The goal of capturing both direct medical and nonmedical costs as well as indirect and out-of-pocket expenses in elderly patients with cancer is a moving target. Resource utilization for the management of cancer including diagnosis, treatment, and supportive care has changed dramatically over the past 2 decades. For instance, several new agents have been approved to treat colorectal cancer and are in wide-scale use. The average wholesale price for these agents over a typical course ranges from $10,000 to more than $30,000.[10] Schrag points out that over the past decade, the average drug costs for the first 2 months of treatment have increased an incredible 340-fold. Rapidly increasing direct medical costs associated with new cancer treatments and support care measures along with increasingly sophisticated and costly imaging have raised serious doubts about our ability as a society to pay for such care. The review reported here again suggests that from the perspective of the patient and family as well as that of society, the problem may be even greater.

However, rather than despairing or considering untenable options such as rationing or otherwise limiting access to effective treatment, strategies must be found to limit the economic impact of emerging technologies. Prohibitions on negotiating drug prices with industry and the importation of drugs from other countries should be reconsidered while strongly encouraging the pharmaceutical industry to reassess pricing policies. No population of cancer patients can benefit more directly by such efforts than the elderly faced with increasing health-care costs while faced with the limitations of a fixed or diminishing income.

Also important are efforts to define and evaluate better prognostic and predictive markers that may permit more targeted application of expensive therapies. Such strategies have the potential to improve both efficacy and cost-effectiveness by directing the best treatment strategy toward patients who are at greatest need and most likely to benefit.[11,12] Finally, it is essential that payers as well as investigators focus increasing attention on both the clinical and economic impact of cancer treatment on patients of all ages as well as their caregivers.

Conclusions

The costs of cancer care are rarely discussed among professionals yet are the focus of frequent discussions within the families of cancer patients.[13] Costs should never become the primary treatment consideration or serve as a barrier to providing proven effective treatment. Efficacy and safety must remain the major focus of the clinical decision to initiate cancer treatment in the elderly.[14] However, we should not lose sight of the nonmedical, indirect, and out-of-pocket costs that elderly cancer patients and their families are faced with and which are never reimbursed. As illustrated in this paper by McKoy et al, these costs leave a large gap in the already difficult financial situation of elderly cancer patients, whose major concern should be the benefits and harms associated with their disease and its treatment.

—Gary H. Lyman, MD, MPH, FRCP (EDIN)