Out-of-pocket medical expenditure and associated factors of advanced colorectal cancer in China: a multi-center cross-sectional study
Original Article

Out-of-pocket medical expenditure and associated factors of advanced colorectal cancer in China: a multi-center cross-sectional study

Hong Wang1#, Li Ma2#, Xiao-Fen Gu3, Li Li4, Wen-Jun Wang5, Ling-Bin Du6, Hui-Fang Xu1, He-Lu Cao7, Xi Zhang8, Ji-Hai Shi9, Yu-Qian Zhao10, Yun-Yong Liu11, Juan-Xiu Huang12, Ji Cao13, Yan-Ping Fan14, Chang-Yan Feng15, Qian Zhu16, Jing-Chang Du17, Xiao-Hui Wang18, Shao-Kai Zhang1, You-Lin Qiao1,19; China Working Group on Colorectal Cancer Survey

1Department of Cancer Epidemiology, Affiliated Cancer Hospital of Zhengzhou University/Henan Cancer Hospital, Henan Engineering Research Center of Cancer Prevention and Control, Henan International Joint Laboratory of Cancer Prevention, Zhengzhou, China; 2Public Health School, Dalian Medical University, Dalian, China; 3Department of Student Affairs, Affiliated Tumor Hospital, Xinjiang Medical University, Ürümqi, China; 4Department of Clinical Research, The First Affiliated Hospital, Jinan University, Guangzhou, China; 5School of Nursing, Jining Medical University, Jining, China; 6Department of Cancer Prevention, The Cancer Hospital of the University of Chinese Academy of Sciences, Zhejiang Cancer Hospital, Hangzhou, China; 7Department of Preventive Health, Xinxiang Central Hospital, Xinxiang, China; 8Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Beijing Office for Cancer Prevention and Control, Peking University Cancer Hospital & Institute, Beijing, China; 9The Clinical Epidemiology of Research Center, Department of Dermatological, The First Affiliated Hospital of Baotou Medical College, Baotou, China; 10Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China; 11Liaoning Office for Cancer Control and Research, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute, Shenyang, China; 12Department of Gastroenterology, Wuzhou Red Cross Hospital, Wuzhou, China; 13Department of Cancer Prevention and Control Office, The First Affiliated Hospital of Guangxi Medical University, Nanning, China; 14State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China; 15Chongqing Key Laboratory of Translational Research for Cancer Metastasis and Individualized Treatment, Chongqing University Cancer Hospital, Chongqing, China; 16School of Public Health and Management, Chongqing Medical University, Chongqing, China; 17School of Public Health, Chengdu Medical College, Chengdu, China; 18Department of Public Health, Gansu Provincial Cancer Hospital, Lanzhou, China; 19Center for Global Health, School of Population Medicine and Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China

Contributions: (I) Conception and design: SK Zhang, YL Qiao; (II) Administrative support: SK Zhang, YL Qiao; (III) Provision of study materials or patients: L Ma, XF Gu, L Li, WJ Wang, LB Du, HL Cao, X Zhang, JH Shi, YQ Zhao, YY Liu, JX Huang, J Cao, YP Fan, CY Feng, Q Zhu, JC Du, XH Wang; (IV) Collection and assembly of data: H Wang, L Ma, XF Gu, L Li, WJ Wang, LB Du, HF Xu, HL Cao, X Zhang, JH Shi, YQ Zhao, YY Liu, JX Huang, J Cao, YP Fan, CY Feng, Q Zhu, JC Du, XH Wang; (V) Data analysis and interpretation: H Wang; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

#These authors contributed equally to this work.

Correspondence to: Shao-Kai Zhang. Department of Cancer Epidemiology, Affiliated Cancer Hospital of Zhengzhou University/Henan Cancer Hospital, Henan Engineering Research Center of Cancer Prevention and Control, Henan International Joint Laboratory of Cancer Prevention, Zhengzhou 450008, China. Email: shaokaizhang@126.com; You-Lin Qiao. Department of Cancer Epidemiology, Affiliated Cancer Hospital of Zhengzhou University/Henan Cancer Hospital, Henan Engineering Research Center of Cancer Prevention and Control, Henan International Joint Laboratory of Cancer Prevention, Zhengzhou 450008, China; Center for Global Health, School of Population Medicine and Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100005, China. Email: qiaoy@cicams.ac.cn.

Background: Colorectal cancer (CRC) causes a substantial disease burden in China. Information on the medical expenditure of CRC patients is critical for decision-makers to allocate medical resources reasonably, however, relevant data is limited in China, especially advanced CRC. The aim of this survey was to quantify the out-of-pocket medical expenditure of advanced CRC and explore associated factors.

Methods: A nation-wide, multi-center, cross-sectional survey was conducted from March 2020 to March 2021. Nineteen hospitals in seven geographical regions were selected by multi-stage stratified sampling. For each eligible CRC patient with stage III or IV disease in the selected hospitals, the socio-demographics, clinical information, and range of out-of-pocket medical expenditure data were collected based on patients’ self-reporting or medical records. Multivariable logistic analysis was used to explore associated factors of medical expenditure. All statistical analyses were conducted using SAS 9.4.

Results: The mean age of the 4,428 advanced CRC patients included was 59.5±11.6 years, 59.6% were male, and 80.1% of patients were in stage III or IV at the time of diagnosis. Besides, 57.2% of patients had an annual household income of less than 50,000 Chinese Yuan (CNY), 40.9% of patients had an out-of-pocket medical expenditure of 50,000–99,999 CNY. As for the affordability of medical expenditure, 33.2% could afford 50,000–99,999 CNY. Multivariate analysis showed that patients who were in the southern [odds ratio (OR): 1.63, 95% confidence interval (CI): 1.31–2.03] and southwestern (OR: 1.55, 95% CI: 1.25–1.93), were in stage III at the time of diagnosis (OR: 1.33, 95% CI: 1.13–1.57), visited three or more hospitals (OR: 1.26, 95% CI: 1.04–1.52), had sought cross-regional health care (OR: 1.60, 95% CI: 1.40–1.83), used genetic testing (OR: 1.26, 95% CI: 1.10–1.45) and targeted drugs (OR: 2.12, 95% CI: 1.79–2.51) had higher out-of-pocket medical expenditure.

Conclusions: Patients with advanced CRC had a high out-of-pocket medical expenditure. It is necessary to strengthen the prevention and control of CRC to reduce the disease burden; also, it is critical to deepen the reform of the medical system, increase proportion of medical insurance reimbursement, and remove barriers to cross-regional health care.

Keywords: Colorectal cancer (CRC); medical expenditure; China


Submitted Jan 21, 2022. Accepted for publication Mar 18, 2022.

doi: 10.21037/atm-22-1001


Introduction

Colorectal cancer (CRC) is the third most common cancer worldwide. There were 1,931,590 new cases of CRC in the world in 2020, of which cases in China accounted for 28.8% (1). The most recently available data from the National Cancer Registry of China reported 388,000 new CRC cases diagnosed in 2015, making CRC the third most common cancer in China (2). Evidence has shown that the incidence and mortality of CRC in China has increased over the past decades and is expected to continuously increase (3-5).

It has been confirmed that there are many modifiable risk factors for CRC, such as smoking, processed meat, alcohol intake, red meat, low intake of vegetables and fruits, body fat, and obesity (6). Reducing these risk factors can effectively reduce the incidence of CRC. In addition, the role of screening in reducing the burden of CRC has reached an international consensus (7,8). In order to curb the rising incidence and mortality of CRC, China has successively launched a number of screening projects in recent years, and the coverage among the population has gradually expanded (9-14). However, despite the emergence of screening programs, nearly half of CRCs in China are diagnosed at an advanced stage. The 5-year survival rate of CRC patients at an early stage is as high as 90%, while that of patients at an advanced stage is only about 30% (15,16), which results in a heavy burden to families and society. In recent years, several new treatments have been developed for patients with advanced CRC, such as targeted therapy, which can effectively prolong the overall survival of CRC patients, but these new treatments are expensive and may lead to a huge economic burden on patients.

Understanding the economic burden of CRC patients and the associated factors is essential to guide cancer prevention and control and inform the relevant healthcare policy in the future. First of all, discerning the true financial burden helps explain the general status of a population’s health under current healthcare system, thus enabling the development of optimal policies. Second, collecting related expenditure of CRC patients is crucial for evaluating the cost-effectiveness and budget impact of population-based intervention programs such as CRC screening. Moreover, mastering the medical expenditures and associated factors can help explain the effect of the current health-care reform policy on cost control and thus facilitate the development of optimal policies.

There have been systematic studies on the medical expenses of cancer patients in many foreign countries, such as the United States and Australia (17,18). And studies showed that the medical expenses of cancer patients are related to the patient’s age, living area, medical insurance status, availability of medical services, cancer stage and other factors (18-20). Considering that the medical system and disease burden of CRC in China are quite different from those in foreign countries, it is necessary to carry out local studies to provide reference for medical decision-making in China. However, studies on the medical expenditure of CRC patients were limited in China, especially multi-center studies with large sample sizes. One previous study indicated that the overall direct medical expenditure associated with CRC diagnosis and subsequent treatment per patient was 37,902 Chinese Yuan (CNY) (2011 value) in China between 2002 and 2011, with an average annual growth rate of 9.2% over the 10-year period (21). Another study showed that the average medical expenditure per CRC patient was 66,291 CNY (2014 value) during the period from 2005 to 2014 (22). As for the associated factors of medical expenditure, studies showed that the expenditures vary within different stages and treatment methods (21,23). However, with the continuous emergence of new diagnostic and treatment methods, previous cost surveys are no longer representative of the current situation, and it is necessary to investigate the latest medical expenses and associated factors.

To improve the understanding of the current situation of the medical expenditure of CRC in China, this study analyzed the medical expenditure and associated factors of advanced CRC patients in China based on a nation-wide multi-center survey conducted from March 2020 to March 2021. We present the following article in accordance with the SURGE reporting checklist (available at https://atm.amegroups.com/article/view/10.21037/atm-22-1001/rc).


Methods

Study design and sites

To comprehensively present the knowledge, medical experience, health-related quality of life and health-care costs among Chinese patients with advanced CRC, a cross-sectional, nation-wide, hospital-based, multi-center survey was conducted across seven geographic regions (northeastern, northern, northwestern, eastern, central, southern, and southwestern) in China from March 2020 to March 2021, and this study is a part of the large sample study. Multi-stage stratified sampling was adopted to determine the participant hospitals. In stage one, two cities of each region were selected by convenient sampling. In stage two, one tertiary cancer hospital and/or one general hospital were selected in each city. A total of nineteen hospitals (ten tertiary cancer hospitals and nine general hospitals) were selected.

Study population

All CRC patients aged ≥18 years old with stage III or IV disease in the selected hospitals were invited by the interviewer verbally to participate current study. Patients were excluded if they had severe physical, cognitive, and/or verbal impairments that interfered with the completion of the questionnaire. Patients will receive a CRC health knowledge booklet in return after being surveyed. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). This research was approved by the independent review board of Henan Cancer Hospital (No. 2019273), the other 18 hospitals were informed and agreed with the study, and informed consent was taken from all the patients.

The sample size of the large-sample survey overall is estimated based on the prevalence of advanced CRC, sample representativeness and response rate. The sample size of this study is consistent with that of large sample survey. It has been estimated that there are about 400,000 advanced CRC patients in China (1,24). To ensure the representativeness of the sample, this study was expected to recruit approximately 1% of the patients. Considering the non-response rate of 10%, more than 4,445 patients would be enrolled into this survey. The sample size of each region was allocated proportionally according to the population density.

Data collection

Information was collected face-to-face by interviewers via a semi-structured questionnaire, and all interviewers were systematically trained before the study was launched. The information of the questionnaire included the following aspects: (I) socio-demographics including birthdate, gender, marital status, education, occupation, annual household income, and medical insurance type; (II) clinical information including number of hospitals visited, cancer type (colon cancer, rectal cancer, and both), duration of cancer (time from the patient’s CRC diagnosis to the date of investigation), cancer stage at the time of diagnosis (CRC staging was consistent with the 8th edition of the American Joint Committee on Cancer tumor-node-metastasis staging system), phases of the disease at the time of investigation [(i) during the first treatment and did not change the regimen; (ii) during the first treatment and changed the regimen; (iii) during the treatment phase after recurrence; (iv) during the phase of regular review], whether the patient had sought cross-regional health care, use of genetic testing and targeted drugs, and therapeutic regimen; and (III) medical expenditure: range of out-of-pocket medical expenditure, including costs of diagnosis, medication, surgery, radiology, medical examinations, nursing care, hospitalization, etc. The cost was collected in the form of categorical variables in the questionnaire [(i) <50,000; (ii) 50,000–99,999; (iii) 100,000–199,999; (iv) ≥200,000]; proportion of medical insurance reimbursement; who bore the medical expenditure; affordability of treatment costs; and related measures to relieve financial pressure, etc.

Statistical analysis

In the current study, if more than 95% of items were filled, the questionnaire was regarded as complete and was included in the analysis. Unfilled items were included in the analysis as missing values. For continuous variables conforming to a normal distribution, such as age, data were presented as the mean ± standard deviation (SD). Otherwise, the median, upper, and lower quartiles were used for description. Categorical variables were presented as frequencies and percentages. To determine the factors associated with medical expenditure, an ordinal logistic regression model was constructed, in which stepwise regression was performed to choose variables included in the final model (Pentry=0.05, Pstay=0.05). In the model, medical expenditure was taken as the dependent variable, and independent variables included socio-demographics (age, gender, marital status, occupation, education, region, annual household income of the patients, annual household income of the patients’ children), and clinical information (number of hospitals visited, cancer type, duration of cancer, cancer stage when diagnosis, phase of the disease at the time of investigation, whether the patients sought cross-region health care, use of gene testing, and use of targeted drugs). All statistical analyses were performed using SAS 9.4 (SAS Institute, Cary, NC, USA), and the significance level was set to two-sided α=0.05.


Results

Patient characteristics

A total of 4,589 CRC patients with stage III or IV disease were investigated, of whom 161 patients were just diagnosed at the time of investigation and had not started any treatment. Therefore, a total 4,428 CRC patients with stage III or IV disease were included in the current analysis. The mean age of the included patients at the time of investigation was 59.5±11.6 years, and 46.4% of the patients were aged 50–64 years. Among the patients, 59.6% were male, 17.7% were unemployed, 55.2% had an education of junior or senior high school, 99.0% of patients had medical insurance, and most of the patients (57.2%) or their children (43.1%) had an annual household income of less than 50,000 CNY (Table 1).

Table 1

Characteristics of advanced colorectal cancer patients

Variables No. %
Age (years), mean ± SD 59.5±11.6
   <50 825 18.6
   50–64 2,053 46.4
   ≥65 1,550 35.0
Gender
   Male 2,638 59.6
   Female 1,790 40.4
Marital status*
   Married 4,178 94.4
   Other 249 5.6
Occupation
   Employees of enterprise, or government 1,750 39.5
   Service staff, farmer, collar-blue worker 1,895 42.8
   Unemployed 783 17.7
Education*
   Primary school or below 1,272 28.8
   Junior or senior high school 2,442 55.2
   Undergraduate or above 711 16.1
Region
   Northeastern 351 7.9
   Northern 545 12.3
   Eastern 1,271 28.7
   Southern 646 14.6
   Central 657 14.8
   Northwestern 313 7.1
   Southern 645 14.6
Health-care insurance type (multiple response)
   Urban employees basic medical insurance 1,868 42.4
   Urban residents basic medical insurance 958 21.7
   New rural cooperative medical scheme 1,503 34.1
   Critical illness insurance program 215 4.9
   Commercial medical insurance 220 5.0
   Uninsured 46 1.0
Annual household income of patients (CNY)
   <50,000 2,533 57.2
   50,000–99,999 1,254 28.3
   ≥100,000 641 14.5
Annual household income of patient’s children (CNY)
   <50,000 1,907 43.1
   50,000–99,999 1,547 34.9
   ≥100,000 974 22.0
Duration of cancer (months), median [P25, P75] 9 [3, 23]
Number of hospitals visited*
   1 1,267 29.2
   2 2,248 51.8
   ≥3 829 19.1
Cancer stages at diagnosis*
   I/II 849 19.9
   III 1,909 44.8
   IV 1,506 35.3
Cancer type*
   Colon 1,995 45.1
   Rectum 2,379 53.7
   Other 53 1.2
Phases of the disease at the time of investigation
   During the first treatment and did not change the regimen 2,088 47.2
   During the first treatment and changed the regimen 532 12.0
   During the treatment phase after recurrence 1,138 25.7
   During the phase of regular review 670 15.1
Has the patient ever sought cross-region health care*
   No 2,789 63.0
   Yes 1,637 37.0
Use of genetic testing*
   No 2,336 52.8
   Yes 2,086 47.2
Use of targeted drugs*
   No 3,005 68.0
   Yes 1,415 32.0
Treatment method (multiple response)
   Surgery 3,734 84.4
   Endoscopic interventional therapy 130 2.9
   Radiotherapy 991 22.4
   Chemotherapy 3,888 87.9
   Targeted therapy 1,298 29.3
   Immunotherapy 104 2.4
   Traditional Chinese medicine treatment 507 11.5
   Palliative treatment 218 4.9

*, some data are missing. SD, standard deviation; CNY, Chinese Yuan.

At the time of investigation, 47.2% of the patients were undergoing the first treatment and did not change the regimen, and the median [P25, P75] duration of cancer was 9 [3, 23] months; 80.1% of the patients were at a stage of III or IV at the time of diagnosis, and 53.7% of the patients had rectal cancer; 51.8% of the patients had visited two hospitals, and 19.1% had visited three or more hospitals. Among the patients, 37.0% had sought cross-regional health care, 47.2% had used genetic testing, and 32.0% had used targeted drugs. The most commonly used treatment methods included chemotherapy (87.9%), surgery (84.4%), targeted therapy (29.3%) and radiotherapy (22.4%) (Table 1).

Medical expenditure and related information

A total of 40.9% of the patients had an out-of-pocket medical expenditure of 50,000–99,999 CNY, and the median [P25, P75] medical insurance reimbursement ratio was 60% [50%, 70%]. Most patients bore the medical expenditure themselves coupled with their spouses (81.4%) or their children (49.3%). When asked about the treatment cost that patients could afford, 33.2% answered that 50,000–99,999 CNY was an affordable treatment cost, and 28.4% of the patients could afford less than 50,000 CNY. With the financial pressure derived from CRC treatment, only 20.9% of patients could afford the current treatment costs without changing their living conditions. In contrast, nearly 80% of patients had taken actions to relieve financial pressure, including reducing household expenses (66.2%), reducing the purchase of large items (57.3%), and borrowing from relatives and friends (25.5%) (Table 2).

Table 2

Medical expenditure and related information of advanced colorectal cancer patients

Variables No. %
Total out-of-pocket medical expenditure (CNY)*
   <50,000 1,065 24.1
   50,000–99,999 1,807 40.9
   100,000–199,999 1,034 23.4
   ≥200,000 510 11.6
Medical insurance reimbursement ratio (%), median [P25, P75] 60 [50, 70]
Who bore the medical expenditure (multiple response)
   Patient and his/her spouse 3,593 81.4
   Siblings of patients 306 6.9
   Children of patients 2,175 49.3
   Parents of patients 163 3.7
   Other relatives of patients 183 4.1
   Other social financing 44 1.0
Affordability of treatment cost (CNY)*
   <50,000 1,250 28.4
   50,000–99,999 1,461 33.2
   100,000–199,999 1,077 24.5
   200,000–499,999 521 11.8
   ≥500,000 95 2.2
Things done to relieve financial pressure derived from the treatment of CRC (multiple response)
   The treatment cost is sufficient and there is no need to change the living standard 926 20.9
   Reduce household expenses 2,927 66.2
   Reduce the purchase of large items 2,532 57.3
   Borrowing from relatives and friends 1,127 25.5
   Borrowing from financial institutions 74 1.7
   Selling house property 102 2.3
   Selling cars 44 1.0
   Selling other valuables 61 1.4
   Other 43 1.0

*, some data are missing. CNY, Chinese Yuan; CRC, colorectal cancer.

Factors associated with out-of-pocket medical expenditure

A multivariate logistic regression analysis was conducted to identify potential associated factors that may be associated with the medical expenditure of advanced CRC patients, and the results are shown in Table 3. Compared with patients under the age of 50, patients aged 50–64 [odds ratio (OR): 0.83, 95% confidence interval (CI): 0.70–0.99] and patients over the age of 65 (OR: 0.66, 95% CI: 0.55–0.80) had lower medical expenditure. Compared to patients in the central area, patients in the eastern area (OR: 0.73, 95% CI: 0.60–0.88) had lower medical expenditure, while those in the southern (OR: 1.63, 95% CI: 1.31–2.03) and southwestern (OR: 1.55, 95% CI: 1.25–1.93) areas had higher medical expenditure. Patients with higher annual household incomes (themselves or their children) had higher medical expenditure. Moreover, patients had higher medical expenditure if they had longer duration of cancer (OR: 1.02, 95% CI: 1.01–1.02), visited three or more hospitals (OR: 1.26, 95% CI: 1.04–1.52), were in stage III at the time of diagnosis (OR: 1.33, 95% CI: 1.13–1.57), were undergoing treatment phases and changed the regimen (OR: 1.66, 95% CI: 1.36–2.03), had recurrence (OR: 3.28, 95% CI: 2.75–3.90), were in the course of regular review (OR: 1.77, 95% CI: 1.48–2.13), had ever sought cross-regional health care (OR: 1.60, 95% CI: 1.40–1.83), used genetic testing (OR: 1.26, 95% CI: 1.10–1.45), and used targeted drugs (OR: 2.12, 95% CI: 1.79–2.51).

Table 3

Multivariable analysis of medical expenditure in advanced colorectal cancer patients

Variables β-coefficient OR (95% CI) P
Age (years)
   <50 Reference 1
   50–64 −0.185 0.83 (0.70, 0.99) 0.034
   ≥65 −0.414 0.66 (0.55, 0.80) <0.001
Region
   Central Reference 1
   Northeastern −0.023 0.98 (0.75, 1.27) 0.861
   Northern 0.018 1.02 (0.81, 1.28) 0.878
   Eastern −0.317 0.73 (0.60, 0.88) 0.001
   Southern 0.488 1.63 (1.31, 2.03) <0.001
   Northwestern −0.102 0.90 (0.70, 1.17) 0.447
   Southwestern 0.440 1.55 (1.25, 1.93) <0.001
Annual household income of patients and spouses (CNY)
   <50,000 Reference 1
   50,000–99,999 0.179 1.20 (1.04, 1.37) 0.012
   ≥100,000 0.306 1.36 (1.13, 1.64) 0.002
Annual household income of patient’s children (CNY)
   <50,000 Reference 1
   50,000–99,999 −0.048 0.95 (0.83, 1.10) 0.511
   ≥100,000 0.251 1.29 (1.08, 1.53) 0.005
Duration time of cancer (months) 0.015 1.02 (1.01, 1.02) <0.001
Number of hospitals visited
   1 Reference 1
   2 −0.104 0.90 (0.78, 1.04) 0.162
   ≥3 0.231 1.26 (1.04, 1.52) 0.018
Cancer stage at the time of diagnosis
   I/II Reference 1
   III 0.286 1.33 (1.13, 1.57) 0.001
   IV 0.056 1.06 (0.88, 1.27) 0.550
Phases of the disease at the time of investigation
   During the first treatment and did not change the regimen Reference 1
   During the first treatment and changed the regimen 0.509 1.66 (1.36, 2.03) <0.001
   During the treatment phase after recurrence 1.187 3.28 (2.75, 3.90) <0.001
   During the phase of regular review 0.573 1.77 (1.48, 2.13) <0.001
Has the patient ever sought cross-regional health care
   No Reference 1
   Yes 0.470 1.60 (1.40, 1.83) <0.001
Use of genetic testing
   No Reference 1
   Yes 0.232 1.26 (1.10, 1.45) 0.001
Use of targeted drugs
   No Reference 1
   Yes 0.750 2.12 (1.79, 2.51) <0.001

OR, odds ratio; CI, confidence interval; CNY, Chinese Yuan.


Discussion

To the best of our knowledge, this study was the latest largest multi-center survey in China to analyze the medical expenditure and associated factors of advanced CRC patients. The findings showed that the out-of-pocket medical expenditure of advanced CRC patients was high, especially in patients who were in southern and southwestern China, visited more hospitals, were in the advanced stage at the time of diagnosis, sought cross-regional health care, and used genetic testing and targeted drugs. Although the medical expenditure of most patients was within the affordable range, they were still higher than the annual household income level.

In the current study, most advanced CRC patients had an average total out-of-pocket medical expenditure of 50,000–99,999 CNY. In a multicenter study that enrolled 14,536 CRC patients diagnosed from 2002 to 2011, the average medical expenditure for patients with stage III and IV disease were 38,918 and 42,614 CNY (2011 value), respectively (21). Another cross-sectional study conducted from 2012 to 2014 reported that the average medical expenditure of 2,356 CRC patients was 61,829 CNY (2014 value), ranging from 51,366 CNY for stage I to 75,673 CNY for stage IV (23). Meanwhile, a more recently conducted multi-center retrospective survey found that the average medical expenditure of 8,465 CRC patients diagnosed between 2012 and 2014 in mainland China was 66,291 CNY (2014 value), however, this study included all clinical stages of CRC patients (22). Notably, the above two retrospective studies suggested that the medical expenditure of CRC patients in China showed a significant growth trend (21,22), of which, one suggested that the annual growth rate was as high as 9.2% (21). Considering the medical insurance reimbursement, the increasing trend of medical expenditure, and currency inflation in recent years, the medical expenditure of advanced CRC patients in the current study seems to be comparable with those in the above studies.

Approximately 80% of advanced CRC patients in the current research were diagnosed with stage III or IV at the time of diagnosis, which may be related to the fact that the target population of this study were patients with stage III or IV disease. However, other studies, which included CRC patients with all stages, also found that about half of patients were in an advanced stage at the time of diagnosis (21-23). In addition, both the current study and other studies indicated that patients with stage I disease accounted for less than 20% of all CRC patients in China, which is far lower than that in countries with national CRC screening programs available, such as Australia (22.1% for stage I) and the United States (38.1% for localized CRC) (25,26). However, with the increasing coverage for cancer screening in China, which is recognized by the Chinese government as a priority (27), downstage shift can be expected.

This study found that the out-of-pocket medical expenditure of CRC patients was associated with many factors. Consistent with other studies (21,23), we found that medical expenditure was higher for patients with advanced stage at the time of diagnosis compared to those with early stage at the time of diagnosis, suggesting that advanced CRC patients in China bear a higher economic burden. Moreover, the use of genetic testing and targeted therapy could significantly increase the medical costs for CRC patients. Targeted therapy is a new treatment method for advanced CRC patients that has been applied in recent years (28). Considering its high price, relevant government departments have taken measures, and some of the targeted drugs have been included in the catalogue of drugs for national basic medical insurance (29), which will greatly reduce the economic burden of CRC patients in the future. In addition, medical expenditure was also related to the region in which the patient was located. Compared with patients in central China, patients in the eastern area had a lower medical expenditure, whereas patients in the southern and southwestern had a higher medical expenditure, which was not consistent with our expectations. It is generally believed that the economic development level of a region is positively correlated with the medical expenditure of patients. We suspect that the out-of-pocket medical expenditure may be related to the proportion of medical insurance reimbursement between regions. The surveyed data showed that the average proportion of medical insurance reimbursement of patients from the central area was 57.9%, and the proportion in the eastern, southern and southwestern areas were 61.5%, 55.1%, and 51.7%, respectively. The out-of-pocket medical expenditure of patients may be relatively low in areas with a high reimbursement ratio.

In terms of the financial burden of advanced CRC patients, this study found that most patients’ out-of-pocket medical expenditure were affordable; however, they also exceeded the annual household income of patients, and patients needed to reduce some daily household expenses to relieve financial pressures. At the same time, some patients needed to seek help from relatives, friends, or other social organizations. In fact, the financial burden of medical expenditure on patients can be expressed by the catastrophic health expenditure, which was measured by the household’s capacity to pay and the threshold was set as equal to or greater than 40% of capacity to pay (30). Previously, a multi-center cross-sectional study involving 2,356 CRC patients conducted from 2012 to 2014 showed that patients spent 59.9% of their household income for the diagnosis and treatment of CRC in a year (23), reaching the level of catastrophic health expenditure. Therefore, the economic burden of CRC patients, especially advanced CRC patients, deserves more attention. It is also necessary to expand the coverage of CRC screening and increase the rate of early diagnosis to reduce the disease burden of CRC, and formulate corresponding policies to control out-of-pocket expenditure.

Nevertheless, the study had several limitations that should be noted. Firstly, the self-reported data may be affected by recall bias and social expectations. Secondly, the cost information collected in this study was only the approximate range of medical expenditure, and the specific expenditure, breakdown of expenditure, and indirect expenditure were not collected. Finally, generalization of the findings could be limited because only advanced CRC patients were enrolled in current study. However, we are planning to conduct further follow-up of the investigated patients with CRC and establish a longitudinal cohort. If possible, we will collect the medical expenditure, non-medical expenditure, and indirect expenditure of the whole disease course of the patients, so as to provide more detailed data support for the prevention and control of CRC in the future.

In summary, this nation-wide multi-center survey illustrated the current medical expenditure and associated factors of advanced CRC patients in China. The findings indicated that the out-of-pocket medical expenditure of advanced CRC patients was high. Although most of them were affordable, they were still higher than the average annual household income. In addition, the treatment cost varied among subgroups. More attention needs to be paid to patients who were in southern and southwestern China, were in the advanced stage at the time of diagnosis, had sought cross-regional health care, and those who used genetic testing and targeted drugs.


Acknowledgments

Funding: This research was funded by Beijing Love Book Cancer Foundation and Merck Serono Co., Ltd.


Footnote

Reporting Checklist: The authors have completed the SURGE reporting checklist. Available at https://atm.amegroups.com/article/view/10.21037/atm-22-1001/rc

Data Sharing Statement: Available at https://atm.amegroups.com/article/view/10.21037/atm-22-1001/dss

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://atm.amegroups.com/article/view/10.21037/atm-22-1001/coif). All authors stated that this research was funded by Merck Serono Co., Ltd. The authors have no other conflicts of interest to declare.

Ethical Statement:The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). This research was approved by the independent review board of Henan Cancer Hospital (No. 2019273), the other 18 hospitals were informed and agreed with the study, and informed consent was taken from all the patients.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.


References

  1. Ferlay J, Ervik M, Lam F, et al. Global Cancer Observatory: Cancer Today. Lyon, France: International Agency for Research on Cancer. Accessed November 25, 2021. Available online: https://gco.iarc.fr/today
  2. Zheng RS, Sun KX, Zhang SW, et al. Report of cancer epidemiology in China, 2015. Zhonghua Zhong Liu Za Zhi 2019;41:19-28. [PubMed]
  3. Chen W, Zheng R, Baade PD, et al. Cancer statistics in China, 2015. CA Cancer J Clin 2016;66:115-32. [Crossref] [PubMed]
  4. Zhang Y, Shi J, Huang H, et al. Burden of colorectal cancer in China. Zhonghua Liu Xing Bing Xue Za Zhi 2015;36:709-14. [PubMed]
  5. Wang H, Cao MD, Liu CC, et al. Disease burden of colorectal cancer in China: any changes in recent years? Zhonghua Liu Xing Bing Xue Za Zhi 2020;41:1633-42. [PubMed]
  6. Dekker E, Tanis PJ, Vleugels JLA, et al. Colorectal cancer. Lancet 2019;394:1467-80. [Crossref] [PubMed]
  7. Davidson KW, Barry MJ, Mangione CM, et al. Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement. JAMA 2021;325:1965-77. [Crossref] [PubMed]
  8. Schreuders EH, Ruco A, Rabeneck L, et al. Colorectal cancer screening: a global overview of existing programmes. Gut 2015;64:1637-49. [Crossref] [PubMed]
  9. Cai SR, Huang YQ, Zhang SZ, et al. Effects of subitems in the colorectal cancer screening protocol on the Chinese colorectal cancer screening program: an analysis based on natural community screening results. BMC Cancer 2019;19:47. [Crossref] [PubMed]
  10. Chen W, Li N, Cao M, et al. Preliminary Analysis of Cancer Screening Program in Urban China from 2013 to 2017. China Cancer 2020;29:1-6.
  11. Li W, Zhao LZ, Ma DW, et al. Predicting the risk for colorectal cancer with personal characteristics and fecal immunochemical test. Medicine (Baltimore) 2018;97:e0529. [Crossref] [PubMed]
  12. Wu WM, Wang Y, Jiang HR, et al. Colorectal Cancer Screening Modalities in Chinese Population: Practice and Lessons in Pudong New Area of Shanghai, China. Front Oncol 2019;9:399. [Crossref] [PubMed]
  13. Chen H, Li N, Ren J, et al. Participation and yield of a population-based colorectal cancer screening programme in China. Gut 2019;68:1450-7. [Crossref] [PubMed]
  14. Chen H, Lu M, Liu C, et al. Comparative Evaluation of Participation and Diagnostic Yield of Colonoscopy vs Fecal Immunochemical Test vs Risk-Adapted Screening in Colorectal Cancer Screening: Interim Analysis of a Multicenter Randomized Controlled Trial (TARGET-C). Am J Gastroenterol 2020;115:1264-74. [Crossref] [PubMed]
  15. Gong Y, Wu C, Zhanng M, et al. Colorectal cancer survival analysis in major areas in shanghai China. China Oncology 2015;25:497-504.
  16. Zhou C, Guo T, Mo M, et al. Survival report of 13.7 thousand surgical colorectal cancer patients from a large single hospital-based cancer registry. China Oncology 2020;30:246-53.
  17. National Institutes of Health. Cancer prevalence and cost of care projections. Accessed February 28, 2022. Available online: https://costprojections.cancer.gov/graph.php
  18. Ananda S, Kosmider S, Tran B, et al. The rapidly escalating cost of treating colorectal cancer in Australia. Asia Pac J Clin Oncol 2016;12:33-40. [Crossref] [PubMed]
  19. Slavova-Azmanova NS, Newton JC, Johnson CE, et al. A cross-sectional analysis of out-of-pocket expenses for people living with a cancer in rural and outer metropolitan Western Australia. Aust Health Rev 2021;45:148-56. [Crossref] [PubMed]
  20. Slavova-Azmanova NS, Newton JC, Saunders C, et al. 'Biggest factors in having cancer were costs and no entitlement to compensation'-The determinants of out-of-pocket costs for cancer care through the lenses of rural and outer metropolitan Western Australians. Aust J Rural Health 2020;28:588-602. [Crossref] [PubMed]
  21. Shi J, Liu G, Wang H, et al. Medical expenditures for colorectal cancer diagnosis and treatment: A 10-year high-level-hospital-based multicenter retrospective survey in China, 2002-2011. Chin J Cancer Res 2019;31:825-37. [Crossref] [PubMed]
  22. Shi JF, Wang L, Ran JC, et al. Clinical characteristics, medical service utilization, and expenditure for colorectal cancer in China, 2005 to 2014: Overall design and results from a multicenter retrospective epidemiologic survey. Cancer 2021;127:1880-93. [Crossref] [PubMed]
  23. Huang HY, Shi JF, Guo LW, et al. Expenditure and financial burden for the diagnosis and treatment of colorectal cancer in China: a hospital-based, multicenter, cross-sectional survey. Chin J Cancer 2017;36:41. [Crossref] [PubMed]
  24. Yao HW, Li XX, Cui L, et al. Annual report of Chinese Colorectal Cancer Surgery Database in 2019:A nationwide registry study. Chinese Journal of Practical Surgery 2020;40:106-10,16.
  25. Australian Institute of Health and Welfare (AIHW). Cancer in Australia 2019. Cancer Series 119. Catalog no. CAN 123. AIHW’ 2019.
  26. National Cancer Institute, Surveillance, Epidemiology, and End Results (SEER) Program. SEER*Explorer. Accessed November 25, 2021. Available online: https://seer.cancer.gov/explorer/application.php
  27. The State Council of China. State Council’s Opinions on Implementing Healthy China Action. Accessed November 25, 2021. Available online: http://www.gov.cn/zhengce/content/2019-07/15/content_5409492.htm
  28. Kirstein MM, Lange A, Prenzler A, et al. Targeted therapies in metastatic colorectal cancer: a systematic review and assessment of currently available data. Oncologist 2014;19:1156-68. [Crossref] [PubMed]
  29. National Healthcare Security Administration. Notice of the National Medical Insurance Administration and the Ministry of Human Resources and Social Security on Issuing the National Basic Medical Insurance, Work Injury Insurance and Maternity Insurance Drug Catalog (2020). Accessed November 25, 2021. Available online: http://www.nhsa.gov.cn/art/2020/12/28/art_37_4220.html
  30. Xu K, Evans DB, Kawabata K, et al. Household catastrophic health expenditure: a multicountry analysis. Lancet 2003;362:111-7. [Crossref] [PubMed]

(English Language Editor: A. Kassem)

Cite this article as: Wang H, Ma L, Gu XF, Li L, Wang WJ, Du LB, Xu HF, Cao HL, Zhang X, Shi JH, Zhao YQ, Liu YY, Huang JX, Cao J, Fan YP, Feng CY, Zhu Q, Du JC, Wang XH, Zhang SK, Qiao YL; China Working Group on Colorectal Cancer Survey. Out-of-pocket medical expenditure and associated factors of advanced colorectal cancer in China: a multi-center cross-sectional study. Ann Transl Med 2022;10(6):356. doi: 10.21037/atm-22-1001

Download Citation