In the media

I can’t afford to have breast cancer

01 June 2016

The survival rate of breast cancer may be increasing, but so is the cost of treatment, finds Alina Hardcastle.

In his budget speech last month, Minister of Health, Aaron Motsoaledi, announced his commitment to reduce the cost of breast cancer drugs, Herceptin, which currently cost R500 000 a year. This follows similar action by Motsoaledi in reducing the cost of medicine for HIV and AIDS sufferers.

According to reports, Swiss pharmaceutical manufacturer, Roche, holds the patent on Herceptin. It too is trying to make the breast cancer drug more accessible to patients as many medical schemes do not pay for it.

So, if certain drugs and procedures are not accessible to those in the public sector, then what is the cost of breast cancer in the private sector, with and without medical aid? If you belong to a medical scheme does it cover everything?

The cost of not being on a medical scheme

To be diagnosed with a disease such as cancer is a frightening and stressful experience and having to worry about medical bills and costs, most certainly doesn’t help.

Sources have stated that the cost for breast cancer in South Africa will always vary as every patient is treated differently. Even if you don’t have cancer, screening for it through mammograms, for example, can also be costly.

Pre-surgery

Dr Sandile Mhlongo, clinical specialist at Discovery Health informs us that, “Breast cancer is usually diagnosed after a clinical examination and special tests done by a doctor.”

A general consultation can cost up to R590 on average which is excluding materials or procedures. If you are not covered by a medical aid the local community day centre (CDC) or the local community health centre (CHC), should see you free of charge.

Prior to your general consultation it is advised for women, and men, to perform regular self-breast examinations in order to detect warning signs of breast cancer.

Dr Duvern Ramiah, specialist radiation oncologist and ambassador of The Cancer Education Initiative explains: “Scans like a bone scan; MRI scan biopsies are often required. Sometimes patients need genetic testing on the breast cancer biopsies (called a mammoprint or Oncotype DX) to decide on the best chemotherapy regimens, and this costs over R30 000.”

Mhlongo adds, “The doctor will use the results from a mammogram and an ultrasound as well as the pathology results from a biopsy to make a diagnosis. An image guided core biopsy is the recommended procedure; however, in some circumstances, a surgical biopsy may be required.  The average cost in 2015 for breast biopsies is in the region of R16 800.”

Surgery

Once a patient is admitted to hospital the costs can also spiral quickly.

Adeliah Jacobs, the project manager of non-profit Pink Drive’s Cape Town branch says: “The most common types of surgery are the lumpectomy (a surgical operation in which a lump is removed from the breast, typically when cancer is present but has not spread.), a mastectomy (a surgical operation to remove a breast) and a double mastectomy (a surgical operation to remove both breasts).”

Extra costs are also incurred if a patient then opts for reconstructive surgery, which is a common procedure option after mastectomies.

Mhlongo’s 2015 data indicates shows that the most commonly requested mastectomy procedures are the complete and radical mastectomies; and the most common reconstructive procedure was breast reconstructive surgery with implants.

“The cost of a mastectomy in 2015 was on average R62 000; the average cost for reconstructive surgery in 2015 varied between R50 000 and R140 000. The cost depends on the complexity of the reconstruction and whether the patient also has nipple and areola reconstruction.”

Post-surgery

The treatment/therapy that can be offered, before or after surgery, include systemic therapy such as chemotherapy with or without hormonal manipulation, targeted biologic treatment and radiation therapy.

Like pre-surgery and surgery, Mhlongo says that treatment recommendations are dependent on numerous factors including the size and location of tumour, age, health status of the patient and extent of the disease.

“Hormonal therapy may be prescribed for a period between five to ten years and will cost on average between R650 and R2 500 per month,” says Mhlongo.

Costs are dependent on the drugs that are used and professional healthcare fees; hormonal therapy is often combined with chemo and radiation therapy. Chemotherapy is based on the patient’s weight, which is calculated on the patient’s body surface area.

Mhlongo adds, “Conventional chemotherapy will on average cost around R25 000 for four treatment cycles to over R140 000 for six cycles of therapy for an average sized patient.

Radiation therapy on average in 2015 cost between R51 000 and R112 000 for between five and six weeks of treatment depending on the complexity of the condition, as well as the type of radiotherapy administered.”

He also adds that patients with metastatic, depending on the type of breast and their response to therapy, may be given treatment for a limited number of cycles of ongoing treatment.

Biological therapies such as Herceptin may cost more than R500 000 for a year of therapy. These drugs are used to treat rare conditions and cancer subtypes which come at a much higher cost than conventional drugs.

The upside to Medical Aid

Private patients would have to pay millions of Rand in medical fees if they don’t make use of what the state provides but what about those who are covered by a medical scheme? Are they fully covered?

The good news is that cancer is one of the conditions covered under prescribed minimum benefits (PMB), which means that all medical schemes in South Africa must cover members according to the standard treatment offered in state facilities.

In 2015 Fedhealth, for example, funded medication for 170 members with breast cancer. A hundred and forty one of these patients received chemotherapy while 29 received radiation treatment. Of the 141 patients receiving chemotherapy, 15 were treated with a specialised drug, the average cost per patient for these members amounted to R267 760 per patient; a total cost of R4 016 404 for 15 patients. These costs are underestimated, as certain costs will be limited by the benefit limit, and costs for one patient can span over more than one benefit year.

Medscheme Health Risk solutions informs us that, “In terms of the general costs that “one” ((the funder) must pay, medical aid benefits will cover all cancer related PMBs (medication and hospital costs) and any additional costs up to available benefit for cancer medication and chemotherapy. The average cost per oncology patient per month is approximately R6100 (R73, 000 per annum).”

Oncology benefits will be limited, depending on the level of cover patients choose. Fedhealth allows access to a specialised drug benefit, which may allow access to funding of specialised drugs for breast cancer where managed care protocols are met. This specialised drug benefit will also vary depending on the type of cover you choose.

If you are diagnosed with cancer, there may be the option to upgrade your cover. Fedhealth patients can, for example, upgrade to an option that has more comprehensive benefits within thirty days of diagnosis or a life-changing event.

Medscheme Health Risk solutions, stress the importance of the screening and preventative benefits that their medical scheme allows access to. Fedhealth pays for mammograms from their wellness benefit on some levels. This provides access to females between 50 and 70 years to mammogram every three years.

Mhlongo states, “We understand that cancer is one of the most traumatic illnesses that a person can go through. Our objective is therefore to ensure that members have peace of mind in terms of their cover if they are diagnosed with cancer.  At the same time, it is important for Discovery Health Medical Scheme to ensure that benefits are managed responsibly so that all members have access to cover and treatment now and in future.”

Discovery offers its members comprehensive benefit packages for both in-hospital treatment and out of hospital treatments, which is structured and aimed at affording healthcare professionals and members flexibility with regards to their decisions. They have also developed reimbursement arrangements with various specialists, hospital groups and other service providers to ensure that healthcare professionals receive a reimbursement that is fair.

“Members have peace of mind that their claims are paid in full and directly to the healthcare provider,” says Mhlongo.

He adds, “In the case of unique treatments and circumstances, the scheme has an expert review process in place to assist with individual case review. This process also includes an independent panel of specialists and experts who guide the scheme by making clinical recommendations in complex and/or unusual cases or certain instances where the prescribed treatment may have less robust clinical evidence.”

Is medical aid enough though?

An Oncology benefit was put into place to reign in the oncologists from prescribing the newer, expensive drugs, but is it enough?

Ramiah says, “The reality is that the oncology benefit that the medical aids provide is not enough for many patients. The reality is that many patients don’t have enough funds to cover everything. This is because when diagnosed with cancer, the medical aid companies put you onto an oncology benefit, which is usually R200 000 or R400 000 for the year. If treatment costs exceed this (which they often do) we need to make a plan, and adjust the treatment we think is best.”

He expresses his concerns that medical aids have not increased the oncology benefit amount since 2011, and not only have treatment cost increased during this time but so has medical aid premiums. Some of the newer immunotherapy agents’ costs over R1 million rand, so they simply say the benefits are exhausted, and the patients need to make a co-payment for the balance.

He adds, “So just from these few figures, you can see that an oncology benefit of R200 000 will not be enough and it is important to note that the doctor’s fees are a very, very small portion of the cost.”

Dr Coenraad Frederik Slabber, medical oncologist, concludes, “The bottom line is that medical aid benefits have not kept up with the cost of modern treatment and that we are facing crises in years to come, when the newer drugs become commercially available in South Africa. At the moment there is a backlog at the Medicine Control Council, and it can take several years for new drugs to be approved.”

source : Moneybags