Medical Costs
Medical costs are categorized as (1) direct medical costs; (2) direct nonmedical costs, ie, amounts spent for caregivers and travel; (3) indirect costs, ie, the economic value of lost productivity due to illness, disability, and death (mortality); and (4) intangible costs, ie, costs associated with pain, suffering, and grief. Pilot studies indicate that direct nonmedical, indirect, and intangible costs may account for 75% of the total cost of cancer care.[18]
"Time costs," defined as time invested by the patient in the hospital, emergency room, doctor's office, or outpatient surgical facility getting chemotherapy or radiation (and in transit), is another important cost consideration. For patients 65 years and older in all phases of care, time costs were found to vary by tumor site and phase of care (Table 2).[2,19,20] Total patient time costs in the initial phase of care were $2.3 billion. Per-patient time costs were as low as $270 for those diagnosed with prostate cancer; for individuals with lung cancer, costs grew by phase to as much as $7,390 in the last year of life.[20]
Cancer Costs
Breast Cancer
In 2006, breast cancer was the most costly cancer for women.[4] Rao et al assessed the cost of treating Medicare beneficiaries with metastatic breast cancer from 1997 to 1999. Mean total direct medical cost was $35,164 per patient as compared to $4,176 per person for the control group, primarily explained by a difference in admission rates (the metastatic breast cancer group averaged 1.7 inpatient admissions per patient, whereas the controls averaged 0.3 inpatient admissions per patient) and length of stay per admission (14.4 days for metastatic breast cancer vs 1.6 days for controls). Metastatic breast cancer patients who were older had lower direct costs than did those who were younger. Since older metastatic breast cancer patients received less combination therapy, the cost of their illness was inversely proportional to their age.
Prostate Cancer
This sex-specific cancer is diagnosed in more than 200,000 men annually, most of whom are over 50 years of age. A longitudinal study of prostate cancer treatments for individuals of all ages and risk levels considered all health-care costs associated with the treatment of prostate cancer, including those associated with side effects and relapse.[21] Prostate-related costs varied according to the patient's age, risk factors, and type of treatment provided. More costly therapies (eg, external-beam irradiation and androgen deprivation) are more commonly used for high-risk older patients; lower cost treatments are used more frequently for younger patients with relatively lower risks. Over 5.5 years, average cumulative costs of prostate cancer were $42,570, ranging from $32,135 for watchful waiting to $69,244 for androgen deprivation therapy.[21] Costs for the 6 months following treatment were $11,495; watchful waiting was the least costly option at $2,568, while external-beam irradiation was the most costly at $24,204.[21]
Colorectal Cancer
Colorectal cancer is the third most common cancer in the United States, accounting for 10.7% of all new cancers (Table 2). Total annual US spending for this disease is approximately $8.4 billion, accounting for 12% of all cancer treatment expenditures.[19] It disproportionately affects older patients, with median age at diagnosis being 71 years. The advent of new pharmaceuticals is one of the primary drivers of colorectal cancer cost. The cost of drug treatment for colorectal cancer rose 340-fold between 1994 and 2004, but only doubled the median survival.[22]
Hematologic Malignancies
Leukemia represents 2.4% of all new cancers for all age groups, accounting for 3.7% of all cancer treatment expenditures. The United States spends about $2.6 billion per year on medical treatment for people of all ages who are being treated for Leukemia.[23] Another important hematologic malignancy, multiple myeloma disproportionately affects older African-American males. It is incurable but requires costly lifelong drugs and expensive stem cell therapy.
Chronic lymphocytic Leukemia (CLL) is most common in the elderly, with a median age of diagnosis of about 64 to 70 years.[24] Cost drivers identified for CLL included costs associated with chemotherapy, intravenous immunoglobulins, transplantation, and the differential staining cytotoxicity assay.[24] According to the US Healthcare Cost and Utilization Project (HCUP), CLL accounted for 6% of total Leukemia charges in 2001.[24]
Acute myelogenous Leukemia (AML) accounts for about half of Leukemia cases, and annual incidence is about 11,900. The prevalence increases with age (median age of onset is 67 years) and is greater in men than in women.[1,4] Fewer than 10% of older persons survive long term with this diagnosis. Mortality rates of 10% to 40% are associated with AML following induction chemotherapy and are commonly attributable to sepsis and pneumonia.
Bennett and Schumock conducted a review of clinical and economic findings for the use of hematopoietic growth factors in older adults with AML.[25] Their review included an Eastern Cooperative Oncology Group (ECOG) study of AML patients who had been randomized to receive granulocyte-macrophage colony-stimulating factor (GM-CSF [Leukine]) or placebo. Cost savings were estimated at $2,310 with GM-CSF (1997 costs); savings were likely due to the decreased number of days with a low neutrophil count (13 vs 17, P < .05) and the corresponding reduction in the number of severe infections (9.6% vs 36.2%, P = .002) in the treatment vs placebo groups.
Head and Neck Squamous Cell Cancer
Together, small cell and squamous cell carcinomas of the head and neck (SCCHN) comprise 5% of all cancers in men and 2% of cancers in women. SCCHN carries a poor prognosis and a 5-year survival rate of less than 50%. Recent data are lacking, but a retrospective cohort analysis of Surveillance, Epidemiology, and End Results (SEER) data (1991-1993) concluded that the health economic burden of SCCHN is substantial, with costs that are comparable to or higher than those of other solid tumors.[26] Health-care costs were significantly higher for those with SCCHN than for those without the diagnosis. Average Medicare payment (in 1998 US dollars) for SSCHN patients was $25,542 higher than that of matched comparison patients, with monthly payments 3 times as high ($1,428 vs $446, respectively).[26] For patients with advanced disease, the costs were even greater. Resource utilization, particularly among patients with advanced-stage disease, accounts for a significant percentage of the costs, largely due to longer hospital stay and utilization of home health care and hospice services.
Lung Cancer
Lung cancer is one of the most costly cancers—annual total costs were estimated at $9.6 billion in 2004.[22] Lung cancer ranks as second most common among noncutaneous malignancies, and non-small-cell lung cancer (NSCLC) accounts for most cases. Lung cancer primarily afflicts older adults, the median age at diagnosis being 68 years, with 40% of patients older than 70 years of age at the time of diagnosis.
Ramsey et al examined community chemotherapy treatment patterns for patients (mean age, 75 years) with advanced NSCLC, diagnosed between 1994 and 1999 (n = 14,875).[27] Patients with locally advanced stage III/IV disease at diagnosis were stratified based on chemotherapy agents received during the first 3 months postdiagnosis. Approximately 31% received chemotherapy, 8% received surgery, and 53% received radiation therapy. Medical care costs were substantially higher for those receiving chemotherapy than for those who did not; costs were highest for those receiving both radiation and chemotherapy. Lifetime costs were more than $10,000 higher for those receiving platinum/taxane combinations than for other regimens, although survival was similar.
