Cost Analysis of AC Treatment Compared to TAC in Breast Cancer patients at the Regional General Hospital of West Nusa Tenggara Province, Indonesia

Baiq Dyah Laili Isro¹, Cyntiya Rahmawati²*, Baiq Lenysia Puspita Anjani²,

Iche Rahma Saputri¹, Suriatin Juhaeniq¹

¹Undergraduate Program in Pharmacy, University of Muhammadiyah Mataram, West Nusa Tenggara, Indonesia.

²Department of Pharmacy, University of Muhammadiyah Mataram, West Nusa Tenggara, Indonesia.

*Corresponding Author E-mail: cyntiya.apt@gmail.com

ABSTRACT:

Breast cancer is a disease that requires high treatment costs. The incidence of breast cancer continues to increase every year, especially in West Nusa Tenggara, Indonesia. This study aims to determine the cost comparison in breast cancer patients using the Doxorubicin Cyclophosphamide (AC) regimen compared to the Paclitaxel Doxorubicin Cyclophosphamide (TAC) regimen at the Regional General Hospital of West Nusa Tenggara Province. The research design uses a retrospective analysis design for the year 2022, comparing the direct medical costs from secondary data of breast cancer patients using chemotherapy regimens AC compared to TAC from the payer's perspective. The sample size is 225 patients using a purposive sampling technique. The results of the study found that the majority of breast cancer patients are in the early elderly category, all breast cancer patients are female, the majority of breast cancer patients had a length of stay of 1-5 days, and the majority of breast cancer patients were discharged alive. The average direct medical costs in breast cancer patients using the AC chemotherapy regimen were Rp. 3,391,015 per patient, while in patients using the TAC chemotherapy regimen, the average direct medical costs were Rp. 4,128,545 per patient. There is a difference in the average direct medical costs between the AC and TAC chemotherapy regimens, where the average TAC medical costs are higher by Rp 737,529 (17,86%) compared to the AC chemotherapy regimen. Thus, it is concluded that there is a significant difference (P <0.05) in the direct medical costs of breast cancer patients using the AC chemotherapy regimen compared to the TAC chemotherapy regimen.

KEYWORDS: Cost-Analysis, Breast Cancer, Regimen AC, Regimen TAC, Hospital.

INTRODUCTION:

The World Health Organization (WHO) states that breast cancer is the most dominant disease in women and experiences an annual increase reaching 1.5 million cases¹. In 2020, there were 685,000 or 15% of women who died due to breast cancer, which is a significant issue in developed countries, but 69% of these cases occurred in developing countries^2-4.

Based on several studies, patients with a cancer diagnosis report high levels of psychological and emotional stress, particularly in breast cancer and in the late stages^5,6. Data provided by the Ministry of Health in Indonesia estimates that 100 new cases of breast cancer occur per 100,000 population, meaning that out of 237 million inhabitants, there are approximately 237,000 breast cancer patients each year⁷. According to the 2018 Basic Health Research (Riskesdes), the incidence of breast cancer has been increasing in Indonesia since 2013, reaching 1.4 per 1,000 population. This has led Indonesia to be ranked 23rd in Asia for the highest number of breast cancer cases⁸. Research results from Riskesdas in West Nusa Tenggara (NTB) show an increase in breast cancer from 0.6% to 0.85% in 2018⁹.

The management of breast cancer is done through three methods: surgery, radiation as a local therapy, and chemotherapy. Most breast cancer patients have a disease that has spread at the time of diagnosis, making local therapy often unsuccessful in eliminating the cancer entirely. Surgery and radiotherapy are commonly used to treat women with early-stage breast cancer, while chemotherapy, hormonal therapy, and targeted therapy are often employed to treat patients with more advanced forms of the disease¹⁰. Chemotherapy treatment can be more effective as it reaches systemic circulation, capable of treating the primary tumor and its spread¹¹. AC (Doxorubicin Cyclophosphamide) and TAC (Paclitaxel Doxorubicin Cyclophosphamide) regimens are anthracycline-based chemotherapy regimens. Currently, first-line chemotherapy for breast cancer is anthracycline-based chemotherapy often combined with cyclophosphamide, fluorouracil, or taxane¹².

Breast cancer is classified as a catastrophic disease, meaning it is high cost, high volume, and high risk, resulting in increased expenditures¹³. In 2016, Indonesian Case-Based Groups (INA-CBG's) claim data noted that cancer became the second-highest treatment cost disease, amounting to 1.8 trillion rupiahs, reaching 2.1 trillion rupiahs by September 2017¹⁴. To determine treatment strategies that provide good outcomes, an analysis of costs is necessary. Decision-making in treatment considers not only safety, efficacy, and quality but also economic aspects.

The high incidence of breast cancer is evident in the number of cases found at the Regional General Hospital of West Nusa Tenggara Province. Preliminary study data from the hospital indicates an increase in breast cancer cases in the last two years, with 514 cases in 2020 and 553 cases in 2021. Based on the above description, researchers are interested in conducting a study on the cost analysis of breast cancer patients using the AC regimen compared to the TAC regimen at the Regional General Hospital of West Nusa Tenggara Province. The aim of this study is to determine which therapy is more efficient between the AC and TAC regimens in treating breast cancer patients at the hospital by calculating the difference in the average total treatment costs.

MATERIALS AND METHODS:

Model overview: This research employs a cost analysis research design. Data collection is conducted retrospectively using information from the year 2022. The study began by describing the characteristics of the patients, such as age, gender, length of hospital stay, and discharge status. Then, comparing the direct medical costs and INA-CBGs tariffs of the AC chemotherapy regimen to the TAC regimen used by breast cancer patients from the payer's perspective (national health insurance/BPJS Kesehatan). The study takes place at the Regional General Hospital of West Nusa Tenggara Province (RSUD Provinsi NTB) using secondary data obtained from the medical records department and the Healthcare Financing Information System (SIJAP).

Study Settings and Study Populations: The population in this research comprises all breast cancer patients receiving chemotherapy in 2022. Purposive sampling is employed in this study, resulting in 54 patients for the AC regimen group and 171 patients for the TAC regimen group, making a total of 225 patients in the overall sample. The sample includes breast cancer patients who meet the inclusion and exclusion criteria.

Inclusion and Exclusion Criteria: Inclusion criteria involve patients diagnosed with breast cancer who received AC or TAC chemotherapy regimens in 2022, breast cancer patients with documented drug and therapy data in SIJAP, and patients covered by the national health insurance (BPJS Kesehatan). Exclusion criteria include incomplete patient data and missing patient data.

Cost Measurement: The components of direct medical costs calculated include chemotherapy, room, visit, procedures, laboratory, support, and pharmacy costs. The costs were calculated by summing the cost components for each patient, both for AC and TAC. Then, the average cost for each cost component was calculated. After that, the average direct medical costs for the AC and TAC regimens were calculated and the cost differences were analyzed statistically. Then, comparing with INA-CBGs tariffs. Then, the comparison between actual average costs and INA-CBGs tariffs were analyzed statistically.

Data Analysis: Data analysis techniques in this research encompass univariate and bivariate analyses. Univariate analysis presents demographic data including age, gender, length of hospital stay, discharge status, and the overview of direct medical costs for breast cancer patients. Bivariate analysis presents statistically significant differences in the average direct medical costs of breast cancer patients using the AC regimen compared to the TAC regimen. In the bivariate analysis, a normality test is conducted. If the data is normally distributed (p>0.05), parametric methods using independent sample T-Test are applied. However, if the data is not normally distributed (p<0.05), non-parametric methods using the Mann-Whitney test are used. The significance value indicates the difference in average costs. If the significance value > 0.05, there is no significant difference, but if the value < 0.05, there is a significant difference. The independent variable is the chemotherapy regimen (AC or TAC) used by breast cancer patients, while the dependent variable is the average direct medical costs.

Table 1. Distribution of Breast Cancer Patient Frequencies

Characteristics	Categories	Frequencies		Percentages
		AC (n=54)	TAC (n=171)	AC (n=54)	TAC (n=171)
Age	Late teens : 17-25 years	0	2	0	1,2%
	Early adults : 26-35 years	1	7	1,9%	4,1%
	Late adults : 36-45 years	16	52	29,6%	30.4%
	Early elderly : 46-55 years	23	72	42,6%	42,1%
	Late elderly : 56-65 years	12	32	22,2%	18,7%
	Very elderly : >65 years	2	6	3,7%	3,5%
Gender	Male	0	0	0%	0%
Gender	Female	54	100	100%	100%
Length of hospital stay	1-5 days	41	134	75,9%	78,4%
Length of hospital stay	>5 days	13	37	24,1%	21,6%
Discharge status	Alive	51	165	94,4%	96,5%
Discharge status	Deceased	3	6	5,6%	3,5%

RESULT:

Characteristics of Breast Cancer Patients:

Based on Table 1, it is known that the majority of breast cancer patients are in the early elderly category, which is ages 46-55 years, both for those using the AC regimen and the TAC regimen. A woman's age is a risk factor influencing the occurrence of breast cancer. The frequency distribution results for age in this study are consistent with several other research findings, indicating that the majority of breast cancer patients undergoing chemotherapy fall into the early elderly category, specifically aged 46 to 55 years^11,15. Long-term changes in estrogen levels increase the risk of breast cancer cell development and division. Hormonal factors are essential in breast cancer risk, and increased exposure to estrogen raises the risk¹⁶.

All breast cancer patients are female, with a percentage of 100%. The result of the frequency distribution of gender in this study is consistent with data from the Australian Institute of Health and Warfare, which indicates that breast cancer is most commonly experienced by women¹⁷. This is because women undergo hormonal changes, such as menstruation, pregnancy, breastfeeding, and estrogen being a crucial hormone for women, whereas men have relatively lower levels of estrogen compared to women. Women possess a higher number of estrogen hormone receptors compared to men, making breast cancer rare in men. According to the findings of Sudhakar et al. (2013), it is stated that in a high percentage of cases, breast cancer is proven to be hormone-dependent as tumor progression relies on high levels of estrogen¹⁸. Furthermore, different models have utilized evidence from cancer and steroid hormones to determine the risk of breast cancer in women with a family history of breast cancer¹⁹.

The majority of breast cancer patients had a length of stay of 1-5 days, with 75.9% of patients using the AC regimen and 78.4% using the TAC regimen. The majority of breast cancer patients were discharged alive, with 94.4% for those using the AC chemotherapy regimen and 96.5% for those using the TAC regimen.

Cost Analysis:

Based on Table 2, it can be seen that the highest average medical costs for breast cancer patients are chemotherapy costs, amounting to Rp. 6,051,852 for the AC regimen and Rp. 6,055,556 for the TAC regimen. This is consistent with Aisyah et al. (2020), where the component that absorbs the most cost is chemotherapy drugs for breast cancer severity levels I and II¹³. Statistical tests using Mann-Whitney show a significant difference in the cost components of visits and pharmacy for both the AC and TAC regimens. This can be observed from the Asymp. Sig values <0.05. In the chemotherapy, room, procedure, lab, and supporting components, the Asymp. Sig values are >0.05, indicating no significant difference between the AC and TAC regimens.

Table 2. Analysis of direct medical costs for breast cancer patients

Cost Components	AC (n=54)		TAC (n=171)		P
Cost Components	Average (Rp)	SD (Rp)	Average (Rp)	SD (Rp)	P
Chemotherapy	6.051.852	3.483.424	6.055.556	4.268.505	0,749
Room	94.923	55.071	102.668	73.500	0,137
Visits	83.397	40.546	107.208	43.424	0,001*
Medical Supplies and Sterile Supply Centre	0	0	0	0	0
Procedures	205.097	162.446	186.029	79.064	0,634
Laboratory	20.069	44.085	13.635	47.888	0,160
Supporting	100.324	267.324	80.421	247.348	0,828
Other services	0	0	0	0	0
Pharmacy	987.205	154.704	1.806.022	656.144	0,009*
Emergency Installation	0	0	0	0	0

Table 4. Analysis of the comparison between actual average costs and INA-CBGs tariffs

Severity Levels	Class	Actual average costs (Rp.)	INA-CBGs tariffs (Rp.)	Difference (Rp.)	P
AC Regimen
Mild Chemotherapy	1 (n=33)	3.536.242	3.039.700	- 496.542	0,001*
	2 (n=7)	3.139.115	2.605.500	-533.615	0,001*
	3 (n= 122)	3.319.512	2.171.200	-1.148.312	0,001*
Moderate Chemotherapy	1 (n=0)	0	0	0	0
	2 (n=0)	0	0	0	0
	3 (n= 1)	4.726.229	4.086.300	-639.929	0,317
Severe Chemotherapy	1 (n=1)	3.002.970	7.744.400	2.508.430	0,317
	2 (n=0)	0	0	0	0
	3 (n=3)	3.641.636	5.531.400	1.889.764	0,037*
TAC Regimen
Mild Chemotherapy	1 (n= 47)	4.149.458	3.039.700	-1.109.758	0,001*
	2 (n=28)	4.019.361	2.605.500	-1.413.861	0,001*
	3 (n=409)	4.086.929	2.171.200	-1.915.729	0,001*
Moderate Chemotherapy	1 (n=0)	0	0	0	0
	2 (n=0)	0	0	0	0
	3 (n=11)	4.819.217	4.086.300	-732.917	0,015*
Severe Chemotherapy	1 (n=3)	4.088.893	7.744.400	3.655.107	0,001*
	2 (n=2)	4.885.379	6.637.700	1.752.322	0,102
	3 (n=13)	4.896.775	5.531.400	634.625	0,001*

Analysis of the Comparison of Actual Average Costs with INA-CBGs Tariffs:

In Table 4, variations in cost differences are observed, including positive and negative differences between the actual average costs of AC and TAC chemotherapy regimens and the INA-CBGs tariffs. A positive cost difference means that the actual cost is smaller than the INA-CBGs tariff, covering the per-patient cost in each chemotherapy treatment episode. A negative cost difference means that the INA-CBGs tariff is smaller than the actual cost, insufficient to cover the real costs at RSUD Provinsi NTB. The severity level of chemotherapy is adjusted to the severity classification of the INA-CBGs tariff. According to Minister of Health Regulation No. 27 Year 2014, the terms mild, moderate, and severe in the description of INA-CBGs codes do not depict the patient's clinical condition or diagnosis or procedure but describe the severity level influenced by secondary diagnoses (complications and comorbidities)²¹. From Table 4, the statistical analysis results using Mann-Whitney and independent sample T-Test can be seen. The analysis of breast cancer patients using the AC chemotherapy regimen shows that the P value is <0.05. This means there is a significant difference between the actual costs and INA-CBGs tariffs, except for moderate chemotherapy class 3 and severe chemotherapy class 1, as the P value is >0.05. The analysis of breast cancer patients using the TAC chemotherapy regimen shows that the P value is <0.05. This means there is a significant difference between the actual costs and INA-CBGs tariffs, except for severe chemotherapy class 2, as the P value is >0.05.

DISCUSSION:

The result of the frequency distribution of Length of Stay (LOS) in this study shows that the majority falls between 1-5 days. This is attributed to some patients opting for outpatient treatment after spending several days in hospitalization. The length of stay is also influenced by the stage of the disease. Patients in the early stages tend to have a shorter duration of hospitalization compared to those in advanced stages. This is because in advanced stages, the disease has already spread to other organs (as seen in cases where it has spread to the lungs and liver). Additionally, the length of stay can be influenced by the varying health conditions of each patient and the presence of various coexisting diseases or complications in each individual patient.

A study by Yuniastin et al. (2022) states that the survival rate of breast cancer patients is related to the stage of breast cancer at the initial diagnosis²². Survival rate estimates the percentage of patients who will survive for a certain period after diagnosis²³. Kartini et al. (2019) found that breast cancer deaths can be avoided by early detection through breast self-examination (SADARI/BSE). BSE aims to prevent the risk of advanced stages, reducing mortality rates, as cancer can be found earlier, providing a longer life expectancy²⁴. Based on the research findings by Yi & Ryu (2017), it is stated that the scores of knowledge and self-efficacy regarding breast cancer and breast self-examination (BSE), resilience, and meaning and purpose in life in the treatment group are higher than those in the control group²⁵. However, based on the research by Geetha, et al. (2017), it shows a gap between knowledge and the practice of BSE among women²⁶.

The results of the direct medical cost overview indicate differences in averages, particularly in the costs of medical personnel, medical procedures, and the costs of drugs and medical equipment. Variations in medical personnel costs are influenced by the level of care; the higher the level of care, the higher the incurred costs. Medical procedure costs are affected by the individual conditions of each patient, which may necessitate additional procedures and subsequently increase the overall cost. The costs of drugs and medical equipment are influenced by the duration of the patient's hospitalization, as well as the type of chemotherapy drugs used, given that anti-cancer drugs have varying prices. Additionally, the different chemotherapy cycles undergone by each patient contribute to varying expenses.

CONCLUSION:

Based on the results of the research conducted at RSUD Provinsi NTB in 2023, it is found that there is a difference in the average direct medical costs between the AC and TAC chemotherapy regimens, with the TAC regimen having a higher average direct medical cost of Rp 737,529 (17,86%) compared to the AC chemotherapy regimen. The statistical analysis yielded a value of Asymp. Sig <0.05, indicating a significant difference in the direct medical costs for breast cancer patients using the AC and TAC chemotherapy regimens.

CONFLICT OF INTEREST:

The author has no conflict of interest.

ACKNOWLEDGMENTS:

The author expresses gratitude to the Ministry of Education, Culture, Research, and Technology (Kemendikbudristek) for funding this research. The researcher also extends thanks to RSUD Provinsi NTB for providing the data needed for the study.

REFERENCES:

1. UICC. Global Cancer Data: GLOBOCAN 2018 | UICC [Internet]. [quoted on January 26, 2024]. Available in: https://www.uicc.org/news/global-cancer-data-globocan-2018

2. Sari TP. The Relationship Between Self-Compassion And Emotion Regulation With Stress In Post-Operative Breast Cancer Patients Undergoing Chemotherapy At Rsu. Dadi Keluarga Purwokerto [Internet] [Bachelor]. University of Muhammadiyah Purwokerto; 2017 [quoted on January 26, 2024]. Available in: https://repository.ump.ac.id/3654/

3. Hariramani N, Jayanthi S. A Systematic Review of Intrinsic Factors and its Influence in Breast Cancer. Res J Pharm Technol. 31th August 2018; 11(8): 3543–6. 10.5958/0974-360X.2018.00654.6

4. Patidar A, S.C.Shivhare, Ateneriya U, Choudhary S. A Comprehensive Review on Breast Cancer. Asian J Nurs Educ Res. 28th March 2012; 2(1): 28–32. https://ajner.com/HTMLPaper.aspx?Journal=Asian+Journal+of+Nursing+Education+and+Research%3BPID%3D2012-2-1-8

5. Lavanya S, Santha NJ, Sethu G. A descriptive study to assess the level of stress among women with selected type of cancer in Erode Cancer Centre at Erode. Asian J Nurs Educ Res. 28th September 2014; 4(3): 321–4. https://ajner.com/AbstractView.aspx?PID=2014-4-3-13

6. W Sampoornam. Stress and Quality of Life among Breast Cancer Patients. Asian J Nurs Educ Res. 28th September 2014; 4(3): 325–7. https://ajner.com/AbstractView.aspx?PID=2014-4-3-14

7. National Committee for Cancer Control. National Guidelines for Cancer Management - Breast Cancer. 2015 [quoted on January 26, 2024]. Available in: https://www.poijaya.org/wp-content/uploads/2021/03/PPKPayudara.pdf

8. Ministry of Health of the Republic of Indonesia. 2018 National Basic Health Research Report (Riskesdas). 2019 [quoted on January 26, 2024]. Available in: https://repository.badankebijakan.kemkes.go.id/id/eprint/3514/1/Laporan%20Riskesdas%202018%20Nasional.pdf

9. Health Research and Development Agency. 2018 Basic Health Research (Riskesdas) Report for Nusa Tenggara Barat Province. 2019 [quoted on January 10, 2024]. Available in: https://repository.badankebijakan.kemkes.go.id/id/eprint/3903/1/LAPORAN%20RISKESDAS%20NTB%202018.pdf

10. Dange VN, Shid SJ, Magdum CS, Mohite SK. A Review on Breast cancer: An Overview. Asian J Pharm Res. 3rd March 2017;7(1):49–51. 10.5958/2231-5691.2017.00008.9

11. Yosmar R, Ningsih L, Ifmaily I. Cost-Effectiveness Analysis Study on Breast Cancer Patients Undergoing Chemotherapy at RSUP DR. M. Djamil Padang. J Farm Higea. 13th June 2020; 12(1): 19–31. http://dx.doi.org/10.52689/higea.v12i1.260

12. Yuan Agita Aprilia Rahayuningrum N. Hematological Profile Of Breast Cancer Patients And Interval Between Chemotherapy Cycles With Caf And Tac Regimens At Dr. Soetomo Hospital Surabaya In 2016 [Thesis]. University of Airlangga; 2018 [Quoted On January 26, 2024]. Available In: http://repository.unair.ac.id/id/eprint/76311

13. Aisyah N, Andayani TM, Puspandari DA. Cost Analysis Of Chemotherapy In Inpatient Breast Cancer Patients Participating In Jkn At RSUD Ulin Banjarmasin. J Ilm Ibnu Sina. October 31, 2018; 3(2): 333–42. https://doi.org/10.36387/jiis.v3i2.189

14. Decision Of The Minister Of Health Of The Republic Of Indonesia. National Guidelines For Medical Services In The Management Of Breast Cancer. 2018 [quoted on January 30, 2024]. Available in: https://yankes.kemkes.go.id/unduhan/fileunduhan_1610414392_632733.pdf

15. K K, Jose R, Sk S, Johny T, R SS, R S. A Study on Socio Demographic and Associated Risk Factors for Cancer Patients in Private Cancer Hospital, Bangalore, India. Res J Pharm Technol. 28th February 2018; 11(2): 677–80. 10.5958/0974-360X.2018.00127.0

16. Sjamsuhidajat DJ. Textbook of Surgery Edition 3. EGC Medical Book; 2010.

17. Welfare AI of H and. Australian Cancer Incidence and Mortality [Internet]. [quoted on February 1, 2024]. Available in: https://data.gov.au/data/dataset/australian-cancer-incidence-and-mortality?fbclid=IwAR1gBJd8P6x--ytbjLnRbZDdw1MNroDXsTKZd8Q6P3h5m-IkOzBqr5feVxk

18. Sudhakar GK, Pai V, Pai A. An overview on current Strategies in Breast Cancer Therapy. Res J Pharmacol Pharmacodyn. 30th December 2014; 5(6): 353–5. https://rjppd.org/HTMLPaper.aspx?Journal=Research%20Journal%20of%20Pharmacology%20and%20Pharmacodynamics;PID=2013-5-6-18

19. Yadav AR, Mohite SK. Cancer- A Silent Killer: An Overview. Asian J Pharm Res. 4th August 2020; 10(3): 213–6. 10.5958/2231-5691.2020.00036.2

20. Mishchenko O, Adonkina V, Tkachova O, Ulanova V, Kalko K, Pyliuha L, dkk. The Results of the Clinical and Economic Assessment of Drugs Prescriptions to patients with Breast Cancer in the Ukrainian Health Care Institution. Res J Pharm Technol. 25th July 2019;12(7):3307–12. 10.5958/0974-360X.2019.00557.2

21. Ministry of Health of the Republic of Indonesia. Minister of Health Regulation No. 27 Year 2014 on the Technical Guidelines for the Indonesian Case Base Groups (INA-CBGs) System. [quoted on February 1, 2024]. Available in: https://peraturan.bpk.go.id/Details/117564/permenkes-no-27-tahun-2014

22. Yuniastini Y, Marhayuni E, Wiratmoko W, Februase EA. Survival Rate Of Breast Cancer Patients Based On Stage At Dr. H. Abdul Moeloek Regional General Hospital, Province. Mahesa Malahayati Health Stud J. 13th April 2022; 2(2): 371–9. https://doi.org/10.33024/mahesa.v2i2.4557

23. Survival Rates and Factors That Affect Prognosis (Outlook) for Non-Hodgkin Lymphoma [Internet]. [quoted on February 1, 2024]. Available in: https://www.cancer.org/cancer/types/non-hodgkin-lymphoma/detection-diagnosis-staging/factors-prognosis.html

24. Kartini, Lubis NL, MorizaT. Analysis Of Factors that Influence Of Delay Treatment In Breast Cancer Patients In The 2018 Simeulue Regional Hospital. Health Information Journal. Vol 17, No.1, June 2019, pp. 16-34. [quoted on February 1, 2024]; Available in: https://jurnal.poltekeskupang.ac.id/index.php/infokes/article/view/240

25. Yi M, Ryu YM. The Effects of Breast Health Education in Women with Breast Cancer. Res J Pharm Technol. 28th July 2017; 10(7): 2295–302. 10.5958/0974-360X.2017.00407.3

26. Geetha M, Menaka K, Padmavathi P. Awareness of Breast self-examination and risk factors of Breast Cancer among Women. Asian J Nurs Educ Res. 9th August 2017; 7(3): 413–6. 10.5958/2349-2996.2017.00082.9

Received on 03.02.2024 Revised on 18.06.2024

Accepted on 31.08.2024 Published on 28.01.2025

Available online from February 27, 2025

Research J. Pharmacy and Technology. 2025;18(2):613-618.

DOI: 10.52711/0974-360X.2025.00091

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Creative Commons License.

Type of Chemotherapy Regimen	Direct Medical Costs		P
Type of Chemotherapy Regimen	Average(Rp)	SD (Rp)	0,001*
AC	3.391.015	403.962
TAC	4.128.545	515.585