Patients aged 65 years and older represent 12% of the US population yet account for approximately 56% of cancer cases and 69% of all cancer mortalities. The overall cost of cancer in 2005 was $209.9 billion—$74 billion for direct medical costs and $118.4 billion for indirect mortality costs. This paper considers the direct, indirect, and out-of-pocket expenditures incurred by cancer patients ‚â• 50 years of age. Several major empirical studies on supportive care for older patients and cancer-related costs were reviewed. Insurance coverage, hematologic malignancies, squamous cell carcinoma of the head and neck, and cancers of the breast, prostate, colorectum, and lung were evaluated. Major sources of direct medical expenditures covered by third-party insurers for patients aged 65 years and older include extended length of hospital stay, home health assistance following hospital discharge, adjuvant prescription medications, lower-risk treatment (for prostate cancer), and advent of new pharmaceuticals (for colorectal cancer). The mean total direct medical cost for breast cancer is $35,164, and the cumulative cost for prostate cancer is $42,570. Emerging targeted cancer drug costs range from $20,000 to $50,000 annually per patient. Additional clinical trials and cost-effective treatments are needed for older patients to ameliorate the disproportionate economic burden among older individuals with cancer. Additional research about cancer costs may also lead to reforms in cancer care reimbursement, and therefore provide access to affordable health care for older patients.
The overall cost of cancer in 2005 was $209.9 billion: $74 billion for direct medical costs (prevention, screening, diagnosis, treatment, and palliation) and $118.4 billion for indirect mortality costs.[1-3] (Indirect mortality cost refers to the cost of lost productivity due to premature death, with "premature" indicating the difference in life expectancies at given ages of individuals with and without the disease.) Medicare or private health insurance programs cover approximately one-third of cancer-related costs. Non-reimbursed or "out-of-pocket" costs constitute the remaining two-thirds.
The most costly cancers for men are prostate, lung, and colorectal cancers, with the corollary in women being breast, colorectal, and lung cancers. Seniors aged 65 years and over represent 12% of the population in the United States, but account for approximately 56% of cancer cases. This disparity is due, in part, to the increased prevalence of cancer as people age and the high rate of comorbid medical illnesses in older individuals. Care for older individuals may require complex protocols that are likely to be costly, and choice of therapy may also be restricted relative to toxicity of the agent and expected years of life remaining.[5,6] Insurance helps, but patients are bearing a growing portion of these expenditures and may face financial hardships as a result of nonreimbursed cancer costs.
This paper provides an overview of several prominent articles and empirical studies on supportive care and cancer-related costs faced by older cancer patients. It focuses primarily on individuals 65 years of age and over (and where cost information was availble, also considers those aged 50 to 64) and reviews several types of cancer. We consider direct, indirect and out-of-pocket expenditures in this discussion.
Americans 65 years of age and older currently account for more than 13% of the US population. Based on current projections by the US Bureau of Census, by 2030, one in five Americans will be over 65 years of age, reflecting 20.1% of the total population (70.2 million persons). The oldest old-Americans age 85 and older—represent the fastest-growing segment of the US population, with more than 50,000 Americans having reached 100 years of age or more. Attendant to this unprecedented aging explosion is the increased incidence of cancer. The cancer burden of the elderly is high in the United States and has increased over time, with 60% of all malignant tumors occurring among persons aged 65 years and older.
Access to Affordable Cancer Care
A recent study of various cancer types found that fewer than 4% of patients were uninsured at the time they were considered for initial treatment, 48% had private insurance or HMO coverage, 16.8% had Medicare but no supplemental insurance, and 7.5% of patients had Medicaid insurance. Most but not all individuals with health insurance have at least some level of coverage for pharmaceuticals. Because of coverage gaps, deductible requirements, and copayments, out-of-pocket expenditures may be large for cancer patients. Recent technologic developments have also affected costs. These include the advent of targeted drugs and other high-tech therapy (Table 1).[4,11-14] Furthermore, while Medicare Part D might reduce the costs faced by some Medicare beneficiaries, it does not necessarily do so for cancer patients who require costly chemotherapy.
Physiologic Changes of Aging
Aging patients present with comorbidities, such as hypertension, diabetes mellitus, osteoporosis, and osteoarthritis. Certain physiologic changes of aging (decreased renal function, impaired hepatic Blood flow, and decreased cardiac reserve, among others) along with pathologic changes combine to effectuate a decrease in the functional status of the elderly cancer patient and to render cancer care in the elderly more expensive over time. Furthermore, elderly patients with cancer who are contemplating surgical treatment and/or chemotherapy will often require more preoperative studies and laboratory tests in an effort to minimize their risks from potentially toxic treatment, thus increasing costs of cancer care.
Many cancer drugs are metabolized by the liver and can fall prey to specific physiologic changes that are attendant to aging. Liver Blood flow decreases by 0.3% to 1.5 % per year; liver size also decreases, and liver function sees a decrement of 25% to 30%. Decreases in hepatic Blood flow lead to increases in serum drug levels and drug half-lives for drugs in phase I hepatic metabolism. This can result in decreased clearance and increased toxicity with the administration of commonly used chemotherapy drugs. Despite the impact of physiologic changes in the elderly that might negatively impact cancer treatment, improvements in supportive care over the last 10 to 20 years have enabled physicians to offer more aggressive, and often costly, treatments to older patients. Particularly, improvements in antiemetic therapy and mucositis prevention have facilitated the administration of cytotoxic therapies to older patients. Older patients are also at higher risk for bone marrow suppression during chemotherapy, and the aggressive use of granulocyte and erythrocyte growth factors in the course of chemotherapy has lessened the risk of severe neutropenia or anemia in the older patient during therapy.[15,16] New mucositis prevention protocols, intensive care unit monitoring, and the introduction of lower-intensity chemotherapy preparation regimens have made allogeneic transplant a possibility in some patients as old as 80 years.
Dr. Edwards receives research support from Merck and Procter & Gamble, and is a speaker for GlaxoSmithKline, Roche, and Eli Lilly. Dr. Bennett is a consultant for and receives grant support from Amgen.
1. American Cancer Society: Cancer facts and figures 2006. Available at www.cancer.org/docroot/STT/stt_0_2006.asp. Accessed February 1, 2007.
2. Brown ML, Lipscomb J, Snyder C: The burden of illness of cancer: Economic cost and quality of life. Annu Rev Pub Health 22:91-113, 2001.
3. Brown ML, Riley GF, Schulsser N, et al: Estimating health care costs related to cancer treatment from SEER-Medicare data. Medical Care 40(8 suppl):IV-104-IV-117, 2002.
4. SEER Cancer Statistics Review 1975-2003: Estimated new cancer cases and deaths for 2006 (Table I-1). Available at seer.cancer.gov/csr/1975_2003/results_single/sect_01_table.01.pdf. Accessed December 19, 2006.
5. American Cancer Society: Cost of cancer on the rise. ACS News Center. Available at www.cancer.org/docroot/NWS/content/NWS_1_1x_Cost_of_Cancer_On_the_Rise.asp. Accessed December 16, 2006.
6. Balducci L, Lyman GH: Cancer in the elderly: Epidemiologic and clinical implications. Clin Geriatr Med 13:1-14, 1997.
7. Hayman JA, Langa KM, Kabeto MU, et al: Estimating the cost of informal caregiving for elderly patients with cancer. J Clin Oncol 19:3219-3225, 2001.
8. US Census Bureau: Available at www.census.gov. Accessed February 12, 2007.
9. Harlan LC, Greene AL, Clegg LX, et al: Insurance status and the use of guideline therapy in the treatment of selected cancers. J Clin Oncol 23:9079-9088, 2005.
10. Stuart B, Briesacher BA, Shea DG, et al: Riding the rollercoaster: The ups and downs in out-of-pocket spending under the standard Medicare drug benefit. Health Aff 24:1022-1031, 2005.
11. Berenson A: A cancer drug shows promise, at a price that many can't pay. New York Times February 15, 2006. Available at www.nytimes.com/2006/02/15/business/15drug.html?ei=5090&en=62aabaec5acffa8. Accessed December 7, 2006.
12. SegotaE, Bukowski RM: The promise of targeted therapy: Cancer drugs become more specific. Cleve Clin J Med 71(7):551-60, 2004.
13. Bicknell R: The realisation of targeted antitumour therapy. Br J Cancer 92(suppl 1):S2-S5, 2005.
14. Tigue CC, Fitzner KA, Alkhatib M, et al: The value of innovation: The economics of targeted drugs for cancer. Targeted Oncology 2:113-119, 2007.
15. Lyman GH, Kuderer NM, Djulbegovic B: Prophylactic granulocyte colony-stimulating factor in patients receiving dose-intensive cancer chemotherapy: A meta-analysis. Am J Med 112:406-411, 2002.
16. Repetto L, Biganzoli L, Koehne CH, et al: EORTC Cancer in the Elderly Task Force Guidelines for the use of colony-stimulating factors in elderly patients with cancer. Eur J Cancer 39:2264-2272, 2003.
17. De Lima M, Giralt S: Allogeneic transplantation for the elderly patient with acute myelogenous Leukemia or myelodysplastic syndrome. Semin Hematol 43:107-117, 2006.
18. Calhoun EA, Bennett CL: Evaluating the total costs of cancer: The Northwestern University Costs of Cancer Program. Oncology (Williston Park) 17:109-114, 2003.
19. National Cancer Institute: Estimates of national expenditures for medical treatment for the 15 most common cancers (Table L2). Cancer Trends Progress Report-2005 Udpate. Available at progressreport.cancer.gov/doc_detail.asp?pid=1&did=2005&chid=25&coid=226&mid=. Accessed April 18, 2007.
20. Yabroff KR, Davis WW, Lamont EB, et al: Patient time costs associated with cancer care. J Natl Cancer Inst 99:14-23, 2007.
21. Wilson LS, Tesoro R, Elkin EP, et al: Cumulative cost pattern comparison of prostate cancer treatments. Cancer 109:518-527, 2007.
22. Schrag D: The price tag on progress—chemotherapy for colorectal cancer. N Engl J Med 351:317-319, 2004.
23. Stephens JM, Gramegna P, Laskin B, et al: Chronic lymphocytic Leukemia: Economic burden and quality of life (literature review). Am J Ther 12:460-466, 2005.
24. Agency for Healthcare Research and Quality: Care of Women in US Hospitals, 2000. HCUP Fact Book No. 3. AHRQ publication no. 02-0044, October 2002. Available at www.ahrq.gov/data/hcup/factbk3/factbk3.htm. Accessed February 26, 2007.
25. Bennett CL, Schumock GT: Cost analyses of adjunct colony stimulating factors for older patients with acute myeloid leukaemia: Can they improve clinical decision making? Drugs Aging 20:479-483, 2003.
26. Lang K, Menzin J, Earle CC, et al: The economic cost of squamous cell cancer of the head and neck: Findings from linked SEER-Medicare data. Arch Otolaryngol Head Neck Surg 130:1269-1275, 2004.
27. Ramsey SD, Howlader N, Etzioni RD, et al: Chemotherapy use, outcomes, and costs for older persons with advanced non-small cell lung cancer: Evidence from Surveillance, Epidemiology and End Results—Medicare. J Clin Oncol 22:4971-4978, 2004.
28. Langa KM, Fendrick AM, Chernew ME, et al: Out-of-pocket health-care expenditures among older americans with cancer. Value Health 7:186-194, 2004.
29. Arozullah AM, Calhoun EA, Wolf M, et al: The financial burden of cancer: Estimates from a study of insured women with breast cancer. J Support Oncol 2:271-278, 2004.
30. McKoy JM, Weitner BB, Fitzner KA, et al: Cost and burden of cancer: A comparison of breast, prostate, colorectal, lung and head and neck cancer. Under review.
31. Bennett CL, Weinberg PD, Lieberman JJ: Cancer insurance policies in Japan and the United States. West J Med 168:17-22, 1998.
32. Reeder CE, Gordon D: Managing oncology costs. Am J Manag Care 12(suppl):S3-S19 (incl quiz). Available at www.ajmc.com/viewIssue.cfm?ID=2034. Accessed December 20, 2006.
33. American Cancer Society: Making a Part D plan decision. Available at www.cancer.org/docroot/MIT/content/MIT_3_1_Making_a_Plan_Decision.asp?sitearea=MIT. Accessed December 20, 2006.
34. Unger JM, Coltman CA Jr, Crowley JJ, et al: Impact of the year 2000 Medicare policy change on older patient enrollment to cancer clinical trials. J Clin Oncol 24:141-144, 2006.
35. Hutchins LF, Unger JM, Crawley CA, et al: Underrepresentation of patients 65 years of age or older in cancer-treatment trials. N Engl J Med 341:2061-2067, 1999.
36. Talarico L, Chen G, Pazdur R: Enrollment of elderly patients in clinical trials for cancer drug registration: A 7-year experience by the US Food and Drug Administration. J Clin Oncol 22:4626-4631, 2004.
37. Bugeja G, Kumar A, Banerjee AK: Exclusion of elderly people from clinical research: A descriptive study of published reports. BMJ 315:1059, 1997.
38. National Cancer Institute: Clinical trials covered under the Medicare anti-cancer drugs national coverage decision. Available at www.cancer.gov/clinicaltrials/developments/NCD179N. Accessed December 19, 2006.
39. Centers for Medicare and Medicaid Services: Medicare coverage—clinical trials. Provider Bulletin. Available at www.cms.hhs.gov/ClinicalTrialPolicies/Downloads/providerbulletin.pdf. Accessed December 15, 2006.
40. Suda KJ, Motl SE, Kuth JC: Inpatient oncology length of stay and hospital costs: Implications for rising inpatient expenditures. J Appl Res 6:126-131, 2006.
41. Chang S, Long SR, Kutikova L, et al: Estimating the cost of cancer: Results on the basis of claims data analyses for cancer patients diagnosed with seven types of cancer during 1999 to 2000. J Clin Oncol 22:3524-3530, 2004.