1. Cost-effectiveness analysis (CEAs)

A central pillar of the work done by the DKFZ Division of Health economics is the elaboration of economic evaluations, particularly cost-effectiveness analysis. Cost-effectiveness analysis evaluates the effectiveness of two or more treatments relative to their cost. Different interventions are currently included in this pillar. The following are some examples:

Economics of colorectal cancer screening


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Colorectal cancer (CRC) is the third most common cancer in men and the second in women in countries with high human development index (HDI), accounting for 0.74 million (or 738,000) new cases and 0.42 million (or 415,000) deaths in 2018. The economic burden of CRC in the European Union in 2009 alone was estimated to amount to €13.1 billion. Early detection and treatment through CRC screening with stool-based tests, sigmoidoscopy or colonoscopy has been shown to be strongly associated with CRC mortality reduction. Furthermore, economic evidence indicates that the above-mentioned strategies are cost effective compared to no screening. There remain, however, open research questions regarding the identification of an optimal strategy and the cost-effectiveness of programs aimed at increasing screening participation rates. Hence, research has been initiated to better understand the economic disease burden in Germany, to systematically review and update recent evidence of the cost-effectiveness of CRC screening, and to use economic modeling to evaluate the cost-effectiveness of CRC screening strategies.

The skin classification project

The application of artificial intelligence is rapidly increasing in the health care sector. In the Skin Classification Project convolutional neural networks (CNN) were designed and trained by the Department of Translational Oncology, National Center for Tumor Diseases to support melanoma diagnosis. The new diagnostic algorithm provided better test characteristics among individuals having lesions already categorized as suspicious by at least one physician compared to the current standard of care in retrospective studies (Brinker et al. 2019). The DKFZ Division of Health Economics is participating in this collaborative research project to evaluate the economic value of introducing the new diagnostic algorithm in everyday clinical practice. During the first stage of the project, an early-phase health economic model was developed based on clinical data derived from the retrospective trial. Model outcomes suggested that the new health technology positively affects health and economic outcomes by avoiding false negative diagnoses and reducing the number of advanced stage melanoma cases due to increased sensitivity of diagnosis. 

Economics of breast cancer screening

Breast cancer screening, especially mammography, has been shown to reduce deaths and increase diagnosis at early stages. Similar to other European countries, Germany has adopted organized population-based screening programs. However, there is evidence that mammography is associated with cumulative risk of false-positive recalls, and has subsequent adverse psychological effects. Nevertheless, there is sufficient evidence that the benefit of mammography outweighs the harms for general population.

Currently, the biennial mammography recommendation in Germany applies to women of average risk, between the ages of 50 and 69, similar to other countries. However, this screening strategy might not work well for women with different risks. For one thing, with the “one-size-fits-all” strategy, lower-risked women might be “over-screened”, whereas the higher-risk ones might be “under-screened”. In recent years, there has been increasing evidence that breast cancer is associated with factors such as family history of breast and ovarian cancers, age, weight, and breast density, among others. There is a need of effective and cost-effective alternative strategies for individuals with different risks, without increasing false-positive rates. This project aims to answer such research questions as: (1) Is risk-based screening strategy more cost-effective compared to biennial mammography for all women aged 50 and above? What about younger women?; (2) Are cost-effectiveness results sensitive to different definitions of risk groups (based on different risk assessment methods)?; (3) Should special strategies be developed for women with dense breasts (tentative, depending on the interest of the subject matter expert)?

2. Health Technology Assessment (HTA)

Comparative analysis of national HTA agencies


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Health Technology Assessment (HTA) is understood as a multidisciplinary as well as comprehensive process supporting decision-making in health care, based on scientific and non-scientific evidence (Banta 2003, Battista 1999). However, in practice HTA rests predominantly on two pillars: the assessment of clinical benefit drawing on principles of evidence-based medicine, and an evaluation of efficiency, usually by means of a variant of cost-effectiveness analysis. For example, well-known HTA agencies as the British National Institute for Health and Care Excellence (NICE) and the German Federal Joint Committee (Gemeinsamer Bundesausschuss, G-BA) have implemented different evaluation approaches, which (may) also reflect variations in HTA outcomes (Fischer et al. 2016, Angelis et al. 2018, Schaefer and Schlander 2019).

Against this background, Ramon Schaefer from the DKFZ Division of Health Economics is currently working on an HTA comparative study, which is exploring the extent to which different methodological choices are associated with different HTA outcomes. Therefore, the study is focusing on assessment results as well as (official and unofficial) evaluation criteria by G-BA and NICE, respectively. In addition, the French Haute Autorité de Santé (HAS) will be included for an analysis of matched condition-intervention pairs.


Selected Publications

T. Ran, C.-Y- Cheng, B. Misselwitz, H. Brenner, J. Ubels, M. Schlander:
Cost–effectiveness of colorectal cancer screening strategies: A systematic review.
Clinical Gastroenterology and Hepatology, in press (2019).
DOI: 10.1016/j.cgh.2019.01.014.

R. Schaefer, M. Schlander:
Is the National Institute for Health and Care Excellence (NICE) in England more ´innovation-friendly´ than the Federal Joint Committee (GBA) in Germany?
Expert Review of Pharmacoeconomics & Outcomes Research, (2019) 19(4) 453-462.
DOI: 10.1080/14737167.2019.1559732.

M. Schlander, C.-Y. Cheng, T. Ran:
The health economics of cancer screening in Germany: Which population-based interventions are cost-effective? [Gesundheitsökonomie der Krebsfrüherkennung in Deutschland: Welche Interventionen sind kosteneffektiv bei bevölkerungsweiter Umsetzung?]
Bundesgesundheitsblatt, (2018) 61(12) 1559-1568.
DOI: 10.1007/s00103-018-2839-3.

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