The 5-year cost of caring for elderly people with cancer in the United States is projected to be $21.1 billion, according to a report today in the Journal of the National Cancer Institute (JNCI).

The estimate is part of a detailed analysis of the per-person and aggregate 5-year costs of caring for Medicare patients (age 65 and older) with cancer. The findings show that costs vary by type of cancer, stage at diagnosis, phase of treatment, and survival.

"The estimates provide a basis for future projections of health care costs that can be used to plan health care programs," said lead investigator Dr. Robin Yabroff of NCI's Division of Cancer Control and Population Sciences. The estimates could also be used to evaluate the cost-effectiveness of anticancer interventions aimed at prevention, screening, or treatment.

The study focused on the 18 most prevalent cancers. Costs were determined for three phases of care: the initial year after diagnosis, the continuing care phase, and the last year of life. Costs tended to be higher during the initial phase and last year of life than in the intervening period.

The average 5-year net costs varied widely, from less than $20,000 for patients with breast cancer or melanoma to more than $40,000 for patients with brain, esophageal, gastric, or ovarian cancers or lymphoma.

For men, cancers of the brain and nervous system were the most costly per patient in each phase of care and over 5 years. For women, these cancers were also the most expensive during the initial and final phases, but ovarian was the most expensive over 5 years.

Few of the study's findings were startling, notes an editorial in JNCI, but, taken together, "they provide the scientifically strongest picture yet" of the incidence costs of cancer in aggregate and by tumor type for this population.

The results show that substantial amounts of money are spent on hospitalizations in the last year of life for people with rapidly fatal cancers. Hospital costs alone are the bulk of the 5-year expenses for these patients.

"The vast majority of the money spent on advanced cancers such as gastric and pancreatic goes toward acute care hospitalizations, despite the fact that such care is unlikely to meaningfully improve the prognoses for these patients," said coauthor Dr. Elizabeth Lamont of Massachusetts General Hospital and Harvard Medical School.

As an oncologist, Dr. Lamont points to studies showing that most people, if confronted with a terminal illness, would prefer to spend their remaining time not in the hospital but rather with family and if possible at home.

"This study puts a price tag on the extra hospital care, and it is not trivial," she said. "Some of this money might be better spent developing systems to help patients avoid unwanted hospitalizations at the end of life."

Dr. David Cutler, a professor of Applied Economics at Harvard University who was not involved in the research, was struck by the magnitude of the costs at the end of life.

"The central question raised by the results is whether all this care is really valuable," he said. "This is a very nice study, and the findings stress the importance of that question."

The study used information from NCI's Surveillance, Epidemiology, and End Results (SEER) program and data on health care costs from the SEER-Medicare database.

The work, led by NCI's Health Services and Economics Branch and Statistical Research and Applications Branch, follows a study last year that estimated the time cancer patients spent on their care.

A challenge for the field will be to standardize the methods of estimating costs for different aspects of the cancer burden as well as other diseases, according to the authors.

—Edward R. Winstead