The Moving Target of Cancer Care Costs

June 1, 2007

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.

In 2007, an estimated 1,444,920 Americans will be diagnosed with cancer and about 559,650 will die from the disease, making cancer the second leading cause of death after heart disease.[1] These estimates do not include noninvasive cancers of any site or most skin cancers, which by themselves amount to almost 1 million cases.[1]

The cancer burden is unevenly distributed in the population, and cancer is considered a disease of the elderly. Patients aged 65 years and older represent only 12% of the population, but they account for 61% of new cancer cases. About 77% of all cancer cases are diagnosed in people over age 55.[1]

Costs of Cancer

Apart from the human toll, there are substantial financial costs associated with cancer. The overall cost of cancer care in 2006 was US$206.3 billion, of which $78.2 billion was the total health expenditure, $17.9 billion was the indirect morbidity cost, and $110.2 billion was attributed to indirect mortality.[1] The costs associated with the management of cancer in the older patient have also been explained in detail in the paper by McKoy and colleagues published in this issue of the journal.[2] These cost considerations are based on the foundation of current medical oncology practice. The critical question is: How much of this practice, and consequently cost associated with it, is informed by reliable evidence?

Research conducted during the past decade convincingly demonstrated a tremendous variation in the practice of medicine—so much so that it is not uncommon for some doctors to undertake a "wait-and-see" policy in a given clinical situation, while in the same setting, others might order a diagnostic test, and still others initiate treatment without testing.[3-7] Many factors—from the structure of local care to the availability of diagnostic technologies to financial incentives—have been invoked in explaining these practice variations in medicine.[3-7] Seen in both the diagnostic and treatment settings, such variations typically result in too little care (underuse, failure to provide an effective service when it would have produced a favorable outcome); too much care (overuse, provision of care when its risks of harm exceed the potential benefits); and the wrong care (misuse, avoidable complications of appropriate care).[8]

Underrepresentation in Trials

Failure to generate and then act on reliable evidence is considered one of the major reasons for suboptimal delivery of modern health-care treatments and other services. Unfortunately, evidence to support the practice of oncology in elderly patients is extremely limited. This is not surprising when only 3% to 5% of all eligible adult cancer patients participate in clinical trials. How can we develop effective interventions for the prevention and treatment of cancer in the elderly if they do not participate in clinical trials, particularly in randomized clinical trials (RCTs), widely considered the most reliable form of medical evidence?[9,10] Practice guidelines, which are ideally based on a systematic review of all RCTs, cannot be developed if the evidence is nonexistent or lacking.[9]

Given the fact that elderly patients are underrepresented in cancer RCTs, the evidence base to guide both current and future prevention and treatment strategies for the elderly is clearly limited. Consequently, we cannot know how much overuse, underuse, or misuse is a part of contemporary medical practice. This also implies that the existing economic analyses really do not measure costs of the "right" medical care but, to a large extent, represent a mixture of overuse, underuse, or misuse of health interventions employed in oncology practice.

Guidelines published by the US Food and Drug Administration for the study of drugs likely to be used in elderly patients state that "drugs should be studied in all age groups, including the geriatric, for which they will have significant utility."[11] Despite these guidelines and the high prevalence of cancer in the elderly population, however, data from several studies show that elderly patients are not adequately represented in research efforts to find innovative treatments for the prevention and treatment of cancer. Again, this makes the applicability of such research findings in the elderly doubtful.[12-15]

Generalizability of Clinical Trials

It has often been argued that it is essential to exclude patients from clinical trials on the basis of functional characteristics (eg, too infirm to participate, medical complications that could confound interpretation of results, presence of extensive comorbidities, or simply unable to provide informed consent).[16] However, age alone or the presence of concomitant illness does not warrant the exclusion of elderly individuals from clinical trials.

We recently evaluated outcomes in 345 RCTs.[12] We found that elderly patients who met the inclusion and exclusion criteria for the trial did not have worse outcomes associated with exposure to experimental treatments.[12] However, generalizibility of our results to other elderly patients with multiple comorbid conditions was limited because of strict inclusion and exclusion criteria built into the trials we evaluated. Florence Keime-Guibert and colleagues recently performed a randomized trial in which they compared supportive care only vs supportive care plus radiotherapy in the treatment of newly diagnosed anaplastic astrocytoma or glioblastoma for "typical" elderly patients with multiple comorbidities.[17] They demonstrated that it is possible to study elderly patients in RCTs and generate needed evidence to inform future practice.

Conclusions

By 2030, the number of persons in the United States over age 65 will have increased twofold and the number of persons over age 85 will be four times what it is today. Because of the relatively high risk of cancer in the elderly, there will be a high prevalence of cases in this population.[1] For physicians interested in practicing geriatric evidence-based medicine, the fact that the bulk of such evidence in oncology is based on trials conducted in young patients must be disheartening.[10]

We need to improve the treatment of the majority of cancer patients at optimal costs. However, optimal cost-effectiveness analysis in geriatric oncology is currently not possible due to the lack of reliable data related to the "effectiveness" part of the equation. One needed economic analysis should focus on assessing the costs of "appropriate" vs "inappropriate" care. This assessment cannot be conducted until we increase the magnitude of reliable medical evidence to inform care in the elderly.

—Ambuj Kumar, MD, MPH
—Benjamin Djulbegovic, MD, PHD

Disclosures:

The authors have no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.

References:

1. American Cancer Society: Cancer Facts and Figures 2007. Atlanta, American Cancer Society, 2007.

2. McKoy JM, Fitzner KA, Edwards BJ, et al: Cost considerations in the management of cancer in the older patient. Oncology (Williston Park) 21:857-863, 2007.

3. Wenneberg J: Which rate is right? N Engl J Med 314:310-311, 1986.

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6. Sirovich BE, Gottlieb DJ, Welch HG, et al: Regional variations in health care intensity and physician perceptions of quality of care. Ann Intern Med 144:641-649, 2006.

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8. Institute of Medicine: Crossing the Quality Chasm. A New Health System for the 21st Century. Washington, DC; National Academy of Sciences; 2001.

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11. US Department of Health and Human Services: Guidance for Industry. Rockville, Md; US Food and Drug Administration; 1997.

12. Kumar A, Soares HP, Balducci L, et al: Treatment tolerance and efficacy in geriatric oncology: A systematic review of phase III randomized trials conducted by five National Cancer Institute-sponsored cooperative groups. J Clin Oncol 25:1272-1276, 2007.

13. Hutchins LF, Unger JM, Crowley JJ, et al: Underrepresentation of patients 65 years of age or older in cancer-treatment trials. N Engl J Med 341:2061-2067, 1999.

14. Murthy VH, Krumholz HM, Gross CP: Participation in cancer clinical trials: Race-, sex-, and age-based disparities. JAMA 291:2720-2726, 2004.

15. 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.

16. Townsley CA, Selby R, Siu LL: Systematic review of barriers to the recruitment of older patients with cancer onto clinical trials. J Clin Oncol 23:3112-3124, 2005.

17. Keime-Guibert F, Chinot O, Taillandier L, et al: Radiotherapy for glioblastoma in the elderly. N Engl J Med 356:1527-1535, 2007.