The findings of this study showed that, the mean age of the people suffering from CRC was 56; which is very lower than this age in western countries. For example in a study conducted in 2008 in America the median and mean age of CRC patients was signified as 64 and 63, respectively.[13
] The results of Karimi Zarchi study[14
] in Tehran with the mean age of 59.7 years also is very close to the results of our study. Some previous studies[15
] are also concluded that the age of people suffering from CRC in Iran is lower than what it is in western countries. These all confirm that the lower age CRC in Iran with increasing in age loss would result in early death and high cost of treatment, which has considerable impact on the economic growth and development of the societies.[17
] In a worldwide population-based study, the economic cost of cancer in 2008 is estimated to be 845 billion $, which was approximately equal to 1.5% of the international gross income.[18
While the findings of this study show that 33% of the patients were under 50 years old, the statistics given in the second international digestive cancer congress stated that 45-47% of the CRC patients in Iran are under 50 years old.[19
] This is while this ratio in European countries was below 20% in 2004.[20
] These findings suggest that the burden of CRC in Iran would be larger than European countries.
In the United Kingdom after 3 years of exercising the new screening policies 71% of the colon cancers were diagnosed at the early stages and the death rate was decreased by 16%.[21
] These may imply that a national screening program from a lower age in Iran may reduce the economic burden of the disease even more than European countries. However, cost-effectiveness analysis of various screening programs could provide stronger evidence about the result of screening programs.
Our results show that 56.1% of the CRC patients are male. This result is supported by the national cancer reports in 2005.[22
] This ratio in the USA in 2008 with 55.3% was very close to our results;[13
] and shows that males are at relatively higher risk of CRC than females.
The findings of this study show that 35.6% of the CRC patients were in the 1st
stages of the disease and more than half of them (64.4%) were in the 4th
stage. This is while in Ferro study[13
] approximately half of the patients were between stages 1-3 of the disease. This might be due to the late referring of the patients for receiving treatments. But, regardless of the cause of the problem, the diagnosis of patients in the final stage of the disease leads to difficult prognosis and treatment and consequently higher treatment cost. Educating the society about cancer with the intention of being able to diagnose the disease in early stages can help patients refer to hospitals for treatment in time with higher success rate and then with lower cost.
Although in all of the stages the most of the costs shown in were related to the medication, but comparing the medication costs in various disease stages show that as the disease stage increase, the percentage of medication cost decrease. This has happened because of the increase in the cost of radiotherapy and the other services.
shows that the 4th stage of the disease has the highest mean of the direct cost, but the median of the treatment cost of CRC patients is increasing with the stage of the disease; Though this increase was not statistically significant based on the Kruskal-Wallis test (P > 0.05). Nonetheless this increase may resulted from the high frequency use of all 3 services in the stages.
The reason that most of the costs are related to the 3rd
stage is probably because of higher 5-year life expectancy in this stage, which is reported to be up to 60%, comparing with stage 4, which is only 5%.[3
] This would imply that the patients in the stage 3 had more chance to receive more services. Tilson study[23
] conducted in Ireland also showed similar results.
In addition to this fact the review of the patients’ profile confirmed that some of the patients in stage IV had left the hospital and refused to receive treatment services. Dissatisfaction from the quality of services, unlikelihood of treatment success, and difficulties in paying the cost of treatment were the main reasons for leaving the SSH and left the treatment protocols before completing them. Nonetheless the direct medical cost of CRC treatment for each patient was more than 16 thousands dollar, which is considerably too high for Iranian population.
Considering the mean of the direct medical costs of CRC  and its prevalence in Iranian population, which is 3.1%,[16
] it is obvious that the direct medical cost of CRC in Iran is at least 38 million $. However, it seems that the direct medical costs of CRC calculated by this study are far less than the actual costs. The following factors could explain this discrepancy:
Defects in the information records of the patient
Since the data used in this study was extracted from the medical records of the patients, any missed out information about the processes and the records of the treatment can cause mistakes in the calculation of the cost. This fact was obviously visible in radiotherapy records. The information was hand written and kept in patients’ protocols.
Public medical tariffs
SSH is a public and teaching hospital in Isfahan and its prices are based on the official public tariffs. The public tariffs are significantly lower than private tariffs and actual costs. On the other hand the government is paying hidden subsidies to public and teaching hospitals.[24
] This could suggest that the cost of treatment in SSH have been lower than actual cost considerably.
Prescribing cheaper protocols
As shown in the main cost driver in all of the stages of disease was the cost of chemical therapy. 5FU/LV and FOLFOX were the most frequently used protocols with 42.5% and 19.1%, respectively. Ferro[13
] showed that the most frequent prescribed protocols were 5FU/LV with 34.9% and FOLFOX with 24.5% in the US. The cost of 5FU/LV and FOLFOX for every cycle was determined as 171 and 6338$ respectively.[13
] This means that 5FU/LV regimen, 42.5% of our prescribed regimen, is 37 times cheaper than FOLFOX. Nonetheless the treatment costs of the two mentioned protocols are much cheaper than the rest of the treatment protocols.[13
] For example in a recent study in Iran[25
] the treatment costs of FOLFOX protocol for metastatic patients and for every cycle was calculated as 754$ and with the addition of Cetoximab to this protocol the costs were calculated as 4267$, which is significantly higher than the recorded cost of chemotherapy in this study .
Partial services implementation
Since the SSH is a public and teaching hospital, a lot of patients continued their treatments in other hospitals. Dissatisfaction from the quality of services, doctors’ advice, and psychological status of the patients may explain this behavior of the patients. The fact that only 14 surgeries took place in the SSH is a good example which support this suggestion. This is while surgery is the main treatment for CRC.[26
Fluctuations in foreign exchange rate in Iran
The costs of services in SHH are recorded in Iranian Rial and the value of Iranian Rial versus the US dollar has decreased in past years noticeably. This change could also illustrate the cost of CRC in Iran lower than its true cost to the Iranian society.