Economic analyses of breast cancer control in low- and middle-income countries: a systematic review

Systematic Reviews, Apr 2013

Background To support the development of global strategies against breast cancer, this study reviews available economic evidence on breast cancer control in low- and middle-income countries (LMICs). Methods A systematic article search was conducted through electronic scientific databases, and studies were included only if they concerned breast cancer, used original data, and originated from LMICs. Independent assessment of inclusion criteria yielded 24 studies that evaluated different kinds of screening, diagnostic, and therapeutic interventions in various age and risk groups. Studies were synthesized and appraised through the use of a checklist, designed for evaluating economic analyses. Results The majority of these studies were of poor quality, particularly in examining costs. Studies demonstrated the economic attractiveness of breast cancer screening strategies, and of novel treatment and diagnostic interventions. Conclusions This review shows that the evidence base to guide strategies for breast cancer control in LMICs is limited and of poor quality. The limited evidence base suggests that screening strategies may be economically attractive in LMICs – yet there is very little evidence to provide specific recommendations on screening by mammography versus clinical breast examination, the frequency of screening, or the target population. These results demonstrate the need for more economic analyses that are of better quality, cover a comprehensive set of interventions and result in clear policy recommendations.

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Economic analyses of breast cancer control in low- and middle-income countries: a systematic review

Zelle and Baltussen Systematic Reviews 0 Department of Primary and Community Care, Radboud University Nijmegen Medical Centre , P.O. Box 9101Internal Postal Code 117, 6500HB Nijmegen , the Netherlands 1 Thomas and colleagues , 1999 [45] 2 Zelle and colleagues , 2012 [35] - Economic analyses of breast cancer low- and middle-income countries: a review control in systematic Zelle and Open Access Economic analyses of breast cancer control in low- and middle-income countries: a systematic review Sten G Zelle* and Rob M Baltussen Results: The majority of these studies were of poor quality, particularly in examining costs. Studies demonstrated the economic attractiveness of breast cancer screening strategies, and of novel treatment and diagnostic interventions. Background Noncommunicable diseases (NCDs) have become increasingly important in low- and middle-income countries (LMICs). Once considered a problem only in high-income countries (HICs), more and more patients who suffer from cancers and other NCDs are now observed in LMICs [1]. This is mainly due to the ageing populations and changing lifestyles in LMICs [2]. The global importance of NCDs has recently been acknowledged through the UN Summit on NCDs, held by the UN General Assembly in September 2011. As highlighted in the summit, the most prominent cause of cancer death among women in LMICs is breast cancer, accounting for 269,000 deaths (12.7% of all cancer deaths) in 2008 [3,4]. In HICs, many efforts have been undertaken to control breast cancer, leading to various improvements in breast cancer outcomes [5,6]. Strategies for breast cancer control are geared towards early detection and early treatment, and although its benefits are still open to discussion [7-9], mammography screening has been widely implemented [10-12]. In these countries, the selection of breast cancer control strategies has often been guided by economic analyses, demonstrating the value of alternative interventions [13-16]. In contrast to the established breast cancer control strategies in HICs, breast cancer is often neglected in LMICs and control strategies lack evidence-based information [17-20]. Policy-makers in LMICs cannot adopt similar breast cancer control strategies as implemented in HICs because most LMICs rely on much smaller budgets, and both the costs and effectiveness of control strategies are highly dependent on the population characteristics and the functioning of the health system [11,20,21]. Against this background, the present review provides an inventory of economic analyses of breast cancer control in LMICs. The paper’s objectives are to present the available economic evidence from LMICs and to assess the methodological quality of the analyses. This research could improve the evidence base on cost-effective breast cancer interventions and could strengthen breast cancer control policy in LMICs. Methods Search strategy and selection criteria In this review, we analyzed publications from the MEDLINE index using PubMed, the Web of Science, Scopus, and Google Scholar. We searched the literature using the keyword ‘breast cancer’, combined with the keywords: ‘developing countries’, ‘Asia’, ‘USSR’, ‘MiddleEast’, ‘Eastern Europe’, ‘West-Indies’, ‘China’, ‘Russia’, ‘India’, ‘Africa,’ or ‘limited resource,’ or combined with: ‘cost-benefit,’ ‘cost-effectiveness,’ ‘costing,’ or ‘cost analysis’. Additionally, we searched these indexes using ‘breast neoplasms’, ‘developing countries,’ and ‘economics’ in MeSH terms. Our search took place in January 2013, and was limited to publications in English. Studies were included only if they concerned breast cancer and originated from LMICs as listed by The World Bank [22]. The selection process is shown in Figure 1. In step 1, articles found by our search in the various indexes were merged in a database, which was then corrected for duplications (in Google Scholar, because of the large number of articles founds, we screened titles until the point that we did not find any further relevant title among the last 500 screened titles; in total, we screened 800 titles in this database). In step 2 we screened the titles of these articles, in step 3 the abstracts and in step 4 the remaining articles were read completely. We excluded publications for which no full-text article versions were available, or those not published in English. Furthermore, we excluded articles that only mentioned costs or cost-effectiveness without presenting original data. Study characteristics We documented the following characteristics from the reviewed articles: country or region, base year of cost data, study population, and breast cancer stage(s) considered. The stage was categorized as stage I to IV according to the American Joint Committee on Cancer [23]. We documented the following methodological characteristics: type of economic evaluation –cost analysis or cost of illness analysis, separately reported costs and effects, cost-effectiveness analysis, (...truncated)


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Sten G Zelle, Rob M Baltussen. Economic analyses of breast cancer control in low- and middle-income countries: a systematic review, Systematic Reviews, 2013, pp. 20, 2, DOI: 10.1186/2046-4053-2-20