Research

Michael Schlander conducted much of his research on cancer economics with his team at the German Cancer Research Center (Deutsches Krebsforschungszentrum, DKFZ) from 2017 through 2025, where he established and led the former Division of Health Economics.

Michael Schlander initiated a series of reports, which appeared from 2018 to 2023 in the German-language periodical “Forum”, the official journal of the German Cancer Society (Deutsche Krebsgesellschaft, DKG). The reviews summarized the available evidence on the epidemiology, burden of disease, and costs of cancer in Germany. The series was enhanced by two introductory papers explicating health economic principles of cost measurement. An additional study reviewed the economic burden of pancreatic cancer in the broader European context.

Selected Publications:

1. Hernandez, D., et al.: Krankheitslast von Brustkrebs in Deutschland: Epidemiologie und Kosten. Forum (2023), DOI: 10.1007/s12312-023-01216-6
2. Hernandez, D., et al.: Krankheitslast von Lungenkrebs in Deutschland: Epidemiologie und Kosten. Forum (2022), DOI: 10.1007/s12312-022-01123-2
3. Hernandez, D., et al.: Krankheitslast von Prostatakrebs in Deutschland: Epidemiologie und Kosten. Forum (2022), Ausgabe 3/2022
4. Hernandez, D., et al.: Messung der Kosten von Krebserkrankungen in Deutschland. Teil 2 - Wirtschaftliche Belastung [Determining the cost of cancer in Germany. Part 2 - economic burden]. Forum 37, 42–48 (2022). DOI: 10.1007/s12312-021-01026-8
5. Hernandez, D., et al.: Messung der Kosten von Krebserkrankungen in Deutschland. Teil 1 - Epidemiologie und Krankheitslast [Determining the cost of cancer in Germany. Part 1 - epidemiology and disease burden]. Forum 36, 406–410 (2021). DOI: 10.1007/s12312-021-00988-z
6. Schlander, M., et al.: Kosten der Onkologie in Deutschland [The cost of cancer in Germany]. Forum (2018). https://doi.org/10.1007/s12312-018-0481-5

Exploring the economics of lung cancer

There is limited information on the real-world health care utilization and the associated costs of lung cancer in Germany. To address this gap, Michael Schlander and his team analyzed health care utilization and cost estimates related to lung cancer treatments using administrative claims data from one of the largest health insurance companies in Germany.

In the initial study, Michael Schlander and his team outlined the methodology for identifying lung cancer patients within the dataset and estimated lung cancer incidence in Germany, considering various patient characteristics. In addition, lung cancer survival rates in relation to comorbidities were examined.

Building on this, two additional studies were conducted. The first focused on measuring  medication costs and identifying prescription patters among lung cancer patients. The second estimated inpatient costs attributable to lung cancer and examined impatient treatment patterns across Germany.

Preliminary results indicated that inpatient costs attributable to lung cancer averaged around €25,000 per patient, with costs approximating €18,000 per year of survival. Significant cost variations were identified based on age and place of residence, while sex and comorbidities appeared to have minimal impact. The average length of stay declined considerably over the 12-year analysis period.

Outpatient prescription costs are estimated at approximately €12,000 per patient, with the lowest costs observed during the initial phase of treatment and the highest during the terminal phase. Additionally, outpatient prescription costs per patient showed a marked increase over the study period.

Cost of cancer drug development

The high cost of research and development (R&D) of new cancer drugs is often cited as a key factor behind rising drug prices, though this remains a topic of ongoing debate. These costs also raise questions about the long-term sustainability of the the business model of R&D-driven biopharmaceutical industry.

In a comprehensive review, conducted jointly with Jorge Mestre-Ferrandiz (Madrid), Chih-Yuan Cheng and Karla Hernandez-Vilalfuerte (both Heidelberg), Michael Schlander analyzed the peer-reviewed literature on the costs associated with bringing a new molecular entity (NME) to market, focusing on factors contributing to the wide variation in published estimates. Reported total average capitalized pre-launch R&D costs ranged from $161 million to $4.54 billion (2019 US dollars), with therapeutic area-specific estimates highest for anticancer drugs, falling between $944 million and $5.4 billion.

The analysis confirmed a consistent trend of rising R&D costs per NME over time. To enhance the rigor and comparability of future studies, a suitability scoring system was developed aimed at improving the validity of research in this field.

Cost of CAR-T cell treatments

Immunotherapies, such as chimeric antigen receptor (CAR) T-cell therapy, represent a promising treatment option for some blood cancers, offering the potential for long-term remission or cure. In August 2018, the European Commission approved the use of two gene therapies for oncology indications, marking a significant milestone in cancer treatment.

Michael Schlander and his team assessed the costs associated with CAR-T cell therapy, including production, patient participation, treatment admission, and toxicity management. Their analysis utilized both micro-costing and gross-costing methods to provide a comprehensive view of the financial implications.

For the first time, results demonstrated that CAR T-cell production in not-for-profit environments, such as the Heidelberg University hospital, can be a less costly and therefore more cost-effective and efficient alternative compared to the current commercial centralized production model. The researchers anticipate further cost reductions in decentralized production as standardization increases, driven by economies of scale and scope, process improvements, and learning curve effects. Such a trend would appear consistent with the early life cycle stage of this innovative technology.

Selected Publications:

1. Hernandez, D., et al.: Survival and comorbidities in lung cancer patients: evidence from administrative claims data in Germany. Oncology Research (2022); 30(4): 173-185
2. Hernandez, D., et al.: Economic burden of pancreatic cancer in Europe: a literature review. Journal of Gastrointestinal Cancer (2022); DOI: 10.1007/s12029-022-00821-3
3. Schlander, M., et al.: How Much Does It Cost to Research and Develop a New Drug? A Systematic Review and Assessment. PharmacoEconomics (2021), 39 (11): 1243-1269
4. Hernandez, D, Schlander, M.: Income loss after a cancer diagnosis in Germany: An analysis based on the socio-economic panel survey. Cancer Medicine (2021), 10(11): 3726–3740
5. Ran, T., et al.: Cost of decentralized CAR T-cell production in an academic nonprofit setting. International Journal of Cancer (2020), 147(12): 3438-3445

Much research in this field has been done in the context of an OECI Task Force, which Michael Schlander inaugurated in March 2021.

More detailed information can be found on the Socioeconomic Impact Research webpage.

Certification of hospitals providing health care for cancer patients has become an important measure to improve quality and outcomes. However, considering the significant additional costs incurred by hopsitals (and ultimately by social insurance and taxpayers) from certification, the cost effectiveness of cancer care provided in certified hospitals was yet to be established.

In cooperation with the team and network of Professor Jochen Schmitt in Dresden, Michael Schlander and his team in Heidelberg, notably Chih-Yuan Cheng and Min Wai Lwin in their role as PhD students, used administrative data to derive information on the efficiency of cancer care delivered in certified cancer centers (CCs) compared to non-certified hospitals (NCHs).

For the first cost effectiveness analysis, colorectal cancer was selected. The study demonstrated longer survival and lower costs for the colon cancer cohort treated in CCs. The surprisingly positive result was supported consistently by a comprehensive set of sensitivity analyses.

Since it was not clear whether these initial health economic findings – which were extremely encouraging for the case in favor of specialized care - can be generalized, a second study was initiated to evaluate the cost effectiveness of breast cancer treatment, again comparing certified cancer centers (CCs) with noncertified hospitals (NCHs). The analysis of certification-related costs and survival outcomes demonstrated that high-quality multidisciplinary care at certified hospitals delivers substantial clinical benefit at a very reasonable incremental cost. These findings provide for the nfirst time robust economic justification for hospital certification programs and offer important insights for health care policy-makers.

While the first analysis was published by Chih-Yuan Cheng and co-authors in 2021, the second study by Min Wai Lwin et al. has been accepted by the International Journal of Cancer and is due to appear in early 2026.

Colorectal cancer (CRC) screening and prevention

In light of the strategic repositioning of the German Cancer Research Center after appointment of a new scientific director, Michael Schlander initiated research into the cost effectiveness of screening and prevention strategies for colorectal, breast, and prostate cancer.

(a) Colorectal Cancer (CRC)

Existing CRC screening models mostly focus on the adenoma pathway of cancer development, thus overlooking the serrated neoplasia pathway, which might result in overly optimistic screening predictions. Michael Schlander’s team in Heidelberg developed a CRC screening model accounting for both pathways, calibrated it with approximate Bayesian computation (ABC) methods, and validated it with large CRC screening trials. The discrete event simulation (DES) model, DECAS (Discrete Event simulation model for the natural history of colorectal cancer from the Adenoma and Serrated neoplasia pathways), has been used as a tool to evaluate the (cost) effectiveness of CRC screening strategies.

An important advancement was the extension by Lwin et al. (2024), which assessed the cost effectiveness of initiating CRC screening at age 45 in Germany. Using the DECAS model, this study compared four screening strategies starting at age 45 with the currently national screening program beginning at age 50. The results demonstrated that initiating screening earlier, particularly with colonoscopy alone or combined with fecal immunochemical tests (FIT), could yield substantial gains in quality-adjusted life years (QALYs) with modest increases in costs. This evidence supports a shift in screening policy to address the rising incidence of early onset colorectal cancer in Germany.

(b) Breast and prostate cancer

While the study by Lwin et al. (2024) represents a significant contribution to the cost effectiveness research in CRC screening, evaluations of breast and prostate cancer screening also yielded valuable insights.

For breast cancer, the use of mammography is widely believed to provide more benefits than harms for the general population, leading to the biennial mammography recommendation for women aged 50 to 69 in Germany. However, this approach may not suit women with varying risk profiles. To address this, the “Wisconsin Model” for evaluating risk-adjusted screening strategies was adapted and used for analyses in the local German context.

For prostate cancer, a Swedish prostate cancer model was adapted and re-calibrated for the German context, in order to evaluate personalized prevention strategies using data from the PROBASE Trial. From the perspective of the German Statutory Health Insurance (SHI), lifetime outcomes were evaluated, including cancer incidence, mortality, overdiagnosis, biopsies, life-years, and quality-adjusted life-years (QALYs) discounted annually at 3%. Digital rectal examination (DER) only was the least cost-effective, yielding high biopsy and overdiagnosis rates with minimal QALY gains. PSA-based risk-adjusted strategies without additional MRI emerged as most cost-effective strategyies, whereas cost effectiveness of adding MRI to the screening algorithm would requie relatively high willingness to pay thresholds. Future research might explore the integration of MRI with ancillary tests, such as 4K-score or risk calculators, to reduce MRI use and associated costs. Also the cost effectiveness of implementing a complex screening strategy might deserve further consideration.

Selected Publications:

1. Lwin, M.W., et al.: A Cost-Effectiveness Analysis of Breast Cancer Treatment in Certified vs Non-Certified Hospitals in Germany. International Journal of Cancer (2026). [In press]
2. Muchadeyi, M.T., et al.: Cost effectiveness analysis of prostate cancer screening strategies in Germany: A microsimulation study. International Jornal of Cancer (2025); 157(8): 1662-1679
3. Lwin, M.W., et al.: Would initiating colorectal cancer screening from age of 45 be cost-effective in Germany? An individual-level simulation analysis. Front. Public Health (2024); 12:1307427
4. Cheng, C.-Y., et al.: Modeling the natural history and screening effects for colorectal cancer using both adenoma and serrated neoplasia pathways: the development, calibration, and validation of a discrete event simulation model. MDM Policy & Practice (2023); DOI: 10.1177/23814683221145701
5. Cheng, C.-Y., et al.: Do certified cancer centers provide more cost-effective care? A health economic analysis of colon cancer care in Germany using administrative data. International Journal of Cancer (2021); 149(10): 1744-1754
6. Khan, S.A., et al.: Estimation of the stage-wise costs of breast cancer in Germany using a modeling approach. Frontiers in Public Health (2023); DOI: 10.3389/fpubh.2022.946544
7. Khan, S.A., et al.: Cost-effectiveness of risk-based breast cancer screening: A systematic review. International Journal of Cancer (2021); 149(4): 790-810.
8. Ran, T., et al.: Cost–effectiveness of colorectal cancer screening strategies: A systematic review. Clinical Gastroenterology and Hepatology (2019); 17(10): 1969-1981

In response to the COVID-19 pandemic, Michael Schlander launched several exploratory and research initiatives. As medical attention and 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.

A cross-sectional online survey of German cancer patients was executed from July 2020 to June 2021 in collaboration with Susanne Weg-Remers of the DKFZ Cancer Information Service (KID). 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 work, the CroKus-1 study (2021; led by Professor Volker Arndt, DKFZ & Baden-Wuerttemberg Cancer Registry), a representative sample of cancer patients and cancer survivors were surveyed in collaboration with Professor Volker Arndt from the Baden-Wuerttemberg Cancer Registry. 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.

In close collaboration with Dr. Julian Maerz (Regensburg and Zurich), Professor Sören Holm (Manchester), and Anett Molnar (Heidelberg), Michael Schlander also addressed broader ethical aspects of healthcare prioritization during the COVID-19 pandemic, particularly with regard to vaccine allocation and resource distribution. Utilizing quantitative models to illustrate the trade-offs in vaccine policy decisions, the need for transparent, national strategies was emphasized, balancing ethical principles like population benefit, reciprocity, social justice, and equal respect for individuals. A related analysis 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 contributed to a deeper understanding of the complexity of ethically defensible medical decision-making in the pandemic, where prioritization invariably involved balancing competing values and outcomes.

Selected Publications:

1. Doege, D., et al.: 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
2. Eckford, R., et al.: The COVID-19 pandemic and cancer patients in Germany: impact on treatment, follow-up and psychological burden. Frontiers in Public Health (2022); DOI: 10.3389/fpubh.2021.788598
3. Gaisser, A., et al.: 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
4. März, J.W., et al.: The ethics of COVID-19 vaccine allocation: Don't forget the trade-offs!. Public Health Ethics (2022); 15(1): 41-50
5. März, J.W., et al.: 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.
6. März, J.W., Schlander, M.: Not kennt kein Gebot? Die Rule of Rescue als Leitprinzip in der Covid-19-Pandemie. AMOS International (2021); 15(3): 39-44