Elsevier

Journal of Cancer Policy

Volume 6, December 2015, Pages 37-43
Journal of Cancer Policy

Cost of treatment for children with acute lymphoblastic leukemia in Bangladesh

https://doi.org/10.1016/j.jcpo.2015.10.002Get rights and content

Highlights

  • In developing countries the cost of treating a child with cancer falls on the family.

  • Although the costs are lower than in high income countries they are still not affordable if you live on 2–9$ per day as 84% of parents in this study in Bangladesh.

  • Solutions are urgently required to ensure essential drugs are available, accessible and affordable in all countries.

Abstract

Background

Acute lymphoblastic leukemia (ALL) is the most common childhood malignancy seen in Bangladesh and is potentially curable. However since parents currently have to pay for the full cost of therapy, high rates of treatment refusal and abandonment are observed, principally as a result of non-affordability. To date, no published data on the exact costs has existed for Bangladesh which makes clear parental counselling at diagnosis impossible.

Methods

A cross-sectional study of the costs incurred by 50 families of children with ALL during therapy was conducted at the Pediatric Hematology & Oncology Department of the Bangabandhu Sheikh Mujib Medical University Hospital in Dhaka (BSMMU) from 2010 to 2011. The patients were all treated on a modified United Kingdom Medical Research Council ALL X1 protocol. Each family was asked to retain and submit all receipts for drugs bought from pharmacies, investigations and hospital procedures (LPs and Bone marrow sampling), transport, food and accommodation. Blood and blood products carried a standard hospital fee.

Results

The basic cost of all treatment for each family was 3234 USD (local currency BDT 226,400) of which 48.6% was for essential and cytotoxic drugs (1571 USD); 9.3% for investigations(299 USD); 2.5% for procedures (79 USD); 0.6% for blood and blood products (20 USD); 12.9% for general treatment costs (416 USD) and 26% (848 USD) for other aspects of care including transport to and from hospital, food and parental lodging. However with an average of three episodes of febrile neutropenia/sepsis the mean overall cost rose to 4443 USD. Where there was refractory fever requiring changes in the antibiotic regimen, an additional average sum of 1740 USD was incurred. In such patients the total costs rose to 7672 USD.

Conclusion

The mean treatment cost for Children with ALL in Bangladesh treated on this protocol was 4443 USD (BDT 311,028) with a range of 3234 USD (BDT 226,400) to 7672 USD (BDT 537,040). This data enables more realistic family counselling regarding the financial burden they face for their child's treatment. Although the costs are considerably lower than recorded in high income countries they remain prohibitively high for most parents in low-middle income countries like Bangladesh. During the period of this study treatment abandonment rates were 16%; 62% of which were reported to be due to families not being able to afford the costs. In a parallel project to our study family monthly incomes were recorded. 33% of families earned less than 5000 BDT/month (71 USD), 51% between 5000 and 20,000 (71–285 USD) and only16% more than 20,000 (greater than 285 USD). Solutions to reduce the cost to families in all low-middle income countries are urgently required. To achieve that requires a National and Global effort from medical professionals, the pharmaceutical industry, International agencies and individual Governments. In the long run only universal health coverage can significantly reduce the financial burden for families.

Introduction

In high-income countries at least 75–80% of children with cancer, particularly acute lymphoblastic leukemia (ALL), can be cured with intensive chemotherapy, administered by fully trained interdisciplinary teams in specialized hospital units. Cooperation and collaboration at both national and international levels has helped to achieve this success [1], [2], [3] The costs of such intensive therapy has been calculated at between 100,000–200,000 USD in high income countries (HICs) where health services are free at the point of care, paid by the public sector and /or insurance schemes which cover most but not necessarily all of such costs [4]. Even in HICs there are still significant “out of pocket expenses” incurred by families in many countries, for example in Canada [5], [6]. In sharp contrast survival in low-middle income countries ranges between 10 and 30% [7], [8]. Delays in diagnosis due to public and professional lack of awareness of the meaning of signs and symptoms of disease and hence late referral, advanced stage of disease at presentation and high levels of treatment refusal/abandonment by families all contribute to this decreased survival [9], [10], [11]. Each of these factors and the reasons for them need to be understood and strategies developed to overcome them if the inequality of survival is to be reduced [9], [10], [11], [12].

The single most significant factor influencing survival is poverty (individual family, community and national) which limits availability of health education, resources, facilities,training and the ability to afford the cost of treatment [7], [8], [10], [11], [12]. In spite of the rising incidence of childhood cancer in developing countries as deaths from communicable diseases are gradually reduced [13], [14], relatively high treatment costs preclude a large number of children living in such low-middle income countries from obtaining appropriate and complete treatment for cancer. Although treatment of childhood ALL has improved with consistent therapy using specific protocols, after achievement of complete remission, patients do require phases of intensive therapy and then outpatient treatment for a further 2 years. Consequently non-compliance with treatment schedules, particularly due to “financial abandonment”, is a major problem [10], [11], [15].

Bangladesh has made huge progress in reducing maternal and under—5 mortality rates, in reducing family sizes and starting the demographic transition to middle income status. However in 2013 per capita income was 1044 USD compared to a world average of 8985 USD and there is no public sector healthcare provision, with the majority of medical bills being paid by patients and families [16]. In order to drive fiscal policy, particularly to relatively more expensive areas of healthcare,such as childhood cancers, it is essential to understand the macro-economic impact of these cancers.

There have been few actual previously published reports on the cost of ALL treatment worldwide and none from Bangladesh. This has made realistic counselling of parents and patients very difficult at the time of initial diagnosis if they have to carry the full financial burden. It also makes policy planning in the context of essential medicines, national fiscal policy towards childhood cancer and donor policy difficult without any reliable estimates of costs. In this paper we address this lacuna in the specific field of childhood cancers, in a low income setting, by analyzing the real world economic costs in Bangladesh of treating ALL.

Section snippets

Patients

50 unselected children with ALL were serially recruited to the economic study between 2010 and 2011 from the Department of Pediatric Hematology and Oncology at the BSMMU Hospital. Exclusions included those children who had central nervous system (CNS) and/or testicular involvement at diagnosis and those who do not achieve complete remission at the end of induction therapy. These complications inevitably decrease the chance of survival and increase costs considerably and if included would skew

Investigations costs

For the initial diagnostic investigations (full blood count/film; bone marrow morphology; chest X-ray, basic biochemistry and cerebro-spinal fluid analysis) the average cost was 33 USD (BDT 2315) with a range of 24–112 USD depending on whether immuno-phenotyping was performed (cost 85 USD = BDT 6000). All of these investigations were carried out “in house” at BSMMU. Patients sometimes came having had some investigations already performed elsewhere, which added to the family’s cost but it was not

Discussion

This study was set up initially to determine the financial impact on parents of children with acute lymphoblastic leukaemia (diagnosed at BSMMU Hospital) regarding treatment costs along with other “out of pocket” expenses, since no such information was previously available. Such information could not only be used to advise future parents but also inform both national and donor policymaking to ensure affordable care for children with ALL.

Using this modified ALL protocol, which forgoes some of

Conflict of interest

Professor Tim Eden has no conflicts of interest to declare and is not a paid employee of the hospital where this work was carried nor received any monies for the research or publishing of this article. He has been responsible as the corresponding author for writing the paper and its editing.

Professor Afiqul Islam is head of the unit at BSMMU where this research was carried out and supervised the research project. He received no financial gain for this work and has no conflict of interest to

Acknowledgements

We wish to thank all the parents of children with leukaemia at BSMMU who agreed to participate in this study and for all the members of the department who assisted to make it possible. We wish to thank World Child Cancer for developing the Twinning programme which has enabled the unit to make some progress and to all who support the department and Professor Richard Sullivan for his support of this study.

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