Journal of Cancer Research and Therapeutics

: 2018  |  Volume : 14  |  Issue : 1  |  Page : 163--170

Medical expenditure for liver cancer in urban China: A 10-year multicenter retrospective survey (2002–2011)

Wu-Qi Qiu1, Ju-Fang Shi2, Lan-Wei Guo3, A-Yan Mao1, Hui-Yao Huang2, Guang-Yu Hu1, Pei Dong1, Fang-Zhou Bai2, Xiao-Ling Yan1, Xian-Zhen Liao4, Guo-Xiang Liu5, Ya-Na Bai6, Jian-Song Ren2, Xiao-Jie Sun7, Xin-Yu Zhu2, Jin-Yi Zhou7, Ji-Yong Gong8, Lin Zhu9, Ling Mai3, Ling-Bing Du10, Qi Zhou11, Xiao-Jing Xing12, Bing-Bing Song13, Yu-Qin Liu14, Pei-An Lou15, Xiao-Hua Sun16, Shou-Ling Wu17, Rong Cao18, Xiao Qi19, Li Lan20, Ying Ren21, Kai Zhang2, Jie He2, Chunfeng Qu2, Min Dai2,  
1 Public Health Information Research Office, Institute of Medical Information, Chinese Academy of Medical Sciences, Beijing, P. R. China
2 Program Office for Cancer Screening in Urban China, Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, National Cancer Center of China, No. 17 Panjiayuannanli, Chaoyang District, Beijing, P. R. China
3 Department of Cancer Epidemiology, Henan Office for Cancer Control and Research, The Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, No. 127 Dongming Road, Zhengzhou, Henan, P. R. China
4 Department of Human Resources, The Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, Henan, P. R. China
5 Department of Health Economics, School of Health Management, Harbin Medical University, Harbin, Heilongjiang, P. R. China
6 Institute of Epidemiology and Health Statistics, Lanzhou University, Lanzhou, Gansu, P. R. China
7 Center for Health Management and Policy, Key Lab of Health Economics and Policy, Shandong University, Jinan, Shandong, P. R. China
8 Science and Education Department of Public Health Division, Shandong Tumor Hospital, Jinan, Shandong, P. R. China
9 Teaching and Research Department, Affiliated Cancer Hospital of Xinjiang Medical University, Urumqi, Xinjiang, P. R. China
10 Zhejiang Office for Cancer Control and Research, Zhejiang Cancer Hospital, Hangzhou, Zhejiang, P. R. China
11 Chongqing Office for Cancer Control and Research, Chongqing Cancer Hospital, Chongqing, P. R. China
12 Liaoning Office for Cancer Control and Research, Liaoning Cancer Hospital & Institute, Shenyang, Liaoning, P. R. China
13 Heilongjiang Office for Cancer Control and Research, Affiliated Cancer Hospital of Harbin Medical University, Harbin, Heilongjiang, P. R. China
14 Cancer Epidemiology Research Center, Gansu Provincial Cancer Hospital, Lanzhou, Gansu, P. R. China
15 Department of Control and Prevention of Chronic Non-Communicable Diseases, Xuzhou Center for Disease Control and Prevention, Xuzhou 221006, Jiangsu, P. R. China
16 Ningbo Clinical Cancer Prevention Guidance Center, Ningbo No. 2 Hospital, Ningbo, Zhejiang, P. R.C Shandong, P. R. China
17 Health Department of Kailuan Group, Kailuan General Hospital, Tangshan, Hebei, P. R. China
18 Department of Health Policy and Economic Research, Guangdong Provincial Institute of Public Health, Guangzhou, Guangdong, P. R. China
19 Department of Occupational Medicine, Tangshan People's Hospital, Tangshan, Hebei, P. R. China
20 Institute of Chronic Disease Prevention and Control, Harbin Center for Disease Control and Prevention, Harbin, Heilongjiang, P. R. China
21 Urban Office of Cancer Early Detection and Treatment, Tieling Central Hospital, Tieling, Liaoning, P. R. China

Correspondence Address:
Associate Prof. A-Yan Mao
Institute of Medical Information, Chinese Academy of Medical Sciences; 3 Yabao Road, Chaoyang District, Beijing, 100020
P. R. China
Dr. Ju-Fang Shi
National Cancer Center, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical School; No.17 Panjiayuannanli, Chaoyang District, Beijing
P. R. China


Objective: This study aims to understand the medical expenditure for liver cancer during 2002-2011 in urban areas of China. Materials and Methods: This is a retrospective study. Based on a stratified cluster sampling method, a medical expenditure survey collected basic personal information from related medical records. Two-tailed independent sample t-test, variance analysis, and Student–Newman–Keuls Tests were used in cost analysis for the corresponding data types. Results: A total of 12,342 liver cancer patients were included in the analysis. Overall average medical expenditure per case for liver cancer diagnosis and treatment in China has increased from ¥21, 950 to ¥40, 386 over the study period. For each liver cancer patient diagnosed between 2009 and 2011, the average expenditures were 29,332 CNY for stage I, 35,754 CNY for stage II, 34,288 CNY for stage III, and 30,275 CNY for stage IV diseases (P < 0.001). Pharmaceuticals accounted for the biggest part of the medical expenditure and it rose from 48.01% to 52.96% during these ten years, and the share of nursing fee expenses was the lowest (around 1%). Over the entire 10-year data period, the per capita expenditure of the east region (32,983 CNY) was higher than that of the west region (26,219 CNY) and slightly higher than the central region (31,018 CNY, P < 0.001). Discussion: As a major cancer in China, liver cancer accounts for a large portion of health economic burden and its medical expenditure is heavy for families. Early diagnosis and treatment for liver cancer will save medical expenditure. Conclusion: The economic burden of liver cancer is high in China and related medical expenditure has increased.

How to cite this article:
Qiu WQ, Shi JF, Guo LW, Mao AY, Huang HY, Hu GY, Dong P, Bai FZ, Yan XL, Liao XZ, Liu GX, Bai YN, Ren JS, Sun XJ, Zhu XY, Zhou JY, Gong JY, Zhu L, Mai L, Du LB, Zhou Q, Xing XJ, Song BB, Liu YQ, Lou PA, Sun XH, Wu SL, Cao R, Qi X, Lan L, Ren Y, Zhang K, He J, Qu C, Dai M. Medical expenditure for liver cancer in urban China: A 10-year multicenter retrospective survey (2002–2011).J Can Res Ther 2018;14:163-170

How to cite this URL:
Qiu WQ, Shi JF, Guo LW, Mao AY, Huang HY, Hu GY, Dong P, Bai FZ, Yan XL, Liao XZ, Liu GX, Bai YN, Ren JS, Sun XJ, Zhu XY, Zhou JY, Gong JY, Zhu L, Mai L, Du LB, Zhou Q, Xing XJ, Song BB, Liu YQ, Lou PA, Sun XH, Wu SL, Cao R, Qi X, Lan L, Ren Y, Zhang K, He J, Qu C, Dai M. Medical expenditure for liver cancer in urban China: A 10-year multicenter retrospective survey (2002–2011). J Can Res Ther [serial online] 2018 [cited 2022 Dec 8 ];14:163-170
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Full Text


In 2010, liver cancer was identified as one of the leading causes of lost disability-adjusted life-years in China and its burden has increased in terms of mortality and disability during the past two decades.[1] The age-standardized 5-year net survival from liver cancer was generally low (10%–20%) in most countries throughout the period of 1995–2009 and in the range of 11.8%–13.3% in China during 2005–2009.[2] Although the prevalence of liver cancer in China is unknown, the overall incidence rate has been estimated at 22.3/100,000 in the Global Cancer 2012 (GLOBOCAN), and half of the estimated new cases and deaths worldwide occurred in China.[3] Moreover, according to the research based on the Chinese Cancer Register, the gaps in morbidity and mortality rates between urban and rural areas, developed and underdeveloped, have become wider in the recent years.[4] The need for prevention strategies is urgent, and implementation of effective measures should be based on evidence from health economic analyses.

The Cancer Screening Program in Urban China (CanSPUC) supported by the National Health and Family Planning Commission of China is a crucial cancer prevention initiative that began in 2012.[5] The CanSPUC is also one of the major projects implemented for China's recent health-care reform and national major public health intervention projects. Cancer screening and early diagnosis are effective measures for cancer prevention and control. Thus, the primary objective of CanSPUC was to explore appropriate operating modes and an implementation approach for high-risk population screening and early diagnosis of major cancers in urban districts of China and promote application of mature screening and early diagnosis technology for common cancer to reduce mortality rate. The lessons learned from the CanSPUC are significant for other similar programs both in China and internationally. During the first phase (2012–2016) of the CanSPUC, the program is being implemented in 13 pilot provinces of China and is expected to cover over 3.5 million urban residents aged between 40 and 69 years (nearly 5% of national urban residents of the same age).

In this study, we focus on liver cancer patients from the pilot provinces and determine the medical expenditure related to these patients from 2002 to 2011. We analyze the change in long-term trends based on the historical medical record data collected from the multicenter retrospective survey conducted by the CanSPUC which provided us a wealth of liver patient information in China for the past decade.

 Materials and Methods

Data source

This study was based on data collected as part of the first phase of the CanSPUC, which included a hospital-based medical expenditure survey. The survey comprised individual case-based medical care cost records from liver cancer patients in the pilot hospitals. Data included demographic, diagnostic information and detailed expenditure information relating to different types of service including registration, ward bed, diagnosis, examination, treatment, surgery, laboratory, nursing, and drugs.

Sample selection

Phase 1 of the CanSPUC covers the 5 consecutive years up to 2016 and has already been completed for the 2012–2014 period in 37 hospitals of 22 cities in the 13 pilot provinces in China. The provinces and their cities include Beijing, Guangdong (Dongguan, Foshan, Guangzhou, Shenzhen, and Zhongshan), Shandong (Jinan), Jiangsu (Nantong and Xuzhou), Liaoning (Shenyang and Tieling), Zhejiang (Hangzhou and Ningbo), Hebei (Tangshan), Henan (Zhengzhou), Heilongjiang (Harbin and Daqing), Hunan (Changsha), Xinjiang (Urumchi), Gansu (Lanzhou and Jinchang), and Chongqing. The first seven provinces are situated in the east region of China, the next three are situated in the central region, and the last three are situated in the western region. A summary of the survey sites and hospitals in the 13 provinces including population size and gross domestic product per capita is provided in [Table 1]. We defined liver cancer by anatomical site and coded topography C22 from the International Classification of Diseases for Oncology (3rd edition; ICD-O-3).{Table 1}

Patients were included in the survey if they met the following criteria: (a) diagnosed as liver cancer (for patients with advanced and metastatic pancreatic cancer, this study focused on the primary cancer), (b) patient's main medical costs were occurred in the pilot hospital, (c) basic personal information and related medical records and clinical information (clinical diagnosis, treatment, and pathological diagnosis) were available, (d) the last hospital discharge occurred between January 1, 2002, and December 31, 2011.

Patients were excluded if they: (a) had two types of primary cancer, (b) they were just diagnosed or were being followed up in the pilot hospitals without inpatient care, (c) if their basic personal and medical information were unavailable or their clinical information (e.g., clinical diagnosis, treatment, and pathological diagnosis) was incomplete, or (d) their last hospital discharge was after the period of January 1, 2002–December 31, 2011. From September 2012 to December 2014, a total of 12,342 liver cancer patients were enrolled from the pilot provinces using a stratified cluster sampling method. Only patients who gave written informed consent were enrolled. The patients were enrolled from two types of institution: general hospitals and specialized hospitals. The patient records which satisfied the criteria were analyzed for the study.

Quality control

The design of the questionnaire on medical-related expenditure of cancer patients used in the survey was revised and confirmed by the CanSPUC working group which included experts with clinical and economic backgrounds. Unified training for investigators was conducted in Beijing before the field investigation was launched in 37 hospitals of the 22 cities of the 13 pilot provinces. Multilevel quality control measures included self-checks by the investigator following completion of the questionnaire on site and double checks by the quality control officer after the completed questionnaire was returned to the local project office. All the survey data were reviewed and verified by the data management working group of the CanSPUC.

Statistical analysis

EpiData 3.1 (EpiData Association, Odense, Denmark) was used to double input the data and SAS9.3 (SAS Institute, Cary/NC, USA) was used to conduct data quality checks and data analysis. We converted all costs to CNY2011 (exchange rate: 1 US$ =6.3009 CNY; December 31, 2011) based on the National Health Care Consumer Price Index of China and assumed that the average case expense of the liver cancer patient in the year related to all the cases' previous medical expenses due to the cancer. A two-tailed independent sample t-test, variance analysis, and Student–Newman–Keuls Test were used in cost analysis for the corresponding data types. The trend in medical expenses from 2002 to 2011 was analyzed by gender, cancer stage, and geographic area.

Ethics approval

We obtained approval for this part of the CanSPUC from the Ethics and Confidentiality Committee of the National Cancer Center of China. We applied strict security constraints to the transmission of data files. We gave every survey sample city a set of unique numeric codes for the name of every file; these codes have no meaning outside the CanSPUC study. All data fields were numeric or coded.


Case characteristics

A summary of case information by region, hospital type, hospital level, gender, diagnosis age, pathology type, clinical stage, and type of therapy is shown in [Table 2]. Nearly 53.46% of the patients came from the east of China, 72.14% were hospitalized in specialized hospitals, and >90% were hospitalized in 3A level hospitals. Almost 80% of patients were male, 29.57% of patients were aged between 45 and 54 years, and 64.54% of patients were diagnosed with hepatocellular carcinoma (HCC). The largest proportion of patients was diagnosed with distant (Stage III) disease and 39.20% of patients had morphological verification. The most common therapies were chemotherapy (23.28%), palliative care (20.13%), and surgery (18.16%). Comorbidity cases also were much more common among liver cancer patients (48.52%).{Table 2}

Subgroup analysis of medical expenditure

Medical expenditure for liver cancer diagnosis and treatment per case was analyzed by subgroup and the results are provided in [Table 3]. We estimated the average expenditure per case of liver cancer patients to be ¥31,020 (30,525–31,516) from the year 2002 to 2011 and ¥35,248 (34,304–36,193) from the year 2009 to 2011. Statistically significant differences in average expenditure per case were identified for region, hospital type, hospital level, gender, pathological type, and clinical stage. During 2009–2011, the mean medical expenditure was highest in the east region (¥39,858) and lowest in the west region (¥22,814). The medical expenditure was higher in the specialized hospitals (¥32,336) than in general hospitals (¥27,611) during 2009–2011. In terms of gender difference, the expenditure was higher for males than for females. Per case expenditure was ¥41,344 for HCC and ¥35,521 for other pathological types during 2009–2011. The most noteworthy difference in subgroup expenditure analysis was for cases in various clinical stages. During 2002–2009, the cases diagnosed with clinical Stage II had the highest mean medical expenditure (¥30,675) followed by those with Stage IV (¥30,394) and Stage III (¥28,952). Expenditure for Stage I diagnosed cases was the lowest (¥28,790). The situation was different from 2009 to 2011 where the mean medical expenditure for clinical Stage II (¥35,754) still ranked the highest, but Stage III (¥34,288) ranked second, Stage IV (¥30,275) was the third highest, and Stage I (¥29,332) remained the lowest.{Table 3}

Medical expenditure by province

[Figure 1] depicts the medical expenditure for liver cancer diagnosis and treatment per case by province. Between 2002 and 2011, mean expenditure per liver cancer case across the 13 provinces was ¥31,020, with the cost in Beijing, Guangdong, Shandong, Henan, Hunan, and Xinjiang above the average and that of Jiangsu, Zhejiang, Liaoning, Hebei, Heilongjiang, Chongqing, and Gansu below the average. The cost in Beijing was the highest (54,356 CNY, 52,215–56,498 CNY). Over the entire 10-year study period, the expenditure per capita of the east region was statistically significantly higher than that of the west region, and slightly higher than that of the central region. Within the west region, the cost per case (43,870 CNY) in Xinjiang was statistically significantly higher than in the other two provinces included.{Figure 1}

Trends of medical expenditure from 2002 to 2011

The trends in medical expenditure per case and other related factors for liver cancer diagnosis and treatment during 2002–2011 are depicted in [Figure 2]. There were significant increases in overall average expenditure and the number of clinical visits. [Figure 2]a shows that the overall average medical expenditure per case for liver cancer diagnosis and treatment in China increased from ¥21,950 to ¥40,386 across the study period. The average growth in expenditure across the study period was 6.29%. The rate of increase was 4.85% during 2002–2009, increasing to 8% during 2009–2011. The number of clinical visits per case increased from 1.41 to 3.23 during the study period. The number of visits declined slightly during 2008–2009, increasing again since 2010. It is worth noting that the growth (1.92 times per case to 3.23 times per case) was most obvious from 2010 to 2011 [Figure 2]b. The expenditure per clinical visit (¥15,459–¥17,888) was relatively stable during these 10 years with an average growth rate of −0.91%. On an average, the length of stay per case for the study period was almost 1 month. The minimum was 25 days, and the maximum was 33 days [Figure 2]d. Daily average expenditure per case was increased from ¥1059 to ¥1446 during 2002–2011. This figure increased most obviously in 2006 and 2008 when the daily average expenditure was ¥1480 and ¥1528, respectively. The average growth rate was 3.17% across the entire study period and 5.38% during 2002–2008 and 2.93% during 2009–2011 [Figure 2]e.{Figure 2}

Time trends for medical expenditure for liver cancer diagnosis and treatment per case are depicted by subgroup in [Figure 3]. There are no obvious differences in the three regions of China during 2002–2006. However, medical expenditure in the western regions decreased every year from 2006 and was significantly lower than that in the other two regions. The gap reached its maximum in 2011 [Figure 3]a. Medical expenditure per case was higher in specialized hospitals than in general hospitals, and in 3A hospitals compared with lower level hospitals. The gap in per case expenditure between specialized and general hospitals narrowed gradually from 2008 and was down to ¥947 in 2010 [Figure 3]b. However, the gap between 3A hospitals and 3A less hospitals widened during 2009–2011 [Figure 3]c. As expected, the higher the number of clinical visits, the higher the medical expenditure per case. Medical expenditure per case for four or more clinical visits fluctuated significantly [Figure 3]f.{Figure 3}

The general trend in per case medical expenditure showed an increase for all age groups with no obvious differences across the four groups [Figure 3]e. Medical expenditure per case for HCC was significantly more than for other pathological types across the study period, and the gap between these two types was most obvious in 2004–2006 and 2010 [Figure 3]g. The trends in expenditure per case were similar for clinical Stage II and III cases, while expenditure per case for clinical Stages I and IV fluctuated significantly [Figure 3]h. Obviously, medical expenditure per case of surgery and chemotherapy was the highest in all therapy types, while palliative care was the lowest. There were no obvious differences in expenditure between radiotherapy and chemotherapy during 2002–2006. Except for radiotherapy, expenditure for the four other therapy types showed an increasing trend. Expenditure in radiotherapy fluctuated significantly. The expenditures increased from ¥20,219 in 2002 to ¥34,796 in 2006, decreased to ¥16,540 in 2007, and then increased to ¥20,540 in 2011 [Figure 3]i. The trends of medical expenditure for males and females per case were similar, but expenditure for males was higher than for females in the decade [Figure 3]d.

Breakdown of medical expenditure

[Figure 4] displays the proportional breakdown of medical expenditure across the 13 pilot provinces from 2002 to 2011. It focuses on the proportional breakdown of total medical expenditure overall and shows that the highest portion of expenditure was for drugs, accounting for 48.01% in 2002 and increasing to 52.96% in 2006. However, the proportional contribution of drugs declines after 2006. On the whole, it also appears that the proportion of spending on treatment and laboratory tests increased over the study period and the proportion of spending on surgery substantially decreased from 16.68% in 2002 to 7.04% in 2011. The shares of spending on inspection stayed around 5% across 2002–2011, as well as that of the bed fee at around 3%. The proportion of diagnosis expenditure first rose from 1.83% in 2002 to 3.39% in 2005, and then fell to 0.61% in 2006. The situation was similar for the nursing fee, which first rose from 0.66% in 2002 to 1.19% in 2003, and fell later to approximately 0.6%.{Figure 4}


As a major cancer in China, liver cancer contributes a large portion to the health economic burden. According to the Chinese Cancer Registry Annual Report 2012, the incident rate of liver cancer was 25.84/10,000 and ranked as the fifth severe cancer in 2008. The Global Burden of Diseases, Injuries, and Risk Factors Study, 2013, indicated that liver cancer ranked as the sixth highest leading cause of years of life lost (YLLs) in China. Based on the large population and high incidence rate, China has the most liver cancer patients in the world, which entails a heavy burden both in terms of people's health and social wealth. Our result shows that HCC is the predominant histologic subtype of liver cancer in adults, comprising approximately 65% of all cases in this study. The average aggregate expenditure per case of HCC in the recent years is significantly greater than other pathological types of liver cancer in China. The results are in line with the burden of illness associated with HCC in the United States.[6]

Expensive medical cost is a heavy economic burden for most Chinese families. The average medical expenditure for liver cancer is ¥35,248 per case in 2012 and there was 1.5 times gap between the eastern (developed region) and western (less developed region) regions. This study parallels previous systematic review and original articles on the economic burden of liver burden in mainland China.[7],[8],[9],[10],[11] According to the China Statistical Yearbook, an average urban resident's disposable income was around ¥121,986 in 2012.[12] Besides direct nonmedical costs, the medical expenditure per clinical visit for liver cancer was almost equivalent to the disposable income of an urban resident for 1 year. For comparison, in Taiwan, the 10-year average cost of patients with liver cancer was NT$418,554.00 (¥82,706.27) (Lang et al. 2008).[13] Although we cannot obtain the whole expenditure data with our study, it can be still speculated that, by taking into account other potential costs such as repeated admissions, indirect medical cost, and loss of labor, the total expenditure for liver cancer patients will bring a heavy economic burden to their families, even though part of the expenditure could be reimbursed by insurance. Moreover, for low-income families, who are usually people without formal jobs and with lower medical insurance, their liver cancer economic burden would be heavier and probably will lead to the poverty-caused-by-disease problem.

Early-stage medical costs are the lowest costs, which indicate the importance of liver cancer screening. We found that the most costly cases classified by clinical stage were Stage II patients followed by Stage III patients during 2009–2011 but the values were similar. The cost per case was similar for Stage I and IV patients with relatively low expenditure per case. This is congruent with the actual clinical practice in China where patients with late-stage cancer usually have limited pharmacologic treatment options. Moreover, this also indicates that liver cancer screening programs that may help the diagnosis and treatment for liver cancer in the early stages will save both medical expenditure and healthy life years.

The changing trends of components of medical expenditure for liver cancer cases reflect the influence of health-care pricing and reform policies in China. According to the traditional health-care pricing mechanism, the labor and service pricing were much lower than the actual cost and the government allowed hospitals to charge an additional 15% higher drug price to compensate for it.[14] Under the incentive of the distorted price system, health-care providers induce patients to demand “big prescriptions” and “more inspections,” which result in an imbalance in the structure of medical expenditure. A growing concern of government and society about high medical costs led to a new health-care reform scheme issued in 2009. Various regions have promoted projects of payment system reforms and have started adjusting the price of medical services since then. Our result shows that, for liver cancer medical costs, the proportion of drug costs has been reduced gradually, and the proportion of treatment and laboratory test costs rose at the same time. However, the proportion of inspection and nursing cost remained almost at the same level from 2006, which means the labor and service price still does not properly reflect the value of labor and capital value of medical personnel.

To get a comprehensive picture about the cost burden of liver cancer in China, we need a whole-course expenditure measure, which means the sum of all health-care costs from a patient's first diagnosis to his/her end point (cure or death), that is, lifetime expenditure. The result of expenditure per case in our research was trying to provide such a figure. However, this study, based on an expert review of cases, although it collected several types of health-care costs for each patient, still cannot determine their whole liver cancer course cost. To reverse this problem, further research should be carried out. Based on the present data content and accessibility, we need to develop a standardized course structure for liver cancer inpatient treatment in China and include each type of health-care cost for one inpatient visit to get the standardized whole-course expenditure.


This is the first country-level liver cancer medical expenditure cross-time study in China. Despite the limitation in whole-course medical burden measure per case, this study has provided a comprehensive illustration of liver cancer inpatient medical expenditure across regions and time. The economic burden of liver cancer is a serious problem in China and related medical expenditure is increasing. This result may provide data-based evidence to urge the Chinese government adjust the relevant disease prevention and control strategy.


We know that cancer patients would always seek medical service in more than one hospital during their entire process from diagnosis to therapy and to the end point, death, particularly under the restriction of health insurance system. Moreover, expenses of the first and the last visits would be very likely to be the highest. However, the data outside the range of studied hospitals in this report were unavailable, and this would potentially lead to significant selection bias in case-based indicator estimation.

Financial support and sponsorship

National Key Public Health Program of China (Cancer Screening Program in Urban China); National Natural Science Foundation of China (81402740, 81773521); State Key Projects Specialized on Infectious Diseases (2017ZX10201201-008-002).

Conflicts of interest

There are no conflicts of interest.


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