The cost burden of breast cancer treatment at Kenyatta national hospital: a patient’s perspective

Abstract

Background Breast cancer ranks highest among the cancers affecting women in Kenya. Treatment involves surgery, adjuvant chemotherapy and radiotherapy. The therapy has significant cost implications. Associated procedures including diagnostic and routine laboratory tests and management of adverse effects of surgery and chemotherapy increases the direct cost to patients and costs to the society given the poor resource setting that Kenya is in. Objective The main objective was to evaluate the direct total medical costs incurred by breast cancer patients at Kenyatta National Hospital from a patient’s perspective. The secondary objective was to identify significant cost components. Methodology This was a hospital based retrospective cohort study. Patients diagnosed with breast Cancer at Kenyatta National Hospital registry and who had undergone mastectomy, chemotherapy and radiotherapy during the period January 2010 and December 2014 were identified. Ninety three patient files were sampled by systematic random sampling. A customized pre tested data collection tool was used to collect socio-demographic, clinical and cost data from patient files. Descriptive and exploratory data analysis was done using STATA Version 10. A micro ingredient approach was used for costing. From patients’ records and the billing department, all the resources used by patients were identified and quantified. The units cost was obtained from the procurement department. These were used to compute the total costs incurred by each patient. The median total cost was then computed. Exploratory data analysis was done to determine associations between categorical variables. A cost function for a patient was obtained by linear regression forward stepwise model building. Ethical approval to conduct the study was given by the Kenyatta National Hospital and University of Nairobi Research and Ethics committee. All costs were converted to international dollars (int $), using the purchasing power parity for Kenya against the United States dollars. The 2014 conversion rate of 40.43 Kenya shillings = 1 international dollars was used. Results The median total cost of treatment to a patient in 2015 for breast cancer was 2658.92 international dollars with an inter quartile range of [2122.24, 2834.67]. The equivalent cost in Kenya shillings was shs 107500 with an inter quartile range of [85748, 114578] The main cost drivers and their contribution to the total treatment cost were surgery (38.5%), laboratory and radiological tests (25.1%), chemotherapy (9%), and management of side effects (14%) arising from the various treatment modalities. Patient and disease related variables that had a significant effect on total cost were stage of the disease (p=0.046), comorbidities (p=0.039) and presence of bone metastasis (p= 0.01). The menopausal status and parity of the participants had no significant effect on the total cost. Discussion The median cost of Breast cancer treatment in Kenyatta National Hospital was int$ 2658.92 which is 15 times the country’s average wage monthly wage level of int$ 177.84. Surgical procedures and laboratory investigations collectively are responsible for 60% of all the costs incurred by the patient. The choice of chemotherapeutic agents explains 15% of cost variation in the total cost model. Patients start therapy late and this contributes to high cost of therapy. New treatments such as transtuzumab are extremely costly Conclusion The total cost of breast cancer treatment is well above the countries wage level and subsidization is required