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The total cost of cancer was €199 billion in Europe in 2018.
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Cancer caused nearly equally large costs within and outside the health-care system.
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The total costs of cancer differed greatly between countries.
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Health spending on cancer has been increasing faster than cancer incidence.
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The productivity loss from premature mortality has been decreasing over time.
Abstract
Background
Cancer care is evolving rapidly, and costs and value of new treatments are frequently debated. Up-to-date evidence on the total cost of cancer is needed to inform policy decisions. This study estimates the cost of cancer in Europe in 2018 and extends a previous analysis for 1995–2014.
Methods
Cancer-specific health expenditure were derived from national estimates. Data on cancer drug sales were obtained from IQVIA. The productivity loss from premature mortality was estimated from data from Eurostat and the World Health Organization. Estimates of the productivity loss from morbidity and informal care costs were based on previous studies.
Findings
The total cost of cancer was €199 billion in Europe (EU-27 plus Iceland, Norway, Switzerland, and the United Kingdom) in 2018. Total costs ranged from €160 per capita in Romania to €578 in Switzerland (after adjustment for price differentials). Health expenditure on cancer care were €103 billion, of which €32 billion were spent on cancer drugs. Informal care costs were €26 billion. The total productivity loss was €70 billion, composed of €50 billion from premature mortality and €20 billion from morbidity.
Interpretation
Health expenditure on cancer care were of a similar magnitude as the sum of non-health-care costs in 2018. Over the last two decades, health spending on cancer has increased faster than the increase in cancer incidence. The productivity loss from premature mortality has decreased because of reductions in mortality in the working-age population. Trends in informal care costs and productivity loss from morbidity are uncertain because of lack of comparable data.
There are few international comparative studies of the cost of cancer. This study provides estimates of the total cost of cancer and key cost components in 31 countries in Europe for the year 2018. It extends the authors’ previous analysis for the period 1995–2014 [
The total cost of cancer and its development over time is a function of the size of the disease burden (cancer incidence, prevalence, and mortality) and technological progress. For instance, a rising number of new cancer patients increases the health-care expenditure for diagnostics and treatment, whereas declining mortality in working-age patients reduces productivity loss. New treatment modalities can improve patient outcomes, but they typically require additional health-care spending.
The disease burden of cancer in Europe has been increasing over time, and population aging is a major contributing factor to this development. The number of newly diagnosed cancer cases gradually increased by around 50% from 2.1 million to 3.1 million cases between 1995 and 2018 in our 31-country sample of Europe [
]. Cancer deaths increased by around 20% from 1.2 million to 1.4 million cases during this period, but deaths in people younger than 65 years decreased. A comparison of age-standardized rates shows that in the absence of population growth and population aging, cancer incidence would still have increased in almost all countries in Europe between 1995 and 2018, whereas cancer mortality would have decreased in almost all countries [
]. The fact that mortality has increased less than incidence between 1995 and 2018 is a reflection of improving patient outcomes. Analyses of the development of five-year survival rates have shown improvements in many cancer types in Europe between 1995 and 2014 [
Global surveillance of trends in cancer survival 2000-14 (CONCORD-3): analysis of individual records for 37 513 025 patients diagnosed with one of 18 cancers from 322 population-based registries in 71 countries.
Global surveillance of cancer survival 1995-2009: analysis of individual data for 25,676,887 patients from 279 population-based registries in 67 countries (CONCORD-2).
In a rapidly evolving disease area as cancer, up-to-date studies of the costs are crucial for understanding the magnitude of the economic burden of cancer and how new treatment modalities and the disease burden are reflected in the costs. Such information is important for policy decisions on both the national and European level.
2. Material and methods
We adopted a societal perspective to estimate the total cost of cancer and its key components (direct costs including cancer drugs, informal care costs, indirect costs) in 2018. The estimated costs for Europe, defined as the 27 member states of the European Union (EU) plus Iceland, Norway, Switzerland, and the United Kingdom, are the sum of the costs of the 31 countries included. Cancer is defined as neoplasms (ICD-10 C00-D48) in the cost calculations. Details of data and methodology are provided in a recently published report [
The direct costs of cancer are defined as expenditures on cancer that are made within the health-care system. We calculated these costs in line with previous analyses [
]. Estimates of total health expenditure for 2018 (or latest available year) were obtained from the Organisation for Economic Co-operation and Development (OECD) and the World Health Organization (WHO) [
]. These data were combined with national estimates of the share of total health expenditure spent on cancer care. In the absence of disease-specific health accounts in most countries, country-specific data on health expenditure on cancer care were gathered from reports and studies from national ministries of health, national statistical offices, research institutes, national cancer societies, peer-reviewed journals, the OECD, and the WHO. National estimates for 20 countries could be obtained, and for the remaining 11 countries, data were imputed based on geographical proximity and similarity in gross domestic product (GDP) per capita.
Data on cancer drugs (ATC code L01, L02 and five agents from L04) were based on national sales data from the MIDAS database maintained by IQVIA. These data are based on list prices, which often do not represent actual final sales prices, as many drugs are granted confidential rebates in most European health systems.
Costs of informal care represent the opportunity cost of time forgone by relatives and friends to provide unpaid care. We based our estimates on previous estimates for EU countries in 2012 [
]. We imputed missing national data for three countries based on geographical proximity and similarity in GDP per capita. We inflation-adjusted and exchange-rate-adjusted the costs to 2018 based on data from Eurostat [
] and scaled up the estimates on malignant neoplasms (ICD-10 C00–C97) to neoplasms (C00-D48) with the same factor as for morbidity-caused productivity loss (mentioned in the paragraph after next of the article).
The indirect costs of cancer are defined as productivity loss attributable to premature mortality and to morbidity. Using the human-capital method, we calculated the productivity loss from premature mortality as the lost earnings after death during working age (15–64 years). Age-specific and sex-specific number of cancer deaths were obtained from Eurostat [
]. Potential years of working life lost were multiplied with sex-specific mean annual earnings from employment (referring to year 2014 but adjusted to 2018 prices) and sex-specific employment rates in the age group 15–64 years, based on data from Eurostat [
]. Future lost earnings were discounted with a 3.5 percent annual discount rate, and a zero real growth rate in future earnings was assumed.
The productivity loss from morbidity comprises lost earnings due to sickness absence and permanent incapacity/disability of employed people. We based our estimates on previous estimates for EU countries in 2009 [
]. We converted these previous country-specific estimates, calculated based on the friction-cost method, to the human-capital method using a factor of 1.7, based on the previous study's own results for the EU [
]. We imputed missing national data for four countries based on geographical proximity and similarity in GDP per capita. We inflation-adjusted and exchange-rate-adjusted the costs to 2018 based on data from Eurostat [
] and scaled up the estimates on malignant neoplasms to neoplasms with a country-specific factor (around 1.02) based on the observed difference in productivity loss from premature mortality between these two definitions of cancer in 2010.
All costs are expressed in euros (€) in 2018 prices and exchange rates. The results are not adjusted for price differentials between countries (purchasing power parities, PPP) [
Many different resources within the health-care system are used in cancer care. This includes medical staff (such as pathologists, surgeons, oncologists), medical equipment (scanners, needles for biopsies), general facilities (hospitals, outpatient clinics), pharmaceuticals (cancer drugs, supportive medications like antiemetic drugs), and vaccines (against human papillomavirus).
The total health expenditure on cancer care amounted to €103 billion in Europe in 2018; see Table 1, Table 2. This corresponded to €195 per capita or 6.2 percent of the total health expenditure. Per-capita health spending on cancer ranged from below €50 in Bulgaria and Romania to over €500 in Switzerland. Country differences strongly related to economic strength (GDP per capita). In addition, total health-care spending as a share of GDP was lower in poorer countries than in wealthier countries. By contrast, all countries spent between 4 and 7 percent of the total health expenditure on cancer care, and there was no systematic difference in relation to how wealthy or poor countries were.
Table 1Total cost of cancer (in million €) in Europe in 2018, by country and component.
Estimated share based on data from similar countries; see Ref. [10].
166
72
257
173
930
Slovenia
234
6.4%
105
77
166
139
616
Spain
5245
4.9%
2841
2529
3440
950
12,164
Sweden
1907
3.7%
572
491
830
960
4189
Switzerland
4366
6.0%
801
597
1716
477
7157
United Kingdom
11,691
5.0%
3249
3213
6633
1465
23,002
Europe
102,607
6.2%
32,008
26,389
49,615
20,418
199,029
Notes: Totals of Europe and costs do not match sums of costs because of rounding. No adjustment for price differentials. Cancer drug expenditure do not include confidential rebates. Data on cancer drugs for Cyprus and Malta could not be obtained, and for Estonia, Greece, and Luxembourg they only include retail sales but not hospital sales.
a Cancer drug expenditure are a subset of the health expenditure on cancer care.
b Estimated share based on data from similar countries; see Ref. [
Cancer drug expenditure are a subset of the health expenditure on cancer care.
Productivity loss from premature mortality
Productivity loss from morbidity
Austria
289
108
45
122
32
488
Belgium
284
90
61
123
109
577
Bulgaria
45
31
6
25
7
83
Croatia
61
36
23
49
104
236
Cyprus
103
–
28
46
11
188
Czechia
102
16
18
41
32
193
Denmark
259
89
132
164
126
680
Estonia
73
4
18
46
57
194
Finland
153
60
61
101
28
344
France
278
77
49
106
68
502
Germany
308
92
62
139
53
562
Greece
88
4
29
56
15
188
Hungary
63
40
17
51
9
140
Iceland
197
60
57
126
115
495
Ireland
234
64
37
109
23
404
Italy
172
75
85
81
5
343
Latvia
57
13
17
47
20
142
Lithuania
70
20
12
40
29
152
Luxembourg
363
12
54
150
61
628
Malta
155
–
25
54
4
238
Netherlands
308
62
57
145
81
591
Norway
296
69
68
115
126
605
Poland
57
15
15
47
21
140
Portugal
96
39
36
64
19
215
Romania
36
18
8
31
8
83
Slovakia
79
30
13
47
32
171
Slovenia
113
51
37
80
67
298
Spain
112
61
54
74
20
261
Sweden
187
57
49
82
95
413
Switzerland
511
94
70
202
56
840
United Kingdom
176
49
48
100
22
347
Europe
195
61
50
94
39
378
Notes: Total costs do not match sum of costs because of rounding. No adjustment for price differentials. Cancer drug expenditure do not include confidential rebates. Data on cancer drugs for Cyprus and Malta could not be obtained for Estonia, Greece, and Luxembourg, and they only include retail sales but not hospital sales.
a Cancer drug expenditure are a subset of the health expenditure on cancer care.
Expenditures on cancer drugs amounted to €32 billion (€61 per capita) in Europe in 2018 (excluding confidential rebates); see Table 1, Table 2. In per capita terms, the top spenders were Austria, Germany, and Switzerland with over €90, and the lowest spenders (with complete data) were Czechia, Latvia, Poland, and Romania with less than €20. There was a clear tendency of wealthier countries to spend more on cancer drugs than poorer countries, but the gap in cancer drug expenditure was smaller than that in overall health expenditure on cancer care. This was a result of poorer countries spending a higher proportion of their cancer-specific health expenditure on cancer drugs.
The development of the direct costs of cancer, including cancer drugs, in Europe between 1995 and 2018, is shown in Fig. 1. The total health expenditure on cancer care amounted to €52 billion in 1995 and increased by 98% to €103 billion in 2018. Expenditures on cancer drugs amounted to €10 billion in 2005 and more than tripled to €32 billion in 2018. As cancer drug expenditure grew faster than the total direct costs, their share increased from 12 percent in 2005 to 31 percent in 2018. The rapid growth in cancer drug expenditure is linked to increased usage (e.g., increased number of cancer patients and new cancer drugs, new patient groups eligible for treatment, use in an adjuvant setting, longer duration of therapy) and to higher (list) prices of new drugs [
Fig. 1Direct costs of cancer in Europe in 1995–2018 (in billion €, 2018 prices and exchange rates). Notes: Costs for 1995 and 2000 represent total direct costs, as it was not possible to separate costs because of lack of data on drugs. Cancer drug expenditure do not include confidential rebates, whose size might have increased over time. The 1995 estimates could only be adjusted for country-specific inflation between 1996 and 2018 due to lack of data.
The development of the direct costs of cancer in Central and Eastern Europe (see Fig. A1) and smaller countries in Northwestern Europe (see Fig. A2) is not too different from the development in Europe as a whole. One of the main differences is that direct costs in Central and Eastern Europe more than tripled between 1995 and 2018. Expenditures on cancer drugs tripled between 2005 and 2018 in both regions alike, in line with the overall development in Europe.
3.2 Cost of informal care
Informal care refers to the services provided by relatives and friends. It includes the time to accompany the patient to the hospital and of care for the patient at home. The cost of informal care amounted to €26 billion (€50 per capita) in Europe in 2018; see Table 1, Table 2. The development of informal care costs over time is difficult to judge because of lack of data, which is discussed in the following section of the article.
3.3 Indirect costs
The indirect costs of cancer are a result of two types of productivity loss. First, productivity loss from premature mortality represents the lost future earnings from patients who die during working age and who otherwise would have continued to work until retirement age. Second, productivity loss from morbidity represents the lost earnings from patients due to temporary absence from work (sickness absence) or permanent discontinuation of work (permanent incapacity/disability).
The productivity loss from premature mortality amounted to €50 billion (€94 per capita) in Europe in 2018; see Table 1, Table 2. This was the result of 2.3 million potential years of working life lost. The productivity loss per capita ranged from €25 in Bulgaria to over €200 in Switzerland. Higher productivity loss in wealthier countries is mostly a reflection of higher earnings levels in these countries, as they actually tended to record a lower number of potential years of working life lost.
The productivity loss from morbidity amounted to €20 billion (€39 per capita) in Europe in 2018; see Table 1, Table 2. This type of productivity loss is smaller than the loss from premature mortality, in line with previous studies on cancer [
The development of the indirect costs of cancer in Europe between 1995 and 2018 is shown in Fig. 2. The productivity loss from premature mortality amounted to €57 billion in 1995 and decreased by 13% to €50 billion in 2018. This reduction resulted from a decline in the number of cancer deaths in working-age patients and a shift of deaths toward older ages due to increased survival. However, only men contributed effectively to this reduction over time as rising female employment rates counteracted a reduction in women. The development of productivity loss from morbidity over time is difficult to judge due to lack of data. We assumed that this type of productivity loss remained constant (€20 billion) between 1995 and 2018. This assumption is partly supported by Finnish data that indicated even a slight decrease in morbidity-caused productivity loss between 2004 and 2014 (if measured in constant prices) [
From a societal perspective, the economic burden of cancer is composed of direct costs, informal care costs, and indirect costs. The total cost of cancer amounted to €199 billion (€378 per capita) in Europe in 2018; see Table 1, Table 2. The total cost per capita was lowest in Bulgaria and Romania with €83 and ten times higher in Switzerland with €840. These large country differences also reflect price differentials. Fig. 3 presents per capita costs adjusted for price differentials. The PPP-adjusted cost per capita ranged from €160 in Romania to €578 in Switzerland, corresponding to a 3.6-fold difference.
Fig. 3Total costs of cancer in Europe in 2018 (in € per capita, PPP-adjusted).
Our results show that the total cost of cancer was €199 billion in Europe in 2018. Expenditure on cancer care made within the health-care system (€103 billion) were of a similar magnitude as the sum of costs arising outside the health-care system (€96 billion). These results can be compared to estimates of the total cost of cardiovascular diseases in the EU-28 in 2015, which amounted to €210 billion and was also almost equally distributed between costs within and outside the health-care system [
]. The major magnitude of non-health-care costs highlights the importance to consider these costs in decision-making in cancer care. A silo budgeting mentality and a lack of applying a societal perspective can lead to suboptimal policy decisions in the design of measures to prevent, detect, and treat cancer.
Health expenditure on cancer care have almost doubled from €52 billion to €103 billion between 1995 and 2018, whereas the number of newly diagnosed cancer cases has increased by about 50%. Costs per cancer patient have thus gone up. At the same time, the share of cancer-specific health expenditure has increased very slowly from 5.9 percent in 1995 to 6.2 percent in 2018. However, this may change in the future. Until now, increasing costs from the introduction of new cancer drugs have largely been offset by reductions in the costs for inpatient care. The process of transforming cancer care from an inpatient to an outpatient setting has progressed far and might produce less savings in the future. Thus, it will become increasingly difficult to finance further investments in new treatments without an increase in the share of health expenditures devoted to cancer care.
To better understand the development and also to corroborate our estimates of cancer-specific health expenditure, a regular provision of disease-specific health expenditure data by public authorities (such as in Germany and the Netherlands) would be needed. In the absence of such data, cost-of-illness studies are the main source of information and were also used in this study. However, such studies might differ in how comprehensively health-care resources are collected, often leading to an underestimation of the true size of the health-care expenditure. By contrast, our estimates of cancer drug expenditure are overestimated, as they are based on sales data which often do not represent actual final sales prices due to confidential and often sizeable rebates. The size of these rebates might also vary between countries and over time. However, the drug expenditure in this study do not include the costs of a few therapeutic radiopharmaceuticals used in cancer treatment, as they are not part of ATC group L (antineoplastic and immunomodulating agents). They also do not include supportive medications such as antiemetic drugs.
Increasing reliance on informal care may be another reason behind the stable share of cancer-specific health expenditure over time. Informal care is both a substitute for and a complement to private and public health services [
]. There is a risk that cost-containment efforts simply shift costs from formal health services to patients and their informal caregivers. Presently, we lack data to answer this question, and our estimate of informal care costs (€26 billion) should be interpreted with caution. The underlying study for this estimate might have missed a large share of patients below the age of 50, and it had to impute data for half of the countries, which means that these estimates are rather crude. An accurate assessment of informal care costs is becoming increasingly important with the growing incidence of cancer among the elderly and the trend of cancer becoming a chronic disease.
The total productivity loss has decreased from €77 to €70 billion between 1995 and 2018. This decrease stems entirely from a reduction in productivity loss from premature mortality due to a decline in cancer deaths in the working-age population. We expect further decreases in the future as long as new treatments that increase survival keep being introduced. The past (and future) development in productivity loss from morbidity is more uncertain because of lack of comparable data between countries. On the one hand, sick leaves and early retirements might have increased due to longer treatment spells as a result of prolonged survival. On the other hand, the change from inpatient to outpatient treatment, together with fewer side effects of treatment, meant that patients could more easily return to work during treatment. However, work performance is only one aspect of cancer survivorship. Health-related quality of life is also an important outcome which needs further study.
5. Conclusions
This study presents up-to-date evidence on the economic burden of cancer in Europe. Cancer caused an estimated cost of €199 billion to society in Europe in 2018. Information on the total cost is important for documenting value for money and potentials for improved patient outcomes through cost-effective spending. Further studies are needed to document the exact magnitude of the key components of the total cost, in particular informal care costs and morbidity-caused productivity loss. The lack of comparable international data on the latter two components limits the feasibility of comparative studies of the burden of any disease.
Funding
This work is based on a chapter in a report funded by the European Federation of Pharmaceutical Industries and Associations (EFPIA) by a grant to IHE, The Swedish Institute for Health Economics. EFPIA has had no involvement in the study design, collection, analysis and interpretation of data, the writing of the report, or the decision to submit the article for publication.
Conflict of interest statement
T.H. and P.L. are employed at IHE, an independent research organization receiving funding from both public and private sector organizations. B.J. reports personal fees from BMS, Celgene, Janssen, Novartis, and Roche and N.W. from Janssen, MSD, Novartis, and Oasmia for participation in advisory boards and educational activities outside the submitted work.
Appendix.
Fig. A1Direct costs of cancer in Central and Eastern Europe in 1995–2018 (in billion €, 2018 prices and exchange rates). Notes: see Fig. 1. Central and Eastern Europe encompasses Bulgaria, Croatia, Czechia, Estonia, Hungary, Latvia, Lithuania, Poland, Romania, Slovakia, and Slovenia.
Fig. A2Direct costs of cancer in smaller countries in Northwestern Europe in 1995–2018 (in billion €, 2018 prices and exchange rates). Notes: see Fig. 1. Smaller countries in Northwestern Europe encompass Austria, Belgium, Denmark, Finland, Iceland, Ireland, Luxembourg, the Netherlands, Norway, Sweden, and Switzerland.
Global surveillance of trends in cancer survival 2000-14 (CONCORD-3): analysis of individual records for 37 513 025 patients diagnosed with one of 18 cancers from 322 population-based registries in 71 countries.
Global surveillance of cancer survival 1995-2009: analysis of individual data for 25,676,887 patients from 279 population-based registries in 67 countries (CONCORD-2).
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