DISABILITY BURDEN AND ECONOMIC LOSS OF CANCER PATIENTS

The Descriptive cross sectional study was conducted over the period of 1st July 2006 to 30th June 2007 (one year) to estimate disability burden and economic loss incurred by cancer patients. The study was carried out among 224 cancer patients who attended the National Institute Cancer Research & Hospital (NIRCH). Data was collected by face-to-face interview using a semi-structured questionnaire and systematic random sampling technique. Disability burden of cancer was measured in terms of years of life lived (YLD) and economic loss was estimated by health care expenditure incurred by the cancer patients. Out of all, major part (59.82%) was male while 40.18% was female and most of them were in middle age group (40-49 years) with mean age of 49.18 (SD±14.66) years. Most of the patients (93%) were Muslims and majority (83%) was married. Maximum number of patients (38.39%) had primary level education with a large illiterate segment (27.68%). By occupation, maximum patients were housewives (28.73%) followed by agriculturers (25.50%). The average family size was 4.6 (SD±2.53) and majority (39.28%) was in poor income group (<Tk.5000). According to primary site, common cancers included cancer of lung (25%) & cervix (16.96%) followed by cancer of breast (13.39%), lymph node & lymphatic (6.70%), larynx (5.36%), oral cavity (5.36%), oesophagus (4.46%), leukemia (4.46%), bone & cartilage (4.02%), stomach (2.68%), skin (2.68%), prostate (1.79%), liver (0.89%), endocrine gland (0.89%) & caner of unknown primary origin (5.36%). Most male cancer patients (73.88%) had smoking habit in contrast to 7.78% female patients, which showed statistical significance (÷2 test, p<0.01). Male patients shared more YLDs (64%) than female patients (36%), which was statistically significant (‘t’ test, p<0.05). It was emerged that the highest YLD was shared by the active age group (63.8%), middle-income group (40.35%) and by poorly educated patients (69%). Average treatment cost incurred by the cancer patients was TK.5,773.11 (±SD272.39) and it was more among the higher income, middle age and educated patients, which were statistically significant (ANOVA, p<0.01). Male patients shared higher average treatment cost (TK.7,158.65 ±SD337.76) than their female counterparts (TK.4387.57 ±SD 207.02) and revealed statistical significance (‘t’ test, p<0.01). Ca Lung incurred highest average treatment cost (TK.8,247.86 ±SD121.43) followed by Ca cervix (TK.7,787.73 ±SD118.56) and Ca breast (TK.7,183.53 ±SD104.63). Half of the patients were treated by combination of surgery, chemotherapy & radiotherapy and surgery being most costly (TK.8,574.96 ±SD 455.23), which was statistically significant (ANOVA, p<0.01).


Introduction:
Cancer holds the second position among the noncommunicable diseases under study of World Health Organization (WHO). 1,2It is evidenced that in the developing societies, demographic transition has contributed to the increased prevalence of cancer and other non-communicable diseases.It was found that about 5 million new cases of cancer are diagnosed and 7.8 million people die of cancer every year globally, of which 3.5 million deaths occur in developing countries. 3,4On the contrary, about 17% Disability Adjusted Life Years (DALYs) are lost in developed worlds and 9.0% DALYs are lost in developing worlds in one year due to cancer.The GBD study specifically demarcated that epidemiological transition is occurring also in South Asia and burden of cancer is J MEDICINE 2008; 9 : 3-9 .

ORIGINAL ARTICLES
[7] It is reported that magnitude of cancer is increasing in a rapid pace globally.2][13][14] About 2 million new cases of cancer are diagnosed each year and 10 lack people are living with different types of cancer with overall incidence rate of 182 per 100,000 population in Bangladesh.9] Cancer causes serious economic damage to the households since medical care required against the disease is usually very expensive.Cancer exert huge economic pressure both on the household economy as well as public health sector. 20It is imperative to estimate the disability and economic burden of cancer patients as no comprehensive and rigorous study in this regard is available at present in the context of Bangladesh.The purpose of this study aims to address the issues related to burden of cancer, which will provide data essential for formulating policies and strategies to combat this burning public health problem.

Rationale:
The present study will explore disability and economic burden shared by cancer patients.The study will have profound academic and policy implications.At the academic level, it may upgrade the knowledge in the public health field by yielding information in different dimension, as there is no similar study available in context in Bangladesh.Besides, important feature of the proposed study will be that it will follow the approach and method used in the GBD study.So that it can generate a set of estimates of the patterns of disability and economic burden of cancer and may be comparable with the estimates of the same in other countries.Besides its academic significance, the study can depict useful policy implications.The study will help in prioritization of cancer comparing with other diseases prevalent in the country in terms of disability burden and economic loss of cancer patients, which will contribute to formulate effective health policy and health care financing.

Materials and Methods:
For estimation of disability burden of cancer in terms of YLD, age weight, time preference, disability weight, discount rate and age at onset of the disease were used.While to estimate the economic loss, direct cost incurred by the patients was calculated.Descriptive cross-sectional study was conducted during the period of 1 st July 2006 to 30 th June 2007 among 224 cancer patients, who attended National Institute of Cancer Research and Hospital.Data was collected by systematic random sampling technique using, which were finalized after pre-testing.Face-to-face interview & by reviewing medical documents were the techniques in this regards.Data was processed by editing & post-coding and analyzed by SPSS software (version 15.0).

Results:
Out of 224 patients, 59.82% were male and 40.18% were female with a male: female ratio of 1.49:1.00.About 55% patients were in the age group of 40-64 years followed by 22.77% patients in geriatric age group (e" 65 years) while the lowest (5.36%) were in pediatric group (0-15 years) and mean age of the patients was 49.18 (SD±14.66)years.Most (93%) of the patients were Muslims and % was married (83%).Regarding educational qualification, 38.39% patients had primary level education while 27.68% were illiterate.Around 29% patients were housewives, followed by 25.50% agriculturers and 20.09% were service holders.Average family size was 4.6 (SD±2.5334)and average monthly family income was TK.8,129.88(SD ±6,809.21)but majority (35.71%) patients had monthly family income between TK. 5,001-TK.10,000.
In respect of primary site of cancer, lung cancer was 25%, cervical cancer (17%) and 13.4% was breast cancer.Among others, Ca Lymph node & Lymphatic (6.70%), larynx (5.36%), oral cavity (5.36%), oesophagus (4.46%), leukemia (4.46%), bone & cartilage (4.02%), stomach (2.68%), skin (2.68%), prostate (1.79%), liver (0.89%) and Ca endocrine gland (0.89%) while 5.36% cancer was of unknown primary origin.It was also revealed that most of all cancers except ca cervix were more in male than female & it was statistically significant (χ 2 test, p<0.01).Lung cancer (64.28%) and cervical cancer (63.16%) were found among older patients (³50 years) followed by 23.21% and 26.32% were detected respectively in the middle age group (40-49 years).Beast cancer was predominant (53.34%) in the middle age group followed by 20% in the older age group.All theses differences were statistically significant (χ 2 test, p<0.05).It was revealed that Ca larynx (33%) and Ca oesophagus (30%) were almost equal in the age group 40-49, e"50 years and unknown primary cancer was detected in all the age group except 16-27 years.A different feature was extracted in case of leukemia as it was only detected in the age group 0-15 years (70%) and 16-27 years (30%).This discrepancy was statistically significant (χ 2 test, p<0.01).Ca Bones & Cartilage and Ca endocrine gland were more common among the middle age group while Ca skin, Ca stomach and Ca prostate were predominant in the older age group.Most of the male patients (74%) had smoking habit while most of the female patients (92%) had no smoking habit and the findings were statistically significant (χ 2 test, p<0.01).
Disability burden of cancer was estimated in terms of YLD, which is depicted in the following Table-I.In respect of sex, large amount of YLD (64%) was incurred by the male patients and mean YLD shared by male patients (131.72) was also higher than the female patients (110.31) and these sex differentials were statistically significant (

Fig-1: Distribution of Average Treatment Cost by Monthly Family Income
For estimation of treatment cost, only direct cost was considered and average treatment cost was estimated TK.5,773.11(±SD272.39).The study conducted Greenwald P et al in USA showed higher cost for hospital care than cost for drug, food and investigation.Moreover the study found more indirect cost shared by cancer patients than direct cost.It was also depicted that educated patients shared higher average treatment cost than illiterate patients, which was statistically significant (ANOVA, p<0.01).The reasons behind this may be the educated patients were more aware and they spent more for investigations and treatment of cancer.

Conclusion:
The

Table - II
Different Types of Treatment Cost (Average) Shared by Cancer Patients

Table - III
Distribution of Average Treatment Cost by Types of Cancer descriptive cross-sectional study was carried out with a view to estimate disability burden and economic loss shared by cancer patients.According to primary site, common cancers included cancer of lung, cervix, breast, lymph node & lymphatic, larynx, oral cavity, oesophagus, bone & cartilage, stomach, skin, prostate, liver, of unknown primary origin and leukaemia.Most of the lung cancer patients were male, who were mostly smokers while most of the female patients were mostly non-smokers and had Ca cervix.Ca lung and Ca cervix were predominant among older patients but Ca breast was predominant in the middle age group.Regarding disability burden, Ca lung shared highest mean YLDs followed by Ca cervix & Ca breast.Male patients shared more YLDs than female patients.It was emerged that the middle age group, lower income group and poorly educated patients shared more mean YLDs.Regarding treatment, half of the patients were treated by combination of surgery, chemotherapy & radiotherapy.The highest average treatment cost was incurred by surgery followed by chemotherapy, radiotherapy & lab investigation.Male patients incurred more treatment cost than their female counterparts.Ca Lung incurred the highest average treatment cost tenured by Ca cervix and Ca breast.Middle & older age group shared the more treatment cost than younger patients.It was also focused that the highest average treatment cost was shared by higher income group and educated patients.The study findings will play a crucial role in policy making to combat the disability & economic burden of cancer in context of Bangladesh.