When Does an Episode of Care for Cancer Begin?

Abstract

Background Little is known about the medical care resources devoted to diagnosing and treating cancer-related symptoms prior to a definitive cancer diagnosis. Previous research using SEER-Medicare data to measure incremental costs and utilization associated with cancer started with the date of diagnosis. We hypothesized that health care use increases prior to diagnosis of a new primary cancer. Methods We used a longitudinal case-control design to estimate incremental medical care utilization rates. Cases were 121,293 persons enrolled between January, 2000 and December, 2008 with one or more primary cancers. We selected 522,839 controls randomly from among all health plan members who had no tumor registry evidence of cancer prior to January, 2009, and we frequency matched controls to cancer cases on a five-to-one ratio by age group, gender, and having health plan eligibility in the year of diagnosis of the index cancer case. Utilization data were extracted for all cases and controls for the period 2000-2008 from standardized distributed data warehouses. To determine when and the extent to which patterns of medical care use change preceding a cancer diagnosis, we compute hospitalization rates, hospital days, emergency department visits, same-day surgical procedures, ambulatory medical office visits, imaging procedures, laboratory tests, and ambulatory prescription dispensings per 1,000 persons per month within integrated delivery systems. Results One- to three-fold increases in monthly utilization rates were observed during the three to five months prior to a cancer diagnosis, compared to matched non-cancer control groups. This pattern was consistent for both aged and non-aged cancer patients. Aged cancer patients had higher utilization rates than non-aged cancer patients throughout the year prior to a cancer diagnosis. Conclusion The pre-diagnosis phase is a resource-intensive component of cancer care episodes and should be included in cost of cancer estimates. More research is needed to determine whether reliable prognostic markers can be identified as the start of a cancer episode prior to a pathology-based diagnosis.

Medical Care Costs for Recurrent versus De Novo Stage IV Cancer by Age at Diagnosis

“…This spike in costs, and the corresponding spike in utilization (Figures ), is consistent with our previous work, which noted a one‐ to threefold increase in monthly utilization of total medical care services during the months leading up to an initial cancer diagnosis (Hornbrook et al. ). De novo patients were younger and in the lung and colorectal cohorts less likely to survive for 12 months after the index diagnosis (Table ) than recurrent patients, but it is not clear that these factors were responsible for the de novo/recurrent cost differential.…”

Breast Cancer Screening in Patients With Newly Diagnosed Lung and Colorectal Cancer: A Population-Based Study of Utilization

“…More than 25% of Medicare dollars are spent at the end of life [40], and cancer consumes a great proportion of overall Medicare expenditures [41], with a 1- to 3-fold increase in monthly health care utilization rates starting from 3 to 5 months before a cancer diagnosis [42]. Mean 5-year net health care costs for Medicare-covered women with colorectal cancer have been estimated as $35,000 [43].…”

Estimating the Cost of Cancer Care in British Columbia and Ontario: A Canadian Inter-Provincial Comparison

“…All patients had a pre-diagnosis phase, defined as the three months before the date of diagnosis. This phase typically includes diagnostic testing to establish the cancer diagnosis (Christensen et al 2012; Hornbrook et al 2013). We divided the time between diagnosis and death into the following three phases based on clinical relevance and join point analysis (Baker et al 1991; Kim et al 2000; Yabroff et al 2008): (1) initial care, which includes the primary course of therapy and any adjuvant therapy, defined as the six months after diagnosis (including date of diagnosis); (2) continuing care, which encompasses surveillance and active follow-up treatment for cancer recurrence and/or new primary cancer, with costs expressed as annual estimates; and (3) terminal care, which captures intensive services, often palliative in nature, defined as the 12 months before death.…”