Barriers and facilitators for colorectal cancer treatment delivery in India

Ferreira Simões, Joana Filipa ORCID: 0000-0002-5294-6282 (2023). Barriers and facilitators for colorectal cancer treatment delivery in India. University of Birmingham. Ph.D.

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Abstract

Introduction: Cancer is a leading cause of mortality worldwide, accounting for nearly 10 million deaths in 2020. Surgery is usually needed to achieve cure and control the disease. The financial burden of cancer surgery for patients and their households at a global level has not been studied before. This thesis aimed to (i) assess out-of-pocket payments (OOPP) for cancer surgery across country income settings; (ii) explore catastrophic expenditure and treatment attrition rates in a cohort of patients with a new treatment decision for colorectal cancer in tertiary care hospitals in India; and (iii) explore barriers and facilitators for colorectal cancer adherence in India.

Methods: An international prospective cohort study compared the proportion of surgeries where out-of-pocket payments were used to pay for the majority of the cost of cancer surgery across country income groups and identified factors associated with OOPP in low- and middle- income countries. A prospective multicentre cohort study of patients with a new treatment decision for colorectal cancer in five tertiary care hospitals in India, reported costs of treatment, catastrophic expenditure and treatment attrition. Catastrophic expenditure was defined as treatment cost being higher than 25% of annual household income. A qualitative study explored the views and perspectives of colorectal cancer professionals on barriers and facilitators for treatment adherence in India.

Results: OOPP for the majority of the cost of cancer surgery were more common in lower country income groups: 0.5% in high income, 5.7% in upper-middle income, 38.6% in lower-middle income, 48.1% in low-income countries. OOPP in low- and middle- income countries were independently associated with male sex, elective surgery and income group. The average OOPP for colorectal cancer care in India was 365,768 Indian Rupees (4667 USD), with surgical costs being among the highest. The catastrophic expenditure rate was 90.1% (182/202) and the treatment attrition rate was 9.4% (19/202). Catastrophic expenditure was independently associated with male sex, primary or no education, private treatment, advanced cancer stage, rectal cancer, and surgical resection. Barriers and facilitators for colorectal cancer adherence in India were identified from fourteen cancer care professionals, summarised into (1) social background and support, (2) patient awareness, education, and beliefs, (3) healthcare system capacity and organisation, (4) clinical events and (5) financial and job protection.

Discussion: There was global inequality in financial protection among patients accessing cancer surgery. Among households seeking tertiary care for colorectal cancer in India, a large proportion suffered catastrophic expenditure. Better financial protection policies are needed to prevent the detrimental effects of OOPP. Treatment adherence is influenced by social, education and financial factors that can be targeted with community and policy interventions. Increasing healthcare system capacity and improving communication with patients can improve the understanding of the available treatment pathways, contributing to better cancer outcomes.

Type of Work:

Thesis (Doctorates > Ph.D.)

Award Type:

Doctorates > Ph.D.

Supervisor(s):