RESEARCH

 

Costing the national clinical guidelines for prostate cancer control and management in South Africa: Public sector perspective

 

 

E Thsehla^{I, II}; M Khoza^III; M K Boachie^IV; W Mdewa^V; S Goldstein^VI; H Somaroo^VII; K J Hofman^VIII

^IMPH, PhD; SAMRC/WITS Centre for Health Economics and Decision Science, Wits School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
^IIMPH, PhD; School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
^IIIMB BCh, MMed (Community Health); Wits School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
^IVMPhil, PhD; SAMRC/WITS Centre for Health Economics and Decision Science, Wits School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
^VBSc (Hons), MPH; SAMRC/WITS Centre for Health Economics and Decision Science, Wits School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
^VIMB BCh, MMed (Community Health); SAMRC/WITS Centre for Health Economics and Decision Science, Wits School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
^VIIMB BCh, MMed (Community Health); Wits School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
^VIIIMB BCh, FAAP; SAMRC/WITS Centre for Health Economics and Decision Science, Wits School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

Correspondence

 

 

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ABSTRACT

BACKGROUND: Prostate cancer (PCa) is the second most common cancer worldwide and the sixth leading cause of cancer deaths in men. In South Africa (SA), PCa accounts for ~13% of male deaths. The direct medical costs associated with PCa diagnosis and treatment according to the national clinical guidelines for prostate cancer control and management are not documented
OBJECTIVES: To estimate the direct medical costs for localised PCa diagnosis and treatment according to the national clinical guidelines for prostate cancer control and management in SA
METHODS: The direct medical costs for diagnosis and treatment of prostate cancer were estimated from the payer's perspective using a micro-costing approach, with a time horizon of 12 months. Cost items were identified from the national PCa clinical guidelines and quantified according to the treatment options for low- (LRPCa), intermediate- (IRPCa) and high-risk (HRPCa) categories. Cost data were obtained from different government databases. The unit costs and PCa incidence data from 2022 were then used to estimate total costs for treating all new PCa cases. Total costs were calculated for each treatment method listed in the clinical guidelines according to PCa risk categories
RESULTS: The total cost for treating 10 944 new PCa cases in 2022 was estimated at ZAR2.1 billion. Per patient costs ranged from ZAR7 265 to ZAR143 156 for LRPCa, ZAR8 926 to ZAR144 817 for IRPCa and ZAR14 874 to ZAR151 872 for HRPCa. The total cost for managing all patients with LRPCa, IRPCa and HRPCa were estimated at ZAR401.3 million, ZAR371.1 million and ZAR1.4 billion, respectively
CONCLUSION: This study estimated the cost for diagnosis and treatment of localised PCa according to national clinical guidelines for PCa control and management. The costs increased with each risk category of the cancer. The study highlights the need for policy-makers to increase early detection and management, to reduce the need for high-cost interventions

Keywords: prostate cancer, cost of illness, clinical guidelines

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Prostate cancer (PCa) is the second most common cancer worldwide and the sixth leading cause of cancer deaths in men.^[1] In 2020, an estimated 1.4 million new cases and 375 000 deaths were reported globally.^[2,3] In 2022, the age-standardised incidence rate ranged between 82.8 per 100 000 in Northern Europe and 6.4 per 100 000 in south central Asia.^[4] In southern Africa, age-standardised incidence rates were estimated at 59.9 per 100 000. In the absence of any intervention, it is estimated that the number of new cases will reach 2.9 million by 2040 globally.^[2]

In South Africa (SA), PCa is the second most common cancer in the population and the most common cancer in males.^[5,6] In 2019, the age-standardised incidence rate for PCa was 59.3 per 100 000 males.^[7] In the same year, 10 495 new cases of PCa were reported. It is estimated that the annual incidence of PCa cases will be as high as 42 181 in 2030.^[8]

PCa is highest among males in the age group 60 - 79 years in SA.^[7] The mean age at diagnosis was estimated at 71.6 years in KwaZulu-Natal Province and 68.9 years in the Western Cape Province in 2014. The main risk factor for PCa is advanced age, ethnicity, and family history of malignancy.^[9] Lack of access to PCa screening, poor socioeconomic status, high unemployment rates and low literacy and education levels have been identified as reasons for delayed diagnosis in SA.^[10]

As the burden of PCa increases the associated economic burden is expected to increase, partially due to a growing older population, advanced technologies, and advanced disease.^[11-13] Globally, it is estimated that PCa will cost PPP624 billion (international dollars) between 2020 and 2050.^[14] In the UK, the 5-year cost of managing PCa was estimated to be ~ZAR2.6 billion.^[15] In eSwatini, the economic cost of managing PCa for a sample of 90 patients who were partially treated in SA was ZAR82.1 million in 2018.^[16]

In SA, the cost of managing PCa is not fully known. In 2021, Gabela et al.^[17] assessed the cost of managing public sector patients with metastatic castration-resistant PCa, and found that an average of ZAR161 540 is required to treat each patient over a period of 12 months. As the country grapples with the increasing burden of non-communicable diseases and the rising cost of healthcare, policymakers are recognising the need for policies that are evidence-based and affordable. Accordingly, part of the process for the formal adoption of the national prostate clinical practice guidelines requires that guidelines are costed. Based on available evidence, there is currently no detailed cost information on the direct medical cost of diagnosing and treating PCa, if patients are managed according to the national clinical guidelines for prostate cancer control and management.^[18] The main aim of this study is to estimate the cost of treating localised PCa cases in a single year using the SA National Department of Health (NDoH) clinical guidelines. The cost estimates from such an exercise would provide insight that supports evidence-based policy adoption and healthcare budget planning.

 

Methods

A cost-of-illness study was conducted from the perspective of the NDoH. This approach is commonly used to estimate the economic burden of a disease within a specific population over a specific time period, typically a year.^['^9,20]

Study population and sample

The study population consisted of all SA males diagnosed with PCa in 2022. According to the National Cancer Registry, 10 944 PCa cases were diagnosed histologically in 2022.^[21] The study sample consisted of all PCa cases, categorised by risk group. PCa risk stratification is done to determine disease prognosis and is used as a reference for choosing the most suitable treatment options for patients. PCa risk stratification is based on the prostate-specific antigen (PSA) level, clinical PCa stage and histological Gleason score. The main risk groups are low-risk disease (LRPCa), intermediate-risk disease (IRPCa) and high-risk disease (HRPCa). The national clinical guidelines for prostate cancer control and management describe each of the risk groups according to the criteria in Table 1.

The proportion of cases by PCa risk group was calculated using information obtained from the literature.^[22] Published data describing the proportion of prostate biopsies by Gleason scores in Gauteng Province for the period 2012 - 2016 were used to determine the proportion of each PCa risk category.^[22] Data from Gauteng were used because 24.1% of the national population resides in the province, and because it has the highest number of migrants from other provinces.

Based on this, we assumed that the proportion of PCa by different risk category would be similar across other provinces. The average Gleason scores were compared with the Gleason scores used in the national clinical practice guidelines for PCa control and management to obtain the proportion of that PCa risk category.^[18]

Parameters and data sources

The national clinical practice guidelines for PCa control and management, and expert advice, were employed to identify the resources used for the diagnosis and treatment of patients with PCa.^[18] Resource identification was based on the treatment options specified for each risk category as described in the guidelines (see Table 2). When not detailed in the guidelines, the opinion of expert oncologists was used to determine the quantity of resources that would be used by a patient in each prostate cancer risk category in a year. Unit cost data were obtained from the Master Health Product List,^[23] the Uniform Patient Fee Schedule (UPFS)^[24] and the National Health Laboratory Services (NHLS) (Table 3).^[25,26] The UPFS is used in the public sector to determine patient costs, while the MHPL contains a list of health products used in the public sector. Level 3 facility (academic and tertiary hospital) fees and specialist (oncologists, urologists, radiologists) consultation fees were used for professional fees. Fig. 1 presents the distribution and treatment pathway for PCa based on the national clinical practice guidelines for PCa control and management.

 

 

Costing approach

We assumed that all the men with confirmed prostate cancer in 2022 received diagnostic tests, and treatment according to their risk category. While disparities in healthcare access across the country and variations in treatment modalities exist, we estimated the cost for all patients using the proposed clinical guidelines to generate evidence for planning and budgeting purposes. The direct medical costs for diagnosis and treatment were calculated using a bottom-up gross costing approach. Cost per patient for each risk category was estimated by identifying resources used, measuring the units and assigning monetary value using tariffs and unit prices from the public sector. The total cost per patient was estimated by adding up the cost of consultations, diagnosis, laboratory tests, imaging and specific treatment costs such as chemotherapy and radiation therapy. Total annual costs were estimated using the number of cases reported by the cancer registry in 2022. Data analysis was conducted using Excel (Microsoft, USA). Costs data from previous years were adjusted for inflation using 2020 as the base year. All costs were reported in ZAR.

Sensitivity analysis

We conducted one-way sensitivity analysis by varying the different risk groups (LRPCa, IRPCa, HRPCa) by ~25% to account for uncertainty in the proportions in each group.

Ethical consideration

Ethical waiver was obtained from the University of the Witwatersrand's Medical Research Ethics Committee (ref. no. R14/49).

 

Results

Fig. 2 shows the distribution of PCa by risk groups in 2022. The number of cases were estimated at 2 189, 1 970 and 6 785 for LRPCa, IRPCa and HRPCa, respectively. A summary of the estimated patient costs and total cost for each treatment option in 2022 is provided in Table 4. The costs of managing a patient with LRPCa were estimated at ZAR7 200 and ZAR143 100 for active surveillance (AS) and external beam radiotherapy (EBRT), respectively, over a period of 12 months from diagnosis. The total per patient cost for LRPCa was estimated at ZAR183 300. The total cost per patient with IRPCa was estimated at ZAR188 300. The cost of managing a patient with HRPCa using EBRT was estimated at ZAR151 800. HRPCa cost per patient was estimated at ZAR207 400.

The total cost for treating all new PCa cases was estimated to be ZAR2.1 billion. Patients with LRPCa had the lowest total costs, with costs estimated to range between ZAR15.9 million and ZAR313.3 million.

Patients with HRPCa had the highest total costs, with costs estimated to range between ZAR100.9 million and ZAR1.0 billion. Fig. 2 shows the distribution of the costs across the risk groups.

Sensitivity analysis

The results from the sensitivity analysis are presented in in Table 5. The overall costs for managing PCa are estimated to range from ZARR1.6 billion to ZAR2.7 billion. For LRPCa, the total cost ranged from ZAR301 million to ZAR501.7 million. For IRPCa, the lowest estimate was ZAR278.2 million, while the highest was ZAR463.8 million. The total cost ranged between ZAR1 billion and ZAR1.7 billion for HRPCa.

 

Discussion

The aim of this study was to estimate the direct medical costs for PCa diagnosis and treatment using the national clinical practice guidelines. The total cost of managing 10 944 PCa patients ranged between ZAR1.6 and ZAR2.7 billion. The total costs of managing patients with LRPCa, IRPCa and HRPCa were estimated at ZAR401 million, ZAR371 million and ZAR1.4 billion, respectively. The total cost per patient increased from ZAR183 000 in the LPRCa group to ZAR207 000 in the HRPCa group.

The findings of this study are consistent with those from previous studies that showed that PCa stage progression is a crucial determinant of treatment costs.^[16,27,28] In Eswatini, the cost of treating stages III (USD1.2 million) and IV (USD2.1 million) were shown to be higher than treatment of stages I (USD0.5 million) and II (USD0.8 million).^[16] Similar results were observed in Canada and Iran.^[27,28]

The results of this study have policy implications. Our results demonstrate the potential cost-savings of preventing and identifying PCa early. Policy-makers should therefore strengthen primary healthcare for the purposes of increased screening in high-risk populations to identify cases with early disease. Approaches that aim to bring high-risk patients in contact with the health system in the areas where they live, work and socialise are likely to be more effective. This can be done by incorporating PCa screening questions into existing health programmes and activities taking place in primary healthcare facilities and within the community. To improve health-seeking behaviour, PCa awareness campaigns could be integrated into community health worker programmes and health education programmes. This could also be achieved through collaboration with key stakeholders such as traditional healers and religious leaders in communities. Furthermore, strengthening primary healthcare interventions for PCa should be done in conjunction with investment in primary healthcare care infrastructure so that there is capacity to diagnose and stage patients early without the need for referral to specialised services.

A situational analysis on the availability and distribution of the diagnostic and treatment interventions mentioned in the clinical guidelines is also recommended. In addition, the analysis should aim to identify factors associated with current challenges, such as shortage and lack of skilled health professionals, long waiting times and poor referral pathways.^[29] A situational analysis could also assist in identifying the underlying issues related to unutilised funds for cancer in provinces such as Gauteng, where millions of ringfenced funds for treatment remain unspent.^[30]

Study strengths and limitations

The study has some strengths and limitations. This is the first known study to estimate the cost of PCa diagnosis and treatment using national PCa clinical guidelines in SA. The results of this study have the potential to contribute to evidence-based decision-making for sustainable healthcare financing of prostate cancer management. The study could also provide guidance for costing of similar guidelines under the National Health Insurance.

Several limitations were identified. The study estimated only the direct medical costs of localised PCa, and metastatic cancer was excluded. It was assumed that all patients reported in the cancer registry will have had a digital rectal examination, a PSA test and a biopsy (for histological diagnosis), as well as an ultrasound and computed tomography or magnetic resonance imaging scan for staging; however, possibly not all patients receive this in the clinical setting, therefore this assumption may have overestimated the costs. Indeed, disparities in treatment modalities across facilities are real, leading to unequal access to cancer services.

Population costs were estimated for all new cases identified in 2022. Our total costs could be an overestimate as our study is from the public sector perspective, while some cases may have been treated in the private sector.

The estimated population costs for patients with HRPCa included all new cases with HRPCa as well as patients with disseminated disease. This has likely underestimated the total population costs, as some patients with disseminated disease are likely to receive radiotherapy as well as additional treatments such as chemotherapy and palliation. Despite these limitations, our estimates provide valuable insights for policy-making in the context of prostate cancer management.

 

Conclusion

This study estimated the cost for diagnosis and treatment of PCa according to national clinical guidelines for PCa control and management. The costs for diagnosis and treatment of PCa showed a direct relationship with the level of PCa. EBRT was the main cost driver for treatment across all PCa risk categories.

The study highlights the potential for cost-saving if patients with operable disease are identified early and treated with radical prostatectomy. Policy-makers should strive to achieve earlier PCa identification and management, to reduce the need for high-cost interventions.

Data availability. We used publicly available data to conduct our analysis. The data are available from the referenced sources.

Declaration. None.

Acknowledgements. The authors would like to acknowledge Profs Paul Ruff and Georgia Demetriou for their input on the services for managing PCa.

Author contributions. ET, MK, MKB, KH conceptualised the study. MK drafted the protocol under the guidance of ET and MKB. MK and ET collected and analysed the data. MK drafted the initial report. ET, MKB, WM, KH, SG and HS reviewed the initial report. ET and MK drafted the manuscript. All authors read and approved the final manuscript.

Funding. This study received funding from the UK National Institute for Health and Care Research (grant numbers NIHR133252) using UK aid from the UK Government to support global health research. Additional funding came from the South African Medical Research Council (grant number 23108).

Conflicts of interest. None.

 

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Correspondence:
E Thsehla
thsehla.eve@gmail.com

Received 15 October 2024
Accepted 2 December 2025