Costs of Initial Cancer Care and its Affecting FactorsSo Young Kim, Sung Gyeong Kim

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Costs of Initial Cancer Care and its Affecting Factors

So Young Kim, Sung Gyeong Kim¹⁾, Jong Hyock Park¹⁾, Eun Cheol Park¹⁾

Division of Cardiovascular & Rare Diseases, Korean Centers for Disease Control and Prevention, National Cancer Control Research Institute, National Cancer Center ¹⁾

Objectives : The purposes of this study is to estimate the cost of cancer care after its diagnosis and to identify factors that can influence the cost of cancer care.

Methods : The study subjects were patients with an initial diagnosis one of four selected tumors and had their first two-years of cancer care at a national cancer center. The data were obtained from medical records and patient surveys. We classified cancer care costs into medical and nonmedical costs, and each cost was analyzed for burden type, medical service, and cancer stage according to cancer types. Factors affecting cancer care costs for the initial phase included demographic variables, socioeco- nomic status and clinical variables.

Results : Cancer care costs for the initial year following diagnosis were higher than the costs for the following successive year after diagnosis. Lung cancer (25,648,000 won) had higher costs than the other three cancer types. Of the total costs, patent burden was more than 50% and medical costs accounted for more than 60%. Inpatient costs

accounted for more than 60% of the medical costs for stomach and liver cancer in the initial phase. Care for late- stage cancer was more expensive than care for early-stage cancer. Nonmedical costs were estimated to be between 4 , 5 0 0 , 0 0 0 t o 6 , 0 0 0 , 0 0 0 w o n w i t h e x p e n s e s f o r t h e caregiver being the highest. The factors affecting cancer care costs were treatment type and cancer stage.

Conclusions : The cancer care costs after diagnosis are substantial and vary by cancer site, cancer stage and t r e a t m e n t t y p e . I t i s u s e f u l f o r p o l i c y m a k e r s a n d r e s e a r c h e r s t o i d e n t i f y t u m o r - s p e c i f i c m e d i c a l a n d nonmedical costs. The effort to reduce cancer costs and early detection for cancer can reduce the burden to society and improve quality of life for the cancer patients.

J Prev Med Public Health 2009;42(4):243-250 Key words : Healthcare costs, Cancer care

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Table 1. Characteristics of study subjects

Characteristics

Cancer site phase of care Stomach

Initial (no.=189)

Continuing (no.=156)

Initial (no.=197)

Initial (no.=162)

Continuing (no.=82)

Initial (no.=180)

Liver Breast Lung

Sex (Male) Age (yr)

< 50 50 - 59 60 Living with partner Education

High school

>High school Family income

2,000,000 won 2,000,000 won Insurance status

NHI

Medical assistance Private insurance

Yes Procedure^*

Surgery CRx TACE/RFA/PEIT Surgery CRx+RT Other (CRx only, CRx+RT, etc) Procedure (CRx)

Yse Cancer stage

0 I II III IV Cancer stage

Limited Extensive Death (no.)

117 (61.9) 061 (32.3) 046 (24.3) 082 (43.4) 160 (84.7) 157 (83.1) 032 (16.9) 125 (66.2) 064 (33.8) 183 (96.8) 006 (3.2) 088 (46.6) 163 (86.2) 000 (0.0) 000 (0.0) 026 (13.8)

062 (32.8) 030 (15.9) 044 (23.3) 053 (28.0)

168 (88.9)

097 (62.2)

052 (33.3) 038 (24.4) 066 (42.3) 132 (84.6) 130 (83.4) 026 (16.7)

097 (62.2) 059 (37.9) 149 (95.5) 007 (4.5) 078 (50.0)

035 (22.4) 000 (0.0) 000 (0.0) 121 (77.6)

059 (37.8) 027 (17.3) 040 (25.6) 030 (19.2)

137 (87.8)

156 (79.2) 042 (21.4) 079 (40.1) 076 (38.6) 177 (89.9) 165 (83.7) 032 (16.2) 103 (52.3) 094 (47.7) 186 (94.4) 011 (5.6) 086 (43.7)

000 (0.0) 114 (57.9) 083 (42.1) 000 (0.0)

010 (5.1) 080 (40.6) 074 (37.6) 033 (16.8)

170 (86.3)

113 (79.0) 034 (23.8) 048 (33.6) 061 (42.7) 128 (89.5) 122 (85.3) 021 (14.7)

080 (56.0) 063 (44.1) 133 (93.0) 010 (7.0) 058 (40.6)

000 (0.0) 091 (63.6) 052 (36.4) 000 (0.0)

004 (2.8) 056 (39.2) 061 (42.7) 022 (15.4)

112 (78.3)

001 (0.6) 112 (69.1) 031 (19.1) 019 (11.7) 139 (85.8) 111 (68.5) 051 (31.5)

058 (35.8) 104 (64.2) 155 (95.7) 007 (4.3)

119 (73.5) 039 (24.0) 000 (0.0) 102 (63.0) 021 (13.0)

007 (4.3) 045 (27.8) 075 (46.3) 030 (18.5) 005 (3.1)

162 (100.0)

000 (0.0)

051 (62.2) 021 (25.6) 010 (12.2) 071 (86.6)

058 (70.7) 024 (29.3)

032 (39.1) 050 (61.0)

078 (95.1) 004 (4.9) 060 (73.2)

082 (100.0) 000 (0.0) 000 (0.0) 000 (0.0)

002 (2.4) 020 (24.4) 041 (50.0) 017 (20.7) 002 (2.4)

080 (97.5)

133 (73.9) 025 (13.9) 043 (23.9) 112 (62.2) 161 (89.4) 157 (87.2) 023 (12.8) 118 (65.5) 062 (34.4) 168 (93.3) 012 (6.7) 055 (30.6)

167 (92.8)

017 (9.4) 009 (5.0) 046 (25.6) 074 (41.1)

013 (7.2) 021 (11.7) 042 (23.3)

081 (66.9)

018 (14.9) 030 (24.8) 073 (60.3) 106 (87.6) 105 (86.8) 016 (13.2)

074 (61.2) 047 (38.8) 111 (91.7) 010 (8.3) 042 (34.7)

121 (100.0)

015 (12.4) 007 (5.8) 032 (26.5) 044 (36.4)

010 (8.3) 013 (10.7) 017 (14.1) NHI: National Health Insurance, CRx: chemotherapy including hormone therapy, TACE: transarterial chemoembolization, RFA: radiofrequency ablation, PEIT: percutaneous ethanol injection therapy, RT: radiotherapy

*Procedure: in case of colorectal cancer, stomach cancer, liver cancer, breast cancer, Procedure: in case of lung cancer, Cancer stage: in case of colorectal cancer, stomach cancer, liver cancer, breast cancer, non-small cell lung cancer, Cancer stage: in case of small cell lung cancer, In case of performing treatment

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Table 2. Costs by type of burden and medical service (Unit: Thousand Won, per capita)

Cancer site Phase of care Type of burden

Medical costs Inpatient Out-

patient Drug Sub-total 1 Rate (%)^*

Non-medical costs Total

Caregiver expenses

Transporta

tion CAM Other Sub-

total 2 Sub- total 1+2

Rate (%) Stomach

Liver

Breast

Lung

Initial

Contin-uing

Initial

Contin-uing

Initial

Contin-uing

Initial

Contin-uing Insurer Patient Sub-total 3 Rate(%) Rate(%) Insurer Patient Sub-total 3 Rate(%) Rate(%) Insurer Patient Sub-total 3 Rate(%) Rate(%) Insurer Patient Sub-total 3 Rate(%) Rate(%) Insurer Patient Sub-total 3 Rate(%) Rate(%) Insurer Patient Sub-total 3 Rate(%) Rate(%) Insurer Patient Sub-total 3 Rate(%) Rate(%) Insurer Patient Sub-total 3 Rate(%) Rate(%)

2,665 2,802 5,467 62 37 344 366 710 31 15 4,383 4,038 8,421 76 55 2,550 2,470 5,020 65 45 1,638 2,231 3,869 31 21 99 126 225 17 8 3,357 4,181 7,538 39 29 1,230 579 1,809 29 21

978 1,577 2,555 29 17 516 727 1,243 55 27 1,086 1,089 2,175 20 14 1,200 938 2,138 28 19 5,230 3,059 8,289 66 45 518 294 812 61 28 6,838 3,878 10,716 55 42 2,788 662 3,450 56 41

282 530 812 9 6 102 217 319 14 7 191 333 524 5 3 198 365 563 7 5 239 186 425 3 2 195 90 285 22 10 328 971 1,299 7 5 669 270 939 15 11

3,925 4,909 8,834 100 61 962 1,310 2,272 100 49 5,660 5,460 11,120 100 73 3,948 3,773 7,721 100 69 7,107 5,476 12,583 100 68 812 510 1,322 100 45 10,523 9,030 19,553 100 76 4,687 1,511 6,198 100 74

56

58

49

44

39

46

24

2,673 2,673 46 18 593 593 25 13 2,199 2,199 45 14 1,327 1,327 39 12 2,440 2,440 41 13 361 361 22 12 2,580 2,580 41 10 844 844 38 10

652 652 11 4 296 296 12 6 810 810 17 5 493 493 14 4 1,083 1,083 18 6 270 270 17 9 1,834 1,834 29 7 757 757 34 9

1,912 1,912 33 13 1,338 1,338 56 29 1,130 1,130 23 7 1,127 1,127 33 10 1,349 1,349 22 7 820 820 51 28 359 359 6 1 97 97 4 1

530 530 9 4 178 178 7 4 699 699 14 4 472 472 14 4 1,142 1,142 19 6 164 164 10 6 1,455 1,455 23 6 532 532 24 6

5,767 5,767 100 39 2,404 2,404 100 51 4,839 4,839 100 30 3,418 3,418 100 31 6,014 6,014 100 32 1,615 1,615 100 55 6,228 6,228 100 24 2,230 2,230 100 26

3,925 10,676 14,601

962 3,714 4,676

5,660 10,299 15,959

3,948 7,191 11,139

7,107 11,490 18,597

812 2,125 2,937

10,523 15,258 25,781

4,687 3,741 8,428

73

79

65

62

72

59

44

CAM: complementary and alterative medicine

* Rate: Patient burden of medial costs, Rate: Patient burden of total costs, Rate: Sub-service costs of subtotal costs (medical or non-medical costs), Rate: Sub-service costs of total costs

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Figure 1. Proportion of medical costs by medical services.

Table 3. Costs by stage at diagnosis and cancer site (Unit: Thousand Won, per capita)

Cancer site Stage

Initial phase

no. Medical costs Non-medical costs

Continuing phase no. Medical costs Non-medical

costs Stomach

Liver

Breast

Lung

Non-small cell

Small cell

I II III IV I II III IV O I II III IV I II III IV Limited Extensive

62 30 44 53 10 80 74 33 7 45 75 30 5 17 9 46 74 13 21

5,410 7,530 8,139 14,157 8,239 10,260 11,451 13,340 9,058 9,463 13,450 14,965 18,285 12,844 16,966 24,404 20,743 14,349 14,494

3,398 5,510 5,677 8,757 3,948 4,538 5,027 5,416 5,166 4,894 6,227 7,465 5,366 4,275 4,585 6,266 6,860 5,244 6,813

59 27 40 30 4 56 61 22 2 20 41 17 2 15 7 32 44 10 13

751 1,825 1,981 6,056 1,108 6,560 8,418 9,944 502 693 917 3,066 1,943 689 745 5,143 9,687 2,373 9,225

1,462 3,201 2,138 3,896 543 3,222 3,885 3,121 694 1,150 1,648 2,015 3,115 710 516 2,384 2,782 1,033 3,579

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Table 4. Factors affecting initial costs of cancer care

Variables Stomach

Coefficient p-value Coefficient p-value Coefficient p-value Coefficient p-value

Liver Breast Lung

Sex Male Female Age (yr) Living with partner

Yes No Education

High school

>High school Income Insurance status

NHI

Medical assistance Private insurance

Yes No Procedure^*

Surgery CRx TACE/RFA/PEIT Surgery CRx+RT Other (CRx only, CRx+RT, etc) Procedure (CRx)

Yse No Cancer stage

I II III IV Metastasis

Yes No Death Yes No R-square

NHI: National Health Insurance, CRx: chemotherapy including hormone therapy, TACE: transarterial chemoembolization, RFA: radiofrequency ablation, PEIT: percutaneous ethanol injection therapy, RT: radiotherapy

* Procedure: in case of colorectal cancer, stomach cancer, liver cancer, breast cancer, Procedure: in case of lung cancer, Cancer stage: in case of colorectal cancer, stomach cancer, liver cancer, breast cancer, Cancer stage: in case of lung cancers, Dependent variable is transformed to a logarithmic scale

-0.0014 -0.0073

-0.0137

-0.0297 -0.0003

-0.2061

-0.0625

-0.4022 -0.5450

-0.1474 -0.1489 -0.5493

-0.0954 -0.48

<0.99

<0.04

<0.89

<0.76

<0.17

<0.29

<0.42

<0.001

<0.20

<0.21

<0.0001

<0.42 -0.0673 -0.0005

-0.0010

-0.1035 -0.0000

-0.0022

-0.0678

-0.2949

-0.0837 -0.2026 -0.1713

-0.2409 0.18

<0.42

<0.91

<0.99

<0.23

<0.87

<0.99

<0.36

<0.0001

<0.59

<0.20

<0.31

<0.01 -0.0075

-0.0870

-0.0106 -0.0001

-0.1924

-0.0059

-0.1654 -0.0176

-0.3561 -0.4853 -0.5183

-0.0142 -0.24

<0.06

<0.41

<0.89

<0.37

<0.25

<0.94

<0.05

<0.88

<0.0001

<0.01

<0.86 -0.0392 -0.0063

-0.3335

-0.0140 -0.0279

-0.0144

-0.0948

-0.6144

-0.0252

-0.25

<0.63

<0.15

<0.005

<0.89

<0.22

<0.91

<0.24

<0.0001

<0.72

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1. Wilking N, Jonsson B. The burden and cost of cancer. Ann Oncol 2007; 18(suppl 3): iii8-iii22.

2. Yabroff KR, Warren JL, Brown ML. Costs of cancer care in the USA: A descriptive review.

Nat Clin Pract Oncol 2007; 4(11): 643-656.

3. Meropol NJ, Schulman KA. Cost of cancer care:

Issues and implications. J Clin Oncol 2007;

25(2): 180-186.

4. Wapner J. Bills of health: In discussing treatments, cancer doctors plan to include cost.

Sci Am 2008; 299(2): 28.

5. Korea National Statistical Office. Annual Report on the Cause of Death Statistics. Daejron: Korea National Statistical Offic; 2007. (Korean) 6. National Cancer Center; Ministry for Health;

Welfare and Family Affairs. Cancer Facts &

Figures 2008. Goyang: National Cancer Center;

2008. (Korean)

7. Yabroff KR, Mariotto AB, Feuer E, Brown M.

Projections of the costs associated with colorectal cancer care in the US, 2000-2020.

Health Econ 2008; 17(8): 947-959.

8. Warren JL, Yabroff KR, Meekins A, Topor M, Lamont EB, Brown ML. Evaluation of trends in the cost of initial cancer treatment. J Natl Cancer Inst 2008; 100(12): 888-897.

9. Yabroff KR, Lamont EB, Mariotto A, Warren JL, Topor M, Meekins A, et al. Cost of care for elderly cancer patients in the United States. J Natl Cancer Inst 2008; 100(9): 630-641.

10. Lang K, Lines LM, Lee DW, Korn JR, Earle CC, Menzin J. Lifetime and treatment-phase costs associated with colorectal cancer:

Evidence from SEER-medicare data. Clin Gastroenterol Hepatol 2009; 7(2): 198-204.

11. Brown ML, Riley GF, Schussler N, Etzioni R.

Estimating health care costs related to cancer treatment from SEER-Medicare data. Med Care 2002; 40(8 Suppl): IV-104-117.

12. Kim SG, Park WS. Out-of-pocket health

expenditures among adults Koreans with cancer. Korean J Med 2006; 70(1): 61-68.

(Korean)

13. Yi JJ, Yoo WK, Kim SY, Kim KK, Yi SW.

Medical expenses by site of cancer and survival time among cancer patients in the last one year of life. J Prev Med Public Health 2005; 38(1): 9-15. (Korean)

14. Choi KS, Park EC, Lim MK, Lim JH, Kim SG, Park JH, et al. Cost of colorectal cancer care in Korea: A prospective group study with a 2-year follow-up. J Korean Soc Coloproctol 2008; 24(5): 357-366.

15. Reeder CE, Gordon D. Managing oncology costs. Am J Manag Care 2006; 12(1 Suppl):

S3-S16.

16. Yabroff KR, Davis WW, Lamont EB, Fahey A, Topor M, Brown ML, et al. Patient time costs associated with cancer care. J Natl Cancer Inst 2007; 99(1): 14-23.

17. Fireman BH, Quesenberry CP, Somkin CP, Jacobson AS, Baer D, West D, et al. Cost of care for cancer in a health maintenance organization. Health Care Financ Rev 1997;

18(4): 51-76.

18. Taplin SH, Barlow W, Urban N, Mandelson MT, Timlin DJ, Ichikawa L, et al. Stage, age, comorbidity, and direct costs of colon, prostate, and breast cancer care. J Natl Cancer Inst 1995; 87(6): 417-426.

19. Warren JL, Brown ML, Fay MP, Schussler N, Potosky AL, Riley GF. Costs of treatment for elderly women with early-stage breast cancer in fee-for service settings. J Clin Oncol 2002;

20(1): 307-316.

20. Langa KM, Fendrick AM, Chernew ME, Kabeto MU, Paisley KL, Hayman JA. Out of pocket healthcare expenditures among older Americans with cancer. Value Health 2004;

7(2): 186-194.

21. Oliver E, Killen J, Kiebert G, Hutton J, Hall R, Higgins B, et al. Treatment pathways, resource use and costs in the management of small cell lung cancer. Thorax 2001; 56(10): 785-790.

22. Penberthy L, Retchin SM, McDonald MK, McClish DK, Desch CE, Riley GF, et al.

Predictors of medicare costs in elderly beneficiaries with breast, colorectal, lung, or

prostate cancer. Health Care Manag Sci 1999;

2(3): 149-160.

23. Kim SG, Yu SH, Park WS, Chung WJ. Out- of-pocket health expenditures by non-elderly and elderly persons in Korea. J Prev Med Public Health 2005; 38(4): 408-414. (Korean) 24. Chang S, Long SR, Kutikova L, Bowman L,

Finley D, Crown WH, et al. Estimating the cost of cancer: Results on the basis of claims data analyses for cancer patients diagnosed with seven types of cancer during 1999 to 2000. J Clin Oncol 2004; 22(17): 3524-3530.

25. Bosanquet N, Sikora K. The economics of cancer care in the UK. Lancet Oncol 2004;

5(9): 568-574.

26. Ries LA, Eisner MP, Kosary CL, Hankey BF, Miller BA, Clegg L, et al. SEER Cancer Statistics Review, 1975-2005. Behesda:

National Cancer Institute; 2007.

27. Wagner L, Lacey MD. The hidden costs of cancer care: An overview with implications and referral resources for oncology nurses. Clin J Oncol Nurs 2004; 8(3): 279-287.

28. Ministry for Health, Welfare and Family Affairs. White Paper on Health, Welfare and Family Affirs. Seoul: Ministry for Health, Welfare; 2007. (Korean)

29. Chirikos TN. Cancer economics: On variations in the costs of treating cancer. Cancer Control 2002; 9(1): 59-66.

30. Levinsky NG, Yu W, Ash A, Moskowitz M, Gazelle G, Saynina O, et al. Influence fo age on medicare expenditures and medical care in the last of life. JAMA 2001; 286(11): 1349-1355.

31. Drummond MF, Sculpher MJ, Torrance GW, O Brien BJ, Stoddart GL. Methods for the Economic Evaluation of Health Care Programmes. 3nd ed. New York: Oxford University Press; 2005.

32. American Cancer Society. Cancer Facts and Figure 2008. Atalanta: American Cancer Society; 2008.

33. Kim SG, Hahm MI, Choi KS, Seung NY, Shin

HR, Park EC. The economic burden of cancer

in Korea in 2002. Eur J Cancer Care (Engl)

2008; 17(2): 136-144.