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Colorectal cancer ranks 2^nd behind breast cancer in 2010 total costs of care by cancer type, and will remain one of the top 5 most costly cancers in 2020.

Projections of the Cost of Cancer Care in the United States: 2010–2020

Those are just two of many facts in an important paper published in the Jan. 19 Journal of the National Cancer Institute. The predicted costs are much higher than previous estimates because the authors used the most current cost data (2006 Medicare) which, for the first time, includes costs of expensive targeted treatments.

The study is powerful because it analyzed different scenarios and assumptions, and broke down costs of three stages of care (initial and final years, and middle years of continuing care) for each type of cancer.

By far, the most important cause of rising costs will be the aging of the U.S. population. Changes in either incidence (the numbers diagnosed) or improved survival will have a much smaller impact over the next 10 years than the aging Boomer bubble. Currently in the U.S., there are about 14 million survivors (58% over age 64). In 10 years, there will more than 18 million survivors, with the largest increase among seniors.

“The rising costs of cancer care illustrate how important it is for us to advance the science of cancer prevention and treatment to ensure that we’re using the most effective approaches,” said Robert Croyle, PHD, director of the National Cancer Institute’s Division of Cancer Control.

In 2010, total cancer care cost an estimated $125 million, with highest cost associated with breast cancer ($16.5 billion), followed by colorectal cancer ($14 billion), and then lymphoma, lung and prostate cancer at $12 billion each. (Note, these figures do not include screening and prevention costs.)

Other facts:

• For most types of cancer, the number of new diagnoses (incidence) is dropping: The highest decreases are seen in lung and colorectal cancers in men estimated at about 2% fewer cases per year.
• Survival also is improving for most cancers, especially for prostate cancer, melanoma and breast cancer. Currently, there are about 1.2 million colorectal cancer survivors in the U.S. (4^th highest after breast, prostate, and melanoma survivors), with that pattern expected to continue in 2020.
• Currently for colorectal cancer, 42% of costs of care occur the first year; 28% of costs occur during the continuing phase; and30% of total colorectal cancer costs are spent in the last year of life.

Read the complete study here.
SOURCE: Mariotto et al, Journal of National Cancer Institute, Volume 103, Number 2, pages 117-128, January 19,2011.

Looking at expense for an entire population, all screening methods except colonoscopy cost less than treating those cancers that developed, and the net cost of colonoscopy screening fell from over $1,300 to less than $300 per individual in the population.

Iris Lansdorp-Vogelaar, Ph.D in the Netherlands and her team used a computer simulation model to project the average lifetime cost of current colorectal cancer screening methods per person versus the lifetime costs per person to treat colorectal cancer.  Their analyses looked at costs in the past, present, and near future.

They took into account both the more expensive chemotherapy used today and reduced rates of colorectal cancer due to increased screening.

Average lifetime treatment savings versus costs of screening per individual for different screening methods were:

• Annual Hemoccult II guaiac FOBT:  $1398 (treatment savings) vs $859 (costs of screening)
• Annual immunochemical fecal testing: $1756 vs $1565
• Sigmoidoscopy every 5 years: $1706 vs $1575
• Sigmoidoscopy and Hemoccult II combined strategy: $1931 vs $1878

Screening colonoscopy every ten years didn’t save money overall, but the total net costs fell from $1,317 to $296.

The model had some limitations which may have led to underestimation of treatment costs.  Therapies other than chemotherapy were not included.  At the same time the model assumed that all patients, including the elderly with other serious health conditions, would receive the new chemotherapies.

Dr. Lansdorp-Vogelaar and her team wrote,

The increasingly costly management of colorectal cancer will approximately double the treatment savings from screening … screening is not only desirable from the perspective of governments and insurance companies to reduce colorectal cancer incidence and mortality, but in addition will also help to contain the increasing costs for the management of colorectal cancer.

They concluded,

With the increase in chemotherapy costs for advanced colorectal cancer, most colorectal cancer screening strategies have become cost saving. As a consequence, screening is a desirable approach not only to reduce colorectal cancer incidence and mortality but also to control the costs of colorectal cancer treatment.

SOURCE: Lansdorp-Vogelaar et al., Journal of the National Cancer Institute, Volume 101, Number 20, October 2009.

A Memo to the Media in the JNCI provides more information.

In addition, there are links to the Surgeon General’s new Family Health Portrait and a report from Families USA on health care insurance costs for laid off workers.

Brief Research Reports

• Patients with deficient mismatch repair genes are rare in stage IV colorectal cancer.  Although cancer related to deficient mismatch repair is found in 10 to 20 percent of earlier stage patients and is associated with better survival, it was found in only 3.5 percent of stage IV patients taking part in a clinical trial.  Those patients had a lower survival than patients with proficient mismatch repair genes (10.2 months compared to 17.9).  Researchers concluded that cancers with deficient mismatch repair have a reduced ability to spread beyond the colon itself (metastasize).  M. Koopman, British Journal of Cancer, online January 22, 2009.
• Morbidly obese have worse outcomes after colon cancer surgery. After colectomies, complications occur in more than 30 percent of patients with a body mass index (BMI) over 34 compared to 20.5 percent of normal weight patients.  More frequent complications include kidney failure, surgical site infection, wounds reopening, and pulmonary embolism.  Occuring in 20.7 percent of patients, site infections were more than twice as common in the morbidly obese. Ryan P. Merkow, M.D. in the Journal of the American College of Surgeons, January 2009.
• Paperless hospital information systems reduce complications, patient deaths, and hospital costs.  Researchers scored the impact of computerizing clinical notes and records, order entries, and decision support in 41 hospitals treating nearly 170,000 patients.  For all hospitals, a 10 percent increase in the technology score resulted in a 15 percent lower death rate.  When doctors had access to decision-making support from computer systems, complications fell by 16 percent.  In addition, computerization lowered bottom-line hospital expense. Ruben Amarasingham, MD, MBA in Archives of Internal Medicine, January 16, 2009.

Other Colorectal Cancer Headlines

• The Surgeon General has updated My Family Health Portrait. Information from the revised online program is not kept on a government or any other site, but is downloaded to an individual’s own computer to protect privacy.  It can then be shared with other family members or doctors.  Family members can add their own information, as well.
• Purchasing extended health insurance guaranteed by COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985) is almost impossible for laid off workers according to a new report from Families USA.  Although benefits and insurance costs vary by state, the national average $1,069 monthly cost for to replace a family policy would use up 84 percent of $1,278 unemployment insurance benefits.  Individual benefits costs average $388, about a third of monthly benefits.  In the US, 61 percent of people get medical coverage from their own or a family member’s employer. Families USA Report: Squeezed: Caught between Unemployment Benefits and Health Care Costs, January 2009.

Over half a billion dollars could potentially be saved if all patients with colorectal cancer that had spread were tested for the KRAS gene before beginning treatment.

Because patients with mutated KRAS in their tumors don’t benefit from treatment with EGFR inhibitors Erbitux® (cetuximab) and Vectibix™ (panitumumab), offering them those drugs is a futile expense.  In addition, trying the drugs delays potentially effective treatment and exposes patients to skin rash and other unnecessary side effects.

Nearly 30,000 people will be diagnosed with  metastatic colorectal cancer in the United States each year.  About a third will have a mutation in the KRAS gene in their tumors.  Upfront testing of all patients at $452 each would cost $13 million.   Assuming, based on information from clinical trials, that the average patient would receive 24 treatments , the cost of Erbitux for each patient would be $71,120.

Not treating patients with KRAS mutations would save $617 million in drug costs. Subtracting the cost of testing, net health care cost savings would be $604 million.

Of course, not all patients would receive EGFR inhibitor drugs as initial treatment.  Frequently, Erbitux or Vectibix is given after cancer has already progressed on other treatments.  Still, given a cost of $3,986 for the first week’s Erbitux treatment and $2,491 each week thereafter, a test costing less than $500 would still save significant dollars.

SOURCE: Shankaran et al., 2009 ASCO GI Symposium, Abstract 298.

The Centers for Medicare and Medicaid Services released a report from the CMS Office of the Actuary on Tuesday that showed overall health care spending grew at a 6.1 percent rate in 2007, down from 6.7 in 2006 and the slowest rate of growth since 1998.  Overall economic growth was 4.8 percent.

Health care spending’s share of the Gross Domestic Product continued to increase, reaching 16.2 percent, an increase of 0.2 percent over 2006.

CMS attributes the slower spending growth to retail prescription spending and lower costs of administering Medicare benefits.

• Prescription drug prices increased by 1.4 percent in 2007 compared to 3.5 percent in 2006.  The slower growth was driven by more use of generics and by generic drug discount programs in large retail chain stores.
• Spending for hospital care, which accounts for about a third of overall health costs, increased by 7.3 percent in 2007 over 6.9 percent in 2006.
• There was no change in physician and clinical services growth in 2007, increasing by 6.3 percent.  However, growth in payments to physicians decreased during the year, while costs for stand-alone clinics and urgent care centers increased.
• Costs for nursing home care increased by 4.8 percent compared to 4 percent in 2006.  Spending for home health care rose by 11.8 percent.
• Spending for public programs including Medicare and Medicare grew more slowly in 2007 at 6.4 percent, down from 8.2 percent.  However, private spending grew somewhat faster at 5.8 percent in 2007 compared to 5.4 in 2006.
• Private insurance health care premiums grew 6 percent, the same as the previous year, but significantly less than the 10.7 increase in 2002.  Increases in payments from health care insurance also slowed to 6.6 percent, down from 9.9 percent in 2002.
• Out-of-pocket spending by individuals grew 5.3 percent, up from 3.3 percent in 2006.
• Overall, the amount of health care paid for by individuals out-of-pocket is decreasing.  In 2007 it represented 12 percent of all health care spending.  It was 14.7 percent in 1998 and 34.8 percent in 1968.

Health care services and supplies were financed by

• businesses (25 percent)
• households (31 percent)
• other private sponsors (4 percent)
• governments (40 percent)

Commenting on the report CMS Acting Administrator Kerry Weems said,

This is another reminder that the cost of health care continues to be a real and pressing concern facing the American public and the federal government. This report – like the reports issued last year on the financial status of Medicare and Medicaid – is a stark reminder that we must redouble our ongoing efforts to reform the delivery of health care services in this country to bring about the goal of affordable, high quality health for all Americans.