Health Economics
- Cancer Risk Factors and Prevention
Prof. Dr. med. Michael Schlander
Head of Division
The aim of the division is to contribute to our understanding of the costs and cost effectiveness of cancer and cancer care—spanning the continuum from prevention and early detection/screening to diagnosis and treatment. To this end, the division has established collaborations both within the DKFZ and its networks, as well as with other German and international scientific institutions.
Our Research
The Division of Health Economics contributes to:
- Exploring the conceptual underpinnings of the logic of cost-effectiveness,
- Developing advanced evaluation paradigms,
- Deepening understanding of the social value of health care programs.
To support these objectives, the research program is structured around three core pillars:
Burden of disease studies
These address the cancer-related burden of disease, the attributable cost of illness, and budgetary impact of interventions. Analyses are conducted from multiple perspectives—societal, payer, and patient—with a particular (but not exclusive) focus on Germany.
Cost-value analyses
These evaluate the cost-effectiveness of clinical intervention strategies in cancer care. Topics range from institutional innovations (e.g., comprehensive cancer centers) to novel developments, including the expanding role of targeted therapies.
Economic methods and Social Costs Value Analysis (SCVA)
This pillar focuses on advancing the methodology of economic evaluations within the existing cost-effectiveness paradigm. It also supports the development of new approaches that better incorporate societal values and priorities in cancer care.
A fourth, overarching pillar complements the program:
Education, training, and outreach
This includes initiatives aimed at disseminating research findings and engaging a wide range of stakeholders to foster dialogue, capacity building, and informed decision-making.
Burden of Disease Studies
Burden and Cost of Cancer - Germany
In collaboration with Forum, the journal of the German Cancer Society, a series of reviews summarized evidence on disease burden and societal/health care costs of major cancers. Two publications addressed principles for measuring cancer costs in Germany; three analyzed epidemiological and cost estimates for specific cancer types. A separate review extended the analysis of pancreatic cancer to the European context.
Selected Publications
D. Hernandez, F. Wagner, K. Hernandez-Villafuerte, M. Schlander:
Economic burden of pancreatic cancer in Europe: a literature review.
Journal of Gastrointestinal Cancer, 2023; 54(2): 391-407.
DOI: 10.1007/s12029-022-00821-3
D. Hernandez, T. Ran, K. Hernandez-Villafuerte, M. Schlander:
Krankheitslast von Darmkrebs in Deutschland: Epidemiologie und Kosten [Disease burden of colorectal cancer in Germany: epidemiology and costs].
Forum, 2023: 38, 58-65.
DOI: 10.1007/s12312-022-01154-9
D. Hernandez, P. Giri, A. von Both, M. Schlander:
Krankheitslast von Lungenkrebs in Deutschland: Epidemiologie und Kosten [Lung cancer disease burden in Germany: epidemiology and costs].
Forum, 2022: 37, 387-404.
DOI: 10.1007/s12312-022-01123-2
D. Hernandez, A. von Both, M. Schlander:
Krankheitslast von Prostatakrebs in Deutschland: Epidemiologie und Kosten [Disease burden of prostate cancer in Germany: epidemiology and costs].
Forum, 2022: 37, 227-234.
DOI: 10.1007/s12312-022-01075-7
D. Hernandez, K. Hernandez-Villafuerte, M. Schlander:
Die Messung der Kosten von Krebserkrankungen in Deutschland. Teil 2 – Wirtschaftliche Belastung [Determining the cost of cancer in Germany. Part 2—economic burden].
Forum, 2022: 37, 42-48.
DOI: 10.1007/s12312-021-01026-8
D. Hernandez, K. Hernandez-Villafuerte, M. Schlander:
Die 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, 2021: 36, 406-410.
DOI: 10.1007/s12312-021-00988-z
M. Schlander, K. Hernandez-Villafuerte, C. Thielscher:
Kosten der Onkologie in Deutschland [Cost of cancer in Germany].
Forum, 2018: 33, 330-337.
DOI: 10.1007/s12312-018-0481-5
Exploring the Economics of Lung Cancer
Real-world data on healthcare utilization and costs related to lung cancer in Germany remain limited. To address this gap, we analyzed administrative claims data from one of the country’s largest health insurers.
The initial study established methods for identifying lung cancer cases, estimated national incidence, and examined survival rates relative to comorbidities. Two follow-up studies focused on (1) medication costs and prescription patterns, and (2) inpatient costs and treatment patterns across Germany.
Preliminary findings showed inpatient costs averaged €25,000 per patient—or approximately €18,000 per year of survival—with notable variation by age and region, but minimal differences by sex or comorbidities. The average hospital stay declined significantly over a 12-year period.
Outpatient prescription costs averaged €12,000 per patient, with lower costs during initial treatment and peaks in the terminal phase. These costs rose substantially over the study period.
Cost of Cancer Drug Development
The high cost of developing new cancer drugs is often cited as a key driver of rising prices and raises concerns about the long-term sustainability of the R&D-based biopharmaceutical industry.
We conducted a comprehensive review of peer-reviewed literature on the costs of bringing a new molecular entity (NME) to market, highlighting factors behind the wide variation in published estimates. Reported capitalized pre-launch R&D costs ranged from $161 million to $4.54 billion (2019 USD), with anticancer drugs among the most expensive—ranging from $944 million to $5.4 billion.
Our analysis confirmed a consistent upward trend in R&D costs per NME. To improve the quality and comparability of future research, we developed a suitability scoring system for evaluating study validity in this field.
Cost of CAR-T Cell Treatments
CAR T-cell therapies offer promising options for certain blood cancers, with the potential for long-term remission or cure. The European Commission approved two such gene therapies in 2018, marking a milestone in cancer treatment.
We evaluated the full cost spectrum of CAR-T cell therapy—including production, patient involvement, admission, and toxicity management—using both micro- and gross-costing approaches.
Our findings showed, for the first time, that production in not-for-profit settings can be a more cost-effective and efficient alternative to centralized models. Further cost reductions are expected as decentralized production benefits from standardization, economies of scale, and process improvements—consistent with the early life cycle stage of this innovative technology.
Selected Publications
D. Hernandez, C.-Y. Cheng, K. Hernandez-Villafuerte, M. Schlander:
Survival and comorbidities in lung cancer patients: evidence from administrative claims data in Germany.
Oncology Research, 2022: 30(4), 173-185.
DOI: 10.32604/or.2022.027262.
T. Ran, S. B. Eichmüller, P. Schmidt, M. Schlander:
Cost of decentralized CAR T cell production in an academic non-profit setting.
International Journal of Cancer, 2020: 147(12), 3438-3445.
DOI: 10.1002/ijc.33156
T. Ran, S. B. Eichmüller, P. Schmidt, M. Schlander:
Reply to: Comments on "Cost of decentralized CAR T cell production in an academic non-profit setting".
International Journal of Cancer, 2021: 148(2), 516-517.
DOI: 10.1002/ijc.33253
M. Schlander, K. Hernandez-Villafuerte, C.-Y. Cheng, J. Mestre-Ferrandiz, M. Baumann:
How much does it cost to research and develop a new drug? A systematic review and assessment.
Pharmacoeconomics, 2021: 39(11), 1243-1269.
DOI: 10.1007/s40273-021-01065-y
M. Schlander, T. Ran, P. Schmidt, S.B. Eichmüller:
Can we reduce the acquisition cost of CAR T cell therapies?
Annals of Oncology, 2020: 31(Supplement 4) S966.
DOI: 10.1016/j.annonc.2020.08.1912
The Socioeconomic Impact of Cancer on Patients and Families
While health economists often analyze costs from societal or payer perspectives, the patient viewpoint remains underexplored in applied research. In the U.S., the concept of financial toxicity has drawn attention to the economic burden of cancer treatment. In contrast, it's often assumed that universal healthcare systems in Europe protect patients from financial hardship.
However, many European cancer patients still face substantial economic strain. Their financial burden includes direct medical and non-medical costs (e.g., co-payments), as well as indirect costs like lost income—often only partially offset by social welfare systems. In addition to these tangible costs, patients and families frequently bear intangible burdens, such as psychological distress, diminished quality of life, and even worse clinical outcomes.
To better reflect this broader experience, we propose using the term socioeconomic impact, which encompasses the full spectrum of financial, psychological, and social consequences for patients, survivors, and their families. Recognizing these impacts is essential to fully understanding the burden of cancer and designing supportive policies and interventions.
Organisation of European Cancer Institutes (OECI) Consensus Task Force
Research on the socioeconomic impact of cancer from the patient and family perspective in Europe is still emerging, characterized by fragmented methods, terminology, and a lack of unified theory. To address these gaps, an international Task Force was launched in March 2021 within the OECI Health Economics Working Group, led by Michael Schlander (chair) and Wim van Harten (co-chair).
The Task Force aimed to develop a European consensus on a comprehensive conceptual framework, consistent taxonomy, and standardized definitions. Its goal is to reduce redundant and non-comparable research and promote more coordinated, rigorous, and policy-relevant efforts.
Since its inception, the Task Force has conducted extensive consensus-building activities, including focus groups, Delphi exercises, and consultations with patient representatives and external experts. This process culminated in 25 consensus recommendations, published in The Lancet Oncology (April 2024), which include a definition of socioeconomic impact, a detailed framework of causes and outcomes, and guidance for developing and validating patient-reported outcome instruments.
Empirical Research
In parallel with the conceptual work, additional empirical studies have explored the socioeconomic impact of cancer. One study analyzed data from the Socio-Economic Panel (SOEP), one of Germany’s largest household surveys, revealing that average job incomes declined by 26% to 28% within the first year following a cancer diagnosis.
In another project, conducted with the DKFZ Unit of Cancer Survivorship (led by Volker Arndt), we analyzed CAESAR study data to assess out-of-pocket expenses and income losses among breast cancer survivors in Germany, identifying key factors contributing to their financial burden.
Selected Publications
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. Published 04 April 2025.
DOI: 10.1007/s41669-025-00568-0
M. Schlander, W. van Harten, V.P. Retèl, P.D. Pham, J.M. Vancoppenolle, J. Ubels, O.S. López, C. Quirland, F. Maza, E. Aas, B. Crusius, A. Escobedo, N. Franzen, J. Fuentes-Cid, D. Hernandez, K. Hernandez-Villafuerte, I. Kirac, A. Paty, T. Philip, S. Smeland, R. Sullivan, E. Vanni, S. Varga, T. Vermeulin, R.D. Eckford:
The socioeconomic impact of cancer on patients and their relatives: Organisation of European Cancer Institutes task force consensus recommendations on conceptual framework, taxonomy, and research directions.
The Lancet. Oncology, 2024: 25 (4), e152–e163.
DOI: 10.1016/S1470-2045(23)00636-8
P.D. Pham, M. Schlander, R. Eckford, K. Hernandez-Villafuerte, J. Ubels:
Developing a conceptual framework for socioeconomic impact research in European cancer patients: A 'best-fit' framework synthesis.
The Patient, 2023: 16(5), 515-536.
DOI:10.1007/s40271-023-00632-z
V. Arndt, D. Hernandez, M. Schlander:
Einkommenseinbußen nach Krebs – Ergebnisse aus Deutschland [Income loss after cancer—Results from Germany].
Onkologie, 2022: 28, 951-956.
DOI: 10.1007/s00761-022-01243-3
D. Hernandez, M. Schlander:
Income loss after a cancer diagnosis in Germany: An analysis based upon the socio-economic panel survey.
Cancer Medicine, 2021: 10 (11), 3726-3740.
DOI: 10.1002/cam4.3913
R. Eckford, K. Hernandez-Villafuerte, A. Spier, L. Hirschberg, M. Schlander:
A systematic review of the socioeconomic impact of cancer on patients and families: Are differences among countries being effectively captured and addressed?
Value in Health, 2020: 23(Supplement 2), S478.
DOI: 10.1016/j.jval.2020.08.453
K. Hernandez-Villafuerte, R. Eckford, A. Spier, M. Schlander:
How to Describe the Socioeconomic Impact of Cancer on Patients and their Families: An Evaluation of Terminology by Global Regions and Healthcare Systems.
Presentation at iHEA 14th World Congress on Health Economics.
Virtual. July 12-15, 2021
M. Schlander:
PRO (“patient-reported outcomes”) und Lebensqualität in der Onkologie [Patient-reported outcomes (PRO) and quality of life in oncology].
Forum 2020: 35, 382-390.
DOI: 10.1007/s12312-020-00841-9
J. Schneider, D. Hernandez, CAESAR study group, M. Schlander, V. Arndt:
Out-of-pocket payments and loss of income among long-term breast cancer survivors in Germany: A multi-regional population-based study.
Journal of Cancer Survivorship, 2023: 17(6), 1639-1659.
DOI: 10.1007/s11764-022-01293-x
[ER1]Updated to reflect where we are now.
Cost Value Analyses
Cost-Effectiveness Analyses (CEAs) of Specialized Cancer Care
Certification of hospitals for cancer care has become an important quality assurance measure, though it incurs significant costs. In collaboration with Jochen Schmitt’s team (NCT Dresden and Center for Evidence-Based Health Care, University of Dresden), we used administrative data to provide the first health economic evidence that colon cancer care in certified German cancer centers improves survival and reduces healthcare costs. Given uncertainties about generalizability, we launched a follow-up study assessing the cost-effectiveness of certified breast cancer care, with plans to include additional tumor types.
For breast cancer screening, mammography shows a favorable benefit-harm balance for the general population, and biennial screening is recommended in Germany for average-risk women aged 50–69. However, this may not suit women with different risk profiles. We adapted the “Wisconsin Model” to evaluate the cost-effectiveness of risk-adjusted screening strategies. For prostate cancer, we are collaborating with Peter Albers (DKFZ, University of Düsseldorf) to assess personalized prevention strategies from the PROBASE Trial, using a recalibrated Swedish natural history model adapted to Germany.
CEAs Alongside Clinical Trials
Health economic evaluation alongside clinical trials offers an unparalleled opportunity to collect relevant health care resource utilization and (quality of life) utility data in addition to the clinical endpoints. A collaboration was established with NCT Heidelberg to support two clinical trials: (1) a randomized phase-III study to compare two schedules of gemtuzumab ozogamicin as an adjunct to intensive induction therapy and to compare intensive postremission therapy double-blinded with or without glasdegib in older patients with newly diagnosed AML (GnG) and (2) a randomized study in newly diagnosed AML with FLT3-ITD comparing Daunorubicin/ Cytarabine or Idarubicin/Cytarabine and Quizartinib to physician’s choice (Q-SOC).
Our support included drafting health economic sections of trial proposals, designing resource use questionnaires, selecting utility measures, and training clinical staff in data collection. Although both trials were discontinued for reasons unrelated to health economics, the Division continues to offer support for embedding economic evaluations in clinical studies.
CEAs of Tumor Prediction Models
The BMG-funded “Tumor Behavior Prediction Initiative” (TPI), led by Titus Brinker (Digital Prevention, Diagnostics and Therapy Guidance, DKFZ), aims to develop new biomarkers to support long-term personalized cancer treatment across multiple cancer types, including melanoma, breast, and colorectal cancer. The Division of Health Economics contributes to this collaborative research project by evaluating the potential value of the routine use of AI-based digital biomarkers in clinical practice.
In the Skin Classification Project, also led by Dr. Brinker, convolutional neural networks (CNNs) were designed to aid melanoma diagnosis. The Division of Health Economics evaluated the potential economic value of introducing such new diagnostic algorithm in everyday clinical practice by designing an early-phase economic model. The initial estimates predicted potential cost savings in the magnitude of €7m for German statutory health insurance through an AI-based assistance system, based on retrospective data.
A follow-up study (Skin Classification Project II) is now underway to refine these estimates of the diagnostic algorithm based on clinical data from a multicenter prospective study. This ongoing evaluation will assess various scenarios and potential outcomes of a real-world implementation through model-based analysis.
CEAs in Precision Medicine and Health Technology Assessment (HTA)
The Division of Health Economics contributes to the EU-funded project CCE-DART (Building Data Rich Clinical Trials), which focuses on improving clinical trial design and methodology for targeted therapies. As cancer research increasingly adopts adaptive, basket, and umbrella trials to evaluate treatments based on biomarkers rather than histology, there remains a gap in robust methods for conducting health economic evaluations alongside these innovative designs.
Through the Basket of Baskets (BoB) case study, we are exploring how to integrate clinical data from such trials into economic evaluations to support health policy decisions on precision oncology approaches.
Prevention & Screening Cost-Effectiveness Models
In response to DKFZ’s strategic focus on cancer prevention, the Division launched three major modeling initiatives assessing screening and prevention strategies for colorectal (CRC), breast, and prostate cancer. All use advanced microsimulation techniques for robust long-term evaluation, moving beyond traditional Markov cohort models.
For CRC, most existing models overlook the serrated neoplasia pathway, potentially leading to overly optimistic results. The Division developed the DECAS model (Discrete Event simulation model for Colorectal cancer from the Adenoma and Serrated neoplasia pathways), calibrated using approximate Bayesian computation and validated against major screening trials. DECAS has been used to evaluate the cost-effectiveness of various CRC screening strategies.
An important advancement was the publication by Lwin et al. (2024), which used DECAS to compare four CRC screening strategies starting at age 45 with the current national program starting at age 50. The results demonstrated that earlier screening—especially colonoscopy or combined with fecal immunochemical tests (FITs)—offers substantial QALY gains at modest additional cost, supporting a policy shift in response to rising early-onset CRC in Germany.
While CRC evaluations are advanced, breast and prostate screening models are still in development. For breast cancer, mammography has been shown 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, we adapted the “Wisconsin Model” for evaluating risk-adjusted screening strategies. For prostate cancer we are collaborating with Peter Albers (Personalized Early Detection of Prostate Cancer, DKFZ) to evaluate personalized prevention strategies using data from the PROBASE Trial. A Swedish prostate cancer model is being adapted and re-calibrated for the German context.
Selected Publications
M.W. Lwin, C.-Y. Cheng, S. Calderazzo, C. Schramm, M. Schlander:
Would initiating colorectal cancer screening from age of 45 be cost-effective in Germany? An individual-level simulation analysis.
Frontiers in public health, published 21 Feb 2024.
DOI: 10.3389/fpubh.2024.1307427
C.-Y. Cheng, S. Calderazzo, C. Schramm, M. Schlander:
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: 8(1), published 21 Jan 2023.
DOI: 10.1177/23814683221145701.
C. -Y. Cheng, T. Datzmann, D. Hernandez, J. Schmitt, M. Schlander:
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.
DOI: 10.1002/ijc.33728
A. Deibel, L. Deng, C. -Y. Cheng, M. Schlander, T. Ran, B. Lang, N. Krupka, N. Beerenwinkel, G. Rogler, R. Wiest, A. Sonnenberg, J. Poleszczuk, B. Misselwitz:
Evaluating key characteristics of ideal colorectal cancer screening modalities: the microsimulation approach.
Gastrointestinal Endoscopy, 2021: 94(2) 379-390.e7.
DOI: 10.1016/j.gie.2021.02.013
M. Schlander:
Risikoadaptierte Früherkennung & Prävention.
Invited oral presentation at the 35th German Cancer Congress (DKK).
Berlin, Germany. November 13-16, 2022.
S. A. Khan, K. Hernandez-Villafuerte, D. Hernandez, M. Schlander:
Estimation of the stage-wise costs of breast cancer in Germany using a modeling approach.
Frontiers in Public Health, 2023: 10, published 6 Jan 2023.
DOI: 10.3389/fpubh.2022.946544
S. A. Khan, K. V. Hernandez-Villafuerte, M. T. Muchadeyi, M. Schlander:
Cost-effectiveness of risk-based breast cancer screening: A systematic review.
International Journal of Cancer, 2021: 149(4) 790-810.
DOI: 10.1002/ijc.33593
A. Molnar, T.J. Brinker, A. Hekler, K.V. Hernandez-Villafuerte, M. Schlander:
Direct costs related to medical management of malignant cutaneous melanoma through the patient pathway.
Value in Health, 2020 23(Supplement 2) S460.
DOI: 10.1016/j.jval.2020.08.348
M. Schlander, C.-Y. Cheng, T. Ran:
The health economics of cancer screening in Germany: Which population-based interventions are cost-effective? [Gesundheitsökonomie der Krebsfrüherkennung in Deutschland: Welche Interventionen sind kosteneffektiv bei bevölkerungsweiter Umsetzung?]
Bundesgesundheitsblatt, 2018: 61(12) 1559-1568.
DOI: 10.1007/s00103-018-2839-3
Cost effectiveness evaluation and HTAs
In practice, HTA rests predominantly on two pillars: the assessment of clinical benefit drawing on principles of evidence-based medicine, and an evaluation of efficiency, usually by means of some variant of cost effectiveness analysis. For example, well-known health technology assessment (HTA) agencies such as the National Institute for Health and Care Excellence (NICE) in England and Wales and the Institute for Quality and Efficiency in Health Care (IQWiG) / Federal Joint Committee (Gemeinsamer Bundesausschuss, G-BA) in Germany have implemented different evaluation approaches, which also reflect variations in HTA outcomes.
Against this background, an empirical analysis as well as a comparative study were conducted to explore the extent to which different methodological choices are associated with different HTA outcomes. These studies primarily focused on assessment and appraisal results as well as (official and unofficial) evaluation criteria by G-BA/IQWiG and NICE, respectively. In a follow-up project, we considered systematically reviewing the data requirements of national HTA agencies such as NICE, G-BA/IQWiG and the French Haute Autorité de Santé (HAS), including their acceptance of data sources, handling of potential bias, as well as underlying differences in methodological choices and their potential implications for HTA outcomes.
Selected Publications
R. Schaefer, D. Hernandez, T. Bärnighausen, P. Kolominsky-Rabas, M. Schlander:
Health technology assessment-informed decision making by the Federal Joint Committee/Institute for Quality and Efficiency in Health Care in Germany and the National Institute for Health and care excellence in England: The role of budget impact.
Value in Health, 2023: 26(7), 1032-1044.
DOI: 10.1016/j.jval.2023.02.018
R. Schaefer, D. Hernandez, L Selberg, M. Schlander:
Health technology assessment (HTA) in England, France and Germany: what do matched drug pairs tell us about recommendations by national HTA agencies?
Journal of Comparative Effectiveness Research, 2021: 10(16), 1187-1195.
DOI: 10.2217/cer-2021-0047
R. Schaefer, M. Schlander:
Is the National Institute for Health and Care Excellence (NICE) in England more ‘innovation-friendly’ than the Federal Joint Committee (G-BA) in Germany?
Expert Review of Pharmacoeconomics & Outcomes Research, 2019: 19(4), 453-462.
DOI: 10.1080/14737167.2019.1559732.
T. Ran, C.-Y. Cheng, B. Misselwitz, H. Brenner, J. Ubels, M. Schlander:
Cost–effectiveness of colorectal cancer screening strategies: A systematic review.
Clinical Gastroenterology and Hepatology, 2019: 17(10), 1969-1981.
DOI: 10.1016/j.cgh.2019.01.014.
Economic methods and Social Cost Value Analysis (SCVA)
Multi-attribute utility (MAU) theory-based instruments to measure health-related quality of life (HRQoL)
Contemporary methods to measure HRQoL in economic evaluations are grounded in multi-attribute utility theory. The Multi-Instrument Comparison (MIC) study compared major instruments, revealing they measure related concepts but differ significantly in sensitivity and content—affecting health service valuations and cost-effectiveness comparisons.
In the German branch of the MIC study (led by Michael Schlander as PI), we found results broadly similar with findings from Australia, Canada, Norway, and the United States. Findings were presented to and discussed with experts from international HTA agencies, including the German Institute for Quality and Efficiency in Health Care (IQWiG).
Further analyses of MIC data showed how six different multi-attribute utility instruments (MAUIs)—EQ-5D, SF-6D, HUI-3, 15D, AQoL-4D, and AQoL-8D—vary in their sensitivity to the dimensions of the SF-36 HRQoL questionnaire. Using data from 8,022 participants across six countries, ordinary least squares regression was applied to assess relationships between SF-36 dimensions (such as physical functioning, mental health, and bodily pain) and utility scores from each MAUI. Results revealed that AQoL-8D is most sensitive to mental health, EQ5D to bodily pain, and 15D to physical functioning. This underscores the critical importance of selecting the appropriate MAUI based on the specific health domains of interest, as different instruments exhibit varied responsiveness to HRQoL changes.
Validity of health state utility values used for cost effectiveness analyses
Health state utility values (HSUVs) represent the weights individuals assign to medical interventions or medical technologies, serving as a critical input in cost effectiveness analysis (CEA) to adjust disease state durations and quality of life, ultimately contributing to quality-adjusted life years (QALYs). Despite their importance, there is no widely accepted quality assurance (QA) tool for interpreting and systematically reviewing HSUV studies.
Our first step was a comprehensive review of QA practices in 73 SRLs of HSUVs published from January 2015 to April 2021, highlighting the need for consensus on definitions and dimensions essential for a robust QA framework. An international, multidisciplinary expert panel of seven purposively selected members was established, employing a modified Delphi method with two anonymous online survey rounds followed by a virtual face-to-face meeting. The process achieved consensus on the definitions of scientific quality, QA, three QA dimensions (reporting, relevance, methodological quality), and the scope of a QA tool for systematic reviews of HSUV studies. Future research will focus on identifying QA items, signaling questions, and response options to finalize the tool, aiming to standardize and improve the evaluation of HSUV studies for more rigorous cost-effectiveness analysis in healthcare.
Value of a statistical life year
The evaluation of health care interventions – in particular in the context of health technology assessments (HTAs) – invariably implies some kind of (explicit or implicit) cost benefit assessment. One possible anchor is the value of a statistical life year (VSLY); however, currently used benchmarks for the willingness-to-pay (WTP) per quality-adjusted life year (QALY) gained are controversial and lack robust empirical support.
Our systematic literature review identified 156 studies reporting original data, yielding 169 unique estimates for the value of a statistical life (VSL). After transformation of VSL into VSLY values, we expressed the VSLY – contingent on variables including regional origin of data, valuation method, and study design – in Euro (2019) and as multiples of annual gross domestic product (GDP) per capita. The median VSLY was €168,367 (mean, €256,701) or 6.3 times annual GDP per capita. Regression results indicated that studies with North American data sources reported significantly higher VSLY estimates. We also observed differences by elicitation method, but not by study design. Overall, our results suggest that the empirical WTP for a statistical life year might be substantially higher than currently accepted international benchmarks for cost-effectiveness within the health care context.
Selected Publications
M. Schlander, D. Hernandez, O. Schwarz, R. Schaefer:
Are Commonly Used Cost-Effectiveness Thresholds Too Low? Empirical Evidence From Economic Studies On The Value Of Life.
International Journal of Technology Assessment in Health Care, 2024: 40(S1), S85.
DOI: 10.1017/S0266462324002435
M.T. Muchadeyi, K. Hernandez-Villafuerte, G.L. Di Tanna, R.D. Eckford, Y. Feng, M. Meregaglia, T. Peasgood, S. Petrou, J. Ubels, M. Schlander:
Quality Appraisal in Systematic Literature Reviews of Studies Eliciting Health State Utility Values: Conceptual Considerations.
Pharmacoeconomics, 2024: 42(7), 767-782.
DOI: 10.1007/s40273-024-01365-z
J. Tetteh, M. Schlander:
Exploring the Sensitivity of Utility Scores Predicted by the EQ-5D, SF-6D, HUI-3, 15D, AQoL4D and AQoL8D Multiattribute Utility Instruments to SF-36 Dimensions.
Value in Health, 2024: 27(S12), S441.
M. Schlander, R. Schaefer, O. Schwarz, J. Richardson:
Can We Predict the Impact of the Differential Sensitivity of Health-Related Quality of Life (HRQoL) Instruments on the Valuation of Health State Changes?
Value in Health, 2024: 27(6), S261.
M. Schlander, O. Schwarz, D. Hernandez, R. Schaefer:
Are North Americans Willing-to-Pay More for Life and Limb?
Value in Health, 2024: 27(6), S218.
M. Schlander, D. Hernandez, O. Schwarz, R. Schaefer:
What Is a Year of Life Worth? Empirical Findings from Worldwide Economic Studies on the Value of a Statistical Life.
Value in Health, 2023: 26 (S12), S277.
M.T. Muchadeyi, K. Hernandez-Villafuerte, M. Schlander:
Quality appraisal for systematic literature reviews of health state utility values: a descriptive analysis.
BMC Medical Research Methodology, 2022: 22(1), 303.
DOI: 10.1186/s12874-022-01784-6.
M. Schlander:
Measuring health-related quality of life.
Oral presentation at Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen (IQWIG).
Köln, Germany. July 9, 2018.
M. Schlander, O. Schwarz, D. Hernandez, R. Schäfer:
The search for a cost effectiveness standard: 1-3 times GDP/Capita?
Poster presentation at Health Technology Assessment international (HTAi) Conference.
Vancouver, Canada. June 1-5, 2018.
M. Schlander, O. Schwarz, D. Hernandez, R. Schaefer.
The Value of a Statistical Life Year (VSLY) – An Analysis of Empirical Economic Studies from 1995 to 2015.
Presentation to the 12th European Conference on Health Economics,
Maastricht, July 14, 2018.
[ER1]Added from Ramon
Social preferences and their measurement
In the European social preferences measurement (ESPM) project, a comprehensive literature review on the allocation of health care resources indicated consistent public support for a range of attributes beyond clinical effectiveness. These include: 1) giving priority to the worst-off patients (in terms of initial health state severity); 2) prioritizing urgent interventions to prevent irreversible harm; 3) avoiding discrimination against persons in "double-jeopardy" (e.g., those with comorbidities); 4) giving preference to younger patients under the “fair innings” argument; and 5) supporting equitable access to effective care regardless of high treatment costs.
A research program was initiated to investigate how citizens value these attributes and how they weigh them against each other—contrasting these social preferences with conventional logic of cost-effectiveness analysis. Concerning orphan indications (or “rarity”, an attribute of primary interest), findings showed that citizens are often willing to accept (sometimes much) higher costs per patient for rare and ultra-rare conditions. However, similar to VSLY studies, full publication of the main ESPM study has been delayed.
A critical follow-up—the “sensitivity-go-size” survey, is underway to test whether citizens’ willingness to pay (WTP) changes with the number of patients treated. Equitable resource allocation for rare diseases remains a global challenge. Despite the high costs of many Orphan Medicinal Products (OMPs), often exceeding traditional cost-effectiveness thresholds, public support for reimbursement remains strong.
Building on insights from the Social Preferences for Health Care Interventions (SoPHI) study, which revealed that WTP does not increase proportionally with disease prevalence—and may even decrease as prevalence rises—this suggests that rare disease treatments receive a uniquely high degree of public endorsement. Yet, it remains unclear whether respondents fully understand this prevalence-WTP dynamic, or whether cognitive biases and framing effects influence their choices.
To address these uncertainties, we are launching a discrete choice experiment (DCE) with a representative sample from Baden-Württemberg. The experiment will systematically vary how prevalence data are presented—comparing absolute figures versus relative representations and numerical versus graphical formats—and test how these interact with treatment cost attributes in shaping WTP decisions. Participants will choose between a standard treatment (no extra cost) and a new treatment (with higher insurance premiums), with scenarios differing by disease rarity, cost level, and presentation style. Conducted in collaboration with an experienced panel data company, this study aims to produce robust, policy-relevant evidence to guide equitable resource allocation for rare and innovative medical treatments in the German healthcare system.
Capabilities and health outcomes.
Assessing the value of medical care necessitates a clear definition of value and its components or “attributes”. Traditional constructs in health economics—such as individual willingness-to-pay (WTP) in cost benefit analysis or Quality-Adjusted Life Years (QALYs) in cost effectiveness evaluations—have faced criticism for either lacking broad acceptance or offering a narrow perspective on healthcare value. Therefore, selecting an appropriate outcome measure for economic evaluations is crucial to ensuring their validity.
Proponents of the capability approach argue that medical interventions extend beyond improving health, enhancing an individual’s freedom to achieve desired states of being and doing. However, operationalizing the measurement of these freedoms, or “capabilities,” has posed significant challenges. To address this, a best-fit framework synthesis was conducted, reviewing prior efforts to translate the capability approach into measurable constructs. This synthesis highlighted limitations in earlier definitions, particularly their failure to adequately reflect the burdens individuals face while achieving capabilities and the vagueness surrounding what constitutes a capability.
A patient-reported outcome (PRO) measure was created using this framework, demonstrating the advantages of comprehensive and precise conceptualizations in applying the capability approach. Initial validation studies indicate that responses to the proposed instrument are relatively unaffected by adapted preferences, suggesting its robustness in capturing genuine capability-related outcomes.
Future research aims to integrate this line of work with ongoing studies on the socioeconomic impact of health conditions, facilitating a more nuanced understanding of how health interventions influence not just physical outcomes but broader life capabilities and social wellbeing.
Selected Publications
J. Ubels, K. Hernandez-Villafuerte, E. Niebauer, M. Schlander:
The Use of a Comprehensive Concept of Capability for Wellbeing Assessment: A Best-Fit Framework Synthesis.
Health Care Analysis, Published online August 19, 2024.
DOI: 10.1007/s10728-024-00488-w
J. Ubels, K. Hernandez-Villafuerte, M. Schlander:
The value of freedom: a review of the current developments and conceptual issues in the measurement of capability.
Journal of Human Development and Capabilities, 2022: 23(3), 327-353.
DOI: 10.1080/19452829.2022.2053506
M. Brougham, M. Schlander, H. Telser, S. Bakshi, O. Sola-Morales:
Use of the Incremental Cost Effectiveness Ratio for Decision-Making Policies - What's the Problem? A Perspective Paper.
Expert Review of Pharmacoeconomics & Outcomes Research, 2022: 22(6), 913-918.
DOI: 10.1080/14737167.2022.2064847.
D. Moro, M. Schlander, H. Telser, O. Sola-Morales, M. D. Clark, A. Olaye, C. Camp, M. Jain, T. Butt, S. Bakshi:
Evaluating discrete choice experiment willingness to pay [DCE-WTP] analysis, and relative social willingness to pay [RS-WTP] analysis in a health technology assessment of a treatment for an ultra-rare childhood disease [CLN2].
Expert Review of Pharmacoeconomics & Outcomes Research, 2022: 22(4), 581-598.
DOI: 10.1080/14737167.2022.2014324
J. M. Heard, C. Vrinten, M. Schlander, C. M. Bellettato, C. van Lingen, M. Scarpa; MetabERN collaboration group:
Availability, accessibility and delivery to patients of the 28 orphan medicines approved by the European Medicine Agency for hereditary metabolic diseases in the MetabERN network.
Orphanet Journal of Rare Diseases, 2020: 15(1), 3.
DOI: 10.1186/s13023-019-1280-5
M.-J. Linton, P. M. Mitchell, H. Al-Janabi, M. Schlander, J. Richardson, A. Iezzi, J. Ubels, J. Coast:
Comparing the German translation of the ICECAP-A capability wellbeing measure to the original English version: Psychometric properties across healthy samples and seven health condition groups.
Applied Research in Quality of Life, 2020: 15, 651-673.
DOI: 10.1007/s11482-018-9681-5
J. J. Caro, J. E. Brazier, J. Karnon, P. Kolominsky-Rabas, A. J. McGuire, E. Nord, M. Schlander:
Determining value in Health Technology Assessment: Stay the course or tack away?
PharmacoEconomics, 2019: 37(3), 293-299.
DOI: 10.1007/s40273-018-0742-2.
J. Richardson, M. Schlander:
Health Technology Assessment (HTA) and economic evaluation: Efficiency or fairness first.
Journal of Market Access & Health Policy, 2019: 7(1), 1557981.
DOI: 10.1080/20016689.2018.1557981
M. Wagner, D. Samaha, R. Casciano, M. Brougham, P. Abrishami, C. Petrie, B. Avouac, L. Mantovani, A. Sarría-Santamera, P. Kind, M. Schlander:
Moving towards accountability for reasonableness: A systematic exploration of the features of legitimate healthcare coverage decision-making processes using rare diseases and regenerative therapies as a case study.
International Journal of Health Policy and Management, 2019: 8 (7), 424-443.
DOI: 10.15171/ijhpm.2019.24.
M. Schlander:
Woran bemisst sich Effizienz im Gesundheitswesen? Zur Klärung fachwissenschaftlicher Begriffe und Kriterien.
Amos International, (2017): 11(1), 22-31.
COVID-19 pandemic related research
In response to the COVID-19 pandemic, we launched several exploratory and research initiatives at the request of the DKFZ Management Board. As 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.
Among our efforts, we explored various data sources to identify early indicators of changes in healthcare utilization and outcomes. Additionally, we represented DKFZ at the COVID-19 & Cancer Task Force of the Union for International Cancer Control (UICC) led by Richard Sullivan (London).
Our first study, in collaboration with the DKFZ Cancer Information Service (Krebsinformationsdienst, KID), was a cross-sectional online survey of German cancer patients (July 2020 to June 2021). 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, the CroKus-1 study (2021), led by Volker Arndt (Baden-Württemberg Cancer Registry, DKFZ), surveyed a representative sample of cancer patients and cancer survivors. 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.
Beyond patient-focused studies, we explored broader ethical considerations in healthcare prioritization during the COVID-19 pandemic, particularly in vaccine allocation and resource distribution. März et al. (2022) utilized quantitative models to illustrate the trade-offs in vaccine policy decisions, emphasizing the need for transparent, national strategies balancing ethical principles like population benefit, reciprocity, social justice, and equal respect for individuals. Another article 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 underscored the complexity of ethical decision-making in pandemics, where prioritization invariably involves balancing competing values and outcomes.
Selected Publications
D. Doege, J. Frick, R.D. 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
R. D. Eckford, A. Gaisser, V. Arndt, M. Baumann, E. Kludt, K. Mehlis, J. Ubels, E. C. Winkler, S. Weg-Remers, M. Schlander:
The COVID-19 pandemic and cancer patients in Germany: impact on treatment, follow-up and psychological burden.
Frontiers in Public Health, 2022: Feb 9, 9:788598
DOI: 10.3389/fpubh.2021.788598
R. Eckford, A. Gaisser, E. Kludt, S. Weg-Remers, M. Schlander:
Financial impact on cancer patients in Germany during the COVID-19 pandemic.
Oral presentation at World Cancer Congress (WCC) 2022.
A. Gaisser, R. D. Eckford, V. Arndt, D. Doege, E. Kludt, J. Ubels, M. Schlander, S. Weg-Remers:
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.
DOI: 10.1007/s00761-022-01096-w
J. W. März, A. Molnar, S. Holm, M. Schlander:
The ethics of COVID-19 vaccine allocation: Don't forget the trade-offs!
Public Health Ethics, 2022: 15(1), 41-50.
DOI: 10.1093/phe/phac001
J. W. März, S. Holm, M. Schlander:
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.
DOI: 10.1007/s11019-021-10045-0
J. W. März, M. Schlander:
Not kennt kein Gebot? Die Rule of Rescue als Leitprinzip in der Covid-19-Pandemie.
AMOS International, 2021: 15(3), 39-44.
Education, Training, and Outreach
Past Open Seminars
April 29, 2025
Making Rational Choices: Are cancer drug prices justified by the added benefit provided?
Prof. Wim G. Goettsch, Utrecht University and Special Advisor in Health Technology Assessment (HTA), Dutch National Health Care Institute (ZIN), Utrecht, Netherlands
February 25, 2025
Data and Process Mining in Health Care – State of the Art
Dr. Lionel Perrier, Centre Léon Bérard and Université Lumière Lyon 2, Lyon, France
December 5, 2023
Health Technology Assessment (HTA) Beyond Checking the Boxes: How to Establish or to Improve Evidence-Informed Deliberative Processes for HTA
Dr. Wija Oortwijn, President, Health Technology Assessment International (HTAi) and Senior Researcher, Radboud University Medical Center, Nijmegen, Netherlands
October 10, 2023
Health Technology Assessment (HTA) Personal Reflections of a Patient Representative in an Appraisal Committee
Cees Smit, Author, Painter, and Patient Advocate; Honorary Doctor, University of Amsterdam
June 13, 2023
“Why Are We Doing This?” Cancer Policy Should be Evidence-Informed: The Roles of Clinical and Cost Effectiveness
Prof. Richard Sullivan, King’s College London, United Kingdom
March 13, 2023
Microsimulation for Cost Effectiveness Analysis of Prostate Cancer Testing
Associate Prof. Mark Clements and Dr. Shuang Hao, Karolinska Institute, Stockholm (Sweden) Department of Medical Epidemiology and Biostatistics, Stockholm, Sweden
June 25, 2020
“Financial Toxicity” – The Financial Impact of Cancer on Patients and Families
Prof. Eva Winkler, Nationales Zentrum für Tumorerkrankungen (NCT), Heidelberg, Germany
February 12, 2020
Health Technology Assessment (HTA) in Europe - What´s Next?
Dr. Alric Rüther, Head of International Affairs, Institute for Quality and Efficiency in Healthcare (IQWIG), Germany
September 4, 2019
Methodological Challenges in the Use of Clinical Study Data for Cost Effectiveness Analyses
Dr. Marko Raseta, Keele University, Newcastle-under-Lyme, United Kingdom
April 25, 2019
(Early) Health Economics of Next Generation Sequencing in Personalized Oncology
Dr. Valesca Retèl, Senior Scientist, Netherlands Cancer Institute (NKI) & University of Twente, Netherlands
February 11, 2019
Health Technology Assessment (HTA) in Europe – Quo Vadis?
Dr. Ansgar Hebborn, Head, European Access Policy Affairs, F. Hoffmann-La Roche AG, Basel, Switzerland
December 12, 2018
How Much Do We Spend on Medicines in the EU? Assessing the Impact of Rebates and Discounts
Dr. Jorge Mestre-Ferrandiz, Independent Health Economist, Madrid, Spain
June 18, 2018
Modeling the Natural History of Colorectal Cancer: A Microsimulation Approach
Dr. Benjamin Misselwitz, University of Zurich, Switzerland
May 17, 2018
Health Economic Evaluation and High-Cost Care: The Need for a Reconsideration
Prof. Jeff Richardson, Monash University, Melbourne, Australia
Team
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Prof. Dr. med. Michael Schlander
Head of Division
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Rachel Eckford
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Katrin Eike-Verfürth
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Min Wai Lwin
Ph.D. Student
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Anett Molnar
Ph.D. Student
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Muchandifunga Muchadeyi
Ph.D. Student
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Dr. Ramon Schäfer
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Polina Skarga
Student Assistant
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Dr. Josephine Tetteh
Researcher
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