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Volume 113
Issue 12
December 2021


ARTICLE CONTENTS

 * Abstract
 * Methods
 * Results
 * Discussion
 * Funding
 * Notes
 * Data Availability
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 * Supplementary data

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Editor's Choice


ANNUAL REPORT TO THE NATION ON THE STATUS OF CANCER, PART 2: PATIENT ECONOMIC
BURDEN ASSOCIATED WITH CANCER CARE

K Robin Yabroff, PhD,
K Robin Yabroff, PhD
Surveillance and Health Equity Science, American Cancer Society
, Kennesaw, GA,
USA
Correspondence to: K. Robin Yabroff, PhD, Department of Surveillance and Health
Equity Science, American Cancer Society, 3380 Chastain Meadows Pkwy NW, Suite
200, Kennesaw, GA 30144, USA (e-mail: Robin.yabroff@cancer.org).
  https://orcid.org/0000-0003-0644-5572
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Angela Mariotto, PhD,
Angela Mariotto, PhD
Division of Cancer Control and Population Sciences, National Cancer Institute
, Rockville, MD,
USA
  https://orcid.org/0000-0003-2423-1834
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Florence Tangka, PhD,
Florence Tangka, PhD
Division of Cancer Prevention and Control, National Center for Chronic Disease
Prevention and Health Promotion, Centers for Disease Control and Prevention
, Atlanta, GA,
USA
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Jingxuan Zhao, MPH,
Jingxuan Zhao, MPH
Surveillance and Health Equity Science, American Cancer Society
, Kennesaw, GA,
USA
  https://orcid.org/0000-0002-2733-2000
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Farhad Islami, MD, PhD,
Farhad Islami, MD, PhD
Surveillance and Health Equity Science, American Cancer Society
, Kennesaw, GA,
USA
  https://orcid.org/0000-0002-7357-5994
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Hyuna Sung, PhD,
Hyuna Sung, PhD
Surveillance and Health Equity Science, American Cancer Society
, Kennesaw, GA,
USA
  https://orcid.org/0000-0002-8021-5997
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Recinda L Sherman, PhD,
Recinda L Sherman, PhD
North American Association of Central Cancer Registries
, Springfield, IL,
USA
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S Jane Henley, MSPH,
S Jane Henley, MSPH
Division of Cancer Prevention and Control, National Center for Chronic Disease
Prevention and Health Promotion, Centers for Disease Control and Prevention
, Atlanta, GA,
USA
  https://orcid.org/0000-0002-2420-306X
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Ahmedin Jemal, DVM, PhD,
Ahmedin Jemal, DVM, PhD
Surveillance and Health Equity Science, American Cancer Society
, Kennesaw, GA,
USA
  https://orcid.org/0000-0002-0000-4111
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Elizabeth M Ward, PhD
Elizabeth M Ward, PhD
North American Association of Central Cancer Registries
, Springfield, IL,
USA
  https://orcid.org/0000-0002-3575-6639
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JNCI: Journal of the National Cancer Institute, Volume 113, Issue 12, December
2021, Pages 1670–1682, https://doi.org/10.1093/jnci/djab192
Published:
26 October 2021
Article history
Received:
14 June 2021
Revision received:
05 August 2021
Accepted:
20 September 2021
Published:
26 October 2021
Corrected and typeset:
28 November 2021

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   K Robin Yabroff, PhD, Angela Mariotto, PhD, Florence Tangka, PhD, Jingxuan
   Zhao, MPH, Farhad Islami, MD, PhD, Hyuna Sung, PhD, Recinda L Sherman, PhD, S
   Jane Henley, MSPH, Ahmedin Jemal, DVM, PhD, Elizabeth M Ward, PhD, Annual
   Report to the Nation on the Status of Cancer, Part 2: Patient Economic Burden
   Associated With Cancer Care, JNCI: Journal of the National Cancer Institute,
   Volume 113, Issue 12, December 2021, Pages 1670–1682,
   https://doi.org/10.1093/jnci/djab192
   
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ABSTRACT

Background

The American Cancer Society, National Cancer Institute, Centers for Disease
Control and Prevention, and North American Association of Central Cancer
Registries provide annual information about cancer occurrence and trends in the
United States. Part 1 of this annual report focuses on national cancer
statistics. This study is part 2, which quantifies patient economic burden
associated with cancer care.

Methods

We used complementary data sources, linked Surveillance, Epidemiology, and End
Results-Medicare, and the Medical Expenditure Panel Survey to develop
comprehensive estimates of patient economic burden, including out-of-pocket and
patient time costs, associated with cancer care. The 2000-2013 Surveillance,
Epidemiology, and End Results-Medicare data were used to estimate net patient
out-of-pocket costs among adults aged 65 years and older for the initial,
continuing, and end-of-life phases of care for all cancer sites combined and
separately for the 21 most common cancer sites. The 2008-2017 Medical
Expenditure Panel Survey data were used to calculate out-of-pocket costs and
time costs associated with cancer among adults aged 18-64 years and 65 years and
older.

Results

Across all cancer sites, annualized net out-of-pocket costs for medical services
and prescriptions drugs covered through a pharmacy benefit among adults aged
65 years and older were highest in the initial ($2200 and $243, respectively)
and end-of-life phases ($3823 and $448, respectively) and lowest in the
continuing phase ($466 and $127, respectively), with substantial variation by
cancer site. Out-of-pocket costs were generally higher for patients diagnosed
with later-stage disease. Net annual time costs associated with cancer were
$304.3 (95% confidence interval = $257.9 to $350.9) and $279.1 (95% confidence
interval = $215.1 to $343.3) for adults aged 18-64 years and ≥65 years,
respectively, with higher time costs among more recently diagnosed survivors.
National patient economic burden, including out-of-pocket and time costs,
associated with cancer care was projected to be $21.1 billion in 2019.

Conclusions

This comprehensive study found that the patient economic burden associated with
cancer care is substantial in the United States at the national and patient
levels.

Topic:
 * cancer
 * adult
 * motor evoked potentials
 * medicare
 * economics
 * out-of-pocket costs

Issue Section:
Articles

Each year, the American Cancer Society, the National Cancer Institute, the
Centers for Disease Control and Prevention, and the North American Association
of Central Cancer Registries collaborate to provide updated information about
cancer occurrence and trends by cancer site, sex, race and ethnicity , and age
in the United States. Part 1 of this annual report focuses on national cancer
statistics and highlights trends in stage-specific survival for melanoma of the
skin (1). This study is part 2 of the report and addresses patient economic
burden associated with cancer in the United States.

Historically, cancer has been one of the most expensive medical conditions to
treat (2), and spending has increased in recent years (3) due in part to
advances in cancer treatment, including targeted therapies, immunotherapies,
advanced imaging, and supportive care; longer treatment durations; and more
treatment combinations. Many people who have received a cancer diagnosis (cancer
survivors) receive medical care directly related to their cancer during the
initial period after diagnosis and for some, recurrence or new primaries, and at
the end-of-life (EOL) (4-6). Many receive additional medical care as a result of
late and lasting effects of disease and its treatment (4–6). Cancer survivors
and their families increasingly face high out-of-pocket costs for their care
(3,7,8), including patient cost-sharing through higher deductibles, copayments,
and coinsurance (9–11). In the absence of charity care, families without health
insurance or with limited coverage may be responsible for the entire cost of
care (12,13). Medical financial hardship is increasingly common, with many
cancer survivors reporting difficulty paying medical bills, high levels of
financial distress, and delaying care or forgoing care altogether because of
cost (14).

In addition to out-of-pocket expenses, cancer survivors also spend time
traveling to and from care and waiting for and receiving care, which represents
time not spent pursuing other activities, including work and leisure (15–18).
This time spent receiving medical care (“patient time cost”) is referred to as
an opportunity cost by health economists. Prior research has shown that patient
time costs can be substantial (15–17) and can result in additional economic
burdens for cancer survivors. Academic health economists have long recommended
including these time costs in cost-effectiveness analyses of medical
interventions (19,20). Estimates of patient out-of-pocket and time costs may
also be useful for both providers and patients as part of informed
decision-making.

Prior research estimating out-of-pocket costs in cancer survivors was limited by
lack of detail on cancer site and stage at diagnosis (21,22). Similarly, most
prior research estimating patient time costs has been limited by a lack of
information for adults aged 18-64 years, who are not age-eligible for Medicare
coverage (15,16). In this study, we build on and extend prior research
estimating health care costs associated with cancer by phase of care using the
Surveillance, Epidemiology, and End Results (SEER) registry data linked with
Medicare enrollment and claims data (SEER-Medicare) to provide detailed
estimates of out-of-pocket costs (4,6,23,24) by cancer site and stage for adults
aged ≥65 years, and the Medical Expenditure Panel Survey (MEPS) data to provide
out-of-pocket (21) and patient time costs (17) stratified by age group
(18-64 years and ≥65 years), with all insurance coverage types. These data
sources are complementary, and, to the extent possible, we take advantage of the
populations included and level of clinical detail to provide comprehensive
information about patient economic burden associated with cancer.


METHODS


DATA SOURCES

SEER-Medicare. The SEER data include age at cancer diagnosis, cancer site, stage
at diagnosis, and date of diagnosis for patients living in SEER geographic areas
diagnosed with incident cancers; patients were followed for vital status and
cause of death (25). Medicare is the federal health insurance program that
covers approximately 95% of adults aged 65 years and older and some younger
adults with certain disabilities or medical conditions (eg, end-stage renal
disease) (26). Medicare enrollment data contain demographic characteristics and
monthly indicators for enrollment in fee-for-service Parts A (inpatient stays),
B (physician and outpatient services), and D (prescription drugs covered through
a pharmacy benefit) (27). The Medicare Part D pharmacy benefit for prescription
drug coverage was introduced in 2006 (28), and approximately 60% of Medicare
beneficiaries had Part D coverage during the study period (4). Medicare claims
data include payments and dates of service. The linked SEER-Medicare database
also includes a 5% random sample of all Medicare beneficiaries residing in the
SEER areas (26). Medicare beneficiaries in the 5% random sample without a cancer
diagnosis serve as controls for calculation of medical care costs associated
with a cancer diagnosis. The SEER-Medicare data in years 2000-2013 were used in
this study to identify cancer patients and survivors; vital status was measured
through December 31, 2013. The observation period for estimating spending was
2007-2013.

Medical Expenditure Panel Survey. The MEPS is an annual nationally
representative household survey of health care access, use, and expenditures in
the US civilian noninstitutionalized population (29). Adults of all ages and
types of health insurance coverage, including the uninsured, are surveyed by the
MEPS. In-person interviews are supplemented with additional information about
types of health-care services and payments by source, including out-of-pocket
payments, from a sample of medical care providers, including physicians,
hospitals, and pharmacies, for household survey respondents. The MEPS provides
annual information about hospital inpatient stays, emergency room visits,
medical provider and outpatient visits, and prescription drugs. The 2008-2017
MEPS data were used in this study and had a combined average annual response
rate ranging from 44% to 59% (29).


ESTIMATING ANNUALIZED NET PATIENT RESPONSIBILITY AND OUT-OF-POCKET COSTS WITH
SEER-MEDICARE DATA

We estimated patient responsibility (the amount not paid by Medicare but by
patients and other payers) and out-of-pocket costs associated with cancer for
both Medicare Parts A and B and Part D from the SEER-Medicare data,
respectively. We identified adults diagnosed with any cancer, between 2000 and
2012 from SEER, building on a prior study of all medical care costs associated
with cancer (4). Survivors were required to have at least 1 month of observation
between 2007 and 2013 in which they were aged 65 years and older and enrolled in
fee-for-service Medicare with both Part A and Part B coverage; only those who
also had Part D coverage were included in analyses of prescription drugs covered
through a pharmacy benefit. Information was reported for the 21 most common
cancer sites as well as all cancer sites combined. We used SEER historic staging
to classify solid tumors into localized-, regional-, or distant-stage disease at
diagnosis.

Phase of Care Definitions for Cancer Survivors and Controls. We used a
phase-of-care approach to assign months of observation between 2007 and 2013
after cancer diagnosis into 3 clinically relevant phases, consistent with
previous studies (4,6,24). Phases include the initial phase, defined as the
first 12 months after each diagnosis; the EOL phase, defined as the 12 months
before death among survivors who died; and the continuing phase, the months
between the initial and the EOL phases (4–6). Patients contributed months of
observation to phases of care based on the date of their diagnosis and date of
death, if they died before December 31, 2013, relative to the study observation
period of 2007-2013. Not all patients contributed months of observation to all
phases of care. Patients diagnosed before 2006 did not contribute to the initial
phase, and patients who survived through 2013 did not contribute to the EOL
phase. We further divided the EOL phase into months of observation contributed
by survivors who died from cancer (EOL-cancer death) or from other causes
(EOL-noncancer death) based on information from the death certificate from SEER.
For cancer patients who survived less than 24 months after their cancer
diagnosis, months were first assigned to the EOL phase and any remaining months
were then assigned to the initial phase. Patients who survived 12 months or less
following diagnosis only contributed to the EOL phase.

Months of observation for controls were assigned to 2 phases: the EOL phase
defined as the 12 months before death among controls who died and the continuing
phase that included all other months. Once the months of observation for cases
and controls were allocated to the respective phases, they were then stratified
by calendar year.

Months of observation for cancer survivors and controls were matched in a 1:1
ratio by phase of care (described below), calendar year, registry, sex, age (to
the nearest year), race, and Medicare Part D enrollment and entitlement status
(described below). If more than 1 control was eligible for matching to a
specific case, the control was randomly selected. Because not all Medicare
beneficiaries have Part D prescription drug coverage, Medicare Part D enrollment
and entitlement status were categorized as not enrolled in Part D, Part D
low-income subsidy (LIS), and Part D non-LIS. Approximately 28% of Medicare Part
D beneficiaries in this sample receive LIS (4), which helps beneficiaries with
low income and limited assets by limiting their out-of-pocket payments for
generic and branded prescription drugs (30). Months of observation for controls
in the continuing phase were matched to those for cases in the initial,
continuing, and EOL-cancer death phases, because it is assumed that health-care
use and costs for controls approximate the noncancer use and costs for the
cases. Months of observation for controls in the EOL phase were matched to those
for cases in the EOL-noncancer death phase, consistent with prior studies.

Estimation of Annualized Net Patient Responsibility and Out-of-Pocket Costs.
Medicare Part A and Part B claims data contain information about Medicare
payments and patient responsibility, a total amount that includes out-of-pocket
costs (ie, deductibles, fixed copayments, coinsurance rates as a percentage of
service costs) as well as payments from other insurers (31). Patient
responsibility was calculated for each month of observation from amounts listed
in the claims based on date of service. Mean monthly net patient responsibility
associated with cancer was calculated as the difference between cases and
controls. The individual components of patient responsibility are not reported
separately by payment source (ie, patient, other insurer), and as a result,
patient out-of-pocket costs cannot be estimated directly from Medicare Part A
and Part B claims data. We used information from the MEPS (described below) to
estimate out-of-pocket costs from patient responsibility amounts for Medicare
Part A and Part B medical services. First, we estimated the components of annual
patient responsibility among Medicare beneficiaries with a cancer history by
payer type (ie, other insurer, patients) from the MEPS. Then we calculated the
percentage of patient out-of-pocket costs relative to patient responsibility
amount (28.9%) from the MEPS and applied this percentage to patient
responsibility amounts for Medicare Part A and Part B medical services to
estimate the patient out-of-pocket costs.

Unlike Medicare Part A and Part B claims data, Medicare Part D claims data
contain information on patient out-of-pocket payments, including copayments,
coinsurance rates as a percentage of prescription drug cost, and deductibles
(24). Patient out-of-pocket cost was calculated for each month of observation
from amounts listed in the Part D claims based on date of service.

Statistical Analyses. The mean monthly patient out-of-pocket cost associated
with cancer was estimated as the difference between the mean monthly cost
between cases and controls matched on phase of care, calendar year, registry,
sex, age, race, and Medicare Part D enrollment and entitlement status. All costs
are reported as annualized mean costs and inflated to 2019 US dollars using the
Consumer Price Index for medical care. Estimates of means, standard errors, and
medians were calculated for net patient responsibility and out-of-pocket costs
for Medicare Part A and B claims and Medicare Part D claims, respectively, by
phase of care, cancer site, and stage at diagnosis.


ESTIMATING PATIENT OUT-OF-POCKET AND TIME COSTS WITH MEPS DATA

We estimated out-of-pocket and time costs among cancer survivors and adults
without a cancer history (as the comparison group) from the MEPS data stratified
by age group (18-64 years and ≥65 years). Cancer survivors were identified from
a question asking if a doctor or other health professional had ever told the
person they had cancer or a malignancy of any kind. Respondents were asked about
their age(s) at each cancer diagnosis, and the time since first cancer diagnosis
was calculated as the difference between age at first diagnosis and age at the
survey interview and categorized as less than 2 years, 2-5 years, 6-10 years,
and longer than 10 years, or unknown. Other characteristics included sex, race
and ethnicity, marital status, educational attainment, health insurance
coverage, and MEPS priority conditions (arthritis, asthma, diabetes, emphysema,
heart disease [angina, coronary heart disease, heart attack, other heart
condition or disease], high cholesterol, hypertension, and stroke), which were
classified by the total number of conditions.

Annual Out-of-Pocket Spending Statistical Analyses. Annual out-of-pocket medical
spending measured in the MEPS included patient out-of-pocket payments for
hospital inpatient stays, emergency room visits, provider and outpatient visits,
prescription drugs, and other medical services not covered by health insurance.
Net out-of-pocket spending associated with cancer was calculated as the
difference between cancer survivors and adults without a cancer history by age
group. All spending was adjusted to 2019 US dollars. To preserve sample weights
and nationally representativeness of our estimates, we did not match adults
without a cancer history to cancer survivors. Instead we used multivariable
2-part models to estimate out-of-pocket costs adjusted for characteristics that
vary between adults with and without a cancer history, including age, sex,
educational attainment, and number of comorbid conditions. In the 2-part model,
the first part is a logistic model for the probability of having any spending,
followed by a generalized linear model with a gamma distribution and a log link
among individuals with any spending. This approach is commonly used with
health-care spending data because of the many individuals with zero spending and
the skewness of the distribution among individuals with any spending
(21,22,32,33). P less than .05 was considered statistically significant, and all
tests of statistical significance were 2-sided. All estimates were weighted to
account for the MEPS complex survey design and survey nonresponse.

Annual Patient Time Costs. Patient time costs include round-trip travel to care,
waiting for care, and receiving care and were estimated by calculating annual
medical service frequencies, applying service-specific time estimates,
summarizing annual patient time, and multiplying by the hourly value of patient
time, as has been done elsewhere (15–17). Medical service categories were
identified from the MEPS visit files and consolidated files (29) and included
overnight hospitalizations, emergency room visits, ambulatory surgery, provider
office-based or hospital outpatient visits, chemotherapy, and radiation therapy.
The MEPS stopped collecting information separately about chemotherapy and
radiation therapy in 2013; estimates of service frequencies for chemotherapy and
radiation therapy are based on data from 2008-2012 only. Annual service
frequency was calculated for each service category. The annual hospital length
of stay was a summary of inpatient days from all hospitalizations for the year.

Estimates of patient time associated with round-trip travel to care, waiting for
care, and receiving care were calculated separately for each service category
using national data sources from previously published studies (15–17). For
example, the average time spent with a physician during an office visit in these
earlier studies was calculated from the National Ambulatory Medical Care Survey.
Patient time for emergency room visits was calculated as the difference between
arrival time and discharge time from the National Hospital Ambulatory Medical
Care Survey Emergency Department Patient Record. Patient time in the hospital
(in days) was measured as the difference between admission and discharge dates
and multiplied by 16 hours, an estimate of waking hours that could alternatively
be spent pursuing usual activities, including work and leisure. Round-trip
travel time to usual source of medical care was estimated from responses to a
question from the MEPS about how long it takes to get to the usual medical
provider and was added to all service time estimates. Waiting time was added to
office-based or hospital outpatient visits, chemotherapy, and radiation therapy
estimates. Time estimates for emergency room visits, hospitalizations, and
ambulatory surgeries were based on the difference between admission and
discharge time, so waiting time was not added to these estimates separately. All
patient time estimates were estimated separately by metropolitan statistical
area and nonmetropolitan statistical area status to reflect any differences in
urban and rural travel, wait time, or practice patterns. As in previous studies
(15–17), we used the median US wage ($19.14/h in 2019) to value patient time in
our primary analyses of all services as well as for service-specific estimates.
Another approach for valuing patient time based on age- and sex-specific wages,
also known as the “human capital” approach (17,18), differentially values time
for people not in the workforce or who have lower-paying jobs than for people
with higher-paid work. In this study, we chose to value patient time equally
with the median wage to avoid these inequities.

Annual Patient Time Cost Statistical Analyses. Estimates of annual service
frequencies, patient time, and patient time costs for cancer survivors and
adults without a cancer history used separate multivariable analyses to control
for age, sex, educational attainment, and the number of comorbid conditions. We
present adjusted predicted marginals from the multivariable regression analyses,
which directly standardize the outcome of each group to the covariate
distribution of the overall population (34). These standardized results can be
compared like percentages. Net patient time cost associated with cancer was
calculated as the difference in time costs between cancer survivors and adults
without a cancer history by age group. P less than .05 was considered
statistically significant, and all tests of statistical significance were
2-sided. All estimates were weighted to account for the MEPS complex survey
design and survey nonresponse.


ESTIMATING NET PATIENT ECONOMIC BURDEN ASSOCIATED WITH CANCER CARE IN THE UNITED
STATES IN 2019

We combined previously published projections of cancer prevalence by phase of
care in 2019 for all cancer sites overall and for 15 selected cancer sites (4)
by age group (<65 years and ≥65 years) with annualized net estimates of
out-of-pocket costs for medical services and prescription drugs covered through
a pharmacy benefit by phase of care from SEER-Medicare to create national
estimates of out-of-pocket spending in 2019. To reflect the greater net
out-of-pocket spending associated with cancer in the younger age group, we used
annual spending amounts for medical services and prescription drugs by age group
(<65 years and ≥65 years) from the MEPS to adjust the SEER-Medicare estimates in
the initial and last year of life-cancer death phases. This general approach has
been used previously in estimating and projecting national spending associated
with cancer based on SEER-Medicare data. Annual net patient time cost estimates
from the MEPS by age group were also combined with the prevalence projections in
2019 to estimate national patient time costs. The sum of out-of-pocket and time
costs reflects the national net patient economic burden associated with cancer
care in 2019.


RESULTS


PATIENT RESPONSIBILITY AND NET OUT-OF-POCKET COST ESTIMATES FROM SEER-MEDICARE
DATA

During 2007-2013, more than 800 000 newly diagnosed patients with cancer aged
65 years and older contributed to the initial phase of care, approximately
1 317 000 to the continuing phase, and approximately 437 000 to the EOL phase
for medical services (Medicare Part A and Part B) (Table 1). The number of newly
diagnosed patients with cancer and controls contributing to each phase of care
by cancer site for prescription drugs covered through a pharmacy benefit was
smaller (Supplementary Table 1, available online), because not all Medicare
beneficiaries elected to enroll in Part D for prescription drug coverage.

Table 1.

Number of cancer patients aged 65 years and older, with Medicare Fee-for-Service
Part A and Part B, SEER-Medicare 2007-2013a

Cancer site . Phase of care

--------------------------------------------------------------------------------

. Initial . Continuing . End-of-life

--------------------------------------------------------------------------------

. Cancer . Other cause
. Bladder 52 490 74 913 15 180 19 633 Brain 2882 2490 7845 1705 Breast 126 034 250 192 22 527 35 908 Cervix
uteri 2238 4224 1618 743 Colorectal 81 226 137 618 42 023 34 596 Esophagus 5275 5125 8449 1689 Hodgkin
lymphoma 1450 2529 854 563 Kidney 26 754 40 003 10 817 8160 Leukemia 18 366 24 824 15 128 7389  AML 2226 1804 7416 1041  CLL 11 763 17 513 3805 4344  CML 2598 3181 1519 1225 Liver 5644 4968 9280 2295 Lung 73 836 70 089 124 277 24 747  NSCLC 68 128 66 400 106 775 23 007  SCLC 5708 3689 17 502 1740 Melanoma 64 428 97 579 7212 15 635 Myeloma 11 734 13 944 9650 3733 Non-Hodgkin
lymphoma 34 448 52 908 18 048 11 367 Oral cavity or
pharynx 15 858 23 432 8261 5277 Ovary 8088 11 807 10 241 1492 Pancreas 8804 5321 29 571 2458 Prostate 158 840 335 539 23 403 48 559 Stomach 9411 10 623 11 809 3333 Thyroid 10 684 19 255 1688 1714 Uterus 22 098 42 161 7561 5804 All
sites combined 808 148 1 316 976 436 986 270 816 

Cancer site . Phase of care

--------------------------------------------------------------------------------

. Initial . Continuing . End-of-life

--------------------------------------------------------------------------------

. Cancer . Other cause
. Bladder 52 490 74 913 15 180 19 633 Brain 2882 2490 7845 1705 Breast 126 034 250 192 22 527 35 908 Cervix
uteri 2238 4224 1618 743 Colorectal 81 226 137 618 42 023 34 596 Esophagus 5275 5125 8449 1689 Hodgkin
lymphoma 1450 2529 854 563 Kidney 26 754 40 003 10 817 8160 Leukemia 18 366 24 824 15 128 7389  AML 2226 1804 7416 1041  CLL 11 763 17 513 3805 4344  CML 2598 3181 1519 1225 Liver 5644 4968 9280 2295 Lung 73 836 70 089 124 277 24 747  NSCLC 68 128 66 400 106 775 23 007  SCLC 5708 3689 17 502 1740 Melanoma 64 428 97 579 7212 15 635 Myeloma 11 734 13 944 9650 3733 Non-Hodgkin
lymphoma 34 448 52 908 18 048 11 367 Oral cavity or
pharynx 15 858 23 432 8261 5277 Ovary 8088 11 807 10 241 1492 Pancreas 8804 5321 29 571 2458 Prostate 158 840 335 539 23 403 48 559 Stomach 9411 10 623 11 809 3333 Thyroid 10 684 19 255 1688 1714 Uterus 22 098 42 161 7561 5804 All
sites combined 808 148 1 316 976 436 986 270 816 

a

Includes patients diagnosed with in-situ and invasive cancers. AML = acute
myeloid leukemia; CLL = chronic lymphocytic leukemia; CML = chronic myeloid
leukemia; NSCLC = non-small cell lung cancer; SCLC = small cell lung cancer;
SEER = Surveillance, Epidemiology, and End Results Program. The reference source
for this table is Mariotto et al., 2020 (4).

Open in new tab
Table 1.

Number of cancer patients aged 65 years and older, with Medicare Fee-for-Service
Part A and Part B, SEER-Medicare 2007-2013a

Cancer site . Phase of care

--------------------------------------------------------------------------------

. Initial . Continuing . End-of-life

--------------------------------------------------------------------------------

. Cancer . Other cause
. Bladder 52 490 74 913 15 180 19 633 Brain 2882 2490 7845 1705 Breast 126 034 250 192 22 527 35 908 Cervix
uteri 2238 4224 1618 743 Colorectal 81 226 137 618 42 023 34 596 Esophagus 5275 5125 8449 1689 Hodgkin
lymphoma 1450 2529 854 563 Kidney 26 754 40 003 10 817 8160 Leukemia 18 366 24 824 15 128 7389  AML 2226 1804 7416 1041  CLL 11 763 17 513 3805 4344  CML 2598 3181 1519 1225 Liver 5644 4968 9280 2295 Lung 73 836 70 089 124 277 24 747  NSCLC 68 128 66 400 106 775 23 007  SCLC 5708 3689 17 502 1740 Melanoma 64 428 97 579 7212 15 635 Myeloma 11 734 13 944 9650 3733 Non-Hodgkin
lymphoma 34 448 52 908 18 048 11 367 Oral cavity or
pharynx 15 858 23 432 8261 5277 Ovary 8088 11 807 10 241 1492 Pancreas 8804 5321 29 571 2458 Prostate 158 840 335 539 23 403 48 559 Stomach 9411 10 623 11 809 3333 Thyroid 10 684 19 255 1688 1714 Uterus 22 098 42 161 7561 5804 All
sites combined 808 148 1 316 976 436 986 270 816 

Cancer site . Phase of care

--------------------------------------------------------------------------------

. Initial . Continuing . End-of-life

--------------------------------------------------------------------------------

. Cancer . Other cause
. Bladder 52 490 74 913 15 180 19 633 Brain 2882 2490 7845 1705 Breast 126 034 250 192 22 527 35 908 Cervix
uteri 2238 4224 1618 743 Colorectal 81 226 137 618 42 023 34 596 Esophagus 5275 5125 8449 1689 Hodgkin
lymphoma 1450 2529 854 563 Kidney 26 754 40 003 10 817 8160 Leukemia 18 366 24 824 15 128 7389  AML 2226 1804 7416 1041  CLL 11 763 17 513 3805 4344  CML 2598 3181 1519 1225 Liver 5644 4968 9280 2295 Lung 73 836 70 089 124 277 24 747  NSCLC 68 128 66 400 106 775 23 007  SCLC 5708 3689 17 502 1740 Melanoma 64 428 97 579 7212 15 635 Myeloma 11 734 13 944 9650 3733 Non-Hodgkin
lymphoma 34 448 52 908 18 048 11 367 Oral cavity or
pharynx 15 858 23 432 8261 5277 Ovary 8088 11 807 10 241 1492 Pancreas 8804 5321 29 571 2458 Prostate 158 840 335 539 23 403 48 559 Stomach 9411 10 623 11 809 3333 Thyroid 10 684 19 255 1688 1714 Uterus 22 098 42 161 7561 5804 All
sites combined 808 148 1 316 976 436 986 270 816 

a

Includes patients diagnosed with in-situ and invasive cancers. AML = acute
myeloid leukemia; CLL = chronic lymphocytic leukemia; CML = chronic myeloid
leukemia; NSCLC = non-small cell lung cancer; SCLC = small cell lung cancer;
SEER = Surveillance, Epidemiology, and End Results Program. The reference source
for this table is Mariotto et al., 2020 (4).

Open in new tab

Annualized Net Patient Out-of-Pocket Costs by Cancer Site and Phase of Care.
Annualized net patient out-of-pocket costs by cancer site and phase of care were
calculated from the net patient responsibility estimates reported in
Supplementary Table 2 (available online). Averaged across all cancer sites,
out-of-pocket costs associated with cancer for medical services were highest in
the initial ($2200) and EOL ($3823) phases and lowest in the continuing phase
($466), following a “U” or “J” shaped curve (Table 2). By cancer site,
out-of-pocket costs for medical services were highest in the initial and end-of
life phases for acute myeloid leukemia ($6093 and $7039, respectively) and brain
cancer ($5751 and $5901, respectively) and in the continuing phase for myeloma
($1532), pancreatic cancer ($1083), and acute myeloid leukemia ($1056).

Table 2.

Net annualized patient out-of-pocket costs associated with cancer by phase of
care, SEER-Medicare 2007-2013a,b,c

Cancer site . Medical services (Medicare parts A and B)

--------------------------------------------------------------------------------

. Prescription drugs covered through pharmacy benefit (Medicare part D)

--------------------------------------------------------------------------------

. Medical services and prescription drugs

--------------------------------------------------------------------------------

. Initial . Continuing . End-of-life cancer death . Initial . Continuing
. End-of-life cancer death . Initial . Continuing . End-of-life cancer death
. Bladder $1472 $503 $3195 $154 $119 $201 $1626 $622 $3396 Brain $5751 $975 $5901 $522 $247 $479 $6273 $1222 $6380 Breast $2206 $384 $2852 $202 $167 $275 $2408 $551 $3127 Cervix
uteri $3038 $349 $3148 −$6 −$36 $29 $3032 $313 $3177 Colorectal $2641 $482 $3857 $66 $30 $91 $2706 $512 $3948 Esophagus $4196 $664 $4459 $336 $113 $210 $4532 $777 $4669 Hodgkin
lymphoma $3802 $617 $4201 $378 $75 $384 $4180 $693 $4585 Kidney $1693 $606 $3388 $309 $222 $938 $2003 $827 $4326 Leukemia $1973 $797 $5176 $642 $413 $582 $2615 $1210 $5758  AML $6093 $1056 $7039 $1267 $335 $639 $7359 $1392 $7678  CLL $1318 $790 $3393 $122 $117 $333 $1440 $907 $3726  CML $1572 $799 $4342 $2456 $2341 $946 $4028 $3141 $5288 Liver $2746 $970 $2745 $577 $466 $773 $3323 $1436 $3517 Lung $3140 $780 $4003 $460 $309 $546 $3601 $1089 $4550  NSCLC $3050 $776 $3930 $470 $312 $588 $3519 $1089 $4518  SCLC $4461 $861 $4474 $325 $236 $274 $4786 $1097 $4748 Melanoma $662 $340 $2980 $123 $95 $440 $786 $434 $3420 Myeloma $3562 $1532 $4132 $2576 $1593 $1818 $6138 $3125 $5950 Non-Hodgkin
lymphoma $3767 $848 $4940 $219 $88 $297 $3987 $936 $5237 Oral cavity or
pharynx $3029 $465 $3978 $161 $36 $186 $3191 $500 $4164 Ovary $3166 $902 $3907 $154 $6 $142 $3320 $908 $4049 Pancreas $4280 $1083 $4158 $819 $519 $871 $5099 $1602 $5029 Prostate $1819 $335 $2830 $95 $48 $533 $1914 $382 $3363 Stomach $3116 $534 $4007 $308 $145 $164 $3424 $678 $4172 Thyroid $1354 $415 $3347 $228 $177 $434 $1582 $592 $3782 Uterus $1944 $337 $3187 $40 $15 $146 $1984 $352 $3333 All
sites combined $2200 $466 $3823 $243 $127 $448 $2443 $593 $4271 

Cancer site . Medical services (Medicare parts A and B)

--------------------------------------------------------------------------------

. Prescription drugs covered through pharmacy benefit (Medicare part D)

--------------------------------------------------------------------------------

. Medical services and prescription drugs

--------------------------------------------------------------------------------

. Initial . Continuing . End-of-life cancer death . Initial . Continuing
. End-of-life cancer death . Initial . Continuing . End-of-life cancer death
. Bladder $1472 $503 $3195 $154 $119 $201 $1626 $622 $3396 Brain $5751 $975 $5901 $522 $247 $479 $6273 $1222 $6380 Breast $2206 $384 $2852 $202 $167 $275 $2408 $551 $3127 Cervix
uteri $3038 $349 $3148 −$6 −$36 $29 $3032 $313 $3177 Colorectal $2641 $482 $3857 $66 $30 $91 $2706 $512 $3948 Esophagus $4196 $664 $4459 $336 $113 $210 $4532 $777 $4669 Hodgkin
lymphoma $3802 $617 $4201 $378 $75 $384 $4180 $693 $4585 Kidney $1693 $606 $3388 $309 $222 $938 $2003 $827 $4326 Leukemia $1973 $797 $5176 $642 $413 $582 $2615 $1210 $5758  AML $6093 $1056 $7039 $1267 $335 $639 $7359 $1392 $7678  CLL $1318 $790 $3393 $122 $117 $333 $1440 $907 $3726  CML $1572 $799 $4342 $2456 $2341 $946 $4028 $3141 $5288 Liver $2746 $970 $2745 $577 $466 $773 $3323 $1436 $3517 Lung $3140 $780 $4003 $460 $309 $546 $3601 $1089 $4550  NSCLC $3050 $776 $3930 $470 $312 $588 $3519 $1089 $4518  SCLC $4461 $861 $4474 $325 $236 $274 $4786 $1097 $4748 Melanoma $662 $340 $2980 $123 $95 $440 $786 $434 $3420 Myeloma $3562 $1532 $4132 $2576 $1593 $1818 $6138 $3125 $5950 Non-Hodgkin
lymphoma $3767 $848 $4940 $219 $88 $297 $3987 $936 $5237 Oral cavity or
pharynx $3029 $465 $3978 $161 $36 $186 $3191 $500 $4164 Ovary $3166 $902 $3907 $154 $6 $142 $3320 $908 $4049 Pancreas $4280 $1083 $4158 $819 $519 $871 $5099 $1602 $5029 Prostate $1819 $335 $2830 $95 $48 $533 $1914 $382 $3363 Stomach $3116 $534 $4007 $308 $145 $164 $3424 $678 $4172 Thyroid $1354 $415 $3347 $228 $177 $434 $1582 $592 $3782 Uterus $1944 $337 $3187 $40 $15 $146 $1984 $352 $3333 All
sites combined $2200 $466 $3823 $243 $127 $448 $2443 $593 $4271 

a

Includes patients diagnosed with in-situ and invasive cancers. AML = acute
myeloid leukemia; CLL = chronic lymphocytic leukemia; CML = chronic myeloid
leukemia; NSCLC = non-small cell lung cancer; SCLC = small cell lung cancer;
SEER = Surveillance, Epidemiology, and End Results Program.

b

Costs associated with cancer are estimated as the difference between cancer
cases and matched controls. All estimates in 2019 US dollars.

c

Out-of-pocket costs estimated from patient responsibility for medical services
(including infusion drugs) under Medicare Parts A/B claims. Out-of-pocket costs
for oral prescription drugs estimated directly from Medicare Part D claims.

Open in new tab
Table 2.

Net annualized patient out-of-pocket costs associated with cancer by phase of
care, SEER-Medicare 2007-2013a,b,c

Cancer site . Medical services (Medicare parts A and B)

--------------------------------------------------------------------------------

. Prescription drugs covered through pharmacy benefit (Medicare part D)

--------------------------------------------------------------------------------

. Medical services and prescription drugs

--------------------------------------------------------------------------------

. Initial . Continuing . End-of-life cancer death . Initial . Continuing
. End-of-life cancer death . Initial . Continuing . End-of-life cancer death
. Bladder $1472 $503 $3195 $154 $119 $201 $1626 $622 $3396 Brain $5751 $975 $5901 $522 $247 $479 $6273 $1222 $6380 Breast $2206 $384 $2852 $202 $167 $275 $2408 $551 $3127 Cervix
uteri $3038 $349 $3148 −$6 −$36 $29 $3032 $313 $3177 Colorectal $2641 $482 $3857 $66 $30 $91 $2706 $512 $3948 Esophagus $4196 $664 $4459 $336 $113 $210 $4532 $777 $4669 Hodgkin
lymphoma $3802 $617 $4201 $378 $75 $384 $4180 $693 $4585 Kidney $1693 $606 $3388 $309 $222 $938 $2003 $827 $4326 Leukemia $1973 $797 $5176 $642 $413 $582 $2615 $1210 $5758  AML $6093 $1056 $7039 $1267 $335 $639 $7359 $1392 $7678  CLL $1318 $790 $3393 $122 $117 $333 $1440 $907 $3726  CML $1572 $799 $4342 $2456 $2341 $946 $4028 $3141 $5288 Liver $2746 $970 $2745 $577 $466 $773 $3323 $1436 $3517 Lung $3140 $780 $4003 $460 $309 $546 $3601 $1089 $4550  NSCLC $3050 $776 $3930 $470 $312 $588 $3519 $1089 $4518  SCLC $4461 $861 $4474 $325 $236 $274 $4786 $1097 $4748 Melanoma $662 $340 $2980 $123 $95 $440 $786 $434 $3420 Myeloma $3562 $1532 $4132 $2576 $1593 $1818 $6138 $3125 $5950 Non-Hodgkin
lymphoma $3767 $848 $4940 $219 $88 $297 $3987 $936 $5237 Oral cavity or
pharynx $3029 $465 $3978 $161 $36 $186 $3191 $500 $4164 Ovary $3166 $902 $3907 $154 $6 $142 $3320 $908 $4049 Pancreas $4280 $1083 $4158 $819 $519 $871 $5099 $1602 $5029 Prostate $1819 $335 $2830 $95 $48 $533 $1914 $382 $3363 Stomach $3116 $534 $4007 $308 $145 $164 $3424 $678 $4172 Thyroid $1354 $415 $3347 $228 $177 $434 $1582 $592 $3782 Uterus $1944 $337 $3187 $40 $15 $146 $1984 $352 $3333 All
sites combined $2200 $466 $3823 $243 $127 $448 $2443 $593 $4271 

Cancer site . Medical services (Medicare parts A and B)

--------------------------------------------------------------------------------

. Prescription drugs covered through pharmacy benefit (Medicare part D)

--------------------------------------------------------------------------------

. Medical services and prescription drugs

--------------------------------------------------------------------------------

. Initial . Continuing . End-of-life cancer death . Initial . Continuing
. End-of-life cancer death . Initial . Continuing . End-of-life cancer death
. Bladder $1472 $503 $3195 $154 $119 $201 $1626 $622 $3396 Brain $5751 $975 $5901 $522 $247 $479 $6273 $1222 $6380 Breast $2206 $384 $2852 $202 $167 $275 $2408 $551 $3127 Cervix
uteri $3038 $349 $3148 −$6 −$36 $29 $3032 $313 $3177 Colorectal $2641 $482 $3857 $66 $30 $91 $2706 $512 $3948 Esophagus $4196 $664 $4459 $336 $113 $210 $4532 $777 $4669 Hodgkin
lymphoma $3802 $617 $4201 $378 $75 $384 $4180 $693 $4585 Kidney $1693 $606 $3388 $309 $222 $938 $2003 $827 $4326 Leukemia $1973 $797 $5176 $642 $413 $582 $2615 $1210 $5758  AML $6093 $1056 $7039 $1267 $335 $639 $7359 $1392 $7678  CLL $1318 $790 $3393 $122 $117 $333 $1440 $907 $3726  CML $1572 $799 $4342 $2456 $2341 $946 $4028 $3141 $5288 Liver $2746 $970 $2745 $577 $466 $773 $3323 $1436 $3517 Lung $3140 $780 $4003 $460 $309 $546 $3601 $1089 $4550  NSCLC $3050 $776 $3930 $470 $312 $588 $3519 $1089 $4518  SCLC $4461 $861 $4474 $325 $236 $274 $4786 $1097 $4748 Melanoma $662 $340 $2980 $123 $95 $440 $786 $434 $3420 Myeloma $3562 $1532 $4132 $2576 $1593 $1818 $6138 $3125 $5950 Non-Hodgkin
lymphoma $3767 $848 $4940 $219 $88 $297 $3987 $936 $5237 Oral cavity or
pharynx $3029 $465 $3978 $161 $36 $186 $3191 $500 $4164 Ovary $3166 $902 $3907 $154 $6 $142 $3320 $908 $4049 Pancreas $4280 $1083 $4158 $819 $519 $871 $5099 $1602 $5029 Prostate $1819 $335 $2830 $95 $48 $533 $1914 $382 $3363 Stomach $3116 $534 $4007 $308 $145 $164 $3424 $678 $4172 Thyroid $1354 $415 $3347 $228 $177 $434 $1582 $592 $3782 Uterus $1944 $337 $3187 $40 $15 $146 $1984 $352 $3333 All
sites combined $2200 $466 $3823 $243 $127 $448 $2443 $593 $4271 

a

Includes patients diagnosed with in-situ and invasive cancers. AML = acute
myeloid leukemia; CLL = chronic lymphocytic leukemia; CML = chronic myeloid
leukemia; NSCLC = non-small cell lung cancer; SCLC = small cell lung cancer;
SEER = Surveillance, Epidemiology, and End Results Program.

b

Costs associated with cancer are estimated as the difference between cancer
cases and matched controls. All estimates in 2019 US dollars.

c

Out-of-pocket costs estimated from patient responsibility for medical services
(including infusion drugs) under Medicare Parts A/B claims. Out-of-pocket costs
for oral prescription drugs estimated directly from Medicare Part D claims.

Open in new tab

Out-of-pocket costs for prescription medications covered through a pharmacy
benefit followed the same pattern overall by phase of care (initial = $243, EOL
= $448, and continuing = $127), with some differences by cancer site (Table 2;
Supplementary Table 3, available online). By cancer site, out-of-pocket costs
were highest in the initial, continuing, and EOL phases for chronic myeloid
leukemia (CML; $2456, $2341, and $946, respectively) and myeloma ($2576, $1593,
and $1818, respectively). Notably, annualized out-of-pocket costs by phase of
care for CML and myeloma were less consistent with a “U-shaped” curve by phase
of care.

Annualized Net Patient Out-of-Pocket Costs by Cancer Site, Phase of Care, and
Stage at Diagnosis. Across all cancer sites, annualized net patient
out-of-pocket costs for medical services were lowest for patients originally
diagnosed with localized disease compared with regional or distant disease
(Table 3; patient responsibility estimates are found in Supplementary Table 4,
available online). In the initial phase of care, annualized costs were $1694,
$3194, and $3540 for cancers diagnosed with localized, regional, or distant
disease, respectively; differences in out-of-pocket costs between localized and
distant stage at diagnosis were greatest for bladder, colorectal, non-small cell
lung cancer (NSCLC), oral cavity or pharynx, and stomach cancers.

Table 3.

Net annualized patient out-of-pocket costs for medical services and prescription
drugs by phase of care and stage at diagnosis, SEER-Medicare 2007-2013a,b,c

Service type and cancer site . Phase of care

--------------------------------------------------------------------------------

. Initial phase

--------------------------------------------------------------------------------

. End-of-life cancer death

--------------------------------------------------------------------------------

. Localized . Regional . Distant . Localized . Regional . Distant . Medical
services (Medicare Parts
A/B)        Bladder $1244 $2956 $3952 $2634 $3564 $4810  Breast $2053 $3108 $3711 $2479 $2893 $3677  Cervix
uteri $2221 $3572 $4100 $2770 $3102 $3690  Colorectal $1755 $3283 $5953 $3000 $3616 $4932  Esophagus $3379 $5092 $4878 $3914 $4467 $5002  Kidney $1508 $1993 $3140 $3007 $3449 $4006  Liver $2742 $2829 $3714 $2647 $2708 $3631  Lung $2238 $3406 $4567 $2840 $3605 $4756   NSCLC $2207 $3313 $4542 $2816 $3540 $4755   SCLC $3514 $4559 $4745 $3274 $4068 $4761  Melanoma $706 $1636 $2719 $2498 $2892 $4575  Oral
cavity or
pharynx $1727 $4044 $4645 $3178 $4154 $4476  Ovary $1891 $3022 $3565 $2965 $3098 $4086  Pancreas $3133 $4858 $4646 $3519 $4256 $4571  Prostated $1834 $1826 $2800 $3047  Stomach $2358 $4260 $4731 $3289 $4010 $4882  Thyroid $1149 $1644 $2520 $3094 $3491 $3480  Uterus $1575 $2769 $3430 $2858 $3278 $3706  All
sites combined $1694 $3194 $3540 $2868 $3604 $4526 Prescription drugs covered
through pharmacy benefit (Medicare part
D)        Bladder $154 $146 $195 $248 $143 $226  Breast $214 $251 $280 $302 $279 $271  Cervix
uteri −$6 −$28 $92 −$53 $44 $32  Colorectal $64 $48 $115 $94 $94 $102  Esophagus $415 $235 $444 $193 $169 $341  Kidney $224 $302 $1713 $627 $979 $1326  Liver $490 $754 $1435 $591 $1008 $1336  Lung $325 $408 $787 $484 $513 $618   NSCLC $324 $417 $851 $499 $550 $687   SCLC $360 $305 $346 $206 $251 $290  Melanoma $125 $236 $434 $445 $350 $438  Oral
cavity or
pharynx $99 $197 $198 $350 $136 $211  Ovary −$5 −$11 $221 $289 $50 $145  Pancreas $449 $796 $1308 $521 $897 $1057  Prostated $85 $290 $507 $640  Stomach $291 $221 $596 $120 $134 $268  Thyroid $222 $232 $316 $745 $434 $218  Uterus $24 $55 $87 $140 $126 $195  All
sites combined $180 $224 $833 $342 $373 $613 

Service type and cancer site . Phase of care

--------------------------------------------------------------------------------

. Initial phase

--------------------------------------------------------------------------------

. End-of-life cancer death

--------------------------------------------------------------------------------

. Localized . Regional . Distant . Localized . Regional . Distant . Medical
services (Medicare Parts
A/B)        Bladder $1244 $2956 $3952 $2634 $3564 $4810  Breast $2053 $3108 $3711 $2479 $2893 $3677  Cervix
uteri $2221 $3572 $4100 $2770 $3102 $3690  Colorectal $1755 $3283 $5953 $3000 $3616 $4932  Esophagus $3379 $5092 $4878 $3914 $4467 $5002  Kidney $1508 $1993 $3140 $3007 $3449 $4006  Liver $2742 $2829 $3714 $2647 $2708 $3631  Lung $2238 $3406 $4567 $2840 $3605 $4756   NSCLC $2207 $3313 $4542 $2816 $3540 $4755   SCLC $3514 $4559 $4745 $3274 $4068 $4761  Melanoma $706 $1636 $2719 $2498 $2892 $4575  Oral
cavity or
pharynx $1727 $4044 $4645 $3178 $4154 $4476  Ovary $1891 $3022 $3565 $2965 $3098 $4086  Pancreas $3133 $4858 $4646 $3519 $4256 $4571  Prostated $1834 $1826 $2800 $3047  Stomach $2358 $4260 $4731 $3289 $4010 $4882  Thyroid $1149 $1644 $2520 $3094 $3491 $3480  Uterus $1575 $2769 $3430 $2858 $3278 $3706  All
sites combined $1694 $3194 $3540 $2868 $3604 $4526 Prescription drugs covered
through pharmacy benefit (Medicare part
D)        Bladder $154 $146 $195 $248 $143 $226  Breast $214 $251 $280 $302 $279 $271  Cervix
uteri −$6 −$28 $92 −$53 $44 $32  Colorectal $64 $48 $115 $94 $94 $102  Esophagus $415 $235 $444 $193 $169 $341  Kidney $224 $302 $1713 $627 $979 $1326  Liver $490 $754 $1435 $591 $1008 $1336  Lung $325 $408 $787 $484 $513 $618   NSCLC $324 $417 $851 $499 $550 $687   SCLC $360 $305 $346 $206 $251 $290  Melanoma $125 $236 $434 $445 $350 $438  Oral
cavity or
pharynx $99 $197 $198 $350 $136 $211  Ovary −$5 −$11 $221 $289 $50 $145  Pancreas $449 $796 $1308 $521 $897 $1057  Prostated $85 $290 $507 $640  Stomach $291 $221 $596 $120 $134 $268  Thyroid $222 $232 $316 $745 $434 $218  Uterus $24 $55 $87 $140 $126 $195  All
sites combined $180 $224 $833 $342 $373 $613 

a

Includes patients diagnosed with invasive cancers with information about stage
at diagnosis; patients diagnosed with in-situ disease or missing information
about stage were excluded from stage-specific analyses. NSCLC = non-small cell
lung cancer; SCLC = small cell lung cancer; SEER = Surveillance, Epidemiology,
and End Results Program.

b

Costs associated with cancer are estimated as the difference between cancer
cases and matched controls. All estimates in 2019 US dollars.

c

Out-of-pocket costs estimated from patient responsibility for medical services
(including infusion drugs) under Medicare Parts A/B claims. Out-of-pocket costs
for oral prescription drugs estimated directly from Medicare Part D claims.

d

Prostate cancer stage reported as localized or regional during some years of
study.

Open in new tab
Table 3.

Net annualized patient out-of-pocket costs for medical services and prescription
drugs by phase of care and stage at diagnosis, SEER-Medicare 2007-2013a,b,c

Service type and cancer site . Phase of care

--------------------------------------------------------------------------------

. Initial phase

--------------------------------------------------------------------------------

. End-of-life cancer death

--------------------------------------------------------------------------------

. Localized . Regional . Distant . Localized . Regional . Distant . Medical
services (Medicare Parts
A/B)        Bladder $1244 $2956 $3952 $2634 $3564 $4810  Breast $2053 $3108 $3711 $2479 $2893 $3677  Cervix
uteri $2221 $3572 $4100 $2770 $3102 $3690  Colorectal $1755 $3283 $5953 $3000 $3616 $4932  Esophagus $3379 $5092 $4878 $3914 $4467 $5002  Kidney $1508 $1993 $3140 $3007 $3449 $4006  Liver $2742 $2829 $3714 $2647 $2708 $3631  Lung $2238 $3406 $4567 $2840 $3605 $4756   NSCLC $2207 $3313 $4542 $2816 $3540 $4755   SCLC $3514 $4559 $4745 $3274 $4068 $4761  Melanoma $706 $1636 $2719 $2498 $2892 $4575  Oral
cavity or
pharynx $1727 $4044 $4645 $3178 $4154 $4476  Ovary $1891 $3022 $3565 $2965 $3098 $4086  Pancreas $3133 $4858 $4646 $3519 $4256 $4571  Prostated $1834 $1826 $2800 $3047  Stomach $2358 $4260 $4731 $3289 $4010 $4882  Thyroid $1149 $1644 $2520 $3094 $3491 $3480  Uterus $1575 $2769 $3430 $2858 $3278 $3706  All
sites combined $1694 $3194 $3540 $2868 $3604 $4526 Prescription drugs covered
through pharmacy benefit (Medicare part
D)        Bladder $154 $146 $195 $248 $143 $226  Breast $214 $251 $280 $302 $279 $271  Cervix
uteri −$6 −$28 $92 −$53 $44 $32  Colorectal $64 $48 $115 $94 $94 $102  Esophagus $415 $235 $444 $193 $169 $341  Kidney $224 $302 $1713 $627 $979 $1326  Liver $490 $754 $1435 $591 $1008 $1336  Lung $325 $408 $787 $484 $513 $618   NSCLC $324 $417 $851 $499 $550 $687   SCLC $360 $305 $346 $206 $251 $290  Melanoma $125 $236 $434 $445 $350 $438  Oral
cavity or
pharynx $99 $197 $198 $350 $136 $211  Ovary −$5 −$11 $221 $289 $50 $145  Pancreas $449 $796 $1308 $521 $897 $1057  Prostated $85 $290 $507 $640  Stomach $291 $221 $596 $120 $134 $268  Thyroid $222 $232 $316 $745 $434 $218  Uterus $24 $55 $87 $140 $126 $195  All
sites combined $180 $224 $833 $342 $373 $613 

Service type and cancer site . Phase of care

--------------------------------------------------------------------------------

. Initial phase

--------------------------------------------------------------------------------

. End-of-life cancer death

--------------------------------------------------------------------------------

. Localized . Regional . Distant . Localized . Regional . Distant . Medical
services (Medicare Parts
A/B)        Bladder $1244 $2956 $3952 $2634 $3564 $4810  Breast $2053 $3108 $3711 $2479 $2893 $3677  Cervix
uteri $2221 $3572 $4100 $2770 $3102 $3690  Colorectal $1755 $3283 $5953 $3000 $3616 $4932  Esophagus $3379 $5092 $4878 $3914 $4467 $5002  Kidney $1508 $1993 $3140 $3007 $3449 $4006  Liver $2742 $2829 $3714 $2647 $2708 $3631  Lung $2238 $3406 $4567 $2840 $3605 $4756   NSCLC $2207 $3313 $4542 $2816 $3540 $4755   SCLC $3514 $4559 $4745 $3274 $4068 $4761  Melanoma $706 $1636 $2719 $2498 $2892 $4575  Oral
cavity or
pharynx $1727 $4044 $4645 $3178 $4154 $4476  Ovary $1891 $3022 $3565 $2965 $3098 $4086  Pancreas $3133 $4858 $4646 $3519 $4256 $4571  Prostated $1834 $1826 $2800 $3047  Stomach $2358 $4260 $4731 $3289 $4010 $4882  Thyroid $1149 $1644 $2520 $3094 $3491 $3480  Uterus $1575 $2769 $3430 $2858 $3278 $3706  All
sites combined $1694 $3194 $3540 $2868 $3604 $4526 Prescription drugs covered
through pharmacy benefit (Medicare part
D)        Bladder $154 $146 $195 $248 $143 $226  Breast $214 $251 $280 $302 $279 $271  Cervix
uteri −$6 −$28 $92 −$53 $44 $32  Colorectal $64 $48 $115 $94 $94 $102  Esophagus $415 $235 $444 $193 $169 $341  Kidney $224 $302 $1713 $627 $979 $1326  Liver $490 $754 $1435 $591 $1008 $1336  Lung $325 $408 $787 $484 $513 $618   NSCLC $324 $417 $851 $499 $550 $687   SCLC $360 $305 $346 $206 $251 $290  Melanoma $125 $236 $434 $445 $350 $438  Oral
cavity or
pharynx $99 $197 $198 $350 $136 $211  Ovary −$5 −$11 $221 $289 $50 $145  Pancreas $449 $796 $1308 $521 $897 $1057  Prostated $85 $290 $507 $640  Stomach $291 $221 $596 $120 $134 $268  Thyroid $222 $232 $316 $745 $434 $218  Uterus $24 $55 $87 $140 $126 $195  All
sites combined $180 $224 $833 $342 $373 $613 

a

Includes patients diagnosed with invasive cancers with information about stage
at diagnosis; patients diagnosed with in-situ disease or missing information
about stage were excluded from stage-specific analyses. NSCLC = non-small cell
lung cancer; SCLC = small cell lung cancer; SEER = Surveillance, Epidemiology,
and End Results Program.

b

Costs associated with cancer are estimated as the difference between cancer
cases and matched controls. All estimates in 2019 US dollars.

c

Out-of-pocket costs estimated from patient responsibility for medical services
(including infusion drugs) under Medicare Parts A/B claims. Out-of-pocket costs
for oral prescription drugs estimated directly from Medicare Part D claims.

d

Prostate cancer stage reported as localized or regional during some years of
study.

Open in new tab

Annualized net patient out-of-pocket costs for medical services for all cancer
sites combined were higher in the EOL phase of care than in the initial phase of
care within stage at diagnosis: $2868 vs $1694, $3604 vs $3194, and $4526 vs
$3540 for cancers diagnosed with localized, regional, or distant disease,
respectively (Table 3). Differences in out-of-pocket costs between localized and
distant stage at diagnosis in the EOL phase of care were greatest for bladder
cancer, colorectal cancer, NSCLC, and melanoma. Out-of-pocket costs in the
continuing phase were also generally higher among patients diagnosed with later
stage disease (Supplementary Table 5, available online).


ANNUAL NET PATIENT OUT-OF-POCKET AND TIME COSTS FROM MEPS DATA

Characteristics of cancer survivors and adults without a cancer history from the
MEPS are shown in Table 4. Cancer survivors in both age groups (18-64 years and
≥65 years) were more likely to be older, non-Hispanic White, have at least some
college education, and have more MEPS priority conditions than adults without a
cancer history. The most common cancer diagnoses among survivors were breast and
prostate cancers (data not shown). Most cancer survivors were diagnosed 6 or
more years before the survey, with fewer cancer survivors diagnosed within
2 years before the survey.

Table 4.

Characteristics of cancer survivors and adults without a cancer history by age
group, MEPS, 2008-2017

Sociodemographic and health characteristics . Aged 18–64 y

--------------------------------------------------------------------------------

. Aged ≥65 y

--------------------------------------------------------------------------------

. Cancer survivors, No. (weighted %) . No cancer history, No. (weighted %)
. Cancer survivors, No. (weighted %) . No cancer history, No. (weighted %)
. Total 8419 (100) 190 283 (100) 9066 (100) 31 569 (100) Age group,
y      18-44 2194 (23.2) 116 178 (59.5) — —  45-49 985 (11.0) 20 642
(10.6) — —  50-54 1356 (16.6) 20 526 (11.3) — —  55-59 1752 (22.1) 18 382
(10.1) — —  60-64 2132 (27.1) 14 555 (8.5) — —  65-69 — — 2295 (23.6) 11 350
(35.1)  70-74 — — 2052 (23.0) 7508 (24.1)  75-79 — — 1830 (19.8) 5405
(17.1)  80+ — — 2889 (33.6) 7306 (23.7) Sex      Male 2631 (35.5) 90 551
(49.9) 4306 (47.6) 13 299 (43.2)  Female 5788 (64.5) 99 732 (50.1) 4760
(52.4) 18 270 (56.8) Race or ethnicity      Non-Hispanic White 5212
(79.3) 75 417 (62.0) 6612 (86.4) 17 503 (75.2)  Non-Hispanic Black 1277
(7.9) 37 624 (12.5) 1285 (6.4) 5798 (9.4)  Hispanic 1457 (8.6) 57 600 (17.0) 763
(4.2) 5092 (8.7)  All other groups 473 (4.2) 19 642 (8.4) 406 (3.0) 3176
(6.7) Marital status      Married or partnered 4616 (61.0) 92 160 (51.7) 4686
(54.7) 16 170 (55.1)  Other 3803 (39.0) 98 121 (48.3) 4380 (45.3) 15 398
(44.9) Educational attainment      Less than high school graduate 1349
(10.6) 40 888 (14.4) 1940 (15.6) 8984 (20.0)  High school graduate 2507
(27.5) 57 126 (28.1) 2949 (33.4) 9626 (31.6)  Some college or more 4563
(61.9) 92 269 (57.5) 4177 (51.0) 12 959 (48.4) No. of MEPS priority
conditionsa      0 2165 (26.0) 103 749 (53.2) 519 (5.8) 2831 (9.0)  1 2015
(24.9) 43 376 (23.8) 1255 (14.3) 5075 (16.3)  2 1671 (20.6) 22 181 (12.3) 2002
(22.2) 7247 (24.0)  3+ 2568 (28.5) 20 977 (10.7) 5290 (57.6) 16 416
(50.6) Health insurance coverage      Age 18-64 y, any private 5425
(73.7) 114 871 (71.6) — —  Age 18-64 y, public only 2079 (17.7) 33 571
(12.4) — —  Age 18-64 y, uninsured 915 (8.7) 41 841 (16.0) — —  Age ≥65 y,
Medicare + private — — 4551 (56.2) 13 830 (52.4)  Age ≥65 y, Medicare +
public — — 1195 (8.8) 5688 (11.3)  Age ≥65 y, Medicare only — — 3239
(35.0) 11 381 (36.4) Years since first cancer diagnosis      Missing 415
(4.4) — 980 (11.2) —  <2 1088 (12.7) — 775 (8.4) —  2-5 2340 (27.4) — 1811
(19.5) —  5-10 1702 (19.7) — 1714 (19.0) —  >10 2874 (35.7) — 3786 (41.8) — 

Sociodemographic and health characteristics . Aged 18–64 y

--------------------------------------------------------------------------------

. Aged ≥65 y

--------------------------------------------------------------------------------

. Cancer survivors, No. (weighted %) . No cancer history, No. (weighted %)
. Cancer survivors, No. (weighted %) . No cancer history, No. (weighted %)
. Total 8419 (100) 190 283 (100) 9066 (100) 31 569 (100) Age group,
y      18-44 2194 (23.2) 116 178 (59.5) — —  45-49 985 (11.0) 20 642
(10.6) — —  50-54 1356 (16.6) 20 526 (11.3) — —  55-59 1752 (22.1) 18 382
(10.1) — —  60-64 2132 (27.1) 14 555 (8.5) — —  65-69 — — 2295 (23.6) 11 350
(35.1)  70-74 — — 2052 (23.0) 7508 (24.1)  75-79 — — 1830 (19.8) 5405
(17.1)  80+ — — 2889 (33.6) 7306 (23.7) Sex      Male 2631 (35.5) 90 551
(49.9) 4306 (47.6) 13 299 (43.2)  Female 5788 (64.5) 99 732 (50.1) 4760
(52.4) 18 270 (56.8) Race or ethnicity      Non-Hispanic White 5212
(79.3) 75 417 (62.0) 6612 (86.4) 17 503 (75.2)  Non-Hispanic Black 1277
(7.9) 37 624 (12.5) 1285 (6.4) 5798 (9.4)  Hispanic 1457 (8.6) 57 600 (17.0) 763
(4.2) 5092 (8.7)  All other groups 473 (4.2) 19 642 (8.4) 406 (3.0) 3176
(6.7) Marital status      Married or partnered 4616 (61.0) 92 160 (51.7) 4686
(54.7) 16 170 (55.1)  Other 3803 (39.0) 98 121 (48.3) 4380 (45.3) 15 398
(44.9) Educational attainment      Less than high school graduate 1349
(10.6) 40 888 (14.4) 1940 (15.6) 8984 (20.0)  High school graduate 2507
(27.5) 57 126 (28.1) 2949 (33.4) 9626 (31.6)  Some college or more 4563
(61.9) 92 269 (57.5) 4177 (51.0) 12 959 (48.4) No. of MEPS priority
conditionsa      0 2165 (26.0) 103 749 (53.2) 519 (5.8) 2831 (9.0)  1 2015
(24.9) 43 376 (23.8) 1255 (14.3) 5075 (16.3)  2 1671 (20.6) 22 181 (12.3) 2002
(22.2) 7247 (24.0)  3+ 2568 (28.5) 20 977 (10.7) 5290 (57.6) 16 416
(50.6) Health insurance coverage      Age 18-64 y, any private 5425
(73.7) 114 871 (71.6) — —  Age 18-64 y, public only 2079 (17.7) 33 571
(12.4) — —  Age 18-64 y, uninsured 915 (8.7) 41 841 (16.0) — —  Age ≥65 y,
Medicare + private — — 4551 (56.2) 13 830 (52.4)  Age ≥65 y, Medicare +
public — — 1195 (8.8) 5688 (11.3)  Age ≥65 y, Medicare only — — 3239
(35.0) 11 381 (36.4) Years since first cancer diagnosis      Missing 415
(4.4) — 980 (11.2) —  <2 1088 (12.7) — 775 (8.4) —  2-5 2340 (27.4) — 1811
(19.5) —  5-10 1702 (19.7) — 1714 (19.0) —  >10 2874 (35.7) — 3786 (41.8) — 

a

Medical Expenditure Panel Survey (MEPS) priority conditions include arthritis,
asthma, diabetes, emphysema, heart disease (angina, coronary heart disease,
heart attack, other heart condition or disease), high cholesterol, hypertension,
and stroke.

Open in new tab
Table 4.

Characteristics of cancer survivors and adults without a cancer history by age
group, MEPS, 2008-2017

Sociodemographic and health characteristics . Aged 18–64 y

--------------------------------------------------------------------------------

. Aged ≥65 y

--------------------------------------------------------------------------------

. Cancer survivors, No. (weighted %) . No cancer history, No. (weighted %)
. Cancer survivors, No. (weighted %) . No cancer history, No. (weighted %)
. Total 8419 (100) 190 283 (100) 9066 (100) 31 569 (100) Age group,
y      18-44 2194 (23.2) 116 178 (59.5) — —  45-49 985 (11.0) 20 642
(10.6) — —  50-54 1356 (16.6) 20 526 (11.3) — —  55-59 1752 (22.1) 18 382
(10.1) — —  60-64 2132 (27.1) 14 555 (8.5) — —  65-69 — — 2295 (23.6) 11 350
(35.1)  70-74 — — 2052 (23.0) 7508 (24.1)  75-79 — — 1830 (19.8) 5405
(17.1)  80+ — — 2889 (33.6) 7306 (23.7) Sex      Male 2631 (35.5) 90 551
(49.9) 4306 (47.6) 13 299 (43.2)  Female 5788 (64.5) 99 732 (50.1) 4760
(52.4) 18 270 (56.8) Race or ethnicity      Non-Hispanic White 5212
(79.3) 75 417 (62.0) 6612 (86.4) 17 503 (75.2)  Non-Hispanic Black 1277
(7.9) 37 624 (12.5) 1285 (6.4) 5798 (9.4)  Hispanic 1457 (8.6) 57 600 (17.0) 763
(4.2) 5092 (8.7)  All other groups 473 (4.2) 19 642 (8.4) 406 (3.0) 3176
(6.7) Marital status      Married or partnered 4616 (61.0) 92 160 (51.7) 4686
(54.7) 16 170 (55.1)  Other 3803 (39.0) 98 121 (48.3) 4380 (45.3) 15 398
(44.9) Educational attainment      Less than high school graduate 1349
(10.6) 40 888 (14.4) 1940 (15.6) 8984 (20.0)  High school graduate 2507
(27.5) 57 126 (28.1) 2949 (33.4) 9626 (31.6)  Some college or more 4563
(61.9) 92 269 (57.5) 4177 (51.0) 12 959 (48.4) No. of MEPS priority
conditionsa      0 2165 (26.0) 103 749 (53.2) 519 (5.8) 2831 (9.0)  1 2015
(24.9) 43 376 (23.8) 1255 (14.3) 5075 (16.3)  2 1671 (20.6) 22 181 (12.3) 2002
(22.2) 7247 (24.0)  3+ 2568 (28.5) 20 977 (10.7) 5290 (57.6) 16 416
(50.6) Health insurance coverage      Age 18-64 y, any private 5425
(73.7) 114 871 (71.6) — —  Age 18-64 y, public only 2079 (17.7) 33 571
(12.4) — —  Age 18-64 y, uninsured 915 (8.7) 41 841 (16.0) — —  Age ≥65 y,
Medicare + private — — 4551 (56.2) 13 830 (52.4)  Age ≥65 y, Medicare +
public — — 1195 (8.8) 5688 (11.3)  Age ≥65 y, Medicare only — — 3239
(35.0) 11 381 (36.4) Years since first cancer diagnosis      Missing 415
(4.4) — 980 (11.2) —  <2 1088 (12.7) — 775 (8.4) —  2-5 2340 (27.4) — 1811
(19.5) —  5-10 1702 (19.7) — 1714 (19.0) —  >10 2874 (35.7) — 3786 (41.8) — 

Sociodemographic and health characteristics . Aged 18–64 y

--------------------------------------------------------------------------------

. Aged ≥65 y

--------------------------------------------------------------------------------

. Cancer survivors, No. (weighted %) . No cancer history, No. (weighted %)
. Cancer survivors, No. (weighted %) . No cancer history, No. (weighted %)
. Total 8419 (100) 190 283 (100) 9066 (100) 31 569 (100) Age group,
y      18-44 2194 (23.2) 116 178 (59.5) — —  45-49 985 (11.0) 20 642
(10.6) — —  50-54 1356 (16.6) 20 526 (11.3) — —  55-59 1752 (22.1) 18 382
(10.1) — —  60-64 2132 (27.1) 14 555 (8.5) — —  65-69 — — 2295 (23.6) 11 350
(35.1)  70-74 — — 2052 (23.0) 7508 (24.1)  75-79 — — 1830 (19.8) 5405
(17.1)  80+ — — 2889 (33.6) 7306 (23.7) Sex      Male 2631 (35.5) 90 551
(49.9) 4306 (47.6) 13 299 (43.2)  Female 5788 (64.5) 99 732 (50.1) 4760
(52.4) 18 270 (56.8) Race or ethnicity      Non-Hispanic White 5212
(79.3) 75 417 (62.0) 6612 (86.4) 17 503 (75.2)  Non-Hispanic Black 1277
(7.9) 37 624 (12.5) 1285 (6.4) 5798 (9.4)  Hispanic 1457 (8.6) 57 600 (17.0) 763
(4.2) 5092 (8.7)  All other groups 473 (4.2) 19 642 (8.4) 406 (3.0) 3176
(6.7) Marital status      Married or partnered 4616 (61.0) 92 160 (51.7) 4686
(54.7) 16 170 (55.1)  Other 3803 (39.0) 98 121 (48.3) 4380 (45.3) 15 398
(44.9) Educational attainment      Less than high school graduate 1349
(10.6) 40 888 (14.4) 1940 (15.6) 8984 (20.0)  High school graduate 2507
(27.5) 57 126 (28.1) 2949 (33.4) 9626 (31.6)  Some college or more 4563
(61.9) 92 269 (57.5) 4177 (51.0) 12 959 (48.4) No. of MEPS priority
conditionsa      0 2165 (26.0) 103 749 (53.2) 519 (5.8) 2831 (9.0)  1 2015
(24.9) 43 376 (23.8) 1255 (14.3) 5075 (16.3)  2 1671 (20.6) 22 181 (12.3) 2002
(22.2) 7247 (24.0)  3+ 2568 (28.5) 20 977 (10.7) 5290 (57.6) 16 416
(50.6) Health insurance coverage      Age 18-64 y, any private 5425
(73.7) 114 871 (71.6) — —  Age 18-64 y, public only 2079 (17.7) 33 571
(12.4) — —  Age 18-64 y, uninsured 915 (8.7) 41 841 (16.0) — —  Age ≥65 y,
Medicare + private — — 4551 (56.2) 13 830 (52.4)  Age ≥65 y, Medicare +
public — — 1195 (8.8) 5688 (11.3)  Age ≥65 y, Medicare only — — 3239
(35.0) 11 381 (36.4) Years since first cancer diagnosis      Missing 415
(4.4) — 980 (11.2) —  <2 1088 (12.7) — 775 (8.4) —  2-5 2340 (27.4) — 1811
(19.5) —  5-10 1702 (19.7) — 1714 (19.0) —  >10 2874 (35.7) — 3786 (41.8) — 

a

Medical Expenditure Panel Survey (MEPS) priority conditions include arthritis,
asthma, diabetes, emphysema, heart disease (angina, coronary heart disease,
heart attack, other heart condition or disease), high cholesterol, hypertension,
and stroke.

Open in new tab

Net Annual Patient Out-of-Pocket Costs. Annual patient out-of-pocket spending
for medical services and prescription drugs covered through a pharmacy benefit
were higher for cancer survivors than for adults without a cancer history
(Table 5). Net annual out-of-pocket costs (95% confidence interval [CI])
associated with cancer were higher among adults aged 18-64 years than adults
aged 65 years and older for medical services ($232.7 [$173.2 to $292.3] vs $97.7
[$11.5 to $184.0]) and prescription drugs ($87.4 [$62.0 to $112.8] vs $67.0
[$31.4 to $102.7]), yielding ratios of 2.38 to 1 and 1.30 to 1, respectively.
Overall, net annual out-of-pocket costs were higher in the younger ($327.4, 95%
CI = $260.0 to $394.9) than in the older group ($173.4, 95% CI = $72.4 to
$274.4).

Table 5.

Annual out-of-pocket costs, by cancer history and age group, MEPS, 2008-2017

Service type . Out-of-pocket cost estimatea (95% CI)

--------------------------------------------------------------------------------

. Pb . Cancer survivors . No cancer history . Net difference . Aged
18-64 y      Medical services $743.0 ($682.3 to $803.8) $510.3 ($496.7 to
$523.9) $232.7 ($173.2 to $292.3) <.001  Prescription medications $280.8 ($256.6
to $305.0) $193.4 ($187.2 to $199.7) $87.4 ($62.0 to $112.8) <.001  Total
out-of-pocket $1031.0 ($962.6 to $1099.4) $703.6 ($687.5 to $719.7) $327.4
($260.0 to $394.9) <.001 Aged ≥65 y      Medical services $1041.8 ($964.1 to
$1119.4) $944.0 ($893.5 to $994.5) $97.7 ($11.5 to $184.0) .03  Prescription
medications $574.5 ($542.9 to $606.1) $507.4 ($490.1 to $524.8) $67.0 ($31.4 to
$102.7) <.001  Total out-of-pocket $1623.7 ($1534.1 to $1712.5) $1450.3 ($1393.0
to $1507.0) $173.4 ($72.4 to $274.4) <.001 

Service type . Out-of-pocket cost estimatea (95% CI)

--------------------------------------------------------------------------------

. Pb . Cancer survivors . No cancer history . Net difference . Aged
18-64 y      Medical services $743.0 ($682.3 to $803.8) $510.3 ($496.7 to
$523.9) $232.7 ($173.2 to $292.3) <.001  Prescription medications $280.8 ($256.6
to $305.0) $193.4 ($187.2 to $199.7) $87.4 ($62.0 to $112.8) <.001  Total
out-of-pocket $1031.0 ($962.6 to $1099.4) $703.6 ($687.5 to $719.7) $327.4
($260.0 to $394.9) <.001 Aged ≥65 y      Medical services $1041.8 ($964.1 to
$1119.4) $944.0 ($893.5 to $994.5) $97.7 ($11.5 to $184.0) .03  Prescription
medications $574.5 ($542.9 to $606.1) $507.4 ($490.1 to $524.8) $67.0 ($31.4 to
$102.7) <.001  Total out-of-pocket $1623.7 ($1534.1 to $1712.5) $1450.3 ($1393.0
to $1507.0) $173.4 ($72.4 to $274.4) <.001 

a

All estimates adjusted for age, sex, educational attainment, and number of
comorbid conditions; and are reported in 2019 US dollars
https://meps.ahrq.gov/about_meps/Price_Index.shtml. CI = confidence interval;
MEPS = Medical Expenditure Panel Survey.

b

Wald’s F, 2-sided.

Open in new tab
Table 5.

Annual out-of-pocket costs, by cancer history and age group, MEPS, 2008-2017

Service type . Out-of-pocket cost estimatea (95% CI)

--------------------------------------------------------------------------------

. Pb . Cancer survivors . No cancer history . Net difference . Aged
18-64 y      Medical services $743.0 ($682.3 to $803.8) $510.3 ($496.7 to
$523.9) $232.7 ($173.2 to $292.3) <.001  Prescription medications $280.8 ($256.6
to $305.0) $193.4 ($187.2 to $199.7) $87.4 ($62.0 to $112.8) <.001  Total
out-of-pocket $1031.0 ($962.6 to $1099.4) $703.6 ($687.5 to $719.7) $327.4
($260.0 to $394.9) <.001 Aged ≥65 y      Medical services $1041.8 ($964.1 to
$1119.4) $944.0 ($893.5 to $994.5) $97.7 ($11.5 to $184.0) .03  Prescription
medications $574.5 ($542.9 to $606.1) $507.4 ($490.1 to $524.8) $67.0 ($31.4 to
$102.7) <.001  Total out-of-pocket $1623.7 ($1534.1 to $1712.5) $1450.3 ($1393.0
to $1507.0) $173.4 ($72.4 to $274.4) <.001 

Service type . Out-of-pocket cost estimatea (95% CI)

--------------------------------------------------------------------------------

. Pb . Cancer survivors . No cancer history . Net difference . Aged
18-64 y      Medical services $743.0 ($682.3 to $803.8) $510.3 ($496.7 to
$523.9) $232.7 ($173.2 to $292.3) <.001  Prescription medications $280.8 ($256.6
to $305.0) $193.4 ($187.2 to $199.7) $87.4 ($62.0 to $112.8) <.001  Total
out-of-pocket $1031.0 ($962.6 to $1099.4) $703.6 ($687.5 to $719.7) $327.4
($260.0 to $394.9) <.001 Aged ≥65 y      Medical services $1041.8 ($964.1 to
$1119.4) $944.0 ($893.5 to $994.5) $97.7 ($11.5 to $184.0) .03  Prescription
medications $574.5 ($542.9 to $606.1) $507.4 ($490.1 to $524.8) $67.0 ($31.4 to
$102.7) <.001  Total out-of-pocket $1623.7 ($1534.1 to $1712.5) $1450.3 ($1393.0
to $1507.0) $173.4 ($72.4 to $274.4) <.001 

a

All estimates adjusted for age, sex, educational attainment, and number of
comorbid conditions; and are reported in 2019 US dollars
https://meps.ahrq.gov/about_meps/Price_Index.shtml. CI = confidence interval;
MEPS = Medical Expenditure Panel Survey.

b

Wald’s F, 2-sided.

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Net Annual Patient Time Costs. Cancer survivors in both age groups (18-64 years
and ≥65 years) were more likely to have overnight hospitalizations, emergency
room visits, ambulatory surgeries, provider office-based or hospital outpatient
visits, chemotherapy, and radiation therapy than adults without a cancer history
(Table 6; Supplementary Table 5, available online). Among adults with these
services, cancer survivors in both age groups also had greater service frequency
(Table 6; Supplementary Table 6, available online) and spent more time receiving
care than their counterparts without a cancer history (Supplementary Table 7,
available online). Net annual mean time costs associated with cancer (95% CI)
were $304.3 ($257.9 to $350.9) for adults aged 18-64 years, and $279.1 ($215.1
to $343.3) for adults aged 65 years and older. In both age groups,
hospitalizations and office visits were the services with the largest
contribution to the overall time costs and accounted for the most of the net
time costs.

Table 6.

Annual medical service use and patient time costs, by cancer history and age
group, MEPS, 2008-2017a,b

Age group and service type . Cancer survivors

--------------------------------------------------------------------------------

. No cancer history

--------------------------------------------------------------------------------

. Net time costs associated with cancer, estimate (95% CI) . % with service
. Mean service use (among adults with service) . Time costs . % with service
. Mean service use (among adults with service) . Time costs . Aged
18-64 y     Service-specific estimates      Emergency room
visits 17.4 1.6 $21.2 12.5 1.4 $12.7 $8.5 ($6.6 to $10.3)   Ambulatory
surgery 17.9 1.8 $39.8 9.6 1.6 $14.9 $24.9 ($21.6 to $28.3)   Inpatient
hospitalization 9.8 7.4 $244.0 5.9 5.5 $88.0 $156.0 ($128.3 to
$212.9)   Chemotherapyc 3.2 8.6 $10.8 0.0 4.1 $0.0 $10.8 ($8.1 to
$13.5)   Radiationc 1.9 15.8 $6.9 0.1 8.3 $0.1 $6.8 ($4.6 to $9.0)   Office
visits 80.6 9.6 $220.5 69.3 7.2 $135.1 $85.4 ($74.1 to $96.8)  Total time
cost — — $566.6 — — $262.3 $304.3 ($257.9 to $350.9) Aged
≥65 y         Service-specific estimates          Emergency room
visits 22.1 1.5 $26.1 19.0 1.5 $21.6 $4.5 ($2.7 to $6.3)   Ambulatory
surgery 34.5 2.3 $80.6 23.5 2.0 $46.8 $33.8 ($27.4 to $40.1)   Inpatient
hospitalization 20.0 8.7 $425.0 15.3 8.3 $314.9 $110.1 ($64.5 to
$176.5)   Chemotherapyc 4.1 8.9 $10.5 0.1 11.1 $0.1 $10.4 ($7.7 to
$13.1)   Radiationc 2.7 17.0 $5.9 0.3 12.3 $0.5 $5.4 ($3.5 to $7.3)   Office
visits 95.2 14.9 $400.5 91.1 11.4 $291.5 $109.0 ($90.7 to $127.4)  Total time
cost — — $982.6 — — $703.5 $279.1 ($215.1 to $343.3) 

Age group and service type . Cancer survivors

--------------------------------------------------------------------------------

. No cancer history

--------------------------------------------------------------------------------

. Net time costs associated with cancer, estimate (95% CI) . % with service
. Mean service use (among adults with service) . Time costs . % with service
. Mean service use (among adults with service) . Time costs . Aged
18-64 y     Service-specific estimates      Emergency room
visits 17.4 1.6 $21.2 12.5 1.4 $12.7 $8.5 ($6.6 to $10.3)   Ambulatory
surgery 17.9 1.8 $39.8 9.6 1.6 $14.9 $24.9 ($21.6 to $28.3)   Inpatient
hospitalization 9.8 7.4 $244.0 5.9 5.5 $88.0 $156.0 ($128.3 to
$212.9)   Chemotherapyc 3.2 8.6 $10.8 0.0 4.1 $0.0 $10.8 ($8.1 to
$13.5)   Radiationc 1.9 15.8 $6.9 0.1 8.3 $0.1 $6.8 ($4.6 to $9.0)   Office
visits 80.6 9.6 $220.5 69.3 7.2 $135.1 $85.4 ($74.1 to $96.8)  Total time
cost — — $566.6 — — $262.3 $304.3 ($257.9 to $350.9) Aged
≥65 y         Service-specific estimates          Emergency room
visits 22.1 1.5 $26.1 19.0 1.5 $21.6 $4.5 ($2.7 to $6.3)   Ambulatory
surgery 34.5 2.3 $80.6 23.5 2.0 $46.8 $33.8 ($27.4 to $40.1)   Inpatient
hospitalization 20.0 8.7 $425.0 15.3 8.3 $314.9 $110.1 ($64.5 to
$176.5)   Chemotherapyc 4.1 8.9 $10.5 0.1 11.1 $0.1 $10.4 ($7.7 to
$13.1)   Radiationc 2.7 17.0 $5.9 0.3 12.3 $0.5 $5.4 ($3.5 to $7.3)   Office
visits 95.2 14.9 $400.5 91.1 11.4 $291.5 $109.0 ($90.7 to $127.4)  Total time
cost — — $982.6 — — $703.5 $279.1 ($215.1 to $343.3) 

a

All estimates adjusted for age, sex, educational attainment, and number of
comorbid conditions. CI = confidence interval; MEPS = Medical Expenditure Panel
Survey.

b

All time cost estimates in 2019 US dollars.

c

Information about use of chemotherapy and radiation therapy was restricted to
years 2008-2012 when these data were collected separately in the MEPS.

Open in new tab
Table 6.

Annual medical service use and patient time costs, by cancer history and age
group, MEPS, 2008-2017a,b

Age group and service type . Cancer survivors

--------------------------------------------------------------------------------

. No cancer history

--------------------------------------------------------------------------------

. Net time costs associated with cancer, estimate (95% CI) . % with service
. Mean service use (among adults with service) . Time costs . % with service
. Mean service use (among adults with service) . Time costs . Aged
18-64 y     Service-specific estimates      Emergency room
visits 17.4 1.6 $21.2 12.5 1.4 $12.7 $8.5 ($6.6 to $10.3)   Ambulatory
surgery 17.9 1.8 $39.8 9.6 1.6 $14.9 $24.9 ($21.6 to $28.3)   Inpatient
hospitalization 9.8 7.4 $244.0 5.9 5.5 $88.0 $156.0 ($128.3 to
$212.9)   Chemotherapyc 3.2 8.6 $10.8 0.0 4.1 $0.0 $10.8 ($8.1 to
$13.5)   Radiationc 1.9 15.8 $6.9 0.1 8.3 $0.1 $6.8 ($4.6 to $9.0)   Office
visits 80.6 9.6 $220.5 69.3 7.2 $135.1 $85.4 ($74.1 to $96.8)  Total time
cost — — $566.6 — — $262.3 $304.3 ($257.9 to $350.9) Aged
≥65 y         Service-specific estimates          Emergency room
visits 22.1 1.5 $26.1 19.0 1.5 $21.6 $4.5 ($2.7 to $6.3)   Ambulatory
surgery 34.5 2.3 $80.6 23.5 2.0 $46.8 $33.8 ($27.4 to $40.1)   Inpatient
hospitalization 20.0 8.7 $425.0 15.3 8.3 $314.9 $110.1 ($64.5 to
$176.5)   Chemotherapyc 4.1 8.9 $10.5 0.1 11.1 $0.1 $10.4 ($7.7 to
$13.1)   Radiationc 2.7 17.0 $5.9 0.3 12.3 $0.5 $5.4 ($3.5 to $7.3)   Office
visits 95.2 14.9 $400.5 91.1 11.4 $291.5 $109.0 ($90.7 to $127.4)  Total time
cost — — $982.6 — — $703.5 $279.1 ($215.1 to $343.3) 

Age group and service type . Cancer survivors

--------------------------------------------------------------------------------

. No cancer history

--------------------------------------------------------------------------------

. Net time costs associated with cancer, estimate (95% CI) . % with service
. Mean service use (among adults with service) . Time costs . % with service
. Mean service use (among adults with service) . Time costs . Aged
18-64 y     Service-specific estimates      Emergency room
visits 17.4 1.6 $21.2 12.5 1.4 $12.7 $8.5 ($6.6 to $10.3)   Ambulatory
surgery 17.9 1.8 $39.8 9.6 1.6 $14.9 $24.9 ($21.6 to $28.3)   Inpatient
hospitalization 9.8 7.4 $244.0 5.9 5.5 $88.0 $156.0 ($128.3 to
$212.9)   Chemotherapyc 3.2 8.6 $10.8 0.0 4.1 $0.0 $10.8 ($8.1 to
$13.5)   Radiationc 1.9 15.8 $6.9 0.1 8.3 $0.1 $6.8 ($4.6 to $9.0)   Office
visits 80.6 9.6 $220.5 69.3 7.2 $135.1 $85.4 ($74.1 to $96.8)  Total time
cost — — $566.6 — — $262.3 $304.3 ($257.9 to $350.9) Aged
≥65 y         Service-specific estimates          Emergency room
visits 22.1 1.5 $26.1 19.0 1.5 $21.6 $4.5 ($2.7 to $6.3)   Ambulatory
surgery 34.5 2.3 $80.6 23.5 2.0 $46.8 $33.8 ($27.4 to $40.1)   Inpatient
hospitalization 20.0 8.7 $425.0 15.3 8.3 $314.9 $110.1 ($64.5 to
$176.5)   Chemotherapyc 4.1 8.9 $10.5 0.1 11.1 $0.1 $10.4 ($7.7 to
$13.1)   Radiationc 2.7 17.0 $5.9 0.3 12.3 $0.5 $5.4 ($3.5 to $7.3)   Office
visits 95.2 14.9 $400.5 91.1 11.4 $291.5 $109.0 ($90.7 to $127.4)  Total time
cost — — $982.6 — — $703.5 $279.1 ($215.1 to $343.3) 

a

All estimates adjusted for age, sex, educational attainment, and number of
comorbid conditions. CI = confidence interval; MEPS = Medical Expenditure Panel
Survey.

b

All time cost estimates in 2019 US dollars.

c

Information about use of chemotherapy and radiation therapy was restricted to
years 2008-2012 when these data were collected separately in the MEPS.

Open in new tab

Out-of-pocket and patient time costs among cancer survivors from the MEPS
stratified by time since diagnosis (ie, ≤2 years, 2-5 years, 6-10 years,
>10 years) are shown in Figure 1. Among cancer survivors in both age groups,
out-of-pocket costs and patient time costs were highest among those who were
more recently diagnosed and were lowest among those diagnosed 6 years or more
before the MEPS survey. In adults aged 18-64 years, mean annual out-of-pocket
costs were $1560 among those diagnosed within 2 years; $1074, diagnosed
2-5 years; $947, diagnosed 6-10 years; and $871, diagnosed more than 10 years
before the survey (Figure 1, A). Annual patient time costs followed a similar
pattern, with highest costs among those diagnosed within 2 years ($1229),
followed by 2-5 years ($566), 6-10 years ($402), and more than 10 years ($432)
before the survey (Figure 1, B).

Figure 1.
Open in new tabDownload slide

Total annual patient out-of-pocket and time costs among cancer survivors, by age
group and time since diagnosis. The figure shows the total annual costs among
cancer survivors by age group and by years since cancer diagnosis in years in 4
panels: (A) annual patient out-of-pocket and (B) time costs are shown for
survivors aged 18-64 years and (C) annual patient out-of-pocket and (D) time
costs for survivors aged 65 years and older, respectively. Data are from the
2008-2017 Medical Expenditure Panel Survey. All estimates were adjusted for age,
sex, educational attainment, and the number of comorbid conditions. All cost
estimates are in 2019 US dollars. Error bars indicate 95% confidence intervals.

Figure 1.
Open in new tabDownload slide

Total annual patient out-of-pocket and time costs among cancer survivors, by age
group and time since diagnosis. The figure shows the total annual costs among
cancer survivors by age group and by years since cancer diagnosis in years in 4
panels: (A) annual patient out-of-pocket and (B) time costs are shown for
survivors aged 18-64 years and (C) annual patient out-of-pocket and (D) time
costs for survivors aged 65 years and older, respectively. Data are from the
2008-2017 Medical Expenditure Panel Survey. All estimates were adjusted for age,
sex, educational attainment, and the number of comorbid conditions. All cost
estimates are in 2019 US dollars. Error bars indicate 95% confidence intervals.

Among the group aged 65 years and older, the highest annual out-of-pocket costs
were $1854 among those diagnosed within 2 years and approximately $1600 for all
other time since diagnosis categories (Figure 1, C). Annual patient time costs
in the older age group were highest ($1623) among those diagnosed within 2 years
of the survey and more similar (approximately $930) in all other years
(Figure 1, D).


NET NATIONAL PATIENT ECONOMIC BURDEN ASSOCIATED WITH CANCER CARE IN 2019

Net national economic burden associated with cancer care for 2019 for all
cancers combined and by selected cancer sites are shown in Table 7. One-year and
5-year relative survival by cancer site and age group are shown in Supplementary
Table 8 (available online), and the underlying prevalence projections by cancer
site, age group, and phase of care are shown in Supplementary Table 9 (available
online). Prevalence projections were then combined with net out-of-pocket costs
for medical services and prescription drugs by site and phase of care from
SEER-Medicare (Table 2), with adjustments for greater net out-of-pocket spending
in the population younger than 65 years from the MEPS (2.38 and 1.30 for medical
services and prescription drugs, respectively; Table 5) and time cost estimates
by age group (Table 6). For example, in the initial phase of care for all cancer
sites combined, net annualized out-of-pocket costs were $2200 and $243 for
medical services and prescription drugs for patients aged 65 years and older,
respectively, and time costs were $279. Corresponding adjustments to the net
out-of-pocket cost estimates for greater spending in the younger population
yielded $5240 and $316 for medical services and prescription drugs for patients
younger than 65 years, respectively, and time cost estimates of $304.

Table 7.

Net patient economic burden associated with cancer in the United States in 2019a

Site . Patient out-of-pocket costs by phase of care (in millions)b

--------------------------------------------------------------------------------

. Patient time cost (in millions) . Patient economic burden (in millions)
. Initial . Continuing . End-of-life cancer death . End-of-life other cause of
death . Total out-of-pocket costs
. Bladder $160.3 $440.9 $62.4 $39.1 $702.6 $235.4 $938.0 Breast $955.4 $1937.3 $181.7 $63.4 $3137.8 $1112.2 $4250.0 Cervix $63.0 $82.7 $17.6 $8.6 $172.0 $82.7 $254.6 Colorectal $497.2 $684.4 $221.2 $57.4 $1460.3 $440.6 $1900.9 Hodgkin
lymphoma $77.3 $153.6 $9.8 $6.3 $247.0 $70.1 $317.1 Kidney $143.9 $410.3 $75.7 $24.2 $654.1 $164.3 $818.3 Leukemia $145.2 $469.6 $118.2 $25.7 $758.7 $131.8 $890.5 Lung $401.4 $416.2 $490.0 $45.4 $1353.0 $162.8 $1515.8 Melanoma $103.2 $540.1 $43.1 $24.2 $710.6 $394.1 $1104.6 Non-Hodgkin
lymphoma $390.2 $611.5 $147.7 $38.1 $1187.5 $218.8 $1406.3 Oral cavity or
pharynx $171.3 $161.8 $78.9 $18.1 $430.0 $109.8 $539.9 Ovary $101.7 $195.8 $74.2 $6.1 $377.8 $72.2 $450.0 Prostate $805.2 $1234.1 $125.2 $97.3 $2261.8 $1035.5 $3297.3 Thyroid $138.3 $499.7 $11.8 $12.6 $662.4 $265.5 $927.8 Corpus
uterine $171.0 $256.8 $47.8 $17.6 $493.2 $231.2 $724.5 All sites
combined $4718.8 $8878.2 $2101.5 $521.4 $16219.9 $4873.6 $21093.6 

Site . Patient out-of-pocket costs by phase of care (in millions)b

--------------------------------------------------------------------------------

. Patient time cost (in millions) . Patient economic burden (in millions)
. Initial . Continuing . End-of-life cancer death . End-of-life other cause of
death . Total out-of-pocket costs
. Bladder $160.3 $440.9 $62.4 $39.1 $702.6 $235.4 $938.0 Breast $955.4 $1937.3 $181.7 $63.4 $3137.8 $1112.2 $4250.0 Cervix $63.0 $82.7 $17.6 $8.6 $172.0 $82.7 $254.6 Colorectal $497.2 $684.4 $221.2 $57.4 $1460.3 $440.6 $1900.9 Hodgkin
lymphoma $77.3 $153.6 $9.8 $6.3 $247.0 $70.1 $317.1 Kidney $143.9 $410.3 $75.7 $24.2 $654.1 $164.3 $818.3 Leukemia $145.2 $469.6 $118.2 $25.7 $758.7 $131.8 $890.5 Lung $401.4 $416.2 $490.0 $45.4 $1353.0 $162.8 $1515.8 Melanoma $103.2 $540.1 $43.1 $24.2 $710.6 $394.1 $1104.6 Non-Hodgkin
lymphoma $390.2 $611.5 $147.7 $38.1 $1187.5 $218.8 $1406.3 Oral cavity or
pharynx $171.3 $161.8 $78.9 $18.1 $430.0 $109.8 $539.9 Ovary $101.7 $195.8 $74.2 $6.1 $377.8 $72.2 $450.0 Prostate $805.2 $1234.1 $125.2 $97.3 $2261.8 $1035.5 $3297.3 Thyroid $138.3 $499.7 $11.8 $12.6 $662.4 $265.5 $927.8 Corpus
uterine $171.0 $256.8 $47.8 $17.6 $493.2 $231.2 $724.5 All sites
combined $4718.8 $8878.2 $2101.5 $521.4 $16219.9 $4873.6 $21093.6 

a

National cancer prevalence estimates by age group, phase of care, and cancer
site combined with annualized patient out-of-pocket costs from Surveillance,
Epidemiology, and End Results Program-Medicare and annual patient time costs
from the Medical Expenditure Panel Survey (MEPS).

b

Out-of-pocket costs estimated from patient responsibility for medical services
(including infusion drugs) under Medicare Parts A/B claims. Out-of-pocket costs
for oral prescription drugs estimated directly from Medicare Part D claims.
Estimates from the MEPS in Table 5 were used to incorporate higher out-of-pocket
spending in younger age group for medical services ($232.7 vs $97.7) and
prescription drugs ($87.4 vs $67.0), yielding ratios of 2.38 and 1.30,
respectively. All estimates are in 2019 US dollars.

Open in new tab
Table 7.

Net patient economic burden associated with cancer in the United States in 2019a

Site . Patient out-of-pocket costs by phase of care (in millions)b

--------------------------------------------------------------------------------

. Patient time cost (in millions) . Patient economic burden (in millions)
. Initial . Continuing . End-of-life cancer death . End-of-life other cause of
death . Total out-of-pocket costs
. Bladder $160.3 $440.9 $62.4 $39.1 $702.6 $235.4 $938.0 Breast $955.4 $1937.3 $181.7 $63.4 $3137.8 $1112.2 $4250.0 Cervix $63.0 $82.7 $17.6 $8.6 $172.0 $82.7 $254.6 Colorectal $497.2 $684.4 $221.2 $57.4 $1460.3 $440.6 $1900.9 Hodgkin
lymphoma $77.3 $153.6 $9.8 $6.3 $247.0 $70.1 $317.1 Kidney $143.9 $410.3 $75.7 $24.2 $654.1 $164.3 $818.3 Leukemia $145.2 $469.6 $118.2 $25.7 $758.7 $131.8 $890.5 Lung $401.4 $416.2 $490.0 $45.4 $1353.0 $162.8 $1515.8 Melanoma $103.2 $540.1 $43.1 $24.2 $710.6 $394.1 $1104.6 Non-Hodgkin
lymphoma $390.2 $611.5 $147.7 $38.1 $1187.5 $218.8 $1406.3 Oral cavity or
pharynx $171.3 $161.8 $78.9 $18.1 $430.0 $109.8 $539.9 Ovary $101.7 $195.8 $74.2 $6.1 $377.8 $72.2 $450.0 Prostate $805.2 $1234.1 $125.2 $97.3 $2261.8 $1035.5 $3297.3 Thyroid $138.3 $499.7 $11.8 $12.6 $662.4 $265.5 $927.8 Corpus
uterine $171.0 $256.8 $47.8 $17.6 $493.2 $231.2 $724.5 All sites
combined $4718.8 $8878.2 $2101.5 $521.4 $16219.9 $4873.6 $21093.6 

Site . Patient out-of-pocket costs by phase of care (in millions)b

--------------------------------------------------------------------------------

. Patient time cost (in millions) . Patient economic burden (in millions)
. Initial . Continuing . End-of-life cancer death . End-of-life other cause of
death . Total out-of-pocket costs
. Bladder $160.3 $440.9 $62.4 $39.1 $702.6 $235.4 $938.0 Breast $955.4 $1937.3 $181.7 $63.4 $3137.8 $1112.2 $4250.0 Cervix $63.0 $82.7 $17.6 $8.6 $172.0 $82.7 $254.6 Colorectal $497.2 $684.4 $221.2 $57.4 $1460.3 $440.6 $1900.9 Hodgkin
lymphoma $77.3 $153.6 $9.8 $6.3 $247.0 $70.1 $317.1 Kidney $143.9 $410.3 $75.7 $24.2 $654.1 $164.3 $818.3 Leukemia $145.2 $469.6 $118.2 $25.7 $758.7 $131.8 $890.5 Lung $401.4 $416.2 $490.0 $45.4 $1353.0 $162.8 $1515.8 Melanoma $103.2 $540.1 $43.1 $24.2 $710.6 $394.1 $1104.6 Non-Hodgkin
lymphoma $390.2 $611.5 $147.7 $38.1 $1187.5 $218.8 $1406.3 Oral cavity or
pharynx $171.3 $161.8 $78.9 $18.1 $430.0 $109.8 $539.9 Ovary $101.7 $195.8 $74.2 $6.1 $377.8 $72.2 $450.0 Prostate $805.2 $1234.1 $125.2 $97.3 $2261.8 $1035.5 $3297.3 Thyroid $138.3 $499.7 $11.8 $12.6 $662.4 $265.5 $927.8 Corpus
uterine $171.0 $256.8 $47.8 $17.6 $493.2 $231.2 $724.5 All sites
combined $4718.8 $8878.2 $2101.5 $521.4 $16219.9 $4873.6 $21093.6 

a

National cancer prevalence estimates by age group, phase of care, and cancer
site combined with annualized patient out-of-pocket costs from Surveillance,
Epidemiology, and End Results Program-Medicare and annual patient time costs
from the Medical Expenditure Panel Survey (MEPS).

b

Out-of-pocket costs estimated from patient responsibility for medical services
(including infusion drugs) under Medicare Parts A/B claims. Out-of-pocket costs
for oral prescription drugs estimated directly from Medicare Part D claims.
Estimates from the MEPS in Table 5 were used to incorporate higher out-of-pocket
spending in younger age group for medical services ($232.7 vs $97.7) and
prescription drugs ($87.4 vs $67.0), yielding ratios of 2.38 and 1.30,
respectively. All estimates are in 2019 US dollars.

Open in new tab

For all cancers combined, patient out-of-pocket costs were projected to be
$16.22 billion, with highest costs for breast ($3.14 billion), prostate ($2.26
billion), colorectal ($1.46 billion), and lung ($1.35 billion) cancers,
reflecting the higher prevalence of these cancers (Supplementary Table 9,
available online). Annual time costs in 2019 were projected to be $4.87 billion
for all cancers combined, with breast ($1.11 billion) and prostate ($1.04
billion) cancers accounting for almost one-half of time costs. In 2019, the
total patient economic burden associated with cancer care was projected to be
$21.1 billion.


DISCUSSION

This study provides comprehensive information about patient economic burden
associated with cancer care in the United States, including estimates of
out-of-pocket costs and patient time costs as part of the annual report to the
nation on the status of cancer. We found that the net patient economic burden of
cancer was $21.1 billion nationally for both out-of-pocket and time costs in
2019, which is approximately 12% of previously reported estimates of net
national medical care spending associated with cancer [$183 billion in 2015 (4)]
and approximately $2700 for patients aged 65 years and older, on average per
person, in the first year after diagnosis alone. Average per person
out-of-pocket spending and time cost associated with cancer in the first year
after diagnosis is even greater for younger patients, approximately $5900.
Cancer survivors may experience challenges with these expenses, because nearly
40% of American families report being unable to afford an unexpected expense of
$400 (35). We estimated annual patient out-of-pocket costs for most cancers well
above this amount, while cancer treatment costs continue to rise (3,7,36). Our
findings can provide cost data for discussions about expected costs of treatment
as part of informed decision making, as highlighted by the American Society of
Clinical Oncology (37), the Institute of Medicine (38), and the President’s
Cancer Panel (39) as an element of high-quality care.

We found substantial variation in the pattern and magnitude of net annualized
patient out-of-pocket costs by cancer site from the SEER-Medicare data,
reflecting differences in treatment intensity and duration and average survival.
For example, our study shows that Medicare beneficiaries aged 65 years and
older, newly diagnosed with CML, might expect more than $4000 in out-of-pocket
costs associated with cancer in the first year following diagnosis and more than
$3000 annually in the following years, due largely to ongoing maintenance
therapy. Medicare beneficiaries with breast cancer might expect out-of-pocket
costs associated with cancer closer to $2400 in the first year after diagnosis
and approximately $550 annually afterwards. All cancer survivors would
experience net annual time cost burdens of approximately $300.

Consistent with other studies of medical care costs associated with cancer by
phase of care (4,6,24), our annualized estimates of out-of-pocket costs from
SEER-Medicare are highest in the initial phase of care and at the EOL phase and
lowest in the continuing phase, following a “U-shaped” or “J-shaped” curve for
medical services and for prescription drugs for most cancer sites. Additionally,
out-of-pocket costs within each phase of care were generally highest for
patients originally diagnosed with distant disease, followed by regional and
localized disease for all solid cancers, reflecting greater treatment intensity
for more advanced disease. These estimates we report by phase of care and stage
at diagnosis may be useful inputs for studies examining the cost-effectiveness
of interventions to increase early detection or to improve other aspects of
cancer care.

Patterns of costs by phase of care were consistent across cancer sites except
for prescription drugs covered through a pharmacy benefit for CML. Increasing
use of maintenance therapies for patients with CML, melanoma, and NSCLC (40,41)
suggests that ongoing evaluation of longer-term patient out-of-pocket cost and
trajectories may be informative. Additionally, growth in the number of effective
oral prescription medications (40) that can be safely administered at home means
that patients would likely spend less time traveling to care and receiving
infusions. In some instances, however, patient cost-sharing for oral anticancer
medications through a pharmacy benefit can be greater than for infusion
medications received in a provider’s office and covered as a medical benefits
(42). Many states have enacted “oral oncology parity” laws, which are intended
to minimize this difference in patient out-of-pocket costs, yet these laws do
not apply to Medicare, Medicaid, or self-funded private plans (34). Prior
research has shown that greater cost-sharing can adversely affect treatment
adherence to oral medications (43,44); ongoing evaluation will be important.

This study is the first, to our knowledge, to report nationally representative
estimates from the MEPS for both net annual patient out-of-pocket and time costs
associated with cancer—key components of patient economic burden. We found that
nationally, time costs represent approximately 23% ($4.9 billion/$21.1 billion)
of the patient economic burden, as shown in Table 7. Academic health economists
have long recommended that patient time costs be included in cost-effectiveness
analyses (19,20), but few studies have included them, in part, because these
data are not routinely available. Exclusion of patient time costs from
cost-effectiveness analyses can bias results to interventions that place a
greater burden on patients and their families (45). Aspects of patient time,
including traveling to and from care, may also serve as a barrier to care (46).

There are multiple approaches for valuing patient time. Because time spent
seeking medical care represents a lost opportunity for usual activities,
including both work and leisure, we chose a single median wage rate, valuing
each person’s time equally, as has been done elsewhere (16,17). Other methods
that value time differently for different populations may lead to inequities
when evaluating the costs associated with health interventions, particularly for
populations who are low income, retired, or otherwise economically marginalized
(47).

Our approach for creating estimates of patient economic burden builds on and
extends standard methods for estimating health-care costs with SEER-Medicare and
MEPS data (15–17). Nonetheless, there are some limitations with this study. Some
of the data used in this study are older and may not fully reflect more recent
patterns of care. Detailed estimates by cancer site and stage at diagnosis from
SEER-Medicare were limited to adults aged 65 years and older. Other studies have
shown that within cancer site and stage at diagnosis, younger cancer patients
tend to receive more intensive treatment than their older counterparts (48–50).
Consistent with greater treatment intensity in younger patients, additional
information on out-of-pockets costs from the MEPS in our study shows that net
out-of-pocket costs associated with cancer are generally higher among adult
cancer survivors aged 18-64 years than adults aged 65 years and older.
Differences in net out-of-pocket costs associated with cancer by age group also
reflect the near universal insurance coverage by the Medicare program among
those aged 65 years and older, whereas nearly all uninsured adults are in the
18- to 64-year age group (51).

Informal caregivers frequently accompany cancer patients to medical care
appointments and provide care in the home; research is increasingly documenting
the burden of cancer diagnoses for family members and other unpaid caregivers
(52,53). Neither the SEER-Medicare nor the MEPS data contain comprehensive
information about family or caregiver economic burden associated with cancer
(54). As a result, our time cost estimates likely understate the annual amount
of time spent receiving cancer-related care from the perspective of persons
outside the health-care system who provide support to cancer survivors. Further
development of longitudinal data resources may inform research quantifying
family or caregiver time costs as well as productivity losses due to caregiver
time spent away from work.

Detailed data by cancer site and phase of care for adults younger than 65 years
are not available from SEER-Medicare, although consistent with our findings from
the MEPS reported here, studies conducted in managed care settings suggest that
costs of care related to cancer are generally higher among younger patients and
survivors than in older populations (55–57). Because of limitations in the
availability of comprehensive data for newly diagnosed cancer patients in the
younger age group, we could not directly create phase of care–specific estimates
for multiple cancer sites for patients and survivors younger than 65 years.
Instead, we used estimates from the MEPS data, which are available for both age
groups, to reflect higher out-of-pocket spending in cancer patients and
survivors younger than 65 years.

Despite this adjustment, our phase of care and national estimates may understate
out-of-pocket costs for adults younger than 65 years. Additionally, the detailed
cost information in SEER-Medicare fee-for-service claims is not available for
patients enrolled in Medicare Advantage (58), private managed care plans that
represented approximately 30% of older Medicare beneficiaries during the study
period (59). As encounter data for Medicare Advantage enrollees become available
through SEER-Medicare, additional research examining any differences in
treatment intensity is warranted. Medicare Part A and Part B claims contain
information about patient responsibility, but patient out-of-pocket costs, a
component of patient responsibility, are not reported separately in claims. We
used information from the MEPS to calculate patient out-of-pocket costs as a
percentage of patient responsibility and applied this percentage to patient
responsibility amounts from SEER-Medicare. Out-of-pocket costs are available
directly from Medicare Part D, however. Additionally, out of-pocket cost
estimates from SEER-Medicare are for patients with insurance coverage and may
not be generalizable to experiences of adults without health insurance coverage
or who are underinsured.

Our estimates of out-of-pocket costs from SEER-Medicare are not treatment
specific, and the expected costs of treatment may influence informed decision
making, such as the choice of oral vs infusion therapies. The MEPS does not
collect information about cancer stage at diagnosis, treatment(s), or other
clinical characteristics. Exact cancer diagnosis date or date of death for
adults who died is unavailable in MEPS, and as a result, we could evaluate total
out-of-pocket and time costs only by year since diagnosis and not by phase of
care. As a result, our MEPS out-of-pocket cost estimates are not directly
comparable with SEER-Medicare out-of-pocket estimates by phase of care, although
they can both be combined with cancer prevalence in a specific year to estimate
annual costs. There were insufficient numbers of cancer survivors in the MEPS to
estimate out-of-pocket and time costs separately for multiple cancer sites;
instead, we report summary measures overall, for all cancer survivors. The
majority of cancer survivors in the MEPS are reporting use and spending many
years following their cancer diagnosis, and estimates may not fully reflect
experiences of new diagnosed patients or those at the end of life when treatment
intensity and out-of-pocket spending are higher. Thus, our out-of-pocket and
patient time cost estimates from the MEPS likely understate these costs.

Despite these limitations, this article provides the most comprehensive
estimates of patient economic burden associated with cancer, including
out-of-pocket and time costs, in the United States published to date. We found
that patient economic burden associated with cancer care is substantial, both
nationally and for individual cancer survivors. Findings reported here can
inform patient and provider understanding about expected costs of care.


FUNDING

No specific funding was provided for this research.


NOTES

Role of the funder: Not applicable.

Disclosures: Authors declare no conflicts of interest.

Author contributions: All authors (KRY, AM, FT, JZ, FI, HS, RLS, JH, AJ, EMW)
contributed to the conceptualization of the study and the writing and review of
the manuscript. KRY wrote the original draft and KRY and AM made decisions about
methodology with the SEER-Medicare data and KRY and JZ made decisions about
methodology with the MEPS data.

Disclaimer: The findings and conclusions in this report are those of the authors
and do not necessarily represent the official position of the American Cancer
Society, Centers for Disease Control and Prevention, the National Cancer
Institute, or the North American Association of Central Cancer Registries.


DATA AVAILABILITY

The linked SEER-Medicare data are available through request from the National
Cancer Institute. The Medical Expenditure Panel Survey (MEPS) data are publicly
available from the Agency for Healthcare Research and Quality website.


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© The Author(s) 2021. Published by Oxford University Press.
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SEE ALSO

 * COMPANION ARTICLE
   
   * Annual Report to the Nation on the Status of Cancer, Part 1: National
     Cancer Statistics

 * COMMENTARY
   
   * Addressing Cancer Financial Hardship Begins With Comprehensive Assessment
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