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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."
Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011
Dr. Shankar P.R.
"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."
Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Original article / research
Full Version
Variation in Cost Among Anticancer Drugs Available in India: A Cross-sectional Study
Correspondence Address :
Dr. Ramanand Janardhanrao Patil,
Associate Professor, Department of Pharmacology, Symbiosis Medical College for Women, Symbiosis International (Deemed University) (SIU), Taluka Mulshi, Pune-412115, Maharashtra, India.
E-mail: ramanand004@gmail.com; ramanand.patil@smcw.siu.edu.in
Introduction: Cancer is an abnormal growth of cells, and it encompasses over 100 types of cancers that affect humans. Cancer management often involves a combination of radiation therapy, surgery, chemotherapy, and targeted therapy. Anticancer drugs, in general, tend to be more expensive compared to other categories of drugs, significantly contributing to the overall drug expenditure incurred by patients.
Aim: To analyse the percentage variation in cost among different brands of anticancer drugs available in the Indian market.
Materials and Methods: A cross-sectional study was conducted in the Department of Pharmacology at Symbiosis Medical College, Symbiosis International University, in Pune, Maharashtra, India. The study duration was six months, from March 2021 to August 2021. Data on the prices of anticancer drugs were collected and analysed using the October 2020 to January 2021 edition of the Current Index of Medical Specialities (CIMS). A total of 29 anticancer drugs with different strengths were considered. The cost of a particular anticancer drug with the same dose and dosage form produced by different companies was compared. Drugs were selected based on their strength and dosage forms. The cost of one tablet, capsule, or injection was calculated in Indian Rupees (INR). The cost of a single unit was compared, and the difference between the maximum and minimum costs was calculated. Subsequently, cost ratios and the percentage of cost variation were determined. The study findings were recorded in both Microsoft Word 2016 and Excel 2016, and they were expressed as absolute numbers and percentages.
Results: Bortezomib 3.5 mg was the costliest among anticancer drug which was priced at INR 18,988.00, while the cheapest was methotrexate 2.5 mg tablet, priced at INR 1.886. Among the anticancer drugs, pacilitaxel 260 mg injection had the highest cost ratio of 1 29.3055, whereas cisplatin 10 mg injection had the lowest cost ratio 1. Regarding cost variation, pacilitaxel 260 mg injection showed the highest percentage of cost variation at 2830.5555%, while cisplatin 10 mg injection showed the lowest at 0%.
Conclusion: This study revealed a significant variation in prices, cost ratios, and cost variation among different anticancer drugs, providing insights into the price discrepancies observed in the market. The findings can help physicians and policymakers become aware of the cost variations among these drugs and make informed decisions regarding pricing.
Cancer, Ceiling price, Cost analysis, Cost variation, Pharmacoeconomic
Cancer is an abnormal growth of cells, also known as malignancy. Over 100 types of cancers affect humans, including breast cancer, skin cancer, lung cancer, colon cancer, prostate cancer, and lymphoma. Symptoms vary depending on the type of cancer. The treatment of cancer includes chemotherapy, radiation, and/or surgery (1). Signs and symptoms may include a lump, prolonged cough, abnormal bleeding, weight loss, and a change in bowel habits (2). Tobacco use is responsible for about 25% of cancer deaths (3). Another 10% are attributed to obesity, poor diet, lack of physical activity, or excessive alcohol consumption (3),(4),(5). Cancer is often treated with a combination of radiation therapy, surgery, chemotherapy, and targeted therapy (3),(6). As of 2019, approximately 18 million new cases occur annually worldwide (7). In 2020, it was projected that there would be 1,392,179 cancer patients in India (8). The most common types of cancer in males are lung cancer, prostate cancer, colorectal cancer, and stomach cancer. In females, the most common types are breast cancer, colorectal cancer, lung cancer, and cervical cancer (9). Generally, anticancer drugs are more expensive than any other category of drugs and significantly contribute to the growing drug expenditure for patients (10).
In developed countries, where a medical insurance system is in place, affordability of anticancer drugs may not be a concern. However, in developing countries like India, where medical insurance is still emerging, affordability becomes a major issue (11). Due to the lack of comparative information on anticancer drug prices, it is challenging for clinicians to prescribe more affordable medicines. Very few studies on cost variation analysis of different anticancer drugs have been published. Adwal SK and Baghel R reported a wide variation in the prices of most anticancer drugs available in India, such as the alkylating agent carboplatin 150 mg injection (1100%) and the lowest variation with the antimetabolite anticancer agent cytarabine 500 mg injection (6.56%) (12). Siddiqui M and Rajkumar SV reported difficulties in determining the true generic price and found that generic cancer drugs are costly in developed countries (13). Prices of anticancer drugs are subject to regular changes, so this study focuses on the cost variation in the year 2020-2021 compared to past literature. It aims to help physicians and policymakers become aware of the cost variations among drugs and make informed decisions regarding pricing. Therefore, this study was designed to analyse the percentage variation in cost among different brands of anticancer drugs available in the Indian market.
A cross-sectional study was conducted in the Department of Pharmacology at Symbiosis Medical College, Symbiosis International University, Pune, Maharashtra, India. The study duration was six months, from March 2021 to August 2021. The study received approval from the Institutional Ethics Committee (IEC) with approval number SIU/IEC/213. Data on the prices of anticancer drugs were collected and analysed using the Current Index of Medical Specialities (CIMS) from October 2020 to January 2021. A total of 29 anticancer drugs with different strengths were considered.
Inclusion criteria: Drugs with the same strengths but manufactured by different companies and with the same strength and quantity were included in the study.
Exclusion criteria: Drugs manufactured by only one company with different strengths were excluded. Drugs without available cost information were also excluded from the study.
Study Procedure
A total of 29 anticancer drugs with different strengths were considered. Anticancer drugs available in different dosage forms, such as oral and parenteral, were analysed for their costs. The cost of anticancer drugs was also analysed according to different classes, such as alkylating agents, topoisomerase-2 inhibitors, and proteasome inhibitors. The cost of a particular anticancer drug with the same dose and dosage form, manufactured by different companies, was compared. Drugs manufactured by only one company or by different companies with different strengths, as well as drugs without cost information, were excluded. Drugs were selected based on their strength and dosage forms. The cost of each brand was entered into a table. Tablets, capsules, or injections with the same quantity were selected. The costs of these dosage forms were compared and calculated in INR.
The difference between the maximum and minimum costs was calculated. Then, the cost ratio and percentage of cost variation were calculated (14). The following formula was used to calculate the price variation:
Price of the most expensive brand-Price of the least expensive brand
Percentage price variation=--------------------------------×100
Price of the least expensive brand
The cost ratio was calculated by dividing the costliest brand by the cheapest brand, showing how many times the costliest brand is more expensive than the cheapest brand (15).
Statistical Analysis
The data from the study was entered into both Microsoft Word 2016 and Excel 2016 and expressed as absolute numbers and percentages. The percentage of cost variation and cost ratio were calculated using the findings. Tables, figures, and charts were used to represent the data.
Anticancer drugs: DThe drugs were selected from 13 different classes in the study.
• Alkylating agents: Among the alkylating agents, the costliest drug is bendamustine (100 mg injection; INR 9,134.00), and the cheapest drug is temozolomide (20 mg capsule; INR 280.00). The cost ratio of temozolomide (100 mg capsule; 2.1468) is the highest, and that of temozolomide (250 mg capsule; 1.6309) is the lowest. The cost variation of temozolomide (100 mg capsule; 114.6881%) is the highest, while that of bendamustine (100 mg injection; 21.1084%) is the lowest.
• Platinum coordination complexes: Among the platinum coordination complexes, the costliest drug is carboplatin (450 mg 45 mL injection; INR 5,900.00), and the cheapest drug is cisplatin (10 mg injection; INR 67.00). The cost ratio of carboplatin (150 mg 15 mL injection; 3.1002) is the highest, and that of cisplatin (10 mg injection; 1) is the lowest. The cost variation of carboplatin (150 mg 15 mL injection; 210.0252%) is the highest, while that of cisplatin (10 mg injection; 0%) is the lowest.
• Antimetabolites: Among the antimetabolites, the costliest drug is pemetrexed (500 mg injection; INR 17,000.00), and the cheapest drug is methotrexate (2.5 mg tablet; INR 1.886).
The cost ratio of pemetrexed (100 mg injection; 7.9754) is the highest, and that of methotrexate (10 mg tablet; 1.0190) is the lowest. The cost variation of pemetrexed (100 mg injection; 697.5460%) is the highest, while that of methotrexate (10 mg tablet; 1.9038%) is the lowest.
• Microtubule damaging agents: Among the microtubule damaging agents, the costliest drug is docetaxel (120 mg/3 mL injection; INR 18,700.00), and the cheapest drug is paclitaxel (260 mg injection; INR 360.00). The cost ratio of paclitaxel (260 mg injection; 29.3055) is the highest, and that of docetaxel (80 mg/2 mL injection; 1.1147) is the lowest. The cost variation of paclitaxel (260 mg injection; 2830.5555%) is the highest, while that of docetaxel (80 mg/2 mL injection; 11.4767%) is the lowest.
• Topoisomerase-2 inhibitor: Among the topoisomerase-2 inhibitors, the costliest drug is etoposide (50 mg capsule; INR 476.00), and the cheapest drug is etoposide (100 mg injection; INR 182.00). The cost ratio and cost variation of etoposide were (50 mg capsule and 100 mg injection; 1.0769) and (50 mg capsule and 100 mg injection; 7.6923%), respectively.
• Antibiotics: Among the antibiotics, the costliest drug is doxorubicin (20 mg/10 mL injection; INR 3,625.00), and the cheapest drug is mitomycin (2 mg injection; INR 135.00). The cost ratio of doxorubicin (20 mg/10 mL injection; 12.1644) is the highest, and that of mitomycin (40 mg injection; 1.0305) is the lowest. The cost variation of doxorubicin (20 mg/10 mL injection; 1116.4429%) is the highest, while that of mitomycin (40 mg injection; 3.0534%) is the lowest.
• Break Point Cluster (BCR)-Abelson (ABL) tyrosine kinase inhibitors: Among BCR-ABL tyrosine kinase inhibitors, the costliest drug is imatinib (400 mg tablet; INR 213.3), and the cheapest drug is imatinib (400 mg tablet; INR 210). The cost ratio and cost variation of imatinib were (400 mg tablet; 1.0157) and (400 mg tablet; 1.5714%), respectively.
• Epidermal Growth Factor (EGF) [Human Epidermal Growth Factor Receptor (HE R)] receptor inhibitors: Among EGF (HER) receptor inhibitors, the costliest drug is gefitinib (250 mg tablet; INR 950.00), and the cheapest drug is gefitinib (250 mg tablet; INR 250). The highest cost ratio is of gefitinib (250 mg tablet; 3.8), and the lowest is of erlotinib (150 mg tablet; 1.0587). The highest cost variation is of gefitinib (250 mg tablet; 280%), and the lowest is of erlotinib (150 mg tablet; 5.8705%).
• Proteasome inhibitors: Among proteasome inhibitors, the costliest drug is bortezomib (3.5 mg injection; INR 18,988), and the cheapest drug is bortezomib (2 mg injection; INR 3,228.00). The highest cost ratio is of bortezomib (2 mg injection; 3.8708), and the lowest is of bortezomib (3.5 mg injection; 2.5079). The highest cost variation is of bortezomib (2 mg injection; 287.0817%), and the lowest is of bortezomib (3.5 mg injection; 150.7991%).
• Biological response modifiers: Among biological response modifiers, the costliest drug is interferon alfa-2B (5MIU injection; INR 2,835.60), and the cheapest drug is interferon alfa-2B (3MIU injection; INR 892.85). The highest cost ratio is of interferon alfa-2B (5MIU injection; 2.1082), and the lowest is of interferon alfa-2B (3MIU injection; 1.9996). The highest cost variation is of interferon alfa-2B (5MIU injection; 110.8252%), and the lowest is of interferon alfa-2B (3MIU injection; 99.9663%).
• Aromatase inhibitors: Among aromatase inhibitors, the costliest drug is letrozole (2.5 mg tablet; INR 79.6), and the cheapest drug is letrozole (2.5 mg tablet; INR 24). The highest cost ratio is of letrozole (2.5 mg tablet; 3.3166), and the lowest is of anastrozole (1 mg tablet; 1.6468). The highest cost variation is of letrozole (2.5 mg tablet; 231.6666%), and the lowest is of anastrozole (1 mg tablet; 64.6857%).
• Anit-androgens: Among antiandrogens, the costliest drug is flutamide (250 mg tablet; INR 14.174), and the cheapest drug is flutamide (250 mg tablet; INR 9.75). The cost ratio of flutamide 250 mg tablet is 1.4537, and the cost variation is 45.3743%.
• Miscellaneous: Among miscellaneous drugs, the costliest drug is amifostine (500 mg injection; INR 13,088.00), and the cheapest drug is lenalidomide (5 mg capsule; INR 63.2). The highest cost ratio is of amifostine (500 mg injection; 3.7394), and the lowest is of hydroxycarbamide (500 mg capsule; 1.0353). The highest cost variation is of amifostine (500 mg injection; 273.9428%), and the lowest is of hydroxycarbamide (500 mg capsule; 3.5327%).
• Maximum cost variation among anticancer drugs: Among anticancer drugs, pacilitaxel 260 mg injection (INR 2,830.5555) showed the highest cost variation. The maximum cost variation among anticancer drugs is shown in (Table/Fig 1)a,b.
Cancer involves abnormal cell growth and has the potential to invade or spread to other parts of the body (3),(16). The prices of drugs in the Indian market are regulated by the National Pharmaceutical Pricing Authority (NPPA), Government of India. The NPPA fixes the ceiling price of a drug based on its essentiality. Pharmaceutical companies are required to set the price of their products equal to or below the ceiling price specified in the Drugs Prices Control Order (DPCO) (17). The 21st World Health Organisation (WHO) model list of essential medicines (2019) also includes many anticancer drugs (18).
Cancer was chosen as the focus because it is one of the most common disorders in India and worldwide, causing significant morbidity and mortality, and requiring prolonged prescription. Data from CIMS between October 2020 and January 2021 was selected for data collection and analysis. Among anticancer drugs, the costliest drug is bortezomib 3.5 mg injection (INR 18,988.00), and the cheapest drug is methotrexate 2.5 mg tablet (INR 1.886). Among anticancer drugs, pacilitaxel 260 mg injection (29.3055) showed the highest cost ratio, while cisplatin 10 mg injection (1) showed the lowest cost ratio. Among anticancer drugs, pacilitaxel 260 mg injection (2,830.5555%) showed the highest cost variation, while cisplatin 10 mg injection (0%) showed the lowest cost variation.
The findings of the present study show a high variation in prices among different anticancer drugs. Clinicians may prescribe costlier drugs due to the influence of pharmaceutical companies, despite the insistence of the Medical Council of India (MCI) to prescribe generic drugs instead of branded ones. Some patients believe that generic and cheap drugs will be less effective and may not cure or control cancer progression. However, there is no available information to prove that costlier drugs are more effective than cheaper ones (19). Clinicians should be aware of the cost variation of drugs and prescribe generic and affordable options, as prescribing cheaper drugs may improve patient compliance. The government needs to take steps to regulate drug prices to ensure affordability for all citizens. It is the responsibility of all stakeholders, including doctors, pharmacists, patients, and authorities, to control drug prices. A study by Adwal SK and Baghel R showed a wide variation in the prices of most anticancer drugs available in India, with the highest variation observed in the alkylating agent carboplatin 150 mg injection (1100%) and the lowest in the anti-metabolite anticancer agent cytarabine 500 mg injection (6.56%) (12).
A study by Siddiqui M and Rajkumar SV highlighted the difficulty in determining the true cost of generic cancer drugs, even in developed countries (13). Another study by Salmasi S et al., showed
• High price variation among anticancer drugs in South East Asian, Western Pacific and East Mediterranean region.
• Mean unit price in Oman was highest (INR 2355.60) and in Taiwan was lowest (INR 492.61) (20).
The findings of various similar studies are presented alongside the present study in (Table/Fig 2) (12),(13),(20).
Limitation(s)
A limitation of this study is the small number of references used. Only data from CIMS was utilised, and further studies are needed to gain a more comprehensive understanding of the cost variation of anticancer drugs. To better comprehend the cost of drugs, pharmacoeconomics should be included in the medical education curriculum. It is important to note that since this study was conducted in 2020-2021, the prices may not accurately reflect the current market prices.
The present study has shown wide variation in the prices, cost ratios, and cost variation of anticancer drugs, helping to understand the price variation among different anticancer drugs. This will assist physicians and policymakers in becoming aware of the cost variations among drugs and making informed decisions regarding prices.
DOI: 10.7860/JCDR/2023/65520.18297
Date of Submission: May 20, 2023
Date of Peer Review: Jun 19, 2023
Date of Acceptance: Jul 11, 2023
Date of Publishing: Aug 01, 2023
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? NA
• For any images presented appropriate consent has been obtained from the subjects. NA
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: May 20, 2023
• Manual Googling: Jun 14, 2023
• iThenticate Software: Jul 07, 2023 (14%)
ETYMOLOGY: Author Origin
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