The impact of this distortion and the unmet need has not been estimated in the published literature, however.


About half a million patients in the United States die of cancer each year (American Cancer Society, 2001), and on average, about $32,000 per patient is spent in the last year of life for the care of Medicare patients dying of cancers (Hogan et al., 2000). The care of cancer is a major part of the business of health care, and many businesses and provider organizations focus exclusively on cancer care. Most literature on diagnosis, treatment, and cost does not address the entire cancer population, but addresses just one type. Thus, this section reviews descriptive accounts that address costs and cost-effectiveness of treatments offered for particular common cancers and then for symptom management and palliative care more generally.

Advanced Lung Cancer (Non-Small Cell Cancer of the Lung)

In contrast to breast, prostate, and colorectal cancers, very little progress has been made in early diagnosis and long-term remission in lung cancer. Furthermore, as the most common cancer among men and women in the United States, lung cancer accounts for approximately 20 percent of all cancer care costs (Desch et al., 1996). The focus of clinical trials has been to prolong survival and increase the number of one- and two-year survivors. Recently, attention has turned to economic evaluations that compare the cost and benefits of such treatments. In their review of the available economic data, Goodwin and Shepherd (1998) conclude that the costs of combination chemotherapy or combined-modality treatment for locally advanced or metastatic lung cancer are well within the range considered acceptable for interventions used for other diseases.

Smith (Thomas J.Smith, personal communication, 2000) proposed asking about the patient’s evaluation of the merits of treatment in this disease in a quite novel and illuminating way. Working with a large regional insurer, Smith generated actuarial estimates of the expenditures from diagnosis of inoperable lung cancer through to death. He proposed to give the patient a choice, after giving the patient a solid understanding of the issues at stake. The patient could choose to have conventional care, with treatments that would probably extend life (for three to four months, on average), or the patient could choose to have hospice care available from the start and also take all of the funds (about $19,000) that would probably have been spent on his or her radiation and chemotherapy. The experiment

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