CANCER INTERVENTIONS TECHNICAL BRIEFING BREAST … · Suppl): 125S-127S. 12. Groot M, Baltussen R, Uyl-de Groot C, Anderson B, Hortobagyi G. Costs and Health Effects of Breast Cancer

Page 1 of 12 (Version dated 12 April 2017)

CANCER INTERVENTIONS TECHNICAL BRIEFING

BREAST CANCER INTERVENTIONS FOR THE APPENDIX 3 OF THE GLOBAL ACTION

PLAN FOR THE PREVENTION AND CONTROL OF NONCOMMUNICABLE DISEA SES

IDENTIFICATION OF INTERVENTIONS

The interventions considered for breast cancer analysis are based on WHO guidance and emphasizes

comprehensive cancer control including diagnosis, staging, multi-modality treatment, survivorship care and

palliative care as well as the first Appendix 3 [1], [2], [3], [4].

METHODOLOGICAL ASSUMPTIONS

- Estimates of incidence of breast cancer and age of diagnosis are sourced from Globocan [5];

- Region-specific data on stage-distribution are based on [6], [7], [8], [9], [10], [11], [12], [13], [14], [15],

[16], [17] when available;

- Disability weights for each health state were drawn from the Global Burden of Disease 2010 disability

weight study [18];

- Modelled intervention effect changes in rates of diagnosis of invasive cancer (e.g. screening) and rates

of mortality (e.g. surgery).

TABLE 1: DATA ELEMENTS USED FOR IMPACT ESTIMATION IN WHO CHOICE ANALYSIS

Procedures Variable Assumptions References

Screening with mammography (once every 2 years for women aged 50-69 years) linked with timely diagnosis and treatment of breast cancer

Screening with Mammography Sensitivity 0.76 IARC, 2016 [19]

Specificity 0.93 IARC, 2016 [19]

Frequency (per year) 1/2 WHO, 2014 [20]

Treatment of breast cancer stages I and II with surgery +/- systemic therapy, including diagnosis, staging, treatment and surveillance after completion of treatment

Annual mortality rate without treatment

Stage I 0.14 Groot et al. 2006 [21]; Zelle et al. 2012 [16], Perez et

al. 2014 [22]; Davies et al. [23]; Feng et al., 2014 [24]

Stage II 0.18

Stage III 0.23

Stage IV 0.50

Annual mortality with treatment

Stage I 0.006 Groot et al. 2006 [21]; Zelle et al. 2012 [16], Perez et


Stage II 0.039

Stage III 0.093

Stage IV 0.27

Impact of treatment (% reduction on mortality compared with no treatment)

Stage I 95.7% Groot et al. 2006 [21]; Zelle et al. 2012 [16], Perez et


Stage II 78.3%

Stage III 59.6%


TABLE 2: COSTING ASSUMPTIONS1 USED IN WHO CHOICE ANALYSIS

Intervention Major costing assumptions

Treatment of breast cancer stages I and II with surgery +/- systemic therapy, incl. diagnosis, staging, treatment and surveillance after completion of treatment

Diagnosis and staging: Diagnostic imaging with bilateral mammogram Biopsy equipment, specimen fixative and staining, Pre-treatment tests and staging studies when indicated including x-ray

and ultrasound. Treatment: Modified radical mastectomy including pre-operative antibiotics,

wound drainage kit Adjuvant systemic therapy including doxorubicin, cyclophosphamide

and paclitaxel [28] Hormone therapy with tamoxifen [28] Management of neutropenia and chemotherapy-associated nausea

including filgrastim, ondansetron and dexamethasone [28] Health workforce costs for treatment including surgery and systemic

therapy Inpatient visit days: 2 days Outpatient visit days: 8 days for stage I, 10 days for stage II Surveillance with annual mammogram and clinical exam for 5 years

Screening with mammography (once every 2 years for women aged 50-69 years) linked with timely diagnosis and treatment of breast cancer

Screening: Screening mammogram Programme monitoring and evaluation, call and recall mechanism [29] Management of screen-positive mammograms with subsequent

diagnostic studies Diagnosis and staging: Biopsy equipment, specimen fixative and staining, Pre-treatment tests and staging studies when indicated including x-ray

and ultrasound Treatment: Modified radical mastectomy including pre-operative antibiotics,

wound drainage kit Adjuvant systemic therapy including doxorubicin, cyclophosphamide

and paclitaxel [28] Hormone therapy with tamoxifen [28] Management of neutropenia and chemotherapy-associated nausea

including filgrastim, ondansetron and dexamethasone [28] Health workforce costs for treatment including surgery and systemic

therapy Inpatient visit days: 2 days Outpatient visit days: 8 days for stage I, 10 days for stage II Surveillance with annual mammogram and clinical exam for 5 years

Palliative care Symptom management including amitriptyline, stool softener, morphine (slow release, immediate release), ondansetron, bisphosphonates [30]

Outpatient or home visit days: 30 visits

1 Prices are taken from the MSH drug price database as median buyer price: http://mshpriceguide.org/en/drug-search-

page-2/.List of consumables identified from WHO Priority Medical Devices in Cancer Management (2017). Systemic therapy treatment regimen taken from WHO List of Essential Medicines. Consumables required include those required for treatment-related complications and surveillance after treatment completion.


References

1. World Health Organization. Global action plan for the prevention and control of noncommunicables

diseases 2013-2020. 2013.

http://apps.who.int/iris/bitstream/10665/94384/1/9789241506236_eng.pdf?ua=1

2. World Health Organization. National cancer control programmes : policies and managerial guidelines.

– 2nd ed. 2002. http://www.who.int/cancer/media/en/408.pdf

3. World Health Organization. Diagnosis and Treatment (Cancer Control: Knowledge into Action: WHO

Guide for Effective Programmes; Module 4). 2008.

http://apps.who.int/iris/bitstream/10665/43827/1/9789241547406_eng.pdf

4. World Health Organization. Guide to cancer early diagnosis. 2017.

http://apps.who.int/iris/bitstream/10665/254500/1/9789241511940-eng.pdf?ua=1

5. International Agency for Research on Cancer. Goblocan 2012: Estimated Cancer Incidence, Mortality

and Prevalence Worldwide in 2012. http://globocan.iarc.fr/Pages/DataSource_and_methods.aspx.

6. International Agency for Research on Cancer. IARC Registry Data.

http://survcan.iarc.fr/survivalstats.php?country=chiangmai&table=Table5b&soumission=subm.

7. Sant et al. Breast Carcinoma Survival in Europe and the United States. Cancer. 2004; 100 ( 4): 715-722.

8. Mandelblatt J et al. Modeling the impact of population screening on breast cancer mortality in the

United States. Breast. Oct 2011; 20 (Suppl 3): S75-81.

9. Schwartsmann G. Breast cancer in South America: challenges to improve early detection and medical

management of a public health problem. J Clin Oncol. 2001;19 (18 Suppl): 118S-124S.

10. Chopra R. The Indian Scene. J Clin Oncol. 2001; 19 (18 Suppl): 106S-111S.

11. Vorobiof D, Sitas F, Vorobiof G. Breast Cancer Incidence in South Africa. J Clin Oncol. 2001; 19 (18

Suppl): 125S-127S.

12. Groot M, Baltussen R, Uyl-de Groot C, Anderson B, Hortobagyi G. Costs and Health Effects of Breast

Cancer Interventions in Epidemiologically Different Regions of Africa, North America, and Asia. Breast

Journal. Jan-Feb 2006; 12 (Suppl 1): S81-90.

13. Brinton L, Figueroa J, Awuah B, Yarney J, Wiafe S, Wood S, Ansong D, Nyarko K, Wiafe-Addai B, Clegg-

Lamptey J. Breast Cancer in Sub Saharan Africa: Opportunities for prevention. Breast Cancer Res.

Treat. April 2014; 144 (3): 467-78.

14. Nïens LM, Zelle SG, Gutiérrez-Delgado C, Pena GR, Balarezo BRH, Steller ER, Rutten FFH. Cost-

Effectiveness of Breast Cancer Control Strategies in Central America: The Cases of Costa Rica and

Mexico. Plos One. 25 April 2014; 9(4): e95836.

15. Zelle SG, Vidaurre T, Abugattas JE, Manrique JE, Sarria G, Jeronimo J, Seinfeld JN, Lauer JA, Sepulveda

CR, Venegas D, Baltussen R.Cost-Effectiveness Analysis of Breast Cancer Control Interventions in Peru.

Plos One. 10 Dec 2013;8(12):e82575.

16. Zelle SG, Nyarko KM, Bosu WK, Aikins M, Niens LM, Lauer JA, Sepulveda CR, Hontelez JAC, Baltussen R.

Costs, effects and cost-effectiveness of breast cancer control in Ghana. Tropical Medicine and

International Health. 2012; 17(8): 1031-1043.

17. Okonkwo Q, Draisma G, der Kinderen A, Brown M, de Koning H. Breast cancer screening policies in

developing countries: a cost-effectiveness analysis for India. Journal of the National Cancer Institute.

2008; 100(18):1290-1300.

18. Institute for Health Metrics and Evaluation (IHME). Global Burden of Disease 2010 Study. The Lancet.

2012.

19. International Agency for Research on Cancer. Breast Cancer Screening: IARC Handbook of Cancer

Prevention. 2016;15.

20. World Health Organization. WHO position paper on mammography screening. 2014.

http://apps.who.int/iris/bitstream/10665/137339/1/9789241507936_eng.pdf?ua=1&ua=1

21. Groot MT, Baltussen R, Uyl-de Groot CA, Anderson BO, Hortobágyi GN. Costs and Health Effects of

Breast Cancer Interventions in Epidemiologically Different Regions of Africa, North America, and Asia.

The Breast Journal. 2006; 12 ( Supplement s1): S1-S122.

22. Perez E , Romond E, Suman V, Jeong J, Sledge G, Geyer CJ, Martino S, Rastogi P, Gralow J, Swain S,

Winer E, Colon-Otero G, Davidson N, Mamounas E, Zujewsk J, Wolmark N. Trastuzumab plus adjuvant

chemotherapy for human epidermal growth factor receptor 2-positive breast cancer: planned joint


http://www.who.int/cancer/media/en/408.pdf



http://globocan.iarc.fr/Pages/DataSource_and_methods.aspx

http://survcan.iarc.fr/survivalstats.php?country=chiangmai&table=Table5b&soumission=subm

http://apps.who.int/iris/bitstream/10665/137339/1/9789241507936_eng.pdf?ua=1&ua=1


analysis of overall survival from NSABP B-31 and NCCTG N9831. J Clin Oncol. 20 Nov 2014; 32(33):

3744-52.

23. Davies C et al. Long-term effects of continuing adjuvant tamoxifen to 10 years versus stopping at 5

years after diagnosis of oestrogen receptor-positive breast cancer: ATLAS, a randomised trial. The

Lancet. 9 March 2013; 381( 9869): 805-16.

24. Feng W, Ke Y, Ze-Dong D, Xiao-Feng H, Peng-Fei Z, Rui-Lei T, Qiu L. Cost-effectiveness analysis of colon

cancer treatments from MOSIAC and No. 16968 trials. World J Gastroenterol. 21 Dec

2014;20(47):17976-84.

25. World Health Organization Media Centre. Early cancer diagnosis saves lives, cuts treatment costs. 3

February 2017. http://www.who.int/mediacentre/news/releases/2017/early-cancer-costs/en/.

26. Ginsberg GM, Lauer JA, Zelle S, Baeten S, Baltussen R. Cost effectiveness of strategies to combat

breast, cervical, and colorectal cancer in sub-saharan africa and south east asia: mathematic

modelling study. BMJ. 2012; 344(e614):1-18.

27. International Agency for Research on Cancer. Globocan 2012: Estimated Cancer Incidence, Mortality

and Prevalence Worldwide in 2012.

2012.http://globocan.iarc.fr/Pages/DataSource_and_methods.aspx.

28. World Health Organization. 19th WHO Model List of Essential Medicines.

http://www.who.int/medicines/publications/essentialmedicines/EML2015_8-May-15.pdf.

29. Lynge E, Tornberg S, von Karsa L, Segnan N, van Delden JJ. Determinants for a successful

implementation of population-based cancer screening programmes. Eur J Cancer. March

2012;48(5):743-8.

30. World Health Organization. Planning and implementing palliative care services: a guide for

programme managers. 2016. http://apps.who.int/iris/bitstream/10665/250584/1/9789241565417-

eng.pdf?ua=1

http://www.who.int/mediacentre/news/releases/2017/early-cancer-costs/en/


CANCER INTERVETIONS TECHNICAL BRIEFING

CERVICAL CANCER INTERVENTIONS FOR THE AP PENDIX 3 OF THE GLOBAL ACTION



The package of interventions for Cervical Cancer are based on those contained in the publication

“Comprehensive cervical cancer control: a guide to essential practice – 2nd edition” of the World Health

Organization (WHO) as well as the first Appendix 3 [1] and [2].


- Incidence estimates and age at diagnosis of cervical cancer are sourced from Globocan [3];

- Estimates of HPV distribution by types taken from [4], [5] and [6];

- Region-specific data on stage-distribution were used when available [7], [8], [9], [10], and [11];

- Transition rates from dysplasia (CIN) to carcinoma are taken from [7];


weight study [12];

- Treatment includes diagnosis, staging, treatment and post surveillance after completion of treatment;

- Modelled interventions effect changes in:

o rates of incidence to invasive cancer (e.g. screening);

o rates of diagnosis of invasive cancer (e.g. screening);

o rates of mortality (e.g. surgery).


TABLE 1: DATA ELEMENTS USED FOR IMPACT ESTIMATION IN WHO CHOICE ANALYSIS


Vaccination against human papillomavirus (2 doses) of 9–13 year old girls

HPV Vaccination Effectiveness of HPV vaccination for types 16 and 18

(reduction in incidence)

90%2 WHO position paper, Oct

2014 [13]; WHO position paper, Sept 2014 [14],

PRIME [15]

Prevention of cervical cancer by screening women aged 30–49 through visual inspection with acetic acid linked with timely treatment of pre-cancerous lesions

Screening with visual Inspection with acetic acid (VIA)

Sensitivity 0.66 IARC, 2005 [16],

Goldie et al.2001 [17]

Specificity 0.77 IARC, 2005 [16]

Frequency (per year) 1/3 WHO, 2014 [1]

Prevention of cervical cancer by screening women aged 30–49 through “Pap” smear (cervical cytology) every 3 years linked with timely treatment of pre-cancerous lesions

Screening with Papanicolaou (“Pap”) smear

Sensitivity 0.62 IARC, 2005 [16]

Specificity 0.95 Goldie et al., 2001 [17]

Frequency 1/3 WHO, 2014 [1]

Prevention of cervical cancer by screening women aged 30–49 through Human papillomavirus test every 5 years linked with timely treatment of pre-cancerous lesions

Screening with HPV DNA test Sensitivity 0.88 WHO,2014 [1]; IARC, 2005 [16]; Goldie et al., 2001 [17] Specificity 0.75

Frequency 1/5 WHO,2014 [1]

Treatment of cervical cancer stages I and II with either surgery or radiotherapy +/- chemotherapy, incl. diagnosis, staging, treatment and post surveillance after completion of treatment


Stage I 0.120 Goldie et al.,2003 [7],

NCCN 2016 [18], and Chuang 2016 [19]

Stage II 0.196

Stage III 0.4766

Stage IV 1.266


Stage I 0.027 Goldie et al.,2003 [7],

NCCN 2016 [18], and Chuang 2016 [19]

Stage II 0.062

Stage III 0.167

Stage IV 0.316

Impact of treatment (% reduction mortality)

Stage I 77.5% Goldie et al.,2003 [7],

NCCN 2016 [18], and Chuang 2016 [19]

Stage II 68.4%

Stage III 65.0%

Stage IV 75.0%

2 90% effectiveness for types 16 and 18 as used in WHO PRIME tool [16]. Estimated Incidence of HPV types 16 and 18 taken

from [4], [5] and [6].


TABLE 2: COSTING ASSUMPTIONS3 USED IN WHO-CHOICE ANALYSIS


Vaccination against human papillomavirus (2 doses) of 9–13 year old girls

Vaccine price4

Vaccine delivery costs4

Prevention of cervical cancer by screening women aged 30–49 through visual inspection with acetic acid linked with timely treatment of pre-cancerous lesions

Screening: visual inspection with acetic acid (VIA) performed by trained

provider5

Treatment: same-day treatment with cryotherapy for individuals with positive findings on VIA

Programme monitoring and evaluation, call and recall mechanism [20]

Outpatient visit: one day6

Prevention of cervical cancer by screening women aged 30–49 through “Pap” smear (cervical cytology) every 3 years linked with timely treatment of pre-cancerous lesions

Screening: cervical smear obtained by trained provider5 and

subsequently reviewed by cytopathologist Treatment: recall and subsequent treatment with cryotherapy for individuals with positive findings on Pap smear

Programme monitoring and evaluation, call and recall mechanism [20] Outpatient visits: two days

6

Prevention of cervical cancer by screening women aged 30–49 through Human papillomavirus test every 5 years linked with timely treatment of pre-cancerous lesions

Screening: provider obtained HPV test5

Recall for positive HPV test with subsequent visual inspection with acetic acid

Treatment: same-day treatment for those with positive findings on VIA with cryotherapy

Programme monitoring and evaluation, call and recall mechanism [20] Outpatient visit: two days

6

Treatment of cervical cancer stages I and II with either surgery or radiotherapy +/- chemotherapy, incl. diagnosis, staging, treatment and post surveillance after completion of treatment

Diagnosis and staging: Diagnostic evaluation with biopsy, specimen fixative and staining, Pre-treatment tests and staging studies when indicated including cross-sectional imaging and ultrasound.

Treatment [1], [18], [19] and [21]: Cone biopsy or simple hysterectomy for microinvasive disease Radical hysterectomy for early invasive surgery Concurrent chemoradiotherapy with cisplatin and stage IB2 or stage II [22] Management of chemotherapy-associated nausea including ondansetron

Health workforce costs for treatment Inpatient visit days: 6 days for stage I, 2 days for stage II Outpatient visit days: 6 days for stage I, 30 days for stage II Surveillance with imaging as indicated for 5 years [18]

Palliative care Symptom management including amitriptyline, stool softener, morphine (slow release, immediate release), ondansetron and urinary catheter, as needed [23]


3 Prices of drugs taken from MSH database: http://mshpriceguide.org/en/drug-search-page-2/.List of consumables

identified from WHO Priority Medical Devices in Cancer Management (2017). Systemic therapy treatment regimen taken from WHO List of Essential Medicines. Consumables required include those required for treatment-related complications and surveillance after treatment completion. 4 Vaccine price and vaccine delivery costs estimated from WHO Prime Tool [15].

5 Referral for subsequent colposcopy and/or biopsy for lesions suspicious for invasive carcinoma

6 Costing includes health workforce time and one or two outpatient facility visits.

http://mshpriceguide.org/en/drug-search-page-2/


References

1. World Health Organization. Comprehensive Cervical Cancer Control - A guide to Essential Practice.

Geneva: WHO Press; 2014.

2. World Health Organization. Global Action Plan for the prevention and control of noncommunicable

diseases. Geneva: WHO Press; 2013.

3. Globocan 2012: Estimated Cancer Incidence, Mortality and Prevalence Worldwide in 2012 [Internet].

International Agency for Research on Cancer. 2017 [cited 7 April 2017]. Available from:

http://globocan.iarc.fr/Pages/DataSource_and_methods.aspx

4. Clifford G, Gallus S, Herrero R, Muñoz N, Snijders P, Vaccarella S et al. Worldwide distribution of human

papillomavirus types in cytologically normal women in the International Agency for Research on Cancer

HPV prevalence surveys: a pooled analysis. The Lancet. 2005;366(9490):991-998.

5. Bruni L, Diaz M, Castellsagué X, Ferrer E, Bosch F, de Sanjosé S. Cervical Human Papillomavirus

Prevalence in 5 Continents: Meta‐Analysis of 1 Million Women with Normal Cytological Findings. The

Journal of Infectious Diseases. 2010;202(12):1789-1799.

6. Smith J, Lindsay L, Hoots B, Keys J, Franceschi S, Winer R et al. Human papillomavirus type distribution in

invasive cervical cancer and high-grade cervical lesions: A meta-analysis update. International Journal of

Cancer. 2007;121(3):621-632.

7. Goldie S, Grima D, Kohli M, Wright T, Weinstein M, Franco E. A comprehensive natural history model of

HPV infection and cervical cancer to estimate the clinical impact of a prophylactic HPV-16/18 vaccine.

International Journal of Cancer. 2003;106(6):896-904.

8. Cutts F. Human papillomavirus and HPV vaccines: a review. Bulletin of the World Health Organization.

2007;85(09):719-726.

9. Quinn M, Benedet J, Odicino F, Maisonneuve P, Beller U, Creasman W et al. Carcinoma of the Cervix

Uteri. International Journal of Gynecology & Obstetrics. 2006;95:S43-S103.

10. Comparative statistics by cancer registry - SurvCan [Internet]. Cancer Survival in Africa, Asia, the

Caribbean and Central America. 2017 [cited 7 April 2017]. Available from:


11. Ginsberg G, Lauer J, Zelle S, Baeten S, Baltussen R. Cost effectiveness of strategies to combat breast,

cervical, and colorectal cancer in sub-Saharan Africa and South East Asia: mathematical modelling study.

BMJ. 2012;344(mar28 3):e2360-e2360.


2012.

13. Efficacy of HPV vaccinator in adolescent girls [Internet]. World Health Organisation. 2014 [cited 7 April

2017]. Available from:

http://www.who.int/immunization/position_papers/hpv_grad_efficacy_young_females.pdf?ua=1

14. World Health Organisation. Human papillomavirus vaccines: WHO position paper, October 2014.

Geneva: WHO Press; 2014 p. No. 43, 2014, 89, 465–492.

15. Jit M, Brisson M, Portnoy A, Hutubessy R. Cost-effectiveness of female human papillomavirus

vaccination in 179 countries: a PRIME modelling study. The Lancet Global Health. 2014;2(7):e406-e414.

16. International Agency for Research on Cancer, World Health Organisation. Cervix Cancer Screening. Lyon:

IARC Press; 2005.

17. Goldie S, Kuhn L, Denny L, Pollack A, Wright T. Policy Analysis of Cervical Cancer Screening Strategies in

Low-Resource Settings. JAMA. 2001;285(24):3107.

18. National Comprehensive Cancer Network. Cervical Cancer: Clinical Practice Guidelines in Oncology

(NCCN Guidelines), Version 1. 2017. https://www.nccn.org/professionals/physician_gls/f_guidelines.asp

19. Chuang L, Temin S, Camacho R, Dueñas-Gonzalez A, Feldman S, Gultekin M et al. Management and Care

of Women With Invasive Cervical Cancer: American Society of Clinical Oncology Resource-Stratified

Clinical Practice Guideline. Journal of Global Oncology. 2016;2(5):311-340.

20. Lynge E, Tornberg S, von Karsa L, Segnan N, van Delden JJ. Determinants for a successful

implementation of population-based cancer screening programmes. Eur J Cancer. March

2012;48(5):743-8.




22. Atun R, Jaffray D, Barton M, Bray F, Baumann M, Vikram B et al. Expanding global access to

radiotherapy. The Lancet Oncology. 2015;16(10):1153-1186.

23. World Health Organization. Planning and implementing palliative care services: a guide for programme

managers. 2016. http://apps.who.int/iris/bitstream/10665/250584/1/9789241565417-eng.pdf?ua=1


CANCER INTERVETIONS TECHNICAL BRIEFING

COLORECTAL CANCER INTERVENTIONS FOR THE APPENDIX 3 OF THE GL OBAL ACTION



The interventions considered for colorectal cancer analysis are based on WHO guidance and emphasizes

comprehensive cancer control including diagnosis, staging, multi-modality treatment, survivorship care and

palliative care as well as the first Appendix 3 [1], [2], [3] and [4].


- Estimates of incidence of colorectal cancer and age of diagnosis are sourced from Globocan [5];

- Region-specific data on stage-distribution and ratio of colon cancer to rectal cancer of 2:1 were based

on [6], [7], [8], [9], [10], [11], [12] and [13];


weight study [14];

- Modelled intervention effect changes in rates of mortality (e.g. surgery).

TABLE 1: DATA ELEMENTS USED FOR IMPACT ESTIMATION IN WHO-CHOICE ANALYSIS


Treatment of colorectal cancer stages I and II with surgery +/- chemotherapy and radiotherapy, incl. diagnosis, staging, treatment and surveillance after completion of treatment


Stage I 0.18

Liu et al., 2014 [15]; NCCN, 2017 [16]

Stage II 0.18

Stage III 0.58

Stage IV 0.90


Stage I 0.01 Frazier et al., 2000 [17]; Wu et al. , 2006 [18]; Chadder et al.,

2016 [19]; NCIN, 2009 [20]

Stage II 0.01

Stage III 0.05

Stage IV 0.57

Impact of treatment (% reduction on mortality)

Stage I 94.4% Liu et al., 2014 [15]; NCCN, 2017 [16];

Frazier et al., 2000 [17]; Wu et al. , 2006 [18]; Chadder et al.,

2016 [19]; NCIN, 2009 [20]

Stage II 94.4%

Stage III 91.4%

Stage IV 36.7%


TABLE 2: COSTING ASSUMPTIONS7 USED IN WHO-CHOICE ANALYSIS


Treatment of colorectal cancer stages I and II with surgery +/- chemotherapy and radiotherapy, incl. diagnosis, staging, treatment and surveillance after completion of treatment

Diagnosis and staging: Diagnosis with colonoscopy, biopsy, specimen fixative and staining Pre-treatment tests and staging studies when indicated including

cross-axial imaging Treatment: Colectomy including pre-operative antibiotics Adjuvant systemic therapy for colon cancer such as capecitabine and

oxaliplatin for select patients with Stage II colon cancer [16] and [21] Neoadjuvant systemic therapy for rectal cancer such as capecitabine

and radiotherapy for select patients with Stage II rectal cancer [16], [21] and [22]

Adjuvant chemotherapy with 5-FU, oxaliplatin and leucovorin for select patients with Stage II rectal cancer [16] and [21]

Management of complications and toxicities including surgical infection, neutropenia and chemotherapy-associated nausea that includes antibiotics, filgrastim and ondansetron [16] and [21]

Health workforce costs for treatment including surgery and systemic therapy

Inpatient visit days: 7 days Outpatient visit days: 8 days for stage I, 30 days for stage II Surveillance including laboratory test, cross-axial imaging and

endoscopy as indicated for 5 years

Palliative care Symptom management including amitriptyline, stool softeners, morphine (slow release, immediate release), ondansetron, amitriptyline [22]


References

1. World Health Organization. Global action plan for the prevention and control of noncommunicables

diseases 2013-2020. 2013.


2. World Health Organization. National cancer control programmes : policies and managerial guidelines.

– 2nd ed. 2002. http://www.who.int/cancer/media/en/408.pdf

3. World Health Organization. Diagnosis and Treatment (Cancer Control: Knowledge into Action: WHO

Guide for Effective Programmes; Module 4). 2008.


4. World Health Organization. Guide to cancer early diagnosis. 2017.


5. International Agency for Research on Cancer. Globocan 2012: Estimated Cancer Incidence, Mortality

and Prevalence Worldwide in 2012. http://globocan.iarc.fr/Pages/DataSource_and_methods.aspx.

7 Prices of drugs taken from MSH database: http://mshpriceguide.org/en/drug-search-page-2/. List of consumables

identified from WHO Priority Medical Devices in Cancer Management (2017). Systemic therapy treatment regimen taken from WHO List of Essential Medicines. Consumables required include those required for treatment-related complications and surveillance after treatment completion.

http://mshpriceguide.org/en/drug-search-page-2/


6. Comparative statistics by cancer registry - SurvCan [Internet]. Cancer Survival in Africa, Asia, the

Caribbean and Central America. 2017 [cited 7 April 2017]. Available from:


7. Graham A, Adeloye D, Grant L, Theodoratou E, Campbell H. Estimating the incidence of colorectal

cancer in Sub–Saharan Africa: A systematic analysis. J Glob Health. Dec 2010; 2(2): 020404.

8. Brenner H, Jansen L, Ulrich A, Chang-Claude J, Hoffmeister M. Survival of patients with symptom- and

screening-detected colorectal cancer. Oncotarget. 12 Jul 2016; 7(28): 44695-44704.

9. Alsanea N, Abduljabbar AS, Alhomoud S, Ashari LH, Hibbert D, Bazarbashi S. Colorectal cancer in Saudi

Arabia: incidence, survival, demographics and implications for national policies. Ann Saudi Med.

2015;35 (3): 196-202.

10. Zorzi M et al. Characteristics of the colorectal cancers diagnosed in the early 2000s in Italy- Figures

from the IMPATTO study on colorectal cancer screening. Epidemiol Prev. 2015; 39(3, Suppl 1): 1-125.

11. Hsu YH, Kung PT, Wang YH, YM Chang, Tsai WC. A comparison of the stages at which cancer is

diagnosed in physicians and in the general population in Taiwan. CMAJ. 22 Sept 2015; 187(13): E412–

E418.

12. Seinfeld J. Cost-benefit analysis of cancer care and control:The case of cervical, colorectal and breast

cancer in low and middle income countries.

http://isites.harvard.edu/fs/docs/icb.topic1011506.files/CCC%20-

%20Breast_Cervical%20and%20Colorectal%20cancer%20cases_AB.pdf

13. Benitez-Majano S, Fowler H, Maringe C, Di Girolamo C, Rachet B. Deriving stage at diagnosis from

multiple population-based sources: colorectal and lung cancer in England. Br J Cancer. 26 Jul 2016;

115(3):391-400.


2012.

15. Liu CY, Chen WTL, Kun PT, Chiu CF, Wang YH, Shieh SH,Tsai WC. Characteristics, survival, and related

factors of newly diagnosed colorectal cancer patients refusing cancer treatments under a universal

health insurance program. BMC Cancer. 2014; 14(446).

16. 1National Comprehensive Cancer Network. Colon Cancer: Clinical Practice Guidelines in Oncology

(NCCN Guidelines), Version 2. 2017.

https://www.nccn.org/professionals/physician_gls/f_guidelines.asp

17. Frazier AL, Colditz GA, Fuchs CS, and et al. Cost-effectiveness of Screening for Colorectal Cancer in the

General Population. JAMA. 2000; 284(15): 1954-1961.

18. Wu GHM, Wang YM, Yen AMF, Wong JM, Lai HC, Warwick J, Chen THHC. Cost-effectiveness analysis of

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