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Paper text:
more than one million women diagnosed with breast cancer every year are estimated 1,2 . in taiwan
, breast cancer has been the most common female cancer and the fourth cause of female cancer death since 2003 3 .
breast cancer has been causing a health concern in women worldwide not only for its increasing incidence but also for the expense of treatment .
economic evaluation of breast cancer treatment is very valuable for providing information to healthcare policy planners , physicians , patients and others to assess the situation and allocate resources to cancer control strategies , understanding the quantity of breast cancer burden and the quality of treatment 4,5 .
published evaluations of costs for breast cancer treatment during the past varied substantially in perspective , methodology and patient populations 6,7 . to the best of our knowledge ,
the potential correlation between the medical expenses and breast cancer incidence and mortality rate has not been sufficiently addressed .
thus , our current study attempted to assess the impact of medical expenses on breast cancer incidence and mortality rate in taiwan .
the national health insurance ( nhi ) service was implemented in taiwan since 1995 , and cancer registration was inaugurated since 1979 . national health insurance ( nhi )
covers comprehensive medical care , including health prevention , clinical care , hospitalization , and social rehabilitation .
medical expenses , including outpatient and inpatient services , were also retrieved from the nhi database .
the national health insurance research database ( nhird ) is a large computerized database which is derived from the system by the bureau of nhi and supported by the national health research institute ( nhri ) .
the nhird is supplied to the scientists in taiwan for aims of research . before the database is released to each researcher ,
all the data in the nhird individual identification information , including patient i d , medical institutions , and care providers , are encrypted .
therefore , the approval of institutional review board was waived for the study . in taiwan ,
the increased trend of breast cancer burden was noticed as a public health issue and the annual incidences of cancer have been published formally by bureau of health promotion every year . in our study ,
breast cancer cases were identified from the national health insurance research database ( nhird ) with corresponding to international classification of diseases , and the ninth revision ( icd-9 ) code 174 , 1740 - 1749 ( malignant neoplasm of female breast ) , 175 , 1750 and 1759 ( malignant neoplasm of male breast ) from january 1999 to december 2006 .
age -specific incidences were estimated by population data obtained from the department of statistics , ministry of the interior .
annual incidences of breast cancer were detailed in table 1 . during 1999 - 2006 ,
the annual incidence ranged from 40.86 to 61.10 and from 0.20 to 0.42 per 100,000 for females and males , respectively .
the combined incidences increase from 20.06 per 100,000 in 1999 to 30.34 per 100,000 in 2006 .
age - specific incidences ( per 100,000/year ) of female breast cancer were listed in table 2 and figure 1 .
the increase in breast cancer incidence did not occur on women aged less than 35 .
age - standardized incidence ( per 100,000 people ) and age - standardized mortality ( per 100,000 people ) of female breast cancer during 1999 - 2006 were shown in figure 2 .
the age - standardized mortality rate for female breast cancer remains essentially unchanged , while the age - standardized incidence increased steadily ( except 2002 - 2003 ) .
expenses of outpatient and inpatient services for breast cancer were detailed in table 3 . the total expenses increase from 1,449,333,521 in 1999 to 4,350,400,592 taiwan dollars 2006 .
the most common coexisting icd-9 code was v58.1 ( encounter for chemotherapy ) , followed by 401.9 ( essential hypertension ) . among the top 20 coexisting icd-9 codes ,
four are directly on cancers , including   encounter for chemotherapy ,   secondary malignant neoplasm of bone and bone marrow ,   secondary and unspecified malignant neoplasm of lymph nodes of axilla and upper limb , and   secondary malignant neoplasm of lung .
16 of the top 20 are on other diseases or symptoms , which are not necessarily caused by breast cancer .
our study showed that medical expenses of breast cancer treatment increased significantly and linearly from 1999 through 2006 in taiwan ( table 3 ) .
however , the age - standardized mortality rate for female breast cancer remained essentially unchanged , while the age - standardized incidence increased steadily ( except 2002 - 2003 ) ( figure 2 ) .
these facts indicate that significantly increased medical expenditure on breast cancer have failed to bring down its mortality and incidence rate .
the primary factors accounting for the significant increase of medical expenses on breast cancer appear to the followings :   a significant amount of the expenses are not directly related to cancer . in our study , among of the top 20 coexisting icd-9 code ( table 4 ) , four are directly on cancers .
16 of the top 20 are on other diseases or symptoms , which are not necessarily caused by breast cancer .   the applications of novel treatment regimens , including newly developed target therapy , hormone therapy and chemotherapy .
hormone therapy steeply increased since 2004 .   a significant expansion of the breast cancer screening program . in taiwan
, the national health service breast cancer screening program was introduced in july , 2002 3 .
after repeated review and improving , breast cancer screening services expand to female 45 - 69 years in 2009 ; and further , women aged 40 - 44 with a family history of breast cancer were covered since 2010 .   increasing incidences of more aggressive breast cancer types that require more comprehensive and costly treatment
. a significantly higher incidence of axillary lymph node metastases for taiwanese women with small breast cancer than for western women was demonstrated 8 .  
poor patients compliances for physicians ' advice lead to disease advance and increase medical expenditure .
our study showed that significantly increased medical expenditure on breast cancer failed to bring down its mortality and incidence rate in taiwan .
the finding has implications for healthcare policy planners in proposing strategies for breast cancer control and allocating the resources
. limitations of this study are stages of diseases and prognosis of the patients not clear due to database not support .
no connected mortality database for estimations of individual medical expense of treatment is also a limitation of our study .
background : the direct impact of medical expenses on breast cancer incidence and mortality rate has not been sufficiently addressed . 
 the purpose of this study is to investigate the potential correlation between the incidence and mortality rate of breast cancer and the medical expenses in taiwan.materials and methods : breast cancer cases were identified from the national health insurance research database ( nhird ) with corresponding to international classification of diseases , and the ninth revision ( icd-9 ) code 174 , 1740 - 1749 , 175 , 1750 and 1759 from january 1999 to december 2006 . 
 age - specific incidences were estimated by population data obtained from the department of statistics , ministry of the interior . 
 medical expenses , including outpatient and inpatient services , were also retrieved from the nhird.results : the incidence increased from 20.06 per 100,000 in 1999 to 30.34 per 100,000 in 2006 ; the total expenses increased from 1,449,333,521 in 1999 to 4,350,400,592 taiwan dollars in 2006 . 
 the age - standardized mortality rate for female breast cancer remained essentially unchanged , while the age - standardized incidence increased steadily ( except 2002 - 2003 ) . among the top 20 coexisting icd-9 codes for expenses , four are directly on cancers , while 16 are on other diseases or symptoms , which are not necessarily caused by breast cancer.conclusions : significantly increased medical expenditure on breast cancer failed to bring down its mortality and incidence rate . 
 the finding has implications for healthcare policy planners in proposing strategies for breast cancer control and allocating the resources .