Public Release: 

Cancer drives patients to poverty in Southeast Asia

Underprivileged patients are at major risk of disease-related 'financial catastrophe,' study in eight low- and middle-income Southeast Asian countries shows

European Society for Medical Oncology

SINGAPORE/LUGANO - Five percent of cancer patients and their families were pushed into poverty in Southeast Asia between March 2012 and September 2013, because of high disease-related costs, a study (1) at the inaugural ESMO Asia 2015 Congress in Singapore shows.

The research, conducted earlier this year, evaluated data collected in eight low and middle-income Southeast Asian countries (Cambodia, Indonesia, Laos, Malaysia, Myanmar, the Philippines, Thailand and Vietnam) to assess patient risk of financial catastrophe (medical expenditures exceeding 30% of annual household income), economic hardship (inability to make necessary household payments) and impoverishment (living on less than 2 US dollars per day), and the association between economic struggles and risk of death. The study shows that cancer resulted in 'financial catastrophe' for almost half of the patients who suffered from economic hardship at the time of diagnosis.

Out-of-pocket healthcare expenditure could have a direct or indirect negative impact on patient's life, potentially affecting quality of life, compliance and death risk. According to study results, up to 20% of patients did not attend their medical appointments or could not pay for medicines. Disadvantaged patients had an 80% higher risk of death within 12 months following diagnosis compared to their counterparts without economic difficulties at baseline.

Commenting on the study, Professor Christoph Zielinski, Medical University of Vienna, Austria, ESMO Board Member and Editor-in-Chief of ESMO Open-Cancer Horizons, said: "Cancer places a significant financial burden on patients, even in middle- and high-income countries. It is therefore no surprise that patients in low and middle-income countries face a relatively larger burden upon their diagnosis. While early detection of cancer can somewhat alleviate this financial burden, patients are still in a precarious situation and are at risk of financial catastrophe.

"Cancer can be an even more terrible disease for poor or socially underprivileged people, and cancer treatment costs constitute only a portion of the problem. Cancer is also linked to morbidity resulting from treatment side-effects, evolvement of the underlying disease, resulting in the inability to follow basic tasks of daily life requiring support by the immediate surroundings, and even terminally severe restrictions in work abilities. Some or many of these aspects can be neutralised by appropriate social programmes, albeit lots of problems remain or become only slightly alleviated by even the best of social systems."

Advanced cancer stages, no health insurance, low income, unemployment and lowest level of education were listed as potential sources of household financial crisis in the prior phase of the ASEAN CosTs In ONcology (ACTION) study (2). "Cancer stage explained most of the financial catastrophic risk and premature deaths observed in the study", senior author, Dr. Nirmala Bhoo-Pathy of the Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia, said. "However, low-income patients remained financially vulnerable, even when diagnosed at very early cancer stages. There appeared to be missed opportunities for surgery in patients with operable malignancies, particularly in low-income groups. Patients without health insurance also remained at higher risk of incurring catastrophic expenditures and dying, even in early stages".

The World Health Organization (WHO) reports 1.7 million new cancer cases every year in Southeast Asia, and the prevalence of cancer mortality is expected to be up to 45% higher in 2030 (3). "Southeast Asia is population- and area-wise comparable to the European Union (EU)," Zielinski said. "However, the similarities end here, as countries of Southeast Asia have a completely different social insurance and security structure, as compared to the EU, and although economic growth is impressive, individual income structures are quite restricted".

Strategies to limit the negative financial impact on cancer patients from low- and middle-income countries should be a priority, as are strategies for treating the disease. Many would be feasible options, according to health policy expert Professor Tikki Pang of the National University of Singapore. "Screening programmes for early detection is a proven strategy in many countries to reduce cancer-related direct and indirect costs, as well as education and awareness raising among the population," he said. "Innovative health insurance models, e.g. a mix of public and private, may also be a useful strategy but each country must decide what schemes suits them best. Another strategy could be promoting the production of generics at national or regional level."

"Our study provides health authorities with significant data to enable them to prioritise cost-effective strategies in cancer control", Bhoo-Pathy said. "Early detection may provide the best avenue to favourably influence economic and disease outcomes in cancer patients from low- and middle-income Southeast Asian countries, followed by increasing accessibility to effective treatments and provision of financial risk protection. The health financing systems in these countries also requires re-examination to ensure that public funds are directed to patients who need them the most."



(1) Abstract 52O "Prioritizing strategies to address the economic impact of cancer in Southeast Asia - N. Bhoo-Pathy, Social and Preventive Medicine, University of Malaya Faculty of Medicine, Kuala Lumpur, Malaysia" will be presented during the ESMO Asia 2015 Congress Presidential Symposium on Sunday 20 December, 16:30 (Singapore time)

Abstract will be available online on 17th December 2015, 23:55 hours (SGT)

(2) "Catastrophic health expenditure and 12-month mortality associated with cancer in Southeast Asia: results from a longitudinal study in eight countries", Author(s): Kimman, Merel; Jan, Stephen; Yip, Cheng Har; et al. Source: Bmc Medicine Volume: 13 Published: AUG 18 2015

(3) World health Organisation (WHO),

Notes to Editors


Information contained in this press release was provided by the abstracts authors and reflects the content of the studies. It does not necessarily express ESMO's point of view.

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Prioritizing strategies to address the economic impact of cancer in Southeast Asia

N. Bhoo-Pathy Social and Preventive Medicine, University of Malaya Faculty of Medicine, Kuala Lumpur, Malaysia

Aim/Background: The ASEAN CosTs In ONcology (ACTION) study revealed that a year after diagnosis, 29% of cancer patients died, 48% had financial catastrophe (FC: out of pocket medical costs exceeding 30% of annual household income), and only 23% were alive with no FC. We estimated the impact of cancer control interventions, and health insurance on economic outcomes and mortality of cancer patients in Southeast Asia (SEA).

Methods: In ACTION study, 9,513 cancer patients with solid and non-solid tumors from 47 hospitals in 8 ASEAN countries were assessed at baseline, 3- and 12 months after diagnosis using questionnaires and cost diaries to determine their risk of FC, economic hardship (EC: inability to make necessary household payments) and impoverishment (living on less than USD2/day). Multinomial regression allowing death as a competing risk was used to assess the association between patient's baseline socio-demographic status and FC, and EH, respectively. Stepwise adjustments for i) health insurance, ii) cancer stage, and iii) cancer therapies were done.

Results: One year after diagnosis, the incidence of mortality and FC ranged from 12% and 45%, respectively in Malaysia to 45% and 50% in Myanmar. Overall, cancer-induced EH was evident in one third of patients of which 45% could not pay for medicines, and 28% resorted to taking personal loans. Five percent of patients were pushed into poverty. Stepwise multivariable regression showed that cancer stage largely explained the incidence of FC and death, followed by cancer therapies. Health insurance did not appear to explain risk of FC. Analysis stratified by cancer stage however showed that low-income patients experienced substantially higher FC and deaths compared to high-income patients across all cancer stages. Patients without health insurance also remained vulnerable to premature deaths even when presenting at earlier cancer stages. Similar results were also observed in multivariable analyses with EH as the outcome.

Conclusions: Cancer down staging via early detection provides the best opportunity to improve economic and survival outcomes of cancer patients in SEA. Nevertheless, providing access to cancer therapies is also important and governments need to improve the financial risk protection for patients.

Disclosure: The author has declared no conflicts of interest.

Keywords: cancer control, economic impact, cancer burden, low- middle income countries

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