
76 14.5 11.8 *The World Bank http://data.worldbank.org/ (accessed September 26, 2014). yGlobocan 2012: Estimated cancer incidence, mortality and prevalence worldwide in 2012; available from http://globocan.iarc.fr/Default.aspx (accessed September 26, 2014). GNI, Gross national income; LI, low income; LMI, lower middle income; UMI, upper middle income.
74 14.2 10.1 69 14.8 9.8 65 14.7 12.2 75 15.0 9.2 71 14.0 9.7 71 14.7 12.0
68 15.1 12.9
102 85.0 215 55.8 119 83.5 20 93.7 410 79.0 108 75.1 51 81.9
40 78.2
89.7 1,730 (LMI) 67.0 5,370 (UMI) 98.4 3,270 (LMI) 53.2 N/A (LI) 29.7 10,400 (UMI) 250.0 3,580 (LMI) 15.1 950 (LI)
Population in 2013 (millions)* GNI/capita in 2013 ($USD Atlas method) and World Bank income classification* Health expenditure per capita in 2012 ($USD)* Out-of-pocket expenditure as % of private expenditure on health in 2012* (%) Life expectancy from birth in 2012 (y)* Risk of cancer at
Background. This study assessed the extent to which individuals with surgically operable cancer in Southeast Asia experience financially catastrophic out-of-pocket costs, discontinuation of treatment, or death. Methods. The ACTION study is a prospective, 8-country, cohort study of adult patients recruited consecutively with an initial diagnosis of cancer from public and private hospitals. Participants were interviewed at baseline and 3 months. In this paper, we identified 4,584 participants in whom surgery was indicated in initial treatment plans and assessed the following competing outcomes: death, financial catastrophe (out-of-pocket costs of >30% of annual household income), treatment discontinuation, and hospitalization without financial catastrophe incurred. We then analyzed a range of predictors using a multinomial regression model. Results. Of the participants, 72% were female and 44% had health insurance at baseline. At 3 months, 31% of participants incurred financial catastrophe, 8% had died, 23% had discontinued treatment, and 38% were hospitalized but avoided financial catastrophe. Health insurance status was found to be associated with lower odds of treatment discontinuation (odds ratio [OR], 0.60; 95% CI, 0.47–0.77) relative to hospitalization without financial catastrophe. Women had greater odds of financial catastrophe than men (OR, 1.35; 95% CI, 1.05–1.74), whereas lower socioeconomic status (range of indicators) was generally found to be associated with higher odds of death, treatment discontinuation, and financial catastrophe. Conclusion. Priority should be given to measures such as programs to extend social health insurance to offset the out-of-pocket costs associated with surgery for cancer faced in particular by women, the uninsured, and individuals of low socioeconomic status in Southeast Asia. (Surgery 2015;157:971-82.)
IN THE ASSOCIATION OF SOUTH-EAST ASIAN NATIONS (ASEAN), with a population of approximately 600 million, there were >700,000 new cases of cancer and 500,000 cancer deaths in 2008.1 This burden will rise with the expected increase in the *Refers to Appendix 3. Funding: Unrestricted educational grant from Roche Asia Pacific. S.J. is the recipient of an Australian National Health and Medical Research Council (NHMRC) Senior Research Fellowship and M.W. is the recipient of an NHMRC Principal Research Fellowship. Accepted for publication February 28, 2015. Reprint requests: Stephen Jan, PhD, The George Institute for Global Health, PO Box M201, Missenden Road, Camperdown, Sydney, NSW 2050, Australia. Email: [email protected] 0039-6060/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.surg.2015.02.012
number of new cases in Asia over the next decade.2 The treatment of most cancers requires some combination of surgery, radiotherapy, and systemic chemotherapy.3 However, the cost associated with surgery can represent a substantial and unexpected economic burden for households, particularly among the poor and underinsured. As a consequence, many patients diagnosed with operable cancer in Asia and around the world face the prospect of financial ruin. Noncommunicable diseases such as cancer have been found to impose significant household economic burden in low- and middle-income countries.4-6 This financial burden is commonly defined in terms of incidence of financial catastrophe, where out-of-pocket expenditure for health care exceeds a defined threshold proportion of annual income, usually 30% of annual household income7-9 or 40% of nonfood expenditure or SURGERY 971
972 The ACTION Study Group
76 14.5 11.8 *The World Bank http://data.worldbank.org/ (accessed September 26, 2014). yGlobocan 2012: Estimated cancer incidence, mortality and prevalence worldwide in 2012; available from http://globocan.iarc.fr/Default.aspx (accessed September 26, 2014). GNI, Gross national income; LI, low income; LMI, lower middle income; UMI, upper middle income.
74 14.2 10.1 69 14.8 9.8 65 14.7 12.2 75 15.0 9.2 71 14.0 9.7 71 14.7 12.0
68 15.1 12.9
102 85.0 215 55.8 119 83.5 20 93.7 410 79.0 108 75.1 51 81.9
40 78.2
89.7 1,730 (LMI) 67.0 5,370 (UMI) 98.4 3,270 (LMI) 53.2 N/A (LI) 29.7 10,400 (UMI) 250.0 3,580 (LMI) 15.1 950 (LI)
Population in 2013 (millions)* GNI/capita in 2013 ($USD Atlas method) and World Bank income classification* Health expenditure per capita in 2012 ($USD)* Out-of-pocket expenditure as % of private expenditure on health in 2012* (%) Life expectancy from birth in 2012 (y)* Risk of cancer at
