Selected Publications

M.-W. Lwin, O. Schoffer, C. Streissnig, P. Wimberger, M. Gerken, V. Bierbaum, C. Bobeth, M. Roessler, P. Droege, TZ. Ruhnke, C. Guenster, K. Kleihues-van Tol, T. Link, A. Scharf, E.C. Sturm-Inwald, K. Kast, T. Papathemelis, O. Ortmann, M. Klinkhammer-Schalke, J. Schmitt, M. Schlander:

A Cost-Effectiveness Analysis of Breast Cancer Treatment in Certified vs Non-Certified Hospitals in Germany.

International Journal of Cancer (2026). DOI: 10.1002/ijc.70388.

Breast cancer (BC) is the most frequently diagnosed malignancy and the leading cause of cancer-related mortality in women. In Germany, the German Cancer Society (Deutsche Krebsgesellschaft) accredits cancer centers to ensure high-quality BC treatment through adherence to clinical guidelines, quality standards and a multidisciplinary approach. Evidence suggests that certified cancer centers (CCs) achieve better clinical outcomes compared to non-certified centers (NCCs). However, the additional services required for certification incur substantial costs, potentially reaching millions of euros annually, necessitating a rigorous cost-effectiveness analysis (CEA). The evaluation revealed that BC care in CCs, despite higher costs across all categories, was associated with an incremental cost effectiveness ratio (ICER) of approximately €15,000 per life year gained. Thus it can be concluded that BC treatment at CCs compared to care provided at NCCs is highly cost effective using conventional criteria.

M. Schlander:

Financing Health Care: Structural Challenges.

Zeitschrift für medizinische Ethik (ZfmE), 72 (2026): 20-46.

The German health care system has grown into a size and level of complexity that impair its transparency and efficiency, combined with high costs and mediocre overall outcomes. At the same time, it relies on economic foundations that are threatened by the poor development of the overall economy. Without economic growth, however, German health care policy-makers will face difficult rationing decisions in the foreseeable future. As part of a necessary reform agenda, a realignment of the dual system of statutory and private health insurance towards a complementary system consisting of mandatory basic insurance and voluntarily insured supplementary benefits should be considered.

J.N.A. Tetteh, M. Schlander:

Exploring the Sensitivity of Utilities Predicted by the EQ-5D, SF-6D, HUI3, 15D, AQoL4D and AQoL8D Multiattribute Utility Instruments to SF-36 Dimensions.

PharmacoEconomics (2026). DOI: 10.1007/s41669-026-00645-y.

Multi-Attribute Utility Instruments (MAUIs) are commonly used in health economics to measure health-related quality of life (HRQoL), yet their sensitivity to different health domains varies. The sensitivity of six widely used MAUIs – the EQ-5D, SF-6D, HUI3, 15D, AQoL-4D, and the AQoL-8D – was assessed against the eight dimensions of the standard instrument to measure HRQoL profiles, the SF-36 survey. The SF-6D and 15D were particularly sensitive to social and role-oriented domains, while EQ-5D and HUI3 demonstrated greater sensitivity to physical health dimensions, especially bodily pain and physical functioning. AQoL-4D and AQoL-8D showed strong sensitivity to mental health. In conclusion, the choice of MAUI significantly impacts observed HRQoL outcomes and resulting utility scores depending on the health domains most relevant to the intervention. This study underscores the need for predictive analysis to inform measurement instrument selection in alignment with specific health contexts.

J. Ubels, J. Vancoppenolle, J. Tetteh, W.H. van Harten, V. Retèl, M. Schlander, N. Franzen:

Towards a validated European instrument to measure the socioeconomic impact of cancer.

International Journal of Cancer (2026). DOI: 10.1002/ijc.70364.

Cancer can impose a substantial financial burden on patients and their families, defined as socio-economic impact (SEI) within the framework of the Organization of European Cancer Institutes (OECI; Schlander et al., 2024). The Socio-Economic Consequences of Cancer (SEC) study (Vancoppenolle et al., 2025) assessed the SEI in 25 European countries using the Canadian Financial Index of Toxicity (FIT) instrument, showing substantial variation – confirming the need for a validated European instrument.
The present analysis is the first study to assess the cross-country validity of the Financial Index of Toxicity (FIT) in Europe using patient-level data from six countries. It reveals limitations in the original model's replicability and establishes the OECI Task Force’s Socioeconomic Impact framework (Schlander et al., 2024) as a useful complementary structure to improve cross-context validity. The findings advance efforts to develop a pan-European tool for measuring the socioeconomic impact of cancer, supporting future policy and patient-centered care improvements.

M.T. Muchadeyi, S. Hao, K. Hernandez-Villafuerte, S.A. Khan, N. Becker, A. Krilaviciute, P. Seibold, R. Gulati, P. Albers, M. Schlander, M. Clements:

Cost effectiveness analysis of prostate cancer screening strategies in Germany: A microsimulation study.

International Jornal of Cancer (2025), 157(8): 1662-1679. Doi: 10.1002/ijc.35513.

Prostate cancer (PCa) represents a significant public health challenge in Germany, with increasing incidence and economic impact. This study assessed the cost-effectiveness of 10 screening strategies: prostate-specific antigen-based risk-adaptive screening (PSA-RAS), with or without magnetic resonance imaging (MRI), in men starting at age 45 or 50 and stopping at 60 or 70, digital rectal examination (DRE) for ages 45-75 years, and no screening. Using a well calibrated microsimulation model (Swedish Prostata) from a statutory health insurance perspective, lifetime outcomes were evaluated, including cancer incidence, mortality, overdiagnosis, biopsies, life-years, and quality-adjusted life-years (QALYs) discounted annually at 3%. Cost and utility inputs were derived from the German diagnostic-related group schedule, fee-for-service catalogues, literature, and expert opinion. DRE-only was the least cost-effective, yielding high biopsy and overdiagnosis rates with minimal QALY gains. PSA-RAS reduced overdiagnosis and biopsy rates, with PSA-RAS (50-60 years) without MRI emerging as the most cost-efficient strategy, saving approximately €1.2 million per 100,000 men compared with no screening. Extending the PSA-RAS to 70 years improved its effectiveness in terms of QALYs. PSA-RAS (50-70) with MRI could become cost-effective at an increasing willingness to pay threshold or decreasing MRI cost. This study suggests the potential of PSA-RAS to improve PCa screening in Germany. Incorporating MRI, reducing MRI cost within the screening setting, and extending screening to 70 to align with EU recommendations could improve the cost-effectiveness of PSA-RAS with MRI. Future research should explore the integration of MRI with ancillary tests, such as 4K-score or risk calculators, to reduce MRI use and associated costs.

S. Holm, M. Schlander:

Population health impact of NICE-recommended new drugs.

Lancet (2025), 405(10497): 2276.

M. Schlander:

Krebs als Armutsrisiko.

Im Fokus Onkologie (2025), 28: 1.

[Editorial]

J. Vancoppenolle , N. Franzen, L. Azarang, T. Juslin, M. Krini, T. Lubbers, J. Mattson, D. Mayeur, R. Menezes, J. Schmitt, F. Scotte, O. Seoane López, T. Skaali, J. Ubels, M. Schlander, V. Retel, W. H. van Harten, on behalf of OECI Working Group Health Economics:

Financial toxicity and socioeconomic impact of cancer in Europe.

ESMO Open (2025), 10(6), 105293.

Background: Even with universal health care, patients living with cancer often face substantial treatment-related costs and income loss in Europe. Insights into the socioeconomic impact of cancer within and across countries are needed to create awareness, inform policy, and develop targeted measurement instruments. The SEC study aims to explore the socioeconomic impact and financial toxicity of cancer and identify vulnerable patient groups across Europe.
Patients and methods: To investigate experiences of a large number of patients, data were collected in a collaborative effort of hospitals and patient organizations across Europe through convenience sampling. Patients undergoing treatment currently or treated within the past 2 years could participate. A 44-item survey was developed to measure the socioeconomic impact following a cancer diagnosis. The primary outcome was the level of financial toxicity, measured by the Financial Index of Toxicity (FIT) score. To identify vulnerable groups, multiple regression analyses were used to investigate the association between the FIT score, clinical characteristics, and socioeconomic demographics, including cancer type, employment status, and country of residence.
Results: A total of 2507 patients across Europe met the inclusion criteria. Fifty-six percent of the patients reported income loss and 86% additional treatment-related expenses. Sixteen percent of patients delayed or avoided medical visits, buying medication, surgery, or other health services. Next to a significant association of the country of residence, our regression models demonstrated that divorced, self-employed patients who were younger (—0.02; P = 0.000) and lower educated (0.75; P = 0.000) with a lower household income (1.21; P = 0.000) and children (0.21; P = 0.000) at the time of diagnosis reported significantly higher FIT scores compared with older patients who were married (—0.56; P = 0.000), retired (—1.55; P = 0.000), or employed (—0.56; P = 0.000).
Conclusions: In every European Union country, a substantial number of patients with cancer report serious financial consequences and stress. Further research is critical to inform well-tailored policies and interventions to limit the socioeconomic impact on patients with cancer.

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), Doi: 10.1007/s41669-025-00568-0.

Background:  A number of instruments have been developed to measure the socioeconomic impact (SEI) of cancer. A standardized comparison of the quality and content validity of these instruments is lacking. This study aimed to (1) conduct a standardized assessment of the quality of SEI instruments and (2) assess the content validity of these instruments using the conceptual framework developed by the Organization of European Cancer Institutes (OECI) for SEI analysis.
Method:  We identified articles measuring the SEI of cancer with ad hoc and/or validated instruments from an existing database. These articles were the initial pearls in a systematic review of published articles that applied and validated these instruments using the pearl-growing search strategy in PubMed, Web of Science, and Google Scholar databases. The Evaluating the Measurement of Patient-Reported Outcomes (EMPRO) tool was utilized to provide quantitative assessment and comparison of the quality of identified instruments. To examine content validity, we allocated each instrument's items against the themes and sub-themes of the established conceptual framework for SEI analysis.
Results:  We identified and investigated 21 validation studies using nine original instruments. The number of articles varied significantly among the identified instruments. The COmprehensive Score for financial Toxicity (COST) instrument was the most frequently used, validated in ten different settings, whereas some newer instruments have not been applied yet. This variation resulted in significant differences in EMPRO overall scores among these instruments. Regarding content validity, we found that not all themes of the OECI framework were covered by the content of the instruments.
Conclusion:  The quality and the application of instruments measuring the SEI of cancer varied significantly. The content of the instruments seems not to cover all related themes of the applied OECI framework in this study. Further studies are warranted to confirm the quality and content validity of the instruments measuring the SEI of cancer.

D. Doege, J. Frick, R. 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.

Treatment modifications and contact restrictions were common during the COVID-19 pandemic and can be stressors for mental health. There is a lack of studies assessing pandemic-related risk factors for anxiety and depression of cancer patients and survivors systematically in multifactorial models. A total of 2391 participants, mean age 65.5 years, ≤5 years post-diagnosis of either lung, prostate, breast, colorectal cancer, or leukemia/lymphoma, were recruited in 2021 via the Baden-Württemberg Cancer Registry, Germany. Sociodemographic information, pandemic-related treatment modifications, contact restrictions, and anxiety/depression (Hospital Anxiety and Depression Scale, HADS) were assessed via self-administered questionnaire. Clinical information (diagnosis, stage, and treatment information) was obtained from the cancer registry. Overall, 22% of participants reported oncological care modifications due to COVID-19, mostly in follow-up care and rehabilitation. Modifications of active cancer treatment were reported by 5.8%. Among those, 50.5% had subclinical anxiety and 55.4% subclinical depression (vs. 37.4% and 45.4%, respectively, for unchanged active treatment). Age <60 years, female sex, lung cancer, low income, and contact restrictions to peer support groups or physicians were identified as independent risk factors for anxiety. Risk factors for depression were lung cancer (both sexes), leukemia/lymphoma (females), recurrence or palliative treatment, living alone, low income, and contact restrictions to relatives, physicians, or caregivers. The study demonstrates that changes in active cancer treatment and contact restrictions are associated with impaired mental well-being. The psychological consequences of treatment changes and the importance for cancer patients to maintain regular contact with their physicians should be considered in future responses to threats to public health.