The economics of managing tuberculosis in cancer patients in an oncology center in eastern India Zoe Bennett 1 , Raja Dhar MD, MRCP, FCCP, MSc 2 , Kingshuk Dhar MD 3 , Krishnendu Das BSc, DMLT 3 , Anusha Harishankar MS 3 , Sanjay Bhattacharya MD, DNB, DipRCPath, FRCPath 3 and Mammen Chandy MD, FRACP, FRCPA, FRCP 4 1 London School of Economics, London, United Kingdom, 2 Department of Pulmonology, Tata Medical Center, Kolkata, India, 3 Department of Microbiology, Tata Medical Center, Kolkata, India and 4 Department of Clinical Hematology, Tata Medical Center, Kolkata, India To the Editor—Cancer increases the chance of tuberculosis because of decreased immunity from disease and treatment (eg, chemotherapy). An intermediate tuberculosis (TB) prevalence country (South Korea) reported a cancer-specific standardized incidence ratio (SIR) for TB of 2.22 among all cancer patients, with the highest rate observed in those with hematologic malignancies (SIR, 6.67) and lowest in those with biliary tract cancers (SIR, 1.34). 1 Understanding the problem of TB in the context of cancer is important because (1) cancer may develop in the background of a previous TB infection; (2) TB may exist concurrently with malignancy in the same patient or clinical specimen; and (3) many diagnostic challenges arise from the multifaceted presentations of these 2 dis- orders. 2 Furthermore, TB leads to direct costs for diagnosis, treatment, and admission, as well as indirect costs from loss of productivity and other societal costs. It has been estimated that 42% of the households with TB patients incurred catastrophic health expenditures from hospitalization due to TB in India compared to 79% for households with cancer patients in 2014. In addition, the likelihood of incurring financial distress was 3.2 times higher for those hospitalized for cancer and 2.6 times for TB patients. 3 This retrospective study was undertaken in a cancer hospital in eastern India between June 2011 and May 2016 among all patients with culture-confirmed tuberculosis to evaluate the direct healthcare costs attributable to TB in cancer patients. The period chosen to calculate costs spanned from 90 days prior to the TB diagnosis to 1 year after the diagnosis to limit the research primarily to the costs surrounding TB, rather than the costs incurred due to cancer. In total, we identified 118 patients with culture-confirmed TB during the study period of 60 months (~2 patients per month). The median age of the TB patients was 48.2 years (range, 6.3–82.1 years); 63 were women (53%) and 55 were men (47%). Of 118 patients, 45 (38%) had a hospital admission during the stipulated follow-up duration for either investigation or treatment. The number of deaths within this period was 4 (3.4%), with 3 deaths occurring in the first 30 days, no deaths in the 90-day period, and 1 death within 1 year of TB confirmation. The mean duration of follow-up of the patients after TB culture positivity was 204 days (6.8 months). The average cost per patient was Indian rupees (Rs.) 19,295 (US$266; 46.1%) for investigation, Rs. 18,686 (US$258; 44.7%) for admission cost, and Rs. 3,864 (US$53; 9.2%) for consultation fees. The investigation costs were divided into 2 categories: radiology (Rs. 10,383, US$143) and laboratory tests (Rs. 8,912, US$123). The laboratory costs were divided into 3 subcategories: hemato- pathology laboratory (Rs. 2,397, US$33), biochemistry (Rs. 3,613, US$50), and mycobacteriology (Rs. 2,902, US$40). When all costs were considered, the total average cost for 1 patient within the 15-month period was Rs. 41,846 (US$577 without anti-TB drugs and $636 with anti-TB drugs) (Tables 1 and 2 and Supplementary Fig. 1). Tuberculosis treatment drains healthcare and social resources. From the provider perspective, the mean drug-sensitive–TB treatment cost per patient varies among countries depending on the state of the economy, from US$14,659 in high-income countries to US$258 in low-income countries. The costs for treat- ing multidrug-resistant (MDR)-TB ranges from US$83,365 in high-income countries to US$1218 in low-income countries. Productivity losses (calculated based on time lost due to seeking treatment and being ill; and taking into account country income) from TB have been estimated to be 16% in high-income countries and 38% in low-income countries. 4 A study from rural India reported that the mean direct cost per patient due to TB was US Table 1. Details of Cost Analysis in Treatment of Tuberculosis Cost Type of Tuberculosis Rs. USD Pulmonary TB Intensive phase 1,140 15.72 Continuation phase 1,020 14.07 Total (includes vitamin B6) 2,448 33.76 Extra-pulmonary TB Intensive phase 1,140 15.72 Continuation phase 2,550 35.17 Total (includes vitamin B6) 4,266 58.83 MDR-TB 5 drugs, 6 mo 75,060 1,035.11 4 drugs, 12–18 mo 108,360–162,540 1,494.34–2,241.51 Total 183,420–237,600 2,529.45–3,276.62 Note. Rs., Indian rupees; TB, tuberculosis; MDR, multidrug-resistant. Cite this article: Bennett Z, et al. (2019) The economics of managing tuberculosis in cancer patients in an oncology center in eastern India. Infection Control & Hospital Epidemiology 2019, 40, 122–124. doi: 10.1017/ice.2018.284 Author for correspondence: Dr Sanjay Bhattacharya, Tata Medical Center, 14 Major Arterial Road (E-W), New Town, Kolkata 700 160, India. E-mail: drsanjay1970@hotmail. com © 2018 by The Society for Healthcare Epidemiology of America. All rights reserved. 122 Zoe Bennett et al