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Cost effectiveness of strategies to combat breast, cervical, and colorectal cancer in sub-Saharan Africa and South East Asia: mathematical modelling study

BMJ 2012; 344 doi: (Published 02 March 2012) Cite this as: BMJ 2012;344:e614
  1. Gary M Ginsberg, health economist1,
  2. Jeremy A Lauer, economist2,
  3. Sten Zelle, PhD researcher4,
  4. Steef Baeten, PhD researcher3,
  5. Rob Baltussen, senior scientist4
  1. 1Department of Medical Technology Assessment, Ministry of Health, Ben Tbai 2, San Simone, Jerusalem, Israel
  2. 2Department of Health Systems Financing, World Health Organization, Geneva, Switzerland
  3. 3Institute of Health Policy and Management, Erasmus Medical Centre, Rotterdam, the Netherlands
  4. 4Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, the Netherlands
  1. Correspondence to: G Ginsberg gary.ginsberg{at}
  • Accepted 10 October 2011


Objective To determine the costs and health effects of interventions to combat breast, cervical, and colorectal cancers in order to guide resource allocation decisions in developing countries.

Setting Two World Health Organization sub-regions of the world: countries in sub-Saharan Africa with very high adult and high child mortality (AfrE); and countries in South East Asia with high adult and high child mortality (SearD).

Design Cost effectiveness analysis of prevention and treatment strategies for breast, cervical, and colorectal cancer, using mathematical modelling based on a lifetime population model.

Data sources Demographic and epidemiological data were taken from the WHO mortality and global burden of disease databases. Estimates of intervention coverage, effectiveness, and resource needs were based on clinical trials, treatment guidelines, and expert opinion. Unit costs were taken from the WHO-CHOICE price database.

Main outcome measures Cost per disability adjusted life year (DALY) averted, expressed in international dollars ($Int) for the year 2005.

Results In both regions certain interventions in cervical cancer control (screening through cervical smear tests or visual inspection with acetic acid in combination with treatment) and colorectal cancer control (increasing the coverage of treatment interventions) cost <$Int2000 per DALY averted and can be considered highly cost effective. In the sub-Saharan African region screening for colorectal cancer (by colonoscopy at age 50 in combination with treatment) costs $Int2000–6000 per DALY averted and can be considered cost effective. In both regions certain interventions in breast cancer control (treatment of all cancer stages in combination with mammography screening) cost $Int2000–6000 per DALY averted and can also be considered cost effective. Other interventions, such as campaigns to eat more fruit and vegetable or subsidies in colorectal cancer control, are not cost effective according to the criteria defined.

Conclusion Highly cost effective interventions to combat cervical and colorectal cancer are available in the African and Asian sub-regions. In cervical cancer control, these include screening through smear tests or visual inspection in combination with treatment. In colorectal cancer, increasing treatment coverage is highly cost effective (screening through colonoscopy is cost effective in the African sub-region). In breast cancer control, mammography screening in combination with treatment of all stages is cost effective.


  • doi: 10.1136/bmj.e586
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  • We thank Stephen Lim for technical input on modelling the effectiveness of colorectal cancer interventions, Cecilia Sepulveda for advice regarding treatment of colorectal and cervical cancers, Ben Johns for advice regarding cost estimation, Inbar Ben-Shahar for detailing the treatment modes for cervical cancer, and Dan Chisholm for editorial work related to this paper and series.

  • Contributors: All authors contributed to the study conception and design, interpretation of data, and drafting of the manuscript. GG, SZ, and SB performed the technical analysis. All authors approved the submitted version of the manuscript. GG is the guarantor of the manuscript.

  • Funding: No external funding or sponsorship.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisation that might have an interest in the submitted work in the previous 3 years; no other relationships or activities that could appear to have influenced the submitted work.

  • JAL is a staff member of the WHO. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the decisions, policy, or views of the WHO.

  • Ethical approval: Not required.

  • Data sharing: No additional data available

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