Edited by: Kyriakos Souliotis, University of Peloponnese, Greece
Reviewed by: Ana Sabo, University of Novi Sad, Serbia; Tomasz Holecki, Medical University of Silesia, Poland
This article was submitted to Health Economics, a section of the journal Frontiers in Public Health
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Colorectal cancer (CRC) is one of the most commonly diagnosed malignant neoplasms. The aim of the study was to evaluate and correlate most important epidemiological and economic indicators of CRC in 11 selected Balkan countries. The number of new CRC cases was 56,960, and the highest 5-year CRC prevalence was in Slovenia, Croatia, and Greece. Age-standardized CRC incidence rates were highest in Slovenia, Serbia, and Croatia, and age-standardized mortality rates were highest in Croatia, Serbia, and Bulgaria. Current Health Expenditure as % of Gross Domestic Product was the highest in Bosnia and Herzegovina and Serbia. The GDP per capita levels have shown positive correlation with the CRC incidence rate and prevalence. Absolute numbers of new and death-related CRC cases and 5-year prevalence in absolute numbers have shown strong positive correlation with GDP in million current US$. It has been shown that various economic indicators can be linked to the rate of incidence and prevalence of the CRC patients in the selected Balkan countries. Therefore, economic factors can influence the epidemiology of CRC, and heavy CRC burden in the Balkan region may be one of the indexes of the economic development.
Non-communicable diseases are responsible for the majority of global deaths, and cancer is expected to be the leading cause of death and the most important barrier to an increasing life expectancy in the twenty-first century (
The 5-year prevalence for CRC expected worldwide is 4,789,635 cases (
According to the global trend, incidence rate of CRC is constantly increasing, and the number of CRC cases is expected to increase by 60% until 2030 (more than 2.2 million new cases and 1.1 million deaths) (
The CRC 5-year survival rate, for example in the United States, was estimated from a 90% cancer cases detected at the localized stage, 70% for regionalized cancers, to 13% for cases diagnosed with distant metastatic cancer (
Health expenditures put more and more pressure on public budgets in most of the countries, especially in connection with the occurrence of population aging throughout the entire Northern Hemisphere (
The aim of the study was to evaluate and correlate most important epidemiological and economic indicators of CRC in 11 selected Balkan countries since realistic estimates are crucial to ensure an adequate return on investment in CRC care.
In our study number of new CRC cases was analyzed, number of death related with CRC, as well as 5-year prevalence per 100,000. Also, age-standardized incidence and mortality rates were analyzed. Age-standardized incidence and mortality rates (ASR) are a summary measure of the rate of disease that a population would have if it had a standard age structure. These data are downloaded from the World Health Organization database—GLOBOCAN (
Selected indicators of health spending analyzed were: Gross Domestic Product (GDP) in million current US$), Gross Domestic Product per Capita in US$; Current Health Expenditure (CHE) as % of Gross Domestic Product (GDP); and Current Health Expenditure (CHE) per Capita in US$. These data are downloaded from the World Health Organization database (
Conducted study concerns 11 countries, which belong to the Balkan region, either geographically, or politically: Albania, Bosnia and Herzegovina, Bulgaria, Croatia, Greece, Montenegro, Romania, Serbia, Slovenia, The Republic of North Macedonia, and Turkey (countries are entirely or mostly/partially within the Balkan region).
Statistical analysis was conducted using IBM SPSS Statistics 19.0 computer program (IBM, USA, 2011). Variables were described in the form of absolute number (%). Relationship between variables was tested by Spearman's rank correlation coefficient. All the analyses were evaluated at the level of statistical significance of
The principles of ICH Good Clinical Practice were strictly followed and the approval from the Ethics Committee was obtained (Approval No 26/04/17 for the study protocol No MFVMA/12/17-19, entitled: Cost-effectiveness and cost-utility analysis of CRC treatment and budget impact analysis from the perspective of the patient, hospital, and third-party payer).
Numbers of new colorectal cancer cases and related deaths, age-standardized incidence, and mortality rates (per 100,000) in selected Balkan countries according to GLOBOCAN in 2018 (
Albania | 374 (4.51) | 186 (3.96) | 928 (31.63) | 8.4 | 3.7 |
Bosnia and Herzegovina | 1,804 (12.54) | 1,074 (11.92) | 4,441 (126.75) | 26.1 | 13.3 |
Bulgaria | 4,553 (12.87) | 2,687 (14.04) | 11,751 (166.99) | 28.5 | 14.9 |
Croatia | 3,356 (13.31) | 2,174 (15.06) | 8,955 (215.01) | 34.1 | 18.9 |
Greece | 7,117 (10.56) | 3,384 (10.16) | 19,570 (175.64) | 26.2 | 9.7 |
Montenegro | 208 (8.79) | 114 (8.86) | 548 (87.09) | 18.6 | 9.2 |
Romania | 10,856 (13.01) | 6,155 (12.09) | 28,364 (144.86) | 26.7 | 13.7 |
Serbia | 6,049 (12.61) | 3,187 (11.84) | 15,347 (175.15) | 36.7 | 16.8 |
Slovenia | 1,970 (14.59) | 737 (11.52) | 5,637 (270.84) | 41.1 | 12.5 |
The Republic of North Macedonia | 984 (12.60) | 472 (11.47) | 2,429 (116.50) | 28.4 | 12.5 |
Turkey | 19,689 (9.35) | 9,996 (8.56) | 48,725 (59.48) | 21.0 | 10.2 |
Both the lowest number of new CRC cases and the lowest number of CRC deaths in 2018 was registered in Montenegro, as the smallest country in the region.
The highest 5-year CRC prevalence was in Slovenia, Croatia and Greece (270.84; 215.01; 175.64 per 100,000 persons, respectively) (
Age-standardized (World) CRC incidence rates were the highest in Slovenia (41.1), Serbia (36.7), and Croatia (34.1), and age-standardized (World) CRC mortality rates were highest in Croatia (18.9), Serbia (16.8), and Bulgaria (14.9) (
Gross Domestic Product in Balkan countries was the highest in Turkey (863,712 million current US$), Greece and Romania (
Economic characteristics in selected Balkan countries (
Albania | 2,934,345 | 11,864 | 4,054 | 6.70 | 271.54 | Upper middle income |
Bosnia and Herzegovina | 3,503,565 | 16,910 | 4,808 | 9.23 | 443.78 | Upper middle income |
Bulgaria | 7,036,852 | 53,238 | 7,442 | 8.23 | 612.48 | Upper middle income |
Croatia | 4,164,772 | 51,624 | 12,319 | 7.18 | 884.49 | High income |
Greece | 11,142,158 | 192,691 | 17,869 | 8.45 | 1510.67 | High income |
Montenegro | 629,217 | 4,845 | 8,652 | 6.00 | 382.10 | Upper middle income |
Romania | 19,580,628 | 189,005 | 9,565 | 4.98 | 476.37 | Upper middle income |
Serbia | 8,762,022 | 38,300 | 5,412 | 9.14 | 494.42 | Upper middle income |
Slovenia | 2,081,259 | 44,709 | 21,659 | 8.47 | 1834.16 | High income |
The Republic of North Macedonia | 2,085,056 | 10,755 | 5,168 | 6.34 | 327.84 | Upper middle income |
Turkey | 81,916,866 | 863,712 | 10,863 | 4.31 | 468.65 | Upper middle income |
However, Current Health Expenditure as % Gross Domestic Product was the highest in Bosnia and Herzegovina and Serbia, but the lowest in Turkey. Current Health Expenditure per Capita in US$ was the highest in Slovenia, Greece, and Croatia (1834.16; 1510.67; 884.49, respectively), and the lowest in Albania. Eight countries of 11 have upper middle income according to income level estimated by the World Bank, while three countries have high income, such as Slovenia, Croatia, and Greece (
In the Balkan countries, the GDP per capita levels (Upper middle income and high income countries) have shown positive correlation with the CRC incidence rate and prevalence (
Correlation analysis between economic and epidemiological colorectal cancer indicators in selected Balkan countries.
New cases (% of all new cancer site cases) | ||||||||||||
Deaths | ||||||||||||
Deaths (% of all death cancer site cases) | ||||||||||||
5-year prevalence | ||||||||||||
Prevalence (per 100,000 persons) | ||||||||||||
ASR incidence | ||||||||||||
ASR mortality | ||||||||||||
GDP (in million current US$) | r = 0.909; |
|||||||||||
GDP per capita in US$ | r = 0.091; p = 0.790 | r = 0.609; p = 0.047 | ||||||||||
Current health expenditure as % GDP | ||||||||||||
Current health expenditure per capita in US$ | ||||||||||||
Income code |
Absolute number of new CRC cases, death-related cases in absolute numbers and 5-year CRC prevalence in absolute numbers have shown strong positive correlation with GDP in million current US$ (these parameters were higher in the countries with higher GDP in comparison to countries with lower GDP);
Five-year CRC prevalence (as proportion of the population per 100,000 persons) was also higher in the countries with higher Current Health Expenditure per Capita in US$ comparing with the countries with lower Current Health Expenditure per Capita in US$);
Colorectal cancer is one of the most common cancers worldwide, with one to two million new cases being diagnosed every year, and with 700,000 cancer-related deaths per year (
Colorectal cancer incidence and mortality are rapidly growing worldwide (
In recent meta-analyses on CRC risk factors a comprehensive risk modeling strategy in order to predict an individual's risk of developing CRC was developed (
Nevertheless, a modification of lifestyle and/or diet could decrease morbidity, but early detection, such as screening programs (SPs) improves prognosis and reduces mortality (
In the 11 selected Balkan countries, the GDP per capita level (Upper middle income and high income countries), as the best measurement of standard of living in particular country, has shown strong correlation with CRC indicators. The 5-year prevalence was significantly higher in the high income countries, such as Slovenia, Croatia, and Greece comparing to other countries in this region. This especially refer to Albania with the lowest GDP per capita in US$ and lowest 5-year prevalence. Estimation of Current Health Expenditure per capita in the US$ also pointed to Slovenia, Greece and Croatia with highest values, and to Albania with lowest one, in accordance with the fact that this is the indicator of the level of resources channeled to the health relative to other uses. Similarly to our data, in the China, the crude incidence and mortality rates showed positive associations with GDP per capita levels, with high-GDP per capita areas having the highest crude rates, followed by middle- and low-GDP per capita areas (
On the contrary, the age-standardized mortality rate was highest in low-GDP per capita areas and lowest in high-GDP per capita areas (
The incidence of CRC worldwide is expected to increase by 80% in the year 2035 (~2.4 million cases). According to data in 2012, 44.6% of the world CRC incidence and 47.8% of its worldwide mortality stems from the Asian continent (
The worldwide mortality of CRC is 693,933 with an ASR value of 8.3 per 100,000 in 2012 (
Total costs of diagnosis and treatment in the CRC patients are high throughout the world (
To some extent, situation concerning CRC costs associated with the stage of the disease is similar in Western countries with larger GDP. In the German study authors showed that the mean incremental annual costs for each phase of CRC (initial, intermediate, and end-of-life phases), were 26,000; 2,300, and 51,700 euro, respectively (
Therefore, the CRC is an enormous burden worldwide that is expected to increase due to the growth and aging of the population, as well as the adoption of risky behaviors and lifestyle, especially in economically less developed countries (
But, globally, ongoing demographic changes will lead to an increasing number of CRC deaths with a doubling of the number of predicted deaths by 2035 (
It has been shown that various economic indicators can be linked to the rate of incidence, as well as prevalence of the CRC patients in the Balkan countries. Namely, the GDP per capita levels (Upper middle income and high income countries) have shown positive correlation with the CRC incidence rate and prevalence. Absolute number of new CRC cases and death-related cases, as well as 5-year CRC prevalence in absolute numbers have shown strong positive correlation with GDP in million current US$. Five-year CRC prevalence (as proportion of the population per 100,000 persons) was also higher in the countries with higher Current Health Expenditure per Capita in US$ comparing with the countries with lower Current Health Expenditure per Capita in US$.
Therefore, economic factors can influence the epidemiology of CRC, and heavy CRC burden in the Balkan region may be one of the indexes of the economic development. Moreover, surveillance of CRC occurrence and outcomes for the development of control strategies should be implemented referring to the Balkan regional, as well as local country level in the future, in order to provide savings to the national health systems.
Publicly available datasets were analyzed in this study. This data can be found here:
BV, NR, MJ, and VD-S jointly designed the study and defined research questions. JM, MJ, FP, and NR did most of the data mining and extraction, purification of files for missing data and artifacts, and statistical analysis. BV, NR, MK, ZZ, DJ, FP, JM, SD, RS, and RZ contributed to the tables and figures creation and interpretation of data. BV, VD-S, MJ, and NR drafted the working version manuscript but all authors contributed to the final version to the extent of important intellectual content.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The handling Editor declared a past co-authorship with one of the authors MJ.