Background: Financial toxicity is a serious concern for patients with cancer. Here, we conducted an investigation of one-year charges for head and neck cancer (HNC) patients and analyzed factors associated with increased charges.
Methods: A review of clinical data and one-year-charges was performed for new HNC patient visits from January 1, 2016 to March 31, 2017 at a tertiary care institution. Two-hundred-and-fourteen patients met inclusion criteria. Demographics and clinical variables were recorded, including primary site, AJCC 7thedition staging, insurance type, comorbidities, treatment modality, new vs. recurrent tumor, and curative vs. palliative pathway. Appropriate statistical tests, notably multivariable regression, were used to investigate factors associated with increased charges.
Results: The mean age was 59.6 years (Table 1). Most of the population was male (65%), white (72%), and privately insured (66%). The most common primary sites were oropharynx (25%; 77% HPV-positive), skin (22%), thyroid (15%), and oral cavity (15%). Ninety percent were treated with curative intent, and 10% were treated with palliative intent. The most common treatment modalities were surgery alone (36%), chemoradiation (21%), and surgery plus chemoradiation (14%).
The mean charge per patient was $291,080 (SD 256,133) with the median and interquartile range being $188,942 (74,384–459,623) (Figures 1-3). Radiation oncology had the largest contribution to mean charge per patient at $105,930, followed by surgery ($83,784), medical oncology ($49,737), and radiology ($23,892).
Total charges were significantly higher for patients treated with curative intent [$212,794 (82,436–471,610), median (IQR)] vs. patients treated with palliative intent [$110,172 (35,800–246,762); p=0.0217; Figure 4]. Curative patients had higher charges for anesthesia [$2,520 (811–5,347) vs. $0 (0–1,790); p=0.0002] and pathology [$1,976 (794–5,335) vs. $0 (0–358); p<0.0001], whereas palliative patients had higher charges for medical oncology [$45,463 (3,250–899,850) vs. $4,004 (255–47,280); p=0.0182]. Total charges did not differ significantly between patients with primary tumors versus those with recurrences [$245,658 (67,598–473,147) vs. $145,407 (77,381–397,166); p=0.3792], nor did it vary by race or insurance type.
Total charges varied significantly depending on clinical stage (p=0.0001). Charges for stage I, II, III, and IV were $66,131 (44,152–148,206), $124,174 (60,456–336,727), $430,060 (128,422–508,467), and $360,744 (148,677–519,839). One reason that stage IV patients did not have a higher charge than stage III patients is that 16% were treated with palliative intent vs. 3% (p=0.058), and palliative treatment of stage IV patients was associated with lower charges [$150,228 (52,341–446,488) vs. $380,274 (181,933–527,701); p=0.0248].
On multivariable analysis (Table 2), Charlson comorbidity index [$18,566 per unit increase (690–36,442); effect size (95% CI); p=0.042], hypopharynx subsite [$250,169 (19,730–480,608); p=0.034], chemotherapy [$234,543 (142,102–326,985); p<0.001], and radiation [$194,629 (95,018–294,239); p<0.001]were associated with increased charges from the base charge of $61,862 USD (-43,576–167,300).
Conclusion: This is the most comprehensive report of charges for treating HNC to date. Increased comorbidity, hypopharynx subsite, chemotherapy, and radiation were associated with higher charges. No evidence for charging bias based on patient-specific factors was evident. These findings are valuable contributions to assessing value in HNC treatment.