troubling role in physician decisionmaking with regard to new modalities for metastatic prostate cancer. Flutamide, a nonsteroidal antiandrogen, may be effective in prolonging the time to progression of disease, improve overall survival, and have a favorable cost-effectiveness profile (Bennett et al., 1996). Because it is an oral medication, Medicare does not cover it. Findings from physician focus groups indicated that the potential out-of-pocket expenses incurred by patients influenced doctors’ prescribing practices and recommendations for or against patient enrollment in flutamide clinical trials (Bennett et al., 1996).

In 1991, the total Medicare payments for prostate cancer care from diagnosis to death (seven years) averaged about $49,000 (Riley et al., 1995). Lifetime lung cancer costs are lower ($29,000), but the longer survival period in prostate cancer ends up costing more in aggregate.

Symptom Management

Pain continues to be the most frequent unrelieved symptom in the advanced cancer patient (Ingham, 1998). As cancer patients approach death, their initial oral analgesic may become inadequate. Although reasonable control could usually be regained with substantial dosage increases, different opioids, routes of administration, and delivery systems often provide more reliable control with fewer side effects. However, advanced pain treatments, such as pamidronate and intrathecal pumps, can greatly increase the cost. Furthermore, Medicare does not generally pay for pain management medications (IOM, 1999). The typical cost for an implanted intrathecal opioid infusion is $23,000, which includes hospitalization and professional fees (G.Fanciullo, personal communication, 2000). This may seem inordinately high, in light of the availability of less expensive modes of pain therapy. Yet, the complexity of the patient’s condition might well lead the clinician to choose the implanted intrathecal approach. In their case report, Seamans and colleagues (2000) found it more cost effective to use intrathecal therapy (total estimated cost at three months, $19,645) over a systemic analgesic therapy (total estimated cost at three months, $31,860).

Home management of terminally ill patients could potentially contribute to decreased costs. A retrospective Canadian study compared the cost of managing cancer patients who required narcotic infusions in hospital and at home. Medical costs, in 1991 Canadian dollars, averaged $370 per inpatient-day and $150 per outpatient-day (Ferris et al., 1991). Other symptoms or advanced cancer complications for which health care resources are used include constipation (Agra et al., 1998; Ramesh et al., 1998), dyspnea (Escalante et al., 1996), common bile duct obstructions (Cvetkovski et al., 1999; Kaskarelis et al., 1996), intractable vomiting (Scheidbach et al., 1999), and dehydration (Bruera et al., 1998).

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