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Medical Treatment Expenses for Lung Cancer in Japan

Motoi Nishi1

1 Department of Fundamental Health Sciences, Health Sciences University of Hokkaido, 1757 Tobetsu, Hokkaido, 061-0293 Japan.

Conflict-of-interest statement: The authors declare that there is no conflict of interest regarding the publication of this paper.

Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http: //creativecommons.org/licenses/by-nc/4.0/

Correspondence to: Motoi Nishi, Department of Fundamental Health Sciences, Health Sciences University of Hokkaido, 1757 Tobetsu, Hokkaido, 061-0293 Japan.
Email: motoi@hoku-iryo-u.ac.jp
Telehpone: +81-(0)133-23-1211

Received: October 28, 2020
Revised: November 16, 2020
Accepted: November 18, 2020
Published online: November 24, 2020

ABSTRACT

Background: Since 1993 lung cancer has been the leading cause of death due to cancer in Japan. In December 2015, nivolumab was approved for the treatment of lung cancer in this country and dramatic effects have been noted in many patients. However, its price is very high, which is one of the causes of rising national medical expenses.

Materials: In 2009 the Ministry of Health, Labour and Welfare of the Japanese Government began to publish the data of medical treatment expenses for the main malignant neoplasms. The numbers of deaths due to malignant neoplasms, including lung cancer, and medical treatment expenses from 2009 to 2017 were obtained from the data published on the sites of the ministry.

Results: From 2015 to 2016, the number of deaths from lung cancer decreased, though it increased from 2009 to 2015. The medical treatment expenses for this cancer increased from 2009 to 2015, but from 2015 to 2016 they increased largely for all age groups (45-64, 65-74 and 75+ years). The increase in the percentage of the expenses spent by the group aged 45-64 years at outpatient clinics from 2015 to 2016 was the highest (10.1 points), and was about 2 times larger than that of those aged 75 and older (4.58). The expense to decrease one death from lung cancer (about $200,000) in the group aged 65-74 years was the smallest, being about 40% of that for the group aged 75 and older (about $500,000). The greater part of the increase in the sale of nivolumab from 2015 to 2016 (about 80%) may be accounted for by medical treatment expenses for lung cancer.

Discussion: It is certain that the introduction of nivolumab for the treatment of lung cancer brought about the increase in the medical treatment expenses from 2015 to 2016. There is a possibility that the cost and quality of life due to treatment with this drug differ by age.

Key words: Japan; Lung cancer; Medical expense; Nivolumab

© 2020 The Authors. Published by ACT Publishing Group Ltd. All rights reserved.

Nishi M. Medical Treatment Expenses for Lung Cancer in Japan. Journal of Tumor 2020; 8(1): 568-571 Available from: URL: http://www.ghrnet.org/index.php/jt/article/view/3038

INTRODUCTION

In Japan cancer has been the leading cause of death since 1981 and its crude morality rate has been increasing[1]. On the other hand, national medical expenses have also been increasing and now have become a burden on the national budget.

Since 1993 lung cancer has been the leading cause of death due to cancer. In December 2015, nivolumab, a molecular targeted drug, was introduced for the treatment of lung cancer, and dramatic effects have been noted in many patients. However, its price is very high, and is one of the causes of rising national medical expense. In this article, the recent changes in medical treatment expenses for lung cancer in Japan are reported.

Materials and Methods

1. Medical treatment expenses

In the statistics of the Japanese Government, the total medical expenses consist of: (1) medical treatment expenses; (2) dental treatment expenses; (3) pharmacy dispensation expenses; (4) visiting care expenses; (5) meal and living expenses during hospitalization; (6) others.

In this article, only medical treatment expenses are examined, and an arbitrary exchange rate of Yen 100 = 1$US is used.

2. Numbers of deaths from malignant neoplasms and lung cancer

The numbers of deaths due to malignant neoplasms, including lung cancer, were obtained from the vital statistics indicated on the site of the Ministry of Health, Labour and Welfare of the Japanese Government.

https://www.e-stat.go.jp/stat-search/files?page=1&layout=datalist&toukei=00450011&tstat=000001028897&cycle=7&year=20180&month=0&tclass1=000001053058&tclass2=000001053061&tclass3=000001053065&result_back=1.

3. Medical treatment expenses

Medical treatment expenses for each of the main diseases have been available since 2009 on the site of the Ministry of Health, Labour and Welfare.

https://www.mhlw.go.jp/toukei/list/37-21.html.

Data about the medical treatment expenses for malignant neoplasms, including lung cancer, from 2009 to 2017 were obtained from this site. The data are indicated by age groups for the ages of 0-14, 14-44, 45-64, 65-69, 70-74 and 75+ years. The medical treatment expenses of the group aged 65-74 years were calculated employing these data. Since the percentages of the medical treatment expenses for the patients aged 44 years or younger were only about 2% every year, they were omitted from this article.

4. Average annual increase in the number of deaths due to lung cancer from 2009 to 2015

From 2009 to 2015, the number of deaths from lung cancer increased. The average annual increase was calculated by adding the number of deaths in 2009 to that in 2015 and dividing the result by 6. Employing this value as the “expected value” and the change from 2015 to 2016 as the “observed value”, the chi-square test was performed.

The difference between the “expected value” and the “observed value” was regarded as the “estimated decrease in the number of deaths.” This value was employed for the calculation of the expense to decrease the number of deaths by one.

5. Average annual increase in the medical treatment expenses for lung cancer from 2009 to 2015

From 2009 to 2015, the medical treatment expenses for lung cancer increased. The average annual increase was calculated by adding the medical treatment expenses in 2009 to those in 2015 and dividing the result by 6.

Employing this value as the “expected value” and the change from 2015 to 2016 as the “observed value”, the chi-square test was performed.

The difference between the “expected value” and the “observed value” was regarded as the “estimated increase in the expenses.” Through dividing the “estimated increase in the expenses” by the “estimated decrease in the number of deaths”, the expense to reduce the number of deaths by one was calculated.

6. Prices and net sales of nivolumab

Prices and net sales of nivolumab were obtained from the data on the site “Answers News”, which is an information site on medical drugs in Japan.

https://answers.ten-navi.com/pharmanews/14616/

RESULTS

1. Numbers of deaths from malignant neoplasms and lung cancer

Table 1 shows the numbers of deaths due to malignant neoplasms, including lung cancer. The numbers of deaths from malignant neoplasms increased from 2009 through 2017, and those due to lung cancer from 2009 to 2015. However, the total number of deaths from lung cancer decreased significantly from 2015 to 2016.

2. Medical treatment expenses for lung cancer

Table 2 shows the changes in the medical treatment expenses for malignant neoplasms and lung cancer. The increase from 2015 to 2016 of those for malignant neoplasms was not significant, but that for lung cancer was significantly high.

In all the age groups the increases from 2015 to 2016 were significant and the largest among the changes between each of the years from 2009 to 2017 (Table 3).

Table 1 Numbers of deaths due to malignant neoplasms and lung cancer.
YearMalignant neoplasmsLung cancerAge (years)
45-6465-74 75+Total
200934410510630176413875167583
201035349910714182414036469813
201135730510778181494085770293
201236096310443186814189971518
201336487210039193154289472734
20143681069259204754321473396
20153703628512212434417474378
20163730887763208594479473838
20173733656999204804628574120
Change
2009-2015#4376.17 -353.00 600.33 903.83 1132.50
2015-20162726.00 -749.00 -384.00 620.00 -540.00
 **********
#annual average, **P<0.001.

Table 2 Medical treatment expenses for malignant neoplasms and lung cancer (million $).
YearMalignant neoplasms Lung cancer
2009291593459
2010303123811
2011318314070
2012332674236
2013337924255
2014344884315
2015358894503
2016370675161
2017381925249
Change
2009-2015#1121.67 174.00
2015-20161178.00 658.00
  **
#annual average,**P<0.001.

Table 3 Medical treatment expenses for lung cancer by age group (million $).
YearAge (years)Total
45-6465-74 75+
2009975119512123459
20101125130912903811
20111201145013294070
20121205155213834236
20131128164513914255
20141057174714214315
20151061186914764503
20161214217916615161
20171178216418015249
Change
2009-2015#14.33 112.33 44.00 174.00
2015-2016153.00 310.00 185.00 658.00
 ********
#annual average, **P<0.001.

3. Percentages of medical treatment expenses for lung cancer at outpatient clinics

The changes in the percentages of medical treatment expenses for lung cancer at outpatient clinics within the total expenses spent by each of the age groups are shown in Table 4. In each of the age groups, the increase from 2015 to 2016 was the largest among the changes between each of the years from 2009 to 2017. The increase in the percentage of the expenses for the group aged 45-64 years at outpatient clinics from 2015 to 2016 was the highest (10.1 points) among the 3 age groups, and was about 2 times larger than that of the group aged 75 years and older (4.58).

Table 4 Percentages of the total medical treatment expenses for lung cancer spent at outpatient clinics(%).
YearAge (years)Total
45-6465-74 75+
200927.2 25.1 25.1 26.0
201027.2 25.4 22.5 25.2
201128.1 25.2 22.9 25.6
201228.6 25.3 23.4 25.9
201330.2 26.6 24.3 27.1
201431.2 27.4 24.9 27.9
201533.6 29.2 25.9 29.5
201643.7 37.1 30.5 36.9
201745.1 38.2 32.5 38.1
Change
2009-2015#1.06 0.68 0.13 0.58
2015-201610.10 7.92 4.58 7.34
#annual average.

4. Medical treatment expenses to decrease the number of deaths from lung cancer by one

Table 5 shows the medical treatment expenses to decrease the number of deaths from lung cancer by one.

The calculation of the “Total” expenses was as follows: (1) The ”expected value” of the number of deaths was 1132.50, and the “observed value” was -540.0 (Table 1). Therefore, the estimated decrease in the number of deaths was 1672.5 (1132.5+540). (2) The ”expected value” of the medical treatment expenses for lung cancer was $174 million, and the “observed value” was $658 million (Table 3). Therefore, the estimated increase in the expenses was $484 million (658-174). (3) The medical treatment expense to decrease the number of deaths death due to lung cancer by one was $484million/1672.5, which comes to $289,387.1.

The expense for the group aged 65-74 years (about $200,000) was the smallest among the 3 age groups, being about 40% of that of the group aged 75 and older (about $500,000).

Table 5 Estimated change in the number of deaths, medical treatment expenses and expenses to decrease deaths due to lung cancer from 2015 to 2016 by one.
  Age (years)Total
45-6465-74 75+
Estimated decrease in the number of deaths396.0 984.3 283.8 1672.5
Estimated increase in the expenses (million $)138.7 197.7 141.0 484.0
Expense to decrease deaths by one ($)350168.4 200812.7 496770.4 289387.1

5. Prices and net sales of nivolumab

Table 6 shows the prices and net sales of nivolumab. In September 2014, nivolumab became available, and its price was $7,298.5 per 100mg. In December 2015, the Japanese Government approved it for the treatment of non-small cell lung cancers. This may be one of the main causes of the increase in medical treatment expenses after 2015. The increase in the net sales from 2015 to 2016 was about $817 million (1039 - 212), and the increase in the medical treatment expenses for lung cancer from 2015 to 2016 was $658 million (Table 2). Thus, the greater part of the increase in the sale of nivolumab from 2015 to 2016 (about 80%) may be accounted for by medical treatment expenses for lung cancer.

Table 6 Prices and net sales of nivolumab.
YearMonth  Price/100mg ($)Net sales (million $)
2014SeptemberCame to market7298.4925
2015DecemberApproval of insurance coverage for non-small cell cancer 212
2016   1039
2017February 3649.25901
2018April 2780.29 
2018November 1737.68 

DISCUSSION

Nivolumab has the benefits of prolonging overall survival and disease-free survival[2,3]. From the viewpoint of cost, however, there is room for argument.

Many cost-effectiveness analyses of nivolumab were reported, but there is little evidence showing that its cost effectiveness is excellent. According to a report by Goeree et al[4], nivolumab was found to have the highest expected per-patient cost, but also improved per-patient life years and QALYs. Nivolumab cost an additional $151,560 per QALY gained compared to docetaxel. Matter-Walstra et al[5] reported that compared with docetaxel, nivolumab was not cost effective for the treatment of nonsquamous non-small cell lung cancer. Li et al[6] reviewed many reports and concluded that nivolumab was not cost effective as a first-line treatment.

In Japan, in 2018, the price was reduced to $1,737.7 per 100mg. This might contribute to a decrease in the medical treatment expenses. However, the reduction in price might lead to the easy use of this medicine and, as a result, it is possible that the total medical treatment expenses could increase. If a patient dies, there are no more treatment expenses. However, if the overall survival rate is improved, the number of patients who continue treatment increases and, consequently, this leads to an increase in expenses.

When the survival rate is improved, many patients receive their treatment at outpatient clinics after remission induction therapy is completed. The increase in the percentages of medical treatment expenses at outpatient clinics may be accounted for by the improvement in the survival rate. In the present study, the increase in the percentage of the expenses at outpatient clinics for the group aged 45-64 years was the largest. If the treatment is done at outpatient clinics, the quality of life of the patient is much improved.

The costs to reduce cancer deaths by one were different by age, as well. Thus, there is a possibility that the cost or quality of life with regard to treatment with nivolumab differs by age. Therefore, the age factor should not be ignored in analyses about cost and quality of life when this drug is employed.

In Japan, the smoking rates were the highest in 1966 (about 80% for males and about 16% for females)[1]. Since that year, the smoking rate has been decreasing and, therefore, it is expected that the incidence rate of lung cancer will decrease in the future. However, if expensive drugs are used for many of the patients, medical treatment expenses will remain high.

REFERENCES

1. Nishi M. Lifestyle and cancer after the Second World War in Japan. J Tumor 2014; 2(8): 197-201. [DOI: 10.6051/ j.issn.1819-6187.2014.02.48]

2. Borghaei H, Paz-Ares L, Horn L, Spigel DR, Steins M, Ready NE, Chow LQ, Vokes EE, Felip E, Holgado E, Barlesi F, Kohlhäufl M, Arrieta O, Burgio MA, Fayette J, Lena H, Poddubskaya E, Gerber DE, Gettinger SN, Rudin CM, Rizvi N, Crinò L, Blumenschein, Jr. GR, Antonia SJ, Dorange C, Harbison CT, Graf Finckenstein F, Brahmer JR. Nivolumab versus docetaxel in advanced nonsquamous non–small-cell lung cancer. New Engl J Med 2015; 373(17): 1627-1639. [DOI:10.1056/NEJMoa1507643]

3. Brahmer, J, Reckamp KL, Baas P, Crinò L, Eberhardt WEE, Poddubskaya E, Antonia S, Pluzanski A, Vokes EE, Holgado E, Waterhouse D, Ready N, Gainor J, Frontera OA, Havel L, Steins M, Garassino MC, Aerts JG, Domine M, Paz-Ares L, Reck M, Baudelet C, Harbison CT, Lestini B, Spigel DR. Nivolumab versus docetaxel in advanced squamous-cell non–small-cell lung cancer. New Engl J Med 2015; 373(2): 123-135. [DOI: 10.1056/NEJMoa1504627]

4. Goeree R, Villeneuve J, Goeree J, Penrod JR, Orsini L, Monfared AAT. Economic evaluation of nivolumab for the treatment of second-line advanced squamous NSCLC in Canada: a comparison of modeling approaches to estimate and extrapolate survival outcomes. J Med Econ 2016; 19(6): 630-644. [DOI: 10.3111/13696998.2016.1151432]

5. Matter-Walstra K, Schwenkglenks M, Aebi S, Dedes K, Diebold J, Pietrini M, Klingbiel D, von Moos R, Gautschi O. A cost-effectiveness analysis of nivolumab versus docetaxel for advanced nonsquamous NSCLC including PD-L1 testing. J Thorac Oncol 2016; 11(11): 1846-1855. [DOI: 10.1016/j.jtho.2016.05.032]

6. Li N, Zheng H, Zheng B, Chen C, Cai H, Liu M. Economic evaluations of immune checkpoint inhibitors for patients with non-small cell lung cancer: A systematic review. Cancer Manag Res 2020; 12: 4503-4518. [DOI: 10.2147/CMAR.S248020]

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