Costs of Treating Elderly Patients With Cancer: What Are We Measuring in the Absence of Reliable Evidence?

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.[1] 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.[2] 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.[3]

Nonmedical Costs

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.[6] 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.[7] 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

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.[8] 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.[4]

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.[9] 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.[6]

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.

Capturing Costs

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)

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. Lyman GH, Kuderer NM: The diagnosis and treatment of cancer in the elderly: Cost effectiveness considerations in Balducci L, Lyman GH, Erschler W (eds): Comprehensive Geriatric Oncology, 2nd ed, pp 510-524. London, Taylor & Francis Publishers, 2004.

2. Balducci L, Hardy CL, Lyman GH: Hemopoietic reserve in the older cancer patient: Clinical and economic considerations. Cancer Control 7:539-547, 2000.

3. Lyman GH: Essentials of clinical decision analysis: A new way to think about cancer and age, in Balducci L, Lyman GH, Erschler W (eds): Comprehensive Geriatric Oncology, 2nd ed, pp 11-25. London, Taylor & Francis Publishers, 2004.

4. Lyman GH: Methodological issues related to health economic analysis in controlled clinical trials, in Crowley J (ed): Handbook of Statistics in Clinical Oncology, pp 291-320. New York, Marcel Dekker, 2001.

5. Lyman GH: Economic analysis of randomized controlled trials. Curr Oncol Rep 3:396-403, 2001.

6. Lyman GH: Time is money for both the healthy and the sick. Med Care 43:637-639, 2005.

7. McCoy 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.

8. Lyman GH, Djulbegovic B: Understanding economic analyses. Evidence-Based Oncology 2:2-5, 2001.

9. Yabroff KR, Davis WW, Lamont EB, et al: Patient time costs associated with cancer care. J Natl Cancer Inst 99:14-23, 2007.

10. Schrag D: The price tag on progress-chemotherapy for colorectal cancer. N Engl J Med 351:317-319, 2004.

11. Lyman GH, Lyman CH, Agboola O: Risk models for predicting chemotherapy-induced neutropenia. Oncologist 10:427-437, 2005.

12. Lyman GH, Cosler LE, Kuderer NM, et al: Impact of a 21-gene RT-PCR assay on treatment decisions in early-stage breast cancer: An economic analysis based on prognostic and predictive validation studies. Cancer 109:1011-1018, 2007.

13. Back A: Talking with patients about the cost of cancer care. J Oncol Pract 3:122-123, 2007.

14. Lyman GH: Economics of cancer care. J Oncol Pract 3:113-114, 2007.