Horton Susan, Gauvreau Cindy L
Health care is informed first and foremost by scientific and medical understanding of how to treat and prevent disease. Economics can, however, provide useful insights to inform policy in the design and implementation of the systems to provide health care, as well as in the process of prioritizing interventions to make the best use of scarce resources. Treating a single cancer patient may require the coordination of many inputs and may cost tens or even hundreds of thousands of dollars in high-income countries (HICs). Ongoing population cancer screening and early detection also require considerable coordination, including treatment for cases detected, and costs. Finally, although knowledge of cancer prevention is inadequate, prevention can be a costly endeavor—as demonstrated by the large sums spent on behavior change promotion (such as smoking cessation) or on vaccines to prevent cancer, such as against human papilloma virus to prevent cervical cancer and hepatitis B virus to prevent liver cancer—and economics can be informative. The second section of this chapter reviews how the availability of resources for cancer care varies by economic status, using the World Bank’s categories of low-income countries (LICs), middle-income countries (MICs) (comprising lower-middle-income countries and upper-middle-income countries), and HICs. At the same time, economy is not destiny. Countries at the same level of economic development differ because other factors intervene. Urbanization affects the patterns of cancer and the ability to access care. Local champions, governmental political leadership, and international partnerships can all loosen the constraints of local economic resources. Conversely, some countries are underachievers in cancer care despite their income level, perhaps because of leadership failures. The third section reviews the cost-effectiveness of interventions for cancer care, where care is here defined to include prevention. The cost-effectiveness of interventions has been well studied in HICs, but much less so in low- and middle-income countries (LMICs). This section summarizes the literature on the economics of cancer care in LMICs; the section also draws on the literature from HICs, particularly for cancer treatment, in areas where reliable studies for LMICs are particularly scarce. It may be possible to make inferences for one country using results from another country; the validity of these inferences rises with the extent of the similarities in the two countries. Where possible, we separate out the findings for high-income economies in Asia, since they are likely to be more relevant for LMICs in this region than the results from North America or Western Europe. We use the resource grouping suggested by Anderson and others (see chapter 3) for the Breast Health Global Initiative and apply this to other cancers. In this framework, facility resource environments fall into four categories of resource availability: Basic. Limited. Enhanced. Maximal. These categories are correlated with the World Bank income groupings. LICs have a preponderance of Basic facilities, rural areas in MICs have more facilities with Limited capabilities, urban areas in MICs have more facilities with Enhanced capabilities, and much of the population in HICs has access to facilities with Maximal capabilities. The implications for the availability of resources specific to cancer care are described. This section requires some interpolation on the authors’ part because of the paucity of previous work in the area and is subject to further validation by experts. The fourth and final section contains conclusions, consisting of summary recommendations of packages of cancer care appropriate for each of the four resource environments, as well as priority areas where further research is required. The appropriateness of a package is defined by feasibility (those resources can be expected to exist or could exist with reasonable investments) and by likely cost-effectiveness (within the limits of available data). Although there are internationally validated resource-specific care guidelines for breast cancer (the Breast Health Global Initiative), no such guidelines are available as yet for other cancers. The packages presented here have been validated in consultation with the chapter authors of this volume (chapters 3 through 8), but need to be further refined by expert consultation.
医疗保健首先基于对疾病治疗和预防的科学及医学理解。然而，经济学能够提供有益的见解，为医疗保健系统设计与实施过程中的政策制定提供参考，也有助于在干预措施的优先排序中充分利用稀缺资源。在高收入国家，治疗一名癌症患者可能需要协调多种投入，花费可能高达数万甚至数十万美元。持续开展的人群癌症筛查和早期检测同样需要大量协调工作，包括对检测出的病例进行治疗以及相应成本。最后，尽管癌症预防知识尚不充分，但预防可能是一项成本高昂的工作——比如在促进行为改变（如戒烟）或预防癌症的疫苗方面投入了大量资金，像用于预防宫颈癌的人乳头瘤病毒疫苗和预防肝癌的乙肝病毒疫苗——而经济学能提供相关信息。本章第二节回顾了癌症治疗资源的可获得性如何因经济状况而有所不同，采用了世界银行对低收入国家、中等收入国家（包括中低收入国家和中高收入国家）和高收入国家的分类。与此同时，经济并非宿命。处于相同经济发展水平的国家存在差异，因为有其他因素介入。城市化影响癌症模式和获得医疗服务的能力。当地倡导者、政府政治领导以及国际伙伴关系都能缓解当地经济资源的限制。相反，一些国家尽管收入水平较高，但在癌症治疗方面表现不佳，可能是由于领导不力。第三节回顾了癌症治疗干预措施的成本效益，这里的治疗定义包括预防。高收入国家对干预措施的成本效益进行了充分研究，但在低收入和中等收入国家的研究较少。本节总结了低收入和中等收入国家癌症治疗经济学方面的文献；同时也借鉴了高收入国家的文献，特别是在低收入和中等收入国家可靠研究尤其匮乏的癌症治疗领域。有可能利用一个国家的结果推断另一个国家的情况；两国相似性越高，这些推断的有效性就越高。在可能的情况下，我们将亚洲高收入经济体的研究结果单独列出，因为它们可能比北美或西欧的结果与该地区低收入和中等收入国家更相关。我们采用安德森等人（见第3章）为全球乳腺癌倡议建议的资源分组，并将其应用于其他癌症。在此框架下，设施资源环境分为四类资源可获得性：基础型、有限型、增强型、最大型。这些类别与世界银行的收入分组相关。低收入国家主要是基础型设施，中等收入国家农村地区有限能力设施较多，中等收入国家城市地区增强能力设施较多，高收入国家大部分人口可获得最大能力设施。文中描述了这些情况对癌症治疗特定资源可获得性的影响。由于该领域此前的研究较少，本节需要作者进行一些补充，并且有待专家进一步验证。第四节也是最后一节包含结论，总结了针对四种资源环境各自适用的癌症治疗方案的建议，以及需要进一步研究的优先领域。一个方案的适用性由可行性（预期这些资源能够存在或通过合理投资可以实现）和可能的成本效益（在现有数据范围内）来界定。尽管有国际认可的乳腺癌特定资源护理指南（全球乳腺癌倡议），但其他癌症尚无此类指南。此处呈现的方案已与本卷各章作者（第3章至第8章）协商验证，但仍需通过专家咨询进一步完善。
