Cancer is in large part a disease of aging, with incidence and mortality rates rising with increasing age. Cancer incidence and mortality rates in the elderly as well as the associated health-care expenditures have grown considerably over the past several decades. In addition, elderly cancer patients appear to be disproportionately affected by the toxicities associated with treatment due to differences in drug metabolism and organ tolerance related to the impact of age on critical organs such as the bone marrow. Elderly patients are also more likely to have comorbid conditions that can further increase toxicity and reduce life expectancy.
The disproportionate impact of cancer and cancer treatment on elderly patients stands in stark contrast to the relative lack of data for this population from controlled clinical trials. Although there have been far too few studies of elderly patients due to their potential increased risk of toxicity, the available trials demonstrate that such patients, nevertheless, benefit from standard treatment and supportive care measures.
Economic and quality-of-life outcomes are all too often either not addressed in clinical trials or relegated to the status of secondary outcomes with limited power to address important health-care questions.[4,5] When economic outcomes have been considered, they are generally limited to the direct costs of receiving medical care. The direct costs of cancer treatment must consider both the actual cost of treatment and the cost of managing treatment-related toxicity as well as subsequent disease progression or recurrence. Only rarely have analyses addressed nonmedical costs such as transportation or child-care expenses and out-of-pocket costs while receiving care. Likewise, few studies have looked at the indirect costs of cancer such as days lost from work by the patient or his caregiver.
Nevertheless, such nonmedical and indirect costs may represent one of the greatest barriers to appropriate cancer treatment among the elderly cancer population on fixed incomes faced with dramatically rising health-care costs. Any comprehensive economic analysis in elderly cancer patients should include not only the direct costs of the medical care but also the indirect and out-of-pocket costs associated with cancer care as discussed in the paper by McKoy et al. Although intangible costs such as pain and suffering and loss of companionship are difficult to measure, they are also very real to the patient and family. While the economic measures used are fundamentally the same in older and younger patients, the increased potential for toxicity, the greater frequency of comorbid conditions, and the limited resources and dependence on fixed incomes among the elderly should always be kept in mind.
Economic studies are most informative when a treatment is associated with an improved clinical outcome but at increased cost, or when it is associated with a lower cost but the same or worse outcome. When clinical effectiveness is the same, a cost-minimization analysis is generally used to compare and identify the least costly approach. Where clinical or quality-adjusted effectiveness differ between treatments, economic analyses are generally based on cost-effectiveness, representing the added cost per life year gained, or cost-utility, representing the added cost per quality-adjusted life year gained.
The majority of economic analyses of cancer care in the elderly, including cost-effectiveness studies of available interventions, are based entirely on direct medical expenditures such as institutional and professional costs and the costs of drugs. Recent studies have suggested that patient time costs add considerably to the total costs of cancer care in both the elderly and the young. Despite frequently voiced concern over the rapidly escalating costs of drugs, the problem appears to be even worse from the economic perspective of the patient, family, and society.
In fact, there are several reasons to believe that such estimates of nonmedical costs are, if anything, underestimates. Family and friends often accompany patients to the health-care provider, suggesting that these studies may underestimate the nonmedical costs from a family or societal perspective. It is also likely that information on travel and service time available from claims data is incomplete, and clearly not all services are reimbursed by Medicare. Finally, there remains ambiguity concerning the valuation of time consumption during retirement, although clearly money has been saved explicitly for the purpose of using and enjoying this time.
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