# Strategies for Appropriate Patient-centered Care to Decrease the Nationwide Cost of Cancers in Korea

## Article information

J Prev Med Public Health. 2017;50(4):217-227
Publication date (electronic) : 2017 June 16
doi : https://doi.org/10.3961/jpmph.17.069
Department of Preventive Medicine, Jeju National University School of Medicine, Jeju, Korea
Corresponding author: Jong-Myon Bae, MD, PhD 102 Jejudaehak-ro, Jeju 63241, Korea Tel: +82-64-755-5567, Fax: +82-64-702-2687 E-mail: jmbae@cheju.ac.kr
Received 2017 April 26; Accepted 2017 June 16.

## Abstract

In terms of years of life lost to premature mortality, cancer imposes the highest burden in Korea. In order to reduce the burden of cancer, the Korean government has implemented cancer control programs aiming to reduce cancer incidence, to increase survival rates, and to decrease cancer mortality. However, these programs may paradoxically increase the cost burden. For examples, a cancer screening program for early detection could bring about over-diagnosis and over-treatment, and supplying medical services in a paternalistic manner could lead to defensive medicine or futile care. As a practical measure to reduce the cost burden of cancer, appropriate cancer care should be established. Ensuring appropriateness requires patient-doctor communication to ensure that utility values are shared and that autonomous decisions are made regarding medical services. Thus, strategies for reducing the cost burden of cancer through ensuring appropriate patient-centered care include introducing value-based medicine, conducting cost-utility studies, and developing patient decision aids.

## INTRODUCTION

Measurements of the diseases burden and predictions of trends form the basis for decision-making and the implementation of public health policies, thereby promoting public health in any country [1]. Worldwide, countries are feeling the pressure of the soaring burden of medical care [2]. Increasingly, more countries are using the diseases burden as an important benchmark to decide how to effectively distribute limited medical resources [3].

So far, approaches to measure the diseases burden have principally focused on using (1) conventional epidemiological indices, (2) measuring the cost burden, and (3) calculating indicators of health-related quality of life (HRQoL) [4]. Of these, with respect to HRQoL, the World Health Organization spearheaded the development of an index known as the disability-adjusted life year (DALY) and continues to conduct research on the global burden of disease [5].

In Korea, in terms of DALYs, cancer had the highest disease burden in 2002 [6]; a decade later, this changed to endocrine diseases in 2012 [7]. However, when the years of life lost to premature mortality are used as the index of disease burden, cancer remained the disease with the highest burden in 2012 [7]. This shows that our interpretation of disease burden may be affected by which indices are used; thus, the use of an alternative index such as the mortality-to-incidence ratio (MIR) has been suggested [8].

Thus, the policies developed to reduce the cancer burden can be summarized as aiming to reduce cancer incidence, to improve the cure rates in cancer patients, and to decrease cancer-related mortality [8]. However, when we assessed the changes in the cancer incidence and mortality rate, and DALYs across a decade, from 2002 to 2012, we found that in contrast to the decreasing mortality rate, the cancer incidence and DALYs increased, showing that there is a need to re-evaluate the cancer burden indices (Table 1). For instance, the national cancer screening programs that were started in order to decrease the cancer burden may paradoxically increase the cost burden of cancer by increasing cancer prevalence [11-14]. Thus, the cost burden would be considered as another index of cancer burden [13].

Indices of the overall cancer burden between 2002 and 2012 in Korea1

The purpose of this paper was to assess whether efforts to reduce the cancer burden are having an effect not only in terms of impacting the cancer-burden–related indices, but also in terms of reducing the cost burden of cancer. And then, we would propose strategies about how to minimize the cost of cancer by implementing adequate cancer treatments centered on the patients who are customers of medical services.

## OUTCOMES OF CANCER BURDEN REDUCTION POLICIES BASED ON CANCER-RELATED STATISTICAL INDICES

### Decreasing Cancer Incidence

Cancer prevention is by far the most effective approach to decrease the cancer burden [15]. Computing the attributable fractions of the risk factors [16] and, then based on these results, developing primary cancer prevention strategies to suppress risk effects should be conducted preferentially and continuously [17]. The fact that the cancer incidence in Koreans has decreased since 2012 is a promising marker, which also reflects an actual reduction in the national burden of cancer [9].

### Improving Cure Rates of Cancer Treatment

Improving the cure rates of cancer treatment in those who already have cancer brings on a reduced burden of cancer. Strategies to increase the cure rate include (1) making early diagnoses and (2) providing more effective medical services.

In Korea, the first of these strategies was the National Cancer Screening Program (NCSP) established in 1999. Till 2016, the program has expanded its list of cancers screened to include the 5 major primary cancers—stomach, liver, colorectal, breast, and uterine cervical—in adults [18]. The findings that all these cancers, except breast cancer, showed a decreasing trend in incidence from 2012 to 2014 [9] and that the total cancer mortality, which had increased between 1983 and 2002, showed a decrease between 2002 and 2007 can be explained as positive outcomes of the NCSP [10]. Nonetheless, further studies containing a cost analysis of the NCSP are required to assess its outcomes more accurately.

Meanwhile, the fact that the incidence rate of breast cancer, which is included as an item in the NCSP, has consistently increased should be considered cautiously with a controversy of the over-diagnosis of the cancer screening [19,20]. Because breast cancer along with thyroid cancer, prostate cancer, and renal cancer is the representative cancer that are over-diagnosed [21,22]. Over-diagnosis in turn causes over-treatment and the abuse of medical services; thus, the result of efforts for early diagnosis could lead to an increase in the cancer burden, counterintuitively [11,23]. For these reasons, the inclusion of breast cancer in the current NCSP should be re-evaluated [24]. Whereas, only screening for cancers whose burden has been shown to be minimized through early diagnosis may lead to a net reduction in the cancer burden [10].

The second strategy is to provide more effective medical services. Recently, much work in this area has involved providing personalized medicine or precision medicine, such as individualized chemotherapy tailored to the genetic make-up of the patient’s cancer [25]. Despite the increasing cost of treating cancer with such improvements in medical technology, the cost-effectiveness of these treatments in reality is scarcely substantial enough to be of any real use for evidence-based decision-making [2,14]. In other words, since a greater emphasis is placed on the efficacy of treatment than on the economic burden, the cost burden of cancers with respect to cancer treatment is increasing [11,12].

Moreover, higher cure rates lead to higher cancer prevalence, which may increase the years lived with disability and in turn contribute to the increased cancer burden [26]. Thus, measures focused on improving cure rates can lead to absolute increases in the cost burden of all cancers, excluding cancer screening program that are known as effective.

### Decreasing Cancer Mortality

Whether cancer treatment was unsuccessful or was successful but the possibility of recurrence remains, decreasing early mortality to improve survival rates in cancer patients is an important part of reducing the burden of cancer. However, by endeavoring to improve the survival rates of cancer patients, we may be promoting defensive medicine or futile death-prolonging treatments, counterintuitively.

Defensive medicine refers to non-essential medical services performed to counteract medical malpractice [27]; thus, such practices can in turn entail costly medical fees, expand the medical insurance budget, and subsequently increase the burden of cancer [12,27]. In terminal cancer patients, death-prolonging treatment may also incur unnecessary expenses to delay death [28].

## SUGGESTIONS FOR CUTTING THE COST BURDEN OF CANCERS: ACHIEVING APPROPRIATE PATIENT-CENTERED CARE

We evaluated how measures, except those aimed at decreasing incidence by controlling risk factors, aimed at reducing the cancer burden by improving 3 indices—the incidence rate, cure rate, and mortality rate—may paradoxically lead to increased costs of cancer treatment and thereby increase the actual cancer burden. Conversely, given that screening for only cancers that can be effectively controlled through early diagnosis leads to real reductions in the cancer burden, a 3-way concerted effort by patients, physicians, and policy-makers should be made to control the cancer burden through the 2 indices above—the cure rate and the mortality rate [29,30].

In particular, more efficient and effective care should be needed against the apparent increment in the economic burden of cancer that reflect the escalating cost of cancer treatments. This calls for a realization of appropriateness of medical services [29]. To practically drive the appropriateness of care, Brook [29] suggested that both patients and physicians must share their values and allow for patient autonomy in decision-making.

The following milestones should be met if Brook’s recommendations are to be followed: (1) a horizontal patient-physician relationship in terms of communication; (2) closing the patient-physician values gap by using various communication tools to allow patients to understand their physicians; and (3) fostering a proactive and autonomous decision-making environment for patients to choose the kind of medical services they receive [30-33]. Employing these practices will prevent us falling into the inconsistency of increasing the cost burden of cancers through mechanisms such as defensive medicine and death-prolonging treatment while aiming to decrease the cost burden of cancers. To achieve the ideal appropriateness of care, the following operational measures for these three milestones were proposed.

Patient-physician communication is one of the most important aspects of cancer treatment [34]. Because it involves informing cancer patients of their final diagnosis as well as discussing the financial implications of having cancer with them [35]. Thus, physicians must utilize action guidelines to build a positive relationship with patients [36]. To this end, a protocol known as SPIKE$was developed [37], so that it need to be adapted and contextualized to the Korean medical environment. Studies have found that younger patients, female patients, and patients with higher educational levels tended to demand a greater level of patient-physician communication [34]. These finding suggests that an educational curriculum should be developed that teaches physicians ways to deal with patients from diverse socio-demographic backgrounds [38]. Physicians should communicate to patients what is set out in the clinical practice guidelines (CPGs), which are developed according to the best evidence [33]. However, CPGs are not easily applicable to real-life contexts because there may not be enough scientific evidences or due to wide variation in the medical services that individual patients expect [31,38]. Further research may be done in cases of insufficient evidence. However, when individual demands differ, the next step should be to determine patient preferences, after which physicians should be able to explain the relationships between the costs of various treatments and the benefit of their outcomes [12]. Underestimating the importance of this step leads to the widespread use of defensive medicine and unnecessary death-prolonging treatment [27,28]. ### Development of a Values Assessment Tool to Determine Patient Preferences Incorporating the preferences of patients in decision-making in medicine is a way of implementing value-based medicine [31]. Patient preferences are closely linked to utility, which influences decision-making processes through an evaluation of the estimated gain and loss [39]. The time trade-off technique is the most widely used indicator for measuring the utility value in patients because it is easy for the lay individual to understand and gives reproducible results [40]. An adapted scale, based on the time-trade-off technique, must be developed for a cost-utility analysis appropriate to the Korean context to be conducted [31]. This would allow cancer patients to make choices that maximize the cost-to-utility ratio with respect to cancer treatment, leading to real reductions in the cost burden of cancers [41]. ### Development of a Tool That Assists Autonomous Decision-making in Patients For cancer patients, as the consumers of medical services, to be completely autonomous in their decision making, the provider of these services, or the physicians, must provide them with sufficient explanations based on the best evidence; only then can patients make an informed choice regarding their preferred mode of treatment [38]. Patient decision aids (PDAs) are currently under development. These PDAs are expected to better inform patients of their situation, to allow them to make an objective assessment of their preferences, and to promote patient autonomy when deciding the kind of care they wish to receive [32,42]. For instance, a PDA has been developed that enables patients to critically evaluate whether they will undergo screening for prostate cancer, a cancer often associated with over-diagnosis [43]; interestingly, the application of this PDA has lowered the rate of screening by 13% [44]. As such, autonomous decisions by medical consumers using PDAs will help in the long run to reduce the wastage of medical resources through practices such as defensive medicine [45,46] and will improve the quality of public health care [38,47]. ## CONCLUSION Thus, the following measures would ensure that appropriate cancer care is established: the development of guidelines that build patient-physician communication competence in physicians; a scale to measure patients’ utility value; and finally, PDAs, which encourage patient autonomy in decision-making on the basis of the best evidences and utility values. Through such measures, not only the patients’ cost burden of cancers but also that of the country as a whole can be reduced. ## Acknowledgements This research was funded by the Jeju National University Research Excellence Foundation in 2017. ## Notes CONFLICT OF INTEREST The author has no conflicts of interest associated with the material presented in this paper. ## SUPPLEMENTAL MATERIAL Supplemental material (Korean version) is available at http://www.jpmph.org/ jpmph-50-4-217-suppl.pdf ## References 1. Williams A. Calculating the global burden of disease: time for a strategic reappraisal? Health Econ 1999;8(1):1–8. 2. Meropol NJ, Schulman KA. Cost of cancer care: issues and implications. J Clin Oncol 2007;25(2):180–186. 3. Yoon SJ, Lee H, Shin Y, Kim YI, Kim CY, Chang H. Estimation of the burden of major cancers in Korea. J Korean Med Sci 2002;17(5):604–610. 4. Yoon SJ, Bae SC. Current scope and perspective of burden of disease study based on health related quality of life. J Korean Med Assoc 2004;47(7):600–602. (Korean). 5. Gong YH, Yoon SJ, Jo MW, Kim A, Kim YA, Yoon J, et al. The burden of cancer in Korea during 2012: findings from a prevalence-based approach. J Korean Med Sci 2016;31 Suppl 2:S168–S177. 6. Yoon SJ, Bae SC, Lee SI, Chang H, Jo HS, Sung JH, et al. Measuring the burden of disease in Korea. J Korean Med Sci 2007;22(3):518–523. 7. Yoon J, Oh IH, Seo H, Kim EJ, Gong YH, Ock M, et al. Disability-adjusted life years for 313 diseases and injuries: the 2012 Korean Burden of Disease Study. J Korean Med Sci 2016;31 Suppl 2:S146–S157. 8. Soerjomataram I, Lortet-Tieulent J, Ferlay J, Forman D, Mathers C, Parkin DM, et al. Estimating and validating disability-adjusted life years at the global level: a methodological framework for cancer. BMC Med Res Methodol 2012;12:125. 9. Jung KW, Won YJ, Oh CM, Kong HJ, Lee DH, Lee KH, et al. Cancer statistics in Korea: incidence, mortality, survival, and prevalence in 2014. Cancer Res Treat 2017;49(2):292–305. 10. Jung KW, Shin HR, Kong HJ, Park S, Won YJ, Choi KS, et al. Long-term trends in cancer mortality in Korea (1983-2007): a joinpoint regression analysis. Asian Pac J Cancer Prev 2010;11(6):1451–1457. 11. Kim YA, Oh IH, Yoon SJ, Kim HJ, Seo HY, Kim EJ, et al. The economic burden of breast cancer in Korea from 2007-2010. Cancer Res Treat 2015;47(4):583–590. 12. Schnipper LE, Meropol NJ, Brock DW. Value and cancer care: toward an equitable future. Clin Cancer Res 2010;16(24):6004–6008. 13. Ljung R, Peterson S, Hallqvist J, Heimerson I, Diderichsen F. Socioeconomic differences in the burden of disease in Sweden. Bull World Health Organ 2005;83(2):92–99. 14. Savage P, Mahmoud S. Development and economic trends in cancer therapeutic drugs: a 5-year update 2010-2014. Br J Cancer 2015;112(6):1037–1041. 15. Farmer P, Frenk J, Knaul FM, Shulman LN, Alleyne G, Armstrong L, et al. Expansion of cancer care and control in countries of low and middle income: a call to action. Lancet 2010;376(9747):1186–1193. 16. Steenland K, Armstrong B. An overview of methods for calculating the burden of disease due to specific risk factors. Epidemiology 2006;17(5):512–519. 17. Kim EJ, Yoon SJ, Jo MW, Kim HJ. Measuring the burden of chronic diseases in Korea in 2007. Public Health 2013;127(9):806–813. 18. Suh M, Choi KS, Park B, Lee YY, Jun JK, Lee DH, et al. Trends in cancer screening rates among Korean men and women: results of the Korean National Cancer Screening Survey, 2004-2013. Cancer Res Treat 2016;48(1):1–10. 19. Løberg M, Lousdal ML, Bretthauer M, Kalager M. Benefits and harms of mammography screening. Breast Cancer Res 2015;17:63. 20. Gøtzsche PC, Jørgensen KJ. Screening for breast cancer with mammography. Cochrane Database Syst Rev 2013;(6):CD001877. 21. Bae JM. Overdiagnosis: epidemiologic concepts and estimation. Epidemiol Health 2015;37e2015004. 22. Bae JM. Epidemiological evidences on overdiagnosis of prostate and kidney cancers in Korean. Epidemiol Health 2015;37e2015015. 23. Welch HG, Black WC. Overdiagnosis in cancer. J Natl Cancer Inst 2010;102(9):605–613. 24. Bae JM. It needs adaptation to the 2015 Korean guideline for breast cancer screening. J Korean Med Assoc 2015;58(9):833–837. (Korean). 25. Jameson JL, Longo DL. Precision medicine: personalized, problematic, and promising. N Engl J Med 2015;372(23):2229–2234. 26. Carlson RW, Allred DC, Anderson BO, Burstein HJ, Carter WB, Edge SB, et al. Breast cancer. Clinical practice guidelines in oncology. J Natl Compr Canc Netw 2009;7(2):122–192. 27. Studdert DM, Mello MM, Sage WM, DesRoches CM, Peugh J, Zapert K, et al. Defensive medicine among high-risk specialist physicians in a volatile malpractice environment. JAMA 2005;293(21):2609–2617. 28. Earle CC, Landrum MB, Souza JM, Neville BA, Weeks JC, Ayanian JZ. Aggressiveness of cancer care near the end of life: is it a quality-of-care issue? J Clin Oncol 2008;26(23):3860–3866. 29. Brook RH. Assessing the appropriateness of care--its time has come. JAMA 2009;302(9):997–998. 30. Dalton WS, Sullivan DM, Yeatman TJ, Fenstermacher DA. The 2010 Health Care Reform Act: a potential opportunity to advance cancer research by taking cancer personally. Clin Cancer Res 2010;16(24):5987–5996. 31. Bae JM. Value-based medicine: concepts and application. Epidemiol Health 2015;37e2015014. 32. Bae JM. Development and application of patient decision aids. Epidemiol Health 2015;37e2015018. 33. Bae JM. Academic strategies based on evidence-practice gaps. Hanyang Med Rev 2015;35(1):3–8. (Korean). 34. Fujimori M, Uchitomi Y. Preferences of cancer patients regarding communication of bad news: a systematic literature review. Jpn J Clin Oncol 2009;39(4):201–216. 35. Grunfeld E, Folkes A, Urquhart R. Do available questionnaires measure the communication factors that patients and families consider important at end of life? J Clin Oncol 2008;26(23):3874–3878. 36. Pollak KI, Arnold RM, Jeffreys AS, Alexander SC, Olsen MK, Abernethy AP, et al. Oncologist communication about emotion during visits with patients with advanced cancer. J Clin Oncol 2007;25(36):5748–5752. 37. McFarlane J, Riggins J, Smith TJ. SPIKE$: a six-step protocol for delivering bad news about the cost of medical care. J Clin Oncol 2008;26(25):4200–4204.
38. Meropol NJ, Schrag D, Smith TJ, Mulvey TM, Langdon RM Jr, Blum D, et al. American Society of Clinical Oncology guidance statement: the cost of cancer care. J Clin Oncol 2009;27(23):3868–3874.
39. Brown MM, Brown GC, Sharma S, Landy J. Health care economic analyses and value-based medicine. Surv Ophthalmol 2003;48(2):204–223.
40. Brown MM, Brown GC, Sharma S, Stein JD, Roth Z, Campanella J, et al. The burden of age-related macular degeneration: a value-based analysis. Curr Opin Ophthalmol 2006;17(3):257–266.
41. Neumann PJ, Palmer JA, Nadler E, Fang C, Ubel P. Cancer therapy costs influence treatment: a national survey of oncologists. Health Aff (Millwood) 2010;29(1):196–202.
42. Lenz M, Buhse S, Kasper J, Kupfer R, Richter T, Mühlhauser I. Decision aids for patients. Dtsch Arztebl Int 2012;109(22-23):401–408.
43. Trevena LJ, Zikmund-Fisher BJ, Edwards A, Gaissmaier W, Galesic M, Han PK, et al. Presenting quantitative information about decision outcomes: a risk communication primer for patient decision aid developers. BMC Med Inform Decis Mak 2013;13 Suppl 2:S7.
44. Stacey D, Légaré F, Lewis K, Barry MJ, Bennett CL, Eden KB, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2017;4:CD001431.
45. O’Connor AM, Llewellyn-Thomas HA, Flood AB. Modifying unwarranted variations in health care: shared decision making using patient decision aids. Health Aff (Millwood) 2004;Suppl Variation:VAR63–VAR72.
46. Döring AC, Hageman MG, Mulder FJ, Guitton TG, Ring D, ; Science of Variation Group, et al. Trigger finger: assessment of surgeon and patient preferences and priorities for decision making. J Hand Surg Am 2014;39(11):2208–2213. e2.
47. O’Connor AM, Wennberg JE, Legare F, Llewellyn-Thomas HA, Moulton BW, Sepucha KR, et al. Toward the ‘tipping point’: decision aids and informed patient choice. Health Aff (Millwood) 2007;26(3):716–725.

## Article information Continued

### Table 1.

Indices of the overall cancer burden between 2002 and 2012 in Korea1

2002 2012
DALY [3,5] 1525 2261
Incidence [9] 229.8 323.3
Mortality [10] 149.0 131.3