J Cancer 2013; 4(7):531-535. doi:10.7150/jca.6211

Research Paper

Significantly Increased Medical Expenditure on Breast Cancer Failing to Bring Down Its Mortality and Incidence Rate

Ming-Lin Ho1,2, Yung-Po Liaw3, Chien-Hsu Lai4, Yen-Yu Chen4, Horng-Der Tsai5, Ming-Chih Chou1,6 Corresponding address, Yi-Hsuan Hsiao7,5 Corresponding address

1. Institute of Medicine, Chung Shan Medical University, No. 110 Sec 1 Chien-Kuo N. Road, Taichung City 40201, Taiwan;
2. Division of Pulmonary Medicine, Department of Internal Medicine, Changhua Christian Hospital, 135 Nanhsiao Street, Changhua, 500 Taiwan;
3. Department of Public Health and Institute of Public Health, Chung Shan Medical University, No. 110 Sec 1 Chien-Kuo N. Road, Taichung City 40201, Taiwan;
4. Department of Neurology, Changhua Christian Hospital, 135 Nanhsiao Street, Changhua, 500 Taiwan;
5. Department of Obstetrics and Gynecology, Changhua Christian Hospital, 135 Nanhsiao Street, Changhua, 500 Taiwan;
6. Division of Thoracic Surgery, Department of Surgery, Chung Shan Medical University Hospital, No. 110 Sec 1 Chien-Kuo N. Road, Taichung City 40201, Taiwan;
7. School of Medicine, Chung Shan Medical University, No. 110 Sec 1 Chien-Kuo N. Road, Taichung City 40201, Taiwan.

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How to cite this article:
Ho ML, Liaw YP, Lai CH, Chen YY, Tsai HD, Chou MC, Hsiao YH. Significantly Increased Medical Expenditure on Breast Cancer Failing to Bring Down Its Mortality and Incidence Rate. J Cancer 2013; 4(7):531-535. doi:10.7150/jca.6211. Available from http://www.jcancer.org/v04p0531.htm

Abstract

Background: The direct impact of medical expenses on breast cancer incidence and mortality rate has not been sufficiently addressed. The purpose of this study is to investigate the potential correlation between the incidence and mortality rate of breast cancer and the medical expenses in Taiwan.

Materials and Methods: Breast cancer cases were identified from the National Health Insurance Research Database (NHIRD) with corresponding to International Classification of Diseases, and the Ninth Revision (ICD-9) code 174, 1740-1749, 175, 1750 and 1759 from January 1999 to December 2006. Age-specific incidences were estimated by population data obtained from the Department of Statistics, Ministry of the Interior. Medical expenses, including outpatient and inpatient services, were also retrieved from the NHIRD.

Results: The incidence increased from 20.06 per 100,000 in 1999 to 30.34 per 100,000 in 2006; the total expenses increased from 1,449,333,521 in 1999 to 4,350,400,592 Taiwan dollars in 2006. The age-standardized mortality rate for female breast cancer remained essentially unchanged, while the age-standardized incidence increased steadily (except 2002-2003). Among the top 20 coexisting ICD-9 codes for expenses, four are directly on cancers, while 16 are on other diseases or symptoms, which are not necessarily caused by breast cancer.

Conclusions: Significantly increased medical expenditure on breast cancer failed to bring down its mortality and incidence rate. The finding has implications for healthcare policy planners in proposing strategies for breast cancer control and allocating the resources.

Keywords: incidence, medical expense, breast cancer, Taiwan.

Introduction

More than one million women diagnosed with breast cancer every year are estimated (1,2). In Taiwan, breast cancer has been the most common female cancer and the fourth cause of female cancer death since 2003 (3).

Breast cancer has been causing a health concern in women worldwide not only for its increasing incidence but also for the expense of treatment. Economic evaluation of breast cancer treatment is very valuable for providing information to healthcare policy planners, physicians, patients and others to assess the situation and allocate resources to cancer control strategies, understanding the quantity of breast cancer burden and the quality of treatment (4,5). Published evaluations of costs for breast cancer treatment during the past varied substantially in perspective, methodology and patient populations (6,7). To the best of our knowledge, the potential correlation between the medical expenses and breast cancer incidence and mortality rate has not been sufficiently addressed. Thus, our current study attempted to assess the impact of medical expenses on breast cancer incidence and mortality rate in Taiwan.

Patients and Methods

The National Health Insurance (NHI) service was implemented in Taiwan since 1995, and Cancer Registration was inaugurated since 1979. National Health Insurance (NHI) covers comprehensive medical care, including health prevention, clinical care, hospitalization, and social rehabilitation. Medical expenses, including outpatient and inpatient services, were also retrieved from the NHI database.

The National Health Insurance Research Database (NHIRD) is a large computerized database which is derived from the system by the Bureau of NHI and supported by the National Health Research Institute (NHRI). The NHIRD is supplied to the scientists in Taiwan for aims of research. Before the database is released to each researcher, all the data in the NHIRD individual identification information, including patient ID, medical institutions, and care providers, are encrypted. Therefore, the approval of Institutional Review Board was waived for the study.

In Taiwan, the increased trend of breast cancer burden was noticed as a public health issue and the annual incidences of cancer have been published formally by Bureau of Health Promotion every year. In our study, the national cancer registry system (https://cris.bhp.doh.gov.tw/pagepub/Home.aspx) is also a data source.

Breast cancer cases were identified from the National Health Insurance Research Database (NHIRD) with corresponding to International Classification of Diseases, and the Ninth Revision (ICD-9) code 174, 1740-1749 (Malignant neoplasm of female breast), 175, 1750 and 1759 (Malignant neoplasm of male breast) from January 1999 to December 2006. Age -specific incidences were estimated by population data obtained from the Department of Statistics, Ministry of the Interior.

Calculations were carried out using SPSS 15.0 and Microsoft Excel 2003.

Results

Annual incidences of breast cancer were detailed in Table 1. During 1999-2006, the annual incidence ranged from 40.86 to 61.10 and from 0.20 to 0.42 per 100,000 for females and males, respectively. The combined incidences increase from 20.06 per 100,000 in 1999 to 30.34 per 100,000 in 2006.

Age-specific incidences (per 100,000/year) of female breast cancer were listed in Table 2 and Figure 1. Peak incidence mostly fell on age 45-59 years during 1999 to 2006. The increase in breast cancer incidence did not occur on women aged less than 35.

 Table 1 

Population, number of cases and incidence of breast cancer by year and gender.

total population (millions)breast cancer casesincidence rate (per 105/year)
femaleMaleTotalfemalemaletotalfemalemaletotal
199910.7811.3122.09440526443140.860.2320.06
200010.8811.3922.28464223466542.650.220.94
200110.9611.4422.41506728509546.220.2422.74
200211.0411.4922.52533941538048.380.3623.89
200311.0411.4922.6532532535748.250.2823.7
200411.1511.5422.69617648622455.40.4227.43
200511.2111.5622.77659448664258.830.4229.17
200611.2811.5922.88689546694161.100.4030.34
 Table 2 

Age-specific incidences (per 100,000/year) of female breast cancer by year.

Age group
(year)
≦1920-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970-7475-7980-84≧85
19990.191.789.4224.9151.8685.24110.12110.78111.3895.0270.4370.9560.5551.1952.22
20000.251.648.8122.4152.7082.88122.44111.32115.4489.9573.7080.4866.2151.1749.46
20010.102.167.3424.2353.5493.44127.36108.81116.66102.6388.1280.3778.6670.0159.19
20020.131.847.7825.9154.6590.92124.65114.86130.87108.89100.4883.8173.1058.9756.70
20030.102.288.4624.2555.3890.44108.93120.15123.56107.4694.3277.8278.7367.5850.77
20040.032.239.3624.7460.9898.50137.34130.84132.83128.45111.1794.4675.7170.0039.06
20050.071.546.7127.7361.54102.81143.11138.58134.91142.75119.4178.5181.3869.6178.64
20060.001.879.5525.3261.92102.49143.67141.89140.09140.73119.52101.4076.3078.3256.20
 Fig 1 

Incidence rate by age groups in the period 1999-2006. Data sources: Taiwan cancer registration system.

J Cancer Image (Click on the image to enlarge.)
 Fig 2 

Age-standardized incidence (per 100,000 people) and Age-standardized mortality (per 100,000 people) of female breast cancer in Taiwan, 1999-2006. Data sources: Taiwan cancer registration system.Table1. Population, number of cases and incidence of breast cancer by year and gender.

J Cancer Image (Click on the image to enlarge.)

Age-standardized incidence (per 100,000 people) and age-standardized mortality (per 100,000 people) of female breast cancer during 1999-2006 were shown in Figure 2. The age-standardized mortality rate for female breast cancer remains essentially unchanged, while the age-standardized incidence increased steadily (except 2002-2003).

Expenses of outpatient and inpatient services for breast cancer were detailed in Table 3. The total expenses increase from 1,449,333,521 in 1999 to 4,350,400,592 Taiwan dollars 2006.

The top 20 coexisting ICD-9 codes were listed in Table 4. The most common coexisting ICD-9 code was V58.1 (Encounter for chemotherapy), followed by 401.9 (essential hypertension). Among the top 20 coexisting ICD-9 codes, four are directly on cancers, including [1] Encounter for chemotherapy, [2] secondary malignant neoplasm of bone and bone marrow, [3] Secondary and unspecified malignant neoplasm of lymph nodes of axilla and upper limb, and [4] secondary malignant neoplasm of lung. 16 of the top 20 are on other diseases or symptoms, which are not necessarily caused by breast cancer.

 Table 3 

Number and total expenses of outpatient and inpatient services for breast cancer patients.

Number of outpatient servicenumber of inpatient servicetotal expenses (TWD)
1999233,46015,8341,449,333,521
2000320,52017,4451,748,047,603
2001349,19118,2851,884,945,689
2002418,37022,4582,360,593,919
2003449,41528,4722,858,184,684
2004545,51440,1433,664,411,771
2005624,33242,0834,111,497,959
2006703,22738,4224,350,400,592
 Table 4 

The top 20 coexisting ICD-9 codes of breast cancer in Taiwan.

ICD-9 codeDiseasefrequency
V581Encounter for chemotherapy149912
4019Essential hypertension, unspecified112057
4659Acute upper respiratory infections of unspecified site96892
25000Diabetes mellitus without mention of complication, Type II [non-insulin dependent type] [NIDDM type]
[adult-onset type] or unspecified type, not stated as uncontrolled
81676
78052Other insomnia75039
1985Secondary malignant neoplasm of bone and bone marrow74155
1963Secondary and unspecified malignant neoplasm of lymph nodes of axilla and upper limb47781
6929Contact dermatitis and other eczema, unspecified cause43031
5640Constipation34942
1970Secondary malignant neoplasm of lung34344
7291Myalgia and myositis, unspecified32371
5369Unspecified functional disorder of stomach31304
6272Menopausal or female climacteric states31010
57140Chronic hepatitis, unspecified29792
73300Osteoporosis, unspecified28474
460Acute nasopharyngitis [common cold]28358
78050Sleep disturbances, unspecified27920
30000Anxiety state, unspecified26169
7862Cough22272
4011Benign essential hypertension19436

Discussion

Our study showed that medical expenses of breast cancer treatment increased significantly and linearly from 1999 through 2006 in Taiwan (Table 3). However, the age-standardized mortality rate for female breast cancer remained essentially unchanged, while the age-standardized incidence increased steadily (except 2002-2003) (Figure 2). These facts indicate that significantly increased medical expenditure on breast cancer have failed to bring down its mortality and incidence rate.

The primary factors accounting for the significant increase of medical expenses on breast cancer appear to the followings: [1] A significant amount of the expenses are not directly related to cancer. In our study, among of the top 20 coexisting ICD-9 code (Table 4), four are directly on cancers. 16 of the top 20 are on other diseases or symptoms, which are not necessarily caused by breast cancer. [2] The applications of novel treatment regimens, including newly developed target therapy, hormone therapy and chemotherapy. Chemotherapy numbers were steadily increasing during the study period. Hormone therapy steeply increased since 2004. [3] A significant expansion of the breast cancer screening program. In Taiwan, the National Health Service breast cancer screening program was introduced in July, 2002 (3). After repeated review and improving, breast cancer screening services expand to female 45-69 years in 2009; and further, women aged 40-44 with a family history of breast cancer were covered since 2010. [4] Increasing incidences of more aggressive breast cancer types that require more comprehensive and costly treatment. A significantly higher incidence of axillary lymph node metastases for Taiwanese women with small breast cancer than for Western women was demonstrated (8). [5] Poor patients compliances for physicians' advice lead to disease advance and increase medical expenditure.

Our study showed that significantly increased medical expenditure on breast cancer failed to bring down its mortality and incidence rate in Taiwan. Furthermore, it might be a similar situation in other countries. The finding has implications for healthcare policy planners in proposing strategies for breast cancer control and allocating the resources.

Limitations of this study are stages of diseases and prognosis of the patients not clear due to database not support. The medical expenses may not reflect the variations for each stage of diseases. No connected mortality database for estimations of individual medical expense of treatment is also a limitation of our study.

Acknowledgements

This study is based in part on data from the National Health Insurance Research Database provided by the Bureau of National Health Insurance, Department of Health and managed by National Health Research Institutes. The interpretation and conclusions contained herein do not represent those of the Bureau of National Health Insurance, the Department of Health or National Health Research Institutes.

Competing Interests

The authors have declared that no competing interest exists.

References

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Author contact

Corresponding address Corresponding author: Yi-Hsuan Hsiao, M.D., PhD. Assistant Professor, School of Medicine, Chung Shan Medical University. Department of Obstetrics and Gynecology, Changhua Christian Hospital, 135 Nanhsiao Street, Changhua, 500 Taiwan. Phone: 886-4-7238595 Fax: 886-4-7228289 E-mail: 54315org.tw; Or Ming-Chih Chou, MD., PhD. Professor, Department of Surgery, Chung Shan Medical University, Taichung, Taiwan. Tel: 886-4-24730022 Fax: 886-4-24723229 E-mail: graduateedu.tw.


Received 2013-3-8
Accepted 2013-8-6
Published 2013-8-10