The direct cost incurred by patients and caregivers in diagnosing and managing prostate cancer in Ghana

Only one public hospital was selected in the Ashanti Region because that is the only referral centre and one of the two national cancer management centres. The researchers selected a private hospital known to provide PCa management services. This strategy was to get a representation for the public and private hospitals involved in the management of PCa. Five (5) private community pharmacies within a 100-m radius of each hospital were randomly selected. This is because, from the researcher’s experience, these community pharmacies are within walking distance from the included hospital, and patients and caregivers will explore the availability of their prescriptions within the stated proximity. The participants recommended private laboratories that provide diagnostic support to their PCa patients. For uniformity, 5 private community pharmacies and 2 private laboratories were selected per hospital. According to ethical principles, facilities that did not consent to the study were excluded.

According to Wong and Bradley, patient registration is an integral facet of healthcare as it provides an avenue for healthcare facilities to keep adequate medical records on patients [16]. In Ghana, this service would incur a direct cost on PCa patients because the National Health Insurance Scheme does not pay for the management of the disease. Therefore, we classified the cost of patient registration, consultation, and other fees paid at the point of facility entry as patient entry costs: Additional file 1. Data on this cost component was collected from the hospitals and private laboratories by the Principal Investigator (PI). However, the private laboratories were restricted to consultation fees because some private laboratories are known to bill patients for specific consultancy services. The community pharmacies were not considered in estimating the entry cost because they provide consultancy, drug information, and other pharmacist-centred services to patients without charges.

The itemized cost of the laboratory investigations: prostate-specific antigen (PSA), free PSA, transrectal ultrasound (TRUS), and biopsy conducted for patients who reported at the hospitals with an impression of prostate and prostate-related conditions were investigated to confirm their availability and cost through the application of Additional file 1. Other investigations such as liver function test (LFT), renal function test (RFT) including serum electrolyte assessment, full blood count determination (FBC), blood group determination, serum phosphatases (acid/alkaline) assessment, computed tomography (CT) scan, magnetic resonance imaging/scan (MRI) - Whole Body Diffusion, and chest radiograph (X-ray) constituted the third modular cost items as indicated in Additional file 1 and complemented clinical management decision making. The PI investigated selected PCa patients’ list of private laboratories or diagnostic/imaging establishments where they seek their services. The PI randomly selected and made contact with 2 private laboratories or diagnostic/imaging establishments per hospital to investigate the availability and cost of the modular items.

The representatives of the hospitals responded to the data collection tool regarding the stage-specific management options and their costs: Additional file 2. The tool had been designed to determine the management approaches according to the invasiveness of the malignancy [17], the Gleason grading system [18, 19], and the Tumour, Node, Metastasis (TNM) staging system [20]. The various pharmaceutical agents, excluding adjuvants and other non-oncologic agents, that were employed in the management of PCa patients were listed by the hospitals’ representatives. The PI generated a master drug list used in the next stage of the COI study - the availability and price of pharmaceuticals.

To report on the supply chain status of PCa medications in Ghana, we studied the availability profile and the prices of these medicines. Five (5) community pharmacies each were randomly selected from the vicinities, within walking distance, of the public and private hospitals and Additional file 3 was administered to their representatives. The PI sent the drug list to the pharmacists of these selected pharmacies to obtain information about the availability and prices of these drugs. The drug list document requested the community pharmacists to provide information on the makeup of the drugs (originator brand or generic), the available strengths of the medications, the dosage forms/units, the pack sizes, and the unit prices.

The direct health cost estimates for diagnosing PCa are outlined in Table 1 and all details could be found in the table. The direct cost components include patient entry; screening laboratory investigations; and clinical management decision investigations. The researchers found that the public hospital charged patients for registration and consultation whilst the private hospital only charged patients a consultation approximately five times the bill incurred at the public facility. The results indicated that amongst the four private laboratories recruited for the study, only one charged their patients; usually for metastatic prostate cancers, an optional consultation of GHC 100.00 ($17.24). Therefore, for patients who required an external laboratory consultation, the total median modular service charge of GHC 96.00 ($16.55) increased by the stated sensitivity amount.

Amongst the 5 screening laboratory workouts: PSA, free PSA, digital rectal examination (DRE), TRUS, and biopsy, only the cost of PSA was the same at all the study sites (GHC 80.00: $ 13.79). The DRE offered by the hospitals did not attract any cost component. Again, the public hospital provided the cheapest biopsy services at the cost of GHC 750.00 ($129.26), whilst one private laboratory provided a biopsy service at GHC 950.00 ($ 163.73), the most expensive. Two private laboratories and a private hospital provided free PSA and USG services at GHC 115.00 ($ 26.71) median price and GHC 160.00 ($ 27.58). There were no optional services and hence, no sensitivity factor. The total median modular service charge was GHC 1205.00 ($ 207.68).

In estimating the modular price for the clinical management decision investigations, the researchers discovered that none of the hospitals was in the position to assess the serum phosphatases (acid/alkaline) of patients, perform a CT scan and an MRI scan (Whole Body Diffusion) at the time of the data collection. Also, the private hospital was not equipped to provide chest X-ray services and blood group determination. Amongst the four (4) private laboratories, one specialized in diagnostic imaging (CT scan and MRI), whilst the three (3) were equipped to provide all the blood work. Only one private laboratory provided the Gleason grading on biopsies service at a price of GHC 100.00 ($ 17.24) higher than the hospitals’ quote. We were informed that the imaging techniques (the CT scan, the MRI, and the chest X-ray) were done to investigate metastasis and hence, were classified as sensitivity factors. The median sum of these sensitivity factors was GHC 5475.00 ($ 943.62) compared to the median modular price without the diagnostic imaging, GHC 385.00 ($ 66.36). Hence, a metastatic PCa patient would spend GHC 5860.00 ($ 1009.98) to enable the multidisciplinary prostate cancer team to make a management decision.

From these results, we submit that for a metastatic PCa case requiring all clinical investigations and private laboratory consultation, the direct cost of diagnosis is estimated at GHC 6876.00 ($ 1185.09) compared to GHC 1686.00 ($ 290.58) for non-metastatic cases that do not require private laboratory consultation. Hence, metastatic prostate cancer increases the diagnostic cost by approximately 4 folds (Modular Price Ratio: 4.08) of non-metastatic prostate cancers.

According to the management protocols of the selected hospitals: Table 2, which are mainly influenced by the stage of the disease, the availability of equipment, and the goals of management, the cancer centre of the public hospital mainly managed PCa with Extended Beam Radiotherapy (EBRT) whilst the private hospital’s option was radical prostatectomy. For these two management arms, we found that patients who opted for radical prostatectomy paid GHC 2150.00 ($ 370.56) higher than patients who were managed on EBRT (GHC 2150.00: $ 370.56). These management options applied to localized PCa of low and moderate grades. However, the public hospital reported including a 6-month androgen deprivation therapy (ADT), at an additional cost of GHC 3000.00 ($ 517.05), for the management of moderate grade localized PCa depending on an assessment of beneficial outcome. The private facility managed locally advanced and metastatic PCa respectively with radiotherapy and ADT, and ADT alone. The radiotherapy needs of the patients being managed by the private hospital were met by the public hospital through a referral and follow-up. The allocation of cost components to these management options was not possible because officials were not privy to the financial commitments made by patients at the various radiotherapy referral centres in the country. Likewise, the cost of ADT for referred patients was not reported because the patients either procured their medicines from community pharmacies or were supplied by the receiving radiotherapy centre. The public facility managed locally advanced PCa with EBRT and ADT for 18 to 24 months. In managing metastatic PCa, the public facility could not allocate management costs because the patients had varied organ metastasis, and most of their prescriptions were obtained from community pharmacies that are walking distance from the hospital. However, the approach included ADT alone or ADT plus palliative radiotherapy or ADT plus abiraterone/docetaxel plus palliative radiotherapy. In instances where the patient had bone metastasis, the management included the addition of bisphosphonates. Goserelin was the ADT agent used by the two hospitals. Further details are contained in Table 2.

The availability profile and prices of the pharmaceutical agents listed by the recruited hospitals for the management of PCa are presented in Table 3. The drug list included abiraterone acetate (250 mg), bicalutamide (50 mg and 150 mg), docetaxel (20 mg, 80 mg and 120 mg), flutamide (250 mg), goserelin (3.6 mg and 10.8 mg) and mitoxantrone (20 mg). We found that all the drugs with the indicated strengths were available in community pharmacies located within the vicinity of the public hospital: Fig. 1. Within the vicinity of the private hospital: Fig. 2, we noticed that none of the pharmacies could supply generics of abiraterone acetate (250 mg), docetaxel (80 mg), and mitoxantrone (20 mg), and only one pharmacy could supply generics of docetaxel (20 mg and 120 mg). Also, only two community pharmacies had the originator brand of abiraterone acetate (250 mg). The mean availability of all the drugs in the community pharmacies located within the vicinity of the public hospital, private hospital, and the combination of the two sites were respectively 61.54, 41.54, and 51.54%. Therefore, none of the drugs had absolute availability at the ten community pharmacies that were sampled. Details of the results are presented in Table 3.

The unit prices of the pharmaceutical agents have been quoted in Table 3. The median local consumer price (MLCP) per unit dose of the investigated drugs has been collated and presented with the unit median international reference price (MIRP). The median drug price ratio (MDPR) of the medications was determined to be in the range of 0.72 and 15.38. The MDPR could not be calculated for abiraterone acetate, docetaxel (120 mg), goserelin, and mitoxantrone due to the unavailability of the MIRP. The originator brand of bicalutamide and generic flutamide had MDPR greater than 4.00 with the flutamide recording the highest (15.38). Comparing the MDPR of bicalutamide (50 mg) to bicalutamide (150 mg), we discovered the former was 2.72 higher than the latter.