Health Economics

Exploring the Economics of Lung Cancer

Real-world data on healthcare utilization and costs related to lung cancer in Germany remain limited. To address this gap, we analyzed administrative claims data from one of the country’s largest health insurers.

The initial study established methods for identifying lung cancer cases, estimated national incidence, and examined survival rates relative to comorbidities. Two follow-up studies focused on (1) medication costs and prescription patterns, and (2) inpatient costs and treatment patterns across Germany.

Preliminary findings showed inpatient costs averaged €25,000 per patient—or approximately €18,000 per year of survival—with notable variation by age and region, but minimal differences by sex or comorbidities. The average hospital stay declined significantly over a 12-year period.

Outpatient prescription costs averaged €12,000 per patient, with lower costs during initial treatment and peaks in the terminal phase. These costs rose substantially over the study period.

Cost of Cancer Drug Development

The high cost of developing new cancer drugs is often cited as a key driver of rising prices and raises concerns about the long-term sustainability of the R&D-based biopharmaceutical industry.

We conducted a comprehensive review of peer-reviewed literature on the costs of bringing a new molecular entity (NME) to market, highlighting factors behind the wide variation in published estimates. Reported capitalized pre-launch R&D costs ranged from $161 million to $4.54 billion (2019 USD), with anticancer drugs among the most expensive—ranging from $944 million to $5.4 billion.

Our analysis confirmed a consistent upward trend in R&D costs per NME. To improve the quality and comparability of future research, we developed a suitability scoring system for evaluating study validity in this field.

Cost of CAR-T Cell Treatments

CAR T-cell therapies offer promising options for certain blood cancers, with the potential for long-term remission or cure. The European Commission approved two such gene therapies in 2018, marking a milestone in cancer treatment.

We evaluated the full cost spectrum of CAR-T cell therapy—including production, patient involvement, admission, and toxicity management—using both micro- and gross-costing approaches.

Our findings showed, for the first time, that production in not-for-profit settings can be a more cost-effective and efficient alternative to centralized models. Further cost reductions are expected as decentralized production benefits from standardization, economies of scale, and process improvements—consistent with the early life cycle stage of this innovative technology.

Selected Publications

D. Hernandez, C.-Y. Cheng, K. Hernandez-Villafuerte, M. Schlander:
Survival and comorbidities in lung cancer patients: evidence from administrative claims data in Germany.
Oncology Research, 2022: 30(4), 173-185.
DOI: 10.32604/or.2022.027262.

T. Ran, S. B. Eichmüller, P. Schmidt, M. Schlander:
Cost of decentralized CAR T cell production in an academic non-profit setting.
International Journal of Cancer, 2020: 147(12), 3438-3445.
DOI: 10.1002/ijc.33156

T. Ran, S. B. Eichmüller, P. Schmidt, M. Schlander:
Reply to: Comments on "Cost of decentralized CAR T cell production in an academic non-profit setting".
International Journal of Cancer, 2021: 148(2), 516-517.
DOI: 10.1002/ijc.33253

M. Schlander, K. Hernandez-Villafuerte, C. -Y. Cheng, J. Mestre-Ferrandiz, M. Baumann:
How much does it cost to research and develop a new drug? A systematic review and assessment.
Pharmacoeconomics, 2021: 39(11), 1243-1269.
DOI: 10.1007/s40273-021-01065-y

M. Schlander, T. Ran, P. Schmict, S.B. Eichmüller:
Can we reduce the acquisition cost of CAR T cell therapies?
Annals of Oncology, 2020: 31(Supplement 4) S966.
DOI: 10.1016/j.annonc.2020.08.1912

The Socioeconomic Impact of Cancer on Patients and Families

While health economists often analyze costs from societal or payer perspectives, the patient viewpoint remains under explored in applied research. In the U.S., the concept of financial toxicity has drawn attention to the economic burden of cancer treatment. In contrast, it's often assumed that universal healthcare systems in Europe protect patients from financial hardship.

However, many European cancer patients still face substantial economic strain. Their financial burden includes direct medical and non-medical costs (e.g., co-payments), as well as indirect costs like lost income—often only partially offset by social welfare systems. In addition to these tangible costs, patients and families frequently bear intangible burdens, such as psychological distress, diminished quality of life, and even worse clinical outcomes.

To better reflect this broader experience, we propose using the term socioeconomic impact, which encompasses the full spectrum of financial, psychological, and social consequences for patients, survivors, and their families. Recognizing these impacts is essential to fully understanding the burden of cancer and designing supportive policies and interventions.

Organisation of European Cancer Institutes (OECI) Consensus Task Force

Research on the socioeconomic impact of cancer from the patient and family perspective in Europe is still emerging, characterized by fragmented methods, terminology, and a lack of unified theory. To address these gaps, an international Task Force was launched in March 2021 within the OECI Health Economics Working Group, led by Michael Schlander (chair) and Wim van Harten (co-chair).

The Task Force aimed to develop a European consensus on a comprehensive conceptual framework, consistent taxonomy, and standardized definitions. Its goal is to reduce redundant and non-comparable research and promote more coordinated, rigorous, and policy-relevant efforts.

Since its inception, the Task Force has conducted extensive consensus-building activities, including focus groups, Delphi exercises, and consultations with patient representatives and external experts. This process culminated in 25 consensus recommendations, published in The Lancet Oncology (April 2024), which include a definition of socioeconomic impact, a detailed framework of causes and outcomes, and guidance for developing and validating patient-reported outcome instruments.

Empirical Research

In parallel with the conceptual work, additional empirical studies have explored the socioeconomic impact of cancer. One study analyzed data from the Socio-Economic Panel (SOEP), one of Germany’s largest household surveys, revealing that average job incomes declined by 26% to 28% within the first year following a cancer diagnosis.

In another project, conducted with the DKFZ Unit of Cancer Survivorship (led by Volker Arndt), we analyzed CAESAR study data to assess out-of-pocket expenses and income losses among breast cancer survivors in Germany, identifying key factors contributing to their financial burden.

Selected Publications

P.D. Pham, J. Ubels, R. Eckford, M. Schlander:
Measuring the Socioeconomic Impact of Cancer: A Systematic Review and Standardized Assessment of Patient-Reported Outcomes (PRO) Instruments.
PharmacoEconomics Open, 2025. Published 04 April 2025
DOI: 10.1007/s41669-025-00568-0

M. Schlander, W. van Harten, V.P. Retèl, P.D. Pham, J. M. Vancoppenolle, J. Ubels, O.S. López, C. Quirland, F. Maza, E. Aas, B. Crusius, A. Escobedo, N. Franzen, J. Fuentes-Cid, D. Hernandez, K. Hernandez-Villafuerte, I. Kirac, A. Paty, T. Philip, S. Smeland, R. Sullivan, E. Vanni, S. Varga, T. Vermeulin, R.D. Eckford:
The socioeconomic impact of cancer on patients and their relatives: Organisation of European Cancer Institutes task force consensus recommendations on conceptual framework, taxonomy, and research directions.
The Lancet. Oncology, 2024: 25 (4), e152–e163.
DOI: 10.1016/S1470-2045(23)00636-8

P.D. Pham, M. Schlander, R. Eckford, K. Hernandez-Villafuerte, J. Ubels:
Developing a conceptual framework for socioeconomic impact research in European cancer patients: A 'best-fit' framework synthesis.
The Patient, 2023: 16(5) 515-536.
DOI:10.1007/s40271-023-00632-z

V. Arndt, D. Hernandez, M. Schlander:
Einkommenseinbußen nach Krebs – Ergebnisse aus Deutschland [Income loss after cancer—Results from Germany].
Onkologie, 2022: 28, 951-956.
DOI: 10.1007/s00761-022-01243-3

D. Hernandez, M. Schlander:
Income loss after a cancer diagnosis in Germany: An analysis based upon the socio-economic panel survey.
Cancer Medicine, 2021: 10 (11), 3726-3740.
DOI: 10.1002/cam4.3913

R. Eckford, K. Hernandez-Villafuerte, A. Spier, L. Hirschberg, M. Schlander:
A systematic review of the socioeconomic impact of cancer on patients and families: Are differences among countries being effectively captured and addressed?
Value in Health, 2020: 23(Supplement 2), S478.
DOI: 10.1016/j.jval.2020.08.453

K. Hernandez-Villafuerte, R. Eckford, A. Spier, M. Schlander:
How to Describe the Socioeconomic Impact of Cancer on Patients and their Families: An Evaluation of Terminology by Global Regions and Healthcare Systems.
Presentation at iHEA 14^th World Congress on Health Economics.
Virtual. July 12-15, 2021

M. Schlander: 
PRO (“patient-reported outcomes”) und Lebensqualität in der Onkologie [Patient-reported outcomes (PRO) and quality of life in oncology].
Forum 2020: 35, 382-390.
DOI: 10.1007/s12312-020-00841-9

J. Schneider, D. Hernandez, CAESAR study group, M. Schlander, V. Arndt:
Out-of-pocket payments and loss of income among long-term breast cancer survivors in Germany: A multi-regional population-based study.
Journal of Cancer Survivorship, 2023: 17(6), 1639-1659.
DOI: 10.1007/s11764-022-01293-x

 [ER1]Updated to reflect where we are now.

Cost effectiveness evaluation and HTAs

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 some variant of cost effectiveness analysis. For example, well-known health technology assessment (HTA) agencies such as the National Institute for Health and Care Excellence (NICE) in England and Wales and the Institute for Quality and Efficiency in Health Care (IQWiG) / Federal Joint Committee (Gemeinsamer Bundesausschuss, G-BA) in Germany have implemented different evaluation approaches, which also reflect variations in HTA outcomes.

Against this background, an empirical analysis as well as a comparative study were conducted to explore the extent to which different methodological choices are associated with different HTA outcomes. These studies primarily focused on assessment and appraisal results as well as (official and unofficial) evaluation criteria by G-BA/IQWiG and NICE, respectively. In a follow-up project, we considered systematically reviewing the data requirements of national HTA agencies such as NICE, G-BA/IQWiG and the French Haute Autorité de Santé (HAS), including their acceptance of data sources, handling of potential bias, as well as underlying differences in methodological choices and their potential implications for HTA outcomes.

Selected Publications

R. Schaefer, D. Hernandez, T. Bärnighausen, P. Kolominsky-Rabas, M. Schlander: 
Health technology assessment-informed decision making by the federal joint committee/institute for quality and efficiency in health care in Germany and the National Institute for health and care excellence in England: The role of budget impact. 
Value in Health, 2023: 26(7) 1032-1044. 
DOI: 10.1016/j.jval.2023.02.018

R. Schaefer, D. Hernandez, L Selberg, M. Schlander:
Health technology assessment (HTA) in England, France and Germany: what do matched drug pairs tell us about recommendations by national HTA agencies?
Journal of Comparative Effectiveness Research, 2021: 10(16) 1187-1195.
DOI: 10.2217/cer-2021-0047

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.

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, 2019: 17(10) 1969-1981.
DOI: 10.1016/j.cgh.2019.01.014.

Social preferences and their measurement

In the European social preferences measurement (ESPM) project, a comprehensive literature review on the allocation of health care resources indicated consistent public support for a range of attributes beyond clinical effectiveness. These include: 1) giving priority to the worst-off patients (in terms of initial health state severity); 2) prioritizing urgent interventions to prevent irreversible harm, 3) avoiding discrimination against persons in "double-jeopardy" (e.g., those with comorbidities); 4) giving preference to younger patients under the “fair innings” argument, and 5) supporting equitable access to effective care regardless of high treatment costs.  

A research program was initiated to investigate how citizens value these attributes and how they weigh them against each other—contrasting these social preferences with conventional logic of cost-effectiveness analysis. Concerning orphan indications (or “rarity”, an attribute of primary interest), findings showed that citizens are often willing to accept (sometimes much) higher costs per patient for rare and ultra-rare conditions. However, similar to VSLY studies, full publication of the main ESPM study has been delayed.

A critical follow-up—the “sensitivity-go-size” survey, is underway to test whether citizens’ willingness to pay (WTP) changes with the number of patients treated. Equitable resource allocation for rare diseases, remains a global challenge. Despite the high costs of many Orphan Medicinal Products (OMPs), often exceeding traditional cost-effectiveness thresholds, public support for reimbursement remains strong.

Building on insights from the Social Preferences for Health Care Interventions (SoPHI) study, which revealed that WTP does not increase proportionally with disease prevalence—and may even decrease as prevalence rises—this suggests that rare disease treatments receive a uniquely high degree of public endorsement. Yet, it remains unclear whether respondents fully understand this prevalence-WTP dynamic, or whether cognitive biases and framing effects influence their choices. 

To address these uncertainties, we are launching a discrete choice experiment (DCE) with a representative sample from Baden-Württemberg. The experiment will systematically vary how prevalence data are presented—comparing absolute figures versus relative representations and numerical verses graphical formats—and test how these interact with treatment cost attributes in shaping WTP decisions. Participants will choose between a standard treatment (no extra cost) and a new treatment (with higher insurance premiums), with scenarios differing by disease rarity, cost level, and presentation style. Conducted in collaboration with an experienced panel data company, this study aims to produce robust, policy-relevant evidence to guide equitable resource allocation for rare and innovative medical treatments in the German healthcare system.

Capabilities and health outcomes.

Assessing the value of medical care necessitates a clear definition of value and its components or “attributes”. Traditional constructs in health economics—such as individual willingness-to-pay (WTP) in cost benefit analysis or Quality-Adjusted Life Years (QALYs) in cost effectiveness evaluations—have faced criticism for either lacking broad acceptance or offering narrow perspective on health healthcare value. Therefore, selecting an appropriate outcome measure for economic evaluations is crucial to ensuring their validity.

Proponents of the capability approach argue that medical interventions extend beyond improving health, enhancing an individual’s freedom to achieve desired states of being and doing. However, operationalizing the measurement of these freedoms, or “capabilities,” has posed significant challenges. To address this, a best-fit framework synthesis was conducted, reviewing prior efforts to translate the capability approach into measurable constructs. This synthesis highlighted limitation in earlier definitions, particularly their failure to adequately reflect the burdens individuals face while achieving capabilities and the vagueness surrounding what constitutes a capability. 

A patient-reported outcome (PRO) measure was created using this framework, demonstrating the advantages of comprehensive and precise conceptualizations in applying the capability approach. Initial validation studies indicate that responses to the proposed instrument are relatively unaffected by adapted preferences, suggesting its robustness in capturing genuine capability-related outcomes.

Future research aims to integrate this line of work with ongoing studies on the socioeconomic impact of health conditions, facilitating a more nuanced understanding of how health interventions influence not just physical outcomes but broader life capabilities and social wellbeing. 

Selected Publications

J. Ubels, K. Hernandez-Villafuerte, E. Niebauer, M. Schlander:
The Use of a Comprehensive Concept of Capability for Wellbeing Assessment: A Best-Fit Framework Synthesis.
Health Care Analysis, Published online August 19, 2024.
DOI: 10.1007/s10728-024-00488-w

J. Ubels, K. Hernandez-Villafuerte, M. Schlander:
The value of freedom: a review of the current developments and conceptual issues in the measurement of capability.
Journal of Human Development and Capabilities, 2022: 23(3), 327-353.
DOI: 10.1080/19452829.2022.2053506

M. Brougham, M. Schlander, H. Telser, S. Bakshi, O. Sola-Morales:
Use of the Incremental Cost Effectiveness Ratio for Decision-Making Policies - What's the Problem? A Perspective Paper.
Expert Review of Pharmacoeconomics & Outcomes Research, 2022: 22(6), 913-918.
DOI: 10.1080/14737167.2022.2064847.

D. Moro, M. Schlander, H. Telser, O. Sola-Morales, M. D. Clark, A. Olaye, C. Camp, M. Jain, T. Butt, S. Bakshi:
Evaluating discrete choice experiment willingness to pay [DCE-WTP] analysis, and relative social willingness to pay [RS-WTP] analysis in a health technology assessment of a treatment for an ultra-rare childhood disease [CLN2].
Expert Review or Pharmacoeconomics & Outcomes Research, 2022: 22(4), 581-598.
DOI: 10.1080/14737167.2022.2014324

J. M. Heard, C. Vrinten, M. Schlander, C. M. Bellettato, C. van Lingen, M. Scarpa; MetabERN collaboration group:
Availability, accessibility and delivery to patients of the 28 orphan medicines approved by the European Medicine Agency for hereditary metabolic diseases in the MetabERN network.
Orphanet Journal of Rare Diseases, 2020: 15, 651-673.
DOI: 10.1186/s13023-019-1280-5

M.-J. Linton, P. M. Mitchell, H. Al-Janabi, M. Schlander, J. Richardson, A. Iezzi, J. Ubels, J. Coast:
Comparing the German translation of the ICECAP-A capability wellbeing measure to the original English version: Psychometric properties across healthy samples and seven health condition groups.
Applied Research in Quality of Life, 2020: 15, 651-673.
DOI: 10.1007/s11482-018-9681-5

J. J. Caro, J. E. Brazier, J. Karnon, P. Kolominsky-Rabas, A. J. McGuire, E. Nord, M. Schlander:
Determining value in Health Technology Assessment: Stay the course or tack away?
PharmacoEconomics, 2019: 37(3), 293-299.
DOI: 10.1007/s40273-018-0742-2.

J. Richardson, M. Schlander:
Health Technology Assessment (HTA) and economic evaluation: Efficiency or fairness first.
Journal of Market Access & Health Policy, 2019: 7(1), 1557981.
DOI: 10.1080/20016689.2018.1557981

M. Wagner, D. Samaha, R. Casciano, M. Brougham, P. Abrishami, C. Petrie, B. Avouac, L. Mantovani, A. Sarría-Santamera, P. Kind, M. Schlander:
Moving towards accountability for reasonableness: A systematic exploration of the features of legitimate healthcare coverage decision-making processes using rare diseases and regenerative therapies as a case study.
International Journal of Health Policy and Management, 2019: 8 (7), 424-443.
DOI: 10.15171/ijhpm.2019.24.

M. Schlander:
Woran bemisst sich Effizienz im Gesundheitswesen? Zur Klärung fachwissenschaftlicher Begriffe und Kriterien.
Amos International, (2017): 11(1), 22-31.

COVID-19 pandemic related research

In response to the COVID-19 pandemic, we launched several exploratory and research initiatives at the request of the DKFZ Management Board. As healthcare resources shifted to combat COVID-19, concerns arose about disruptions in care and increased psychological strain for vulnerable groups, particularly cancer patients—concerns later confirmed by emerging evidence. 

Among our efforts, we explored various data sources to identify early indicators of changes in healthcare utilization and outcomes. Additionally, we represented DKFZ at the COVID-19 & Cancer Task Force of the Union for International Cancer Control (UICC) led by Richard Sullivan (London).

Our first study, in collaboration with the DKFZ Cancer Information Service (Krebsinformationsdienst, KID), was a cross-sectional online survey of German cancer patients (July 2020 to June 2021). It assessed changes in cancer care alongside psychological and financial impacts of the pandemic and broader financial consequences unrelated to COVID-19. Among the 621 respondents, 13% reported changes to their treatment or care plans, primarily in follow-up care (56%), treatment monitoring (29%), and psychological counseling (20%). Anxiety (55%) and depression (39%) were prevalent, with higher rates among those whose care was disrupted. Despite universal healthcare coverage, 66% faced out-of-pocket expenses, over a quarter exceeding €200/month. Additionally, 20% incurred pandemic-related healthcare costs, and 16.5% experienced income loss due to COVID-19. Among employed/ self-employed respondents (51.1%), 31.8% were unable to work due to cancer, strongly correlating with anxiety (57.1%) and depression (65.8%). Younger patients and women were particularly concerned about job security and long-term financial hardship, with 19.5% fearing persistent financial losses.  

Building on this, the CroKus-1 study (2021), led by Volker Arndt (Baden-Württemberg Cancer Registry, DKFZ), surveyed a representative sample of cancer patients and cancer survivors. Results showed that 22% experienced care modifications, with 5.8% reporting changes to active treatments (surgery, systemic therapy, or radiotherapy). These patients reported significantly higher anxiety (25.2%) and depression (30%) compared to those whose treatments remained unchanged (anxiety: 15.6%; depression: 19%). Risk factors for anxiety included being under 60, female, diagnosed with lung cancer, having a low income, or facing restricted access to physicians or peer support. Depression risk factors were similar but also included living alone, undergoing recurrence or palliative treatment, and limited contact with relatives and caregivers. 

Beyond patient-focused studies, we explored broader ethical considerations in healthcare prioritization during the COVID-19 pandemic, particularly in vaccine allocation and resource distribution. März et al. (2022) utilized quantitative models to illustrate the trade-offs in vaccine policy decisions, emphasizing the need for transparent, national strategies balancing ethical principles like population benefit, reciprocity, social justice, and equal respect for individuals. Another article examined how real-world policies reflected the Rule of Rescue—the ethical impulse to save identifiable lives in immediate danger—while cautioning against relying solely on this principle during public health crises. These findings underscored the complexity of ethical decision-making in pandemics, where prioritization invariably involves balancing competing values and outcomes. 

Selected Publications

D. Doege, J. Frick, R.D. Eckford, L. Koch-Gallenkamp, M. Schlander, Baden-Württemberg Cancer Registry, V. Arndt:
Anxiety and depression in cancer patients and survivors in the context of restrictions in contact and oncological care during the COVID-19 pandemic.
International Journal of Cancer, 2025: 156(4), 711-722.
DOI: 10.1002/ijc.35204

R. D. Eckford, A. Gaisser, V. Arndt, M. Baumann, E. Kludt, K. Mehlis, J. Ubels, E. C. Winkler, S. Weg-Remers, M. Schlander:
The COVID-19 pandemic and cancer patients in Germany: impact on treatment, follow-up and psychological burden.
Frontiers in Public Health, published online 2022 Feb 9: Article 788598.
DOI: 10.3389/fpubh.2021.788598

R. Eckford, A. Gaisser, E. Kludt, S. Weg-Remers, M. Schlander:
Financial impact on cancer patients in Germany during the COVID-19 pandemic.
Oral presentation at World Cancer Congress (WCC) 2022. 

A. Gaisser, R. D. Eckford, V. Arndt, D. Doege, E. Kludt, J. Ubels, M. Schlander, S. Weg-Remers:
Fast zwei Jahre Coronapandemie aus der Perspektive von Krebsbetroffenen [Nearly two years of the coronavirus pandemic from the perspective of people affected by cancer].
Der Onkologe, 2022: 28(3), 248-252.
DOI: 10.1007/s00761-022-01096-w.

J. W. März, A. Molnar, S. Holm, M. Schlander:
The ethics of COVID-19 vaccine allocation: Don't forget the trade-offs!
Public Health Ethics, 2022: 15 (1), 41-50.
DOI: 10.1093/phe/phac001.

J. W. März, S. Holm, M. Schlander:
Resource allocation in the COVID-19 health crisis: are COVID-19 preventive measures consistent with the Rule of Rescue?
Medicine, Health Care and Philosophy, 2021: 24(4), 487-492.
DOI: 10.1007/s11019-021-10045-0

J. W. März, M. Schlander:
Not kennt kein Gebot? Die Rule of Rescue als Leitprinzip in der Covid-19-Pandemie.
AMOS International, 2021: 15(3), 39-44.