The contribution of working with communities as partners to leverage health resources
In this report, we demonstrated the benefit and feasibility of working with communities as local partners especially in primary prevention and early detection of cancer. In communities, places such as community health centres, schools, places of worships and workplaces are organized avenues for partnership and leverage for the community. Community primary health-care facilities, Faith-based institutions, community-based organizations (CBOs), community political leaders and workplace managers are resourceful community-based institutions and structures through which cancer primary prevention and early detection services to the communities.
In regard to cancer awareness efforts through health education and use of mass media channels on primary prevention of cancer, early detection and cancer management, more people were reached through community partnership. For instance; 77.9% of people were health- educated through outreaches and ninety-two (95%) cancer awareness TVs and radio talk-shows were sponsored by local community partners.
Pertaining to cancer screening, overall, more people were screened in outreaches except for prostate screening; 63.0% cervical, 64.4% breast and 38.7% prostate screening. This is probably due to long-distance and associated cost involved in travelling to a tertiary hospital for cancer information and screening services. Therefore, bringing services closer to the people especially those in rural hard to reach and hard to live areas is an opportunity for the community members.
It was also observed that the screen-positive rate and cancer suspicious rate were higher in hospital-based screening than in outreaches. This could be so because some people might choose to visit the hospital only when they evaluate themselves to be most at risk or are driven by early warning signs and symptoms. Therefore, cancer awareness and screening outreaches, especially in rural areas, could significantly contribute to cancer risk reduction and early detection.
From the annual UCI workplan and budget, the average annualized budget for Cancer Outreach Service during 2016/17, 2017/18 and 2018/19 was 188,775,000 Uganda shillings (54,000 USD), equivalent to 162,000 USD spread over the three financial years. This excludes the costs of training health workers and developing cancer information, education and communication materials that were funded through the African development bank ‘East Africa Centre of Excellence for Oncology project’ at the Uganda Cancer Institute. When human resource cost like salaries except for outreach staff facilitation allowances is not considered, the 162,000 USD cancer outreach budget for the three financial years is only 1.3% of the total 12,716,855USD estimated cost of cancer screening during the three years period. Meaning that greatest portion (98.7%) of the outreach cost was absorbed by through community partnership. This portion of 98.7% was covered by the monetary and non-monetary community assets like arrangement of venues, local community health facilities and social mobilization among others. The UCI contribution was used in screening supplies and staff allowances.
A well-organized outreach model could bridge the cancer health-equity disparity especially for the rural residents and socio-economically disadvantaged individuals. Countries like South Africa, Nigeria, Canada and the USA used mobile cancer-preventive outreaches to increase access to primary prevention and early detection services [18, 19] [20].
These illustrate the benefit of working in collaboration with communities as partners and outreaching the rural population. Most importantly is the cost-sharing, leverage for scarce resources and increased capacity to sustain programs that promote primary prevention and early detection of cancer. Knowing the fact that low-income settings are characterized by inadequate investment in national cancer control, then the contribution of locally available community assets, whatever small it is, should not be ignored.
Unit costs for screening, pre-cancer treatment, managing localized and advanced cancer diseases
A snapshot into Costing cancer screening and treatment
The two common approaches applied in costing health-care services are; ‘incremental’ and ‘base case’ scenarios [21]. For simplicity, incremental economic costs involve two major steps; (1) the ingredients approach, that is quantities of resources used and (2) unit costs or prices are assigned to resources consumed [21, 22]. Alternatively, the ‘Base-case scenario’ is applied. In the ‘Base- case scenario’ the assumed resources used per client or patient is multiplied by their estimated unit costs and the influence of alternative assumptions for input parameters is tested through sensitivity analyses [21, 22]. The ‘Base-case scenario’ make assumptions for the costs of inputs, number of clients screened and treated by each service provider, effective working time of capital and staff, costs of training, duration of screening or patient management per client [21, 22].
Cervical cancer screening and treatment cost
In East Africa, it is reported that the cost of cervical cancer care in publicly funded cancer hospitals vary by cancer stage [8], however, it is lower than the cost of cancer care in high-income countries. For instance, in Tanzania, the average cost of hospital-based screening using visual inspection with acetic acid (VIA) per patient excluding human resource cost is US$ 1.45 [8], the average cost of cryotherapy for treating cervical-precancer lesions per patient is US$ 28.97 whereas the average cost of treating an early stage (stages 1 and 2) patient is US$ 3000 [8]. This differs from the cost reported in Ghana by Quentin et al.[9] where the incremental economic costs per client screened with VIA varied from 4.93 US$ to 14.75 US$, whereas the cost of cryotherapy varied from 47.26 US$ to 84.48 US$ [9]. In the same study the ‘base-case’ assumptions modelling, the cost of VIA was found to be 6.12 US$ per woman and cost of cryotherapy was found to be 27.96 US$. In publicly funded hospitals in Tanzania, early-stage cervical cancer disease (stages 1 and 2) cost average of US$ 1740 per patient [8]. This is because early-stage cervical cancer patients receive curative therapy; radiotherapy and chemotherapy that cost US$ 1547.48 and US$ 316.53, respectively, whereas late-stage cervical cancer patients receive only palliative radiotherapy at an average cost of US$ 773.52 [8]. If the costs of human resources and treatment facilities are accounted for, this cost would be higher as observed in other parts of the world.
The average cost of cervical cancer screening using Pap smear was found to average at 91Euro in high-income countries [7]. The individual patient-level clinical cost per patient including cancer diagnostic tests, cancer staging, treatment based on the FIGO stage I-IV, chemotherapy and outpatient care increases with the stage of cancer disease. The average cost in high-income settings varies by stages for example in Europe; 17 514 Euro (18,000USD) for FIGO Ia1-Ib1, 43 950 for FIGO Ib2, 45 126 for FIGO II, 41 125 for FIGO III and 51 420 for FIGO IV [7]. This amounts to an average cost of 33,189.17 Euro, equivalent of US $36,751.07 per cervical cancer patient.
Breast cancer screening and treatment cost
Women with breast cancer in sub-Saharan Africa (SSA) are younger compared with the western countries (Black and Richmond 2019). Majority of breast cancer patients present with advanced cancer when treatment options are limited and characterized by poor prognoses. Some of the reasons for late presentation could be lack of access to early detection services and practices such as mammography and breast examination. In the Medicare scheme in the United States, the age-standardized breast screening-related cost per woman varied across regions from $42 to $107 [10]. The average market cost of early-disease breast cancer surgery; lumpectomy or mastectomy in Uganda as at 2018 was 10,500,000 Uganda shillings (US$ 3000).
In a systematic review of Global treatment costs of breast cancer by stage based on FIGO staging system [11], the average cumulative treatment costs weighted by sample sizes were $29,724 at stage I, $39,322 at stage II, $57,827 at stage III, and $62,108 at stage IV in 2015 US dollars. On average, the costs at stage II, III and IV were 32%, 95%, and 109% higher than the cost at stage I [11]. In the other studies where invasive breast cancer was categorized as local, regional and distant, the average costs weighted by sample sizes were $63,664, $89,898 and $168,906 [11]. The costs of managing regional and distant breast cancer were 41% and 165% higher than that of localized breast cancer [11]. These costs are quite high for individuals of low-income countries like Uganda. Therefore, investing and tapping local community assets to focus on primary prevention or early detection when cancer could be managed and better-quality life is guaranteed are crucial options.
Prostate cancer screening and treatment cost
In a study by Fourcade et al [12] on prostate cancer treatment cost per patient for localized disease in European and American countries excluding follow-up and adverse events cost varies by countries; 5851 Euro per patient in France, 3698 Euro per patient in Germany, 3682 Euro per patient in UK and 10, 296 Euro in Canada, an average of 5,881 euro (6369 USD) per patient. Another study observed that patients with regional prostate cancer experience higher total cost per patient to the average tune of 16, 608 euro, an equivalent of 18,000 USD [13, 14]. Prostate cancer surgery on average cost 10,000 USD per patient (Pate et al. 2013). The average market cost of early -disease prostate surgery in Uganda as of 2018 was 15,000,000 Uganda shillings (US$ 4,286). The average market cost of prostate screening using PSA, DRE with or without ultrasound scan in Uganda as of 2018 was estimated at 105,000 Uganda shillings (US$ 30).
Comparing the unit costs for screening, pre-cancer treatment, managing localized and advanced cancer diseases
Cancer is a costly group of diseases with complex varying screening, diagnostic and treatment modalities worldwide. For example, the screening, diagnostic, and treatment costs for the three commonest Cancers in Uganda; Cervical, Breast and Prostate cancers vary significantly even if they were of the same disease-stage. It is a common concern among cancer experts in high-income countries about over-diagnosis of cancer [2], while low-income countries are characterized by under-diagnosis or no diagnosis of even the most prevalent cancers. This is usually attributed to; better cancer screening program with a fairly balanced supply of health technologies in high-income countries compared to low-income countries [3, 5].
The low-income status fixes many countries with inadequate number of multi-disciplinary cancer experts especially clinical oncologists [6] and limited early detection technology options [5]. With the high prevalence of infectious diseases like malaria, HIV/AIDS and Tuberculosis, Cancer control programs are not usually the top priorities of governments and international funders compared to infectious diseases in low-income countries. The low-income status of many African countries exacerbates this complex situation with either one or no comprehensive cancer centre, opportunistic or health camp-based screening programs. This leaves the majority (80%) of cancer patients with one option of battling cancer when it is advanced at a costly price while the majority who could not afford the cost languish with untold suffering or seek help from traditional and alternative medical practitioners such as herbalists and self-proclaimed spiritual healers.
When you look at the cost of cancer awareness with screening and cost of managing cancer disease, the unit cost incurred in cancer screening is thousands-folds less than the unit cost of managing in any stage of cancer disease. The cost of managing cancer disease increases with the stage of cancer progression [7]. For example, the average unit cost for managing localized Cervical cancer cases is 2,941 times higher than the average unit cost of cervical screening. The average unit cost for managing advanced cervical cancer (Regional or distant) is 6,005 times higher than the average unit cost of screening. The average unit cost for managing advanced Cervical cancer (Regional or distant) is 1,314 times higher than the average unit cost of pre-cancer treatment of Cervical lesions using cryotherapy. The average unit cost of managing advanced Cervical cancer cases is two-fold higher the unit cost for managing localized Cervical cancer cases. This means residents of low-income countries are likely to continue experiencing catastrophic expenditure for cancer treatment if no local options of community assets are tapped into primary prevention and early detection of cancer.
Similar catastrophic costs are observed in other types of cancer. For instance, the average unit cost for managing localized Breast cancer cases is 708 times higher than the average unit cost of screening. The average unit cost for managing advanced Breast cancer (Regional or distant) is 1479 times higher than the average unit cost of breast screening. The average unit cost for managing advanced Breast cancer is 21 times higher than the average unit cost of pre-cancer treatment of Breast cancer lesions using Lumpectomy. The average unit cost for managing advanced Breast cancer (Regional or distant) is two times higher than the average unit cost for managing localized cervical cancer cases. In the context of prostate cancer; the average unit cost for managing localized Prostate cancer cases is 212 times higher than the average unit cost of screening. The average unit cost for managing advanced Prostate cancer (Regional or distant) is 600 times higher than the average unit cost of screening. The average unit cost for managing advanced Prostate cancer (Regional or distant) is 4.2 times higher than the average unit cost of pre-cancer treatment of Prostate lesions using surgical intervention. The average unit cost for managing advanced Prostate cancer (Regional or distant) is 2.8 times higher than the average unit cost for managing localized cervical cancer cases.