Skip to main content Accessibility help

Valuing end-of-life care in the United States: the case of new cancer drugs

  • Corinna Sorenson (a1)

New cancer therapies offer the hope of improved diagnosis to patients with life-threatening disease. Over the past 5–10 years, a number of specialty drugs have entered clinical practice to provide better systemic therapy for advanced cancers that respond to few therapeutic alternatives. To date, however, such advances have been only modestly effective in extending life and come with a high price tag, raising questions about their value for money, patient access and implications for health care costs. This article explores some of the key issues present in valuing end-of-life care in the United States in the case of advanced cancer drugs, from the difficult trade-offs between their limited health benefits and high costs to the technical, political and social challenges in assessing their value and applying such evidence to inform policy and practice. A number of initial steps are discussed that could be pursued to improve the value of advanced cancer care.

Corresponding author
*Correspondence to: Corinna Sorenson, London School of Economics and Political Science, LSE Health, Cowdray House, Houghton Street, London WC2A 2AE, UK. Email:
Hide All
Abernethy, A. P., Raman, G., Balk, E. M., Hammond, J. M., Orlando, L. A., Wheeler, J. L., Lau, J.McCrory, D. C. (2009), ‘Systematic review: reliability of compendia methods for off-label oncology indications’, Annals of Internal Medicine, 150: 336343.
Alexander, G. C., Casalino, L. P.Meltzer, D. O. (2003), ‘Patient–physician communication about out-of-pocket costs’, Journal of the American Medical Association, 290(7): 953958.
American Cancer Society (2010), Cancer Facts & Figures 2010, Atlanta: American Cancer Society.
Ancker, J. S.Kaufman, D. (2007), ‘Rethinking health numeracy: a multidisciplinary literature review’, Journal of the American Medical Informatics Association, 14: 713721.
Bach, P. B. (2009), ‘Limits on Medicare's ability to control rising spending on cancer drugs’, New England Journal of Medicine, 360(6): 626633.
Barnato, A. E., Herdon, M. B., Anthony, D. L., Gallagher, P. M., Skinner, J. S., Bynum, J. P. W.Fisher, E. S. (2007), ‘Are regional variations in end-of-life care intensity explained by patient preferences? A study of the US Medicare Population’, Medical Care, 45(5): 386393.
Becker, G. S., Philipson, T. J., Soares, R. R. (2007), The Value of Life Near Its End and Terminal Care, National Bureau of Economic Research Working Paper 1333, Cambridge, MA: NBER.
Berenson, A. (2005), ‘Cancer drugs offer hope, but at a huge expense’, New York Times, July 12.
Burns, J. (2011), ‘UnitedHealthcare's bold effort to deal with cancer drug costs’, Managed Care Magazine, January 2011.
Callahan, D. (2009), Taming the Beloved Beast: How Medical Technology Costs Are Destroying Our Health Care System, Princeton and Oxford: Princeton University Press.
Centers for Disease Control and Prevention (CDC) (2010), National Vital Statistics Reports, Vol. 58, No. 19, May 20. Atlanta: CDC.
Chalkidou, K. (2012), ‘Evidence and values: paying for end of life drugs in the British NHS’, Health Economics, Policy and Law.
Cohen, J.Looney, W. (2010), ‘What is the value of oncology medicines?’, Nature Biotechnology, 28: 11601163.
Danzon, P. M.Taylor, E. (2010), ‘Drug pricing and value in oncology’, Oncologist, 15(Supplement 1): 2431.
Department of Health (2010), Equity and Excellence: Liberating the NHS, London: The Stationery Office Limited.
de Souza, J. A., Ratain, M. J.Fendrick, A. M. (2012), ‘Value-based insurance design: aligning incentives, benefits, and evidence in oncology’, Journal of the National Comprehensive Cancer Network, 10(1): 1823.
DoBias, M. (2011), ‘No death panels, please, but poll shows Americans can handle end-of-life chat’, National Journal, March 8.
Drummond, M.Towse, A. (2012), ‘Is it time to consider the role of patient co-payments for pharmaceuticals in Europe?’, European Journal of Health Economics, 13(1): 15.
Earle, C. C., Landrum, M. B., Souza, J. M., Neville, B. A., Weeks, J. C.Ayanian, J. Z. (2008), ‘Aggressiveness of cancer near the end of life: is it a quality of care issue?’, Journal of Clinical Oncology, 26: 38603866.
Epstein, S. S. (2005), Cancer-Gate: How to Win the Losing War on Cancer, Amityville, NY: Baywood.
Faden, R. R., Chalkidou, K., Appleby, J., Waters, H. R.Leider, J. (2009), ‘Expensive cancer drugs: a comparison between the United States and the United Kingdom’, Milbank Q, 87: 789819.
Faguet, G. B. (2005), The War on Cancer: An Anatomy of Failure, A Blueprint for the Future, Dordrecht, the Netherlands: Springer.
Fojo, T.Grady, C. (2009), ‘How much is life worth: Cetuximab, non-small cell lung cancer, and the $440 billion question’, Journal of National Cancer Institute, 101: 10441048.
Freemantle, N.Drummond, M. F. (2010), ‘AHRQ Series Commentary 3: The United States addresses comparative effectiveness but not cost-effectiveness through the Effective Health-Care Program’, Journal of Clinical Epidemiology, 63: 479480.
Garau, M., Shah, K. K., Mason, A. R., Wang, Q., Towse, A., Drummond, M. F. (2010), Using QALYs in Cancer: A Review of the Methodological Limitations, Office of Health Economics, Research Paper 10/01, October 2010, London: OHE.
Garber, A. M.Sox, H. C. (2010), ‘The role of costs in comparative effectiveness research’, Health Affairs, 29(10): 18051811.
Gatyas, G., Longwell, L. (2008), ‘IMS Health reports U.S. prescription sales grew 3.8 percent in 2007, to $286.5 billion’. Press release, March 12. Norwalk, CT: IMS Health.
Gawande, A. (2010), ‘Letting go: what should medicine do when it can't save your life?’, The New Yorker, August 2.
Gerber, A. S., Patashnik, E. M., Doherty, D.Cowling, C. (2010), ‘The public wants information, not broad mandates, from comparative effectiveness research’, Health Affairs, 29(10): 18721881.
Giezen, T. J., Mantel-Teeuwisse, A. K., Straus, S., Schellekens, H., Leufkens, H.Egberts, A. C. G. (2008), ‘Safety-related regulatory actions for biologicals approved in the United States and the European Union’, Journal of the American Medical Association, 300(16): 18871896.
Goodman, D. (2011), ‘End-of-life cancer care in Ontario and the United States: quality by accident or quality by design?’, Journal of the National Cancer Institute, 103(11): 12.
Goldman, D. P., Jena, A. B., Lakdawalla, D. N., Malin, J. L., Malkin, J. D.Sun, E. (2010), ‘The value of specialty oncology drugs’, Health Services Research, 45(1): 115132.
Goodman, D. C., Fisher, E. S., Chang, C., Morden, N. E., Jacobson, J. O., Murray, K.Miesfeldt, S. (2010), Quality of End-of-Life Cancer Care for Medicare Beneficiaries: Regional and Hospital-Specific Analyses, A Report of the Dartmouth Atlas Project, November, Lebanon, NH: Dartmouth Institute.
Goodman, D. C., Fisher, E. S., Chang, C., Morden, N. E., Jacobson, J. O., Murray, K.Miesfeldt, S. (2011), Quality of End-of-Life Cancer Care for Medicare Beneficiaries: Regional and Hospital-Specific Analyses, A Report of the Dartmouth Atlas Project, November, Lebanon, NH: Dartmouth Institute.
Gusmano, M. K.Gray, B. H. (2010), Evidence and Fear: Navigating the Politics of Evidence Based Medicine, AcademyHealth Reports, June, Washington, DC: AcademyHealth.
Harrington, S. E.Smith, T. J. (2008), ‘The role of chemotherapy at the end of life: “when is enough, enough”?’, Journal of the American Medical Association, 299: 26672678.
Hecht, J. R., Mitchell, E., Chidiac, T., Scroggin, C., Hagenstad, C., Spigel, D., Marshall, J., Cohn, A., Stella, P., Deeter, R., Shahlin, S.Amado, R. G. (2009), ‘A randomized phase IIIB trial of chemotherapy, bevacizumab, and panitumumab compared with chemotherapy and bevacizumab alone for metastatic colorectal cancer’, Journal of Clinical Oncology, 27(5): 672680.
Himmelstein, D. U., Thorne, D., Warren, E.Woolhandler, S. (2009), ‘Medical bankruptcy in the United States, 2007: results of a national study’, American Journal of Medicine, 122: 741746.
Hollingsworth, J. M., Zhang, Y., Krein, S. L., Ye, Z.Hollenbeck, B. K. (2010), ‘Understanding the variation in treatment intensity among patients with early stage bladder cancer’, Cancer, 378: 35873594.
Hsu, J., Price, M., Huang, J., Brand, R.Fung, V. (2006), ‘Unintended consequences of caps on Medicare drug benefits’, New England Journal of Medicine, 354: 23492359.
Huskamp, H. A., Keating, N. L., Malin, J. L., Zaslavsky, A. M., Weeks, J. C., Earle, C. C., Teno, J. M., Virnig, B. A., Kahn, K. L., He, Y.Ayanian, J. Z. (2009), ‘Discussions with physicians about hospice among patients with metastatic lung cancer’, Archives of Internal Medicine, 169: 954962.
IOM (2007), Learning What Works Best: The Nation's Need for Evidence on Comparative Effectiveness in Health Care, IOM Roundtable on Evidence-Based Medicine,. Washington, DC: Institute of Medicine.
IOM (2009), Initial National Priorities for Comparative Effectiveness Research, Report Brief, June 2009, Washington, DC: Institute of Medicine,
Jacobson, M., O'Malley, A. J., Earle, C. C., Pakes, J., Gaccione, P.Newhouse, J. P. (2006), ‘Does reimbursement influence chemotherapy treatment for cancer patients?’, Health Affairs, 25: 437443.
Jeffreys, B. (2007), ‘Fears over NHS cancer drug costs’, BBC, May 14.
Keating, N. L., Landrum, M. B., Rogers, S. O., Baum, S. K., Virnig, B. A., Huskamp, H. A., Earle, C. C.Kahn, K. L. (2010), ‘Physicians factors associated with discussions about end-of-life care’, Cancer, 116: 9981006.
Kim, P. (2007), ‘Costs of cancer: the patient perspective’, Journal of Clinical Oncology, 25(2): 228232.
Kolata, G., Pollack, A. (2008), ‘The evidence gap: costly cancer drug offers hope, but also a dilemma’, New York Times, July 6.
Langa, K. M., Fedrick, A. M., Chernew, M. E., Kabeto, M. U., Paisley, K. L.Haymen, J. A. (2004), ‘Out-of-pocket health care expenditures among older Americans with cancer’, Value Health, 7(2): 186194.
Lubitz, J. D.Riley, G. F. (1993), ‘Trends in Medicare payments in the last year of life’, New England Journal of Medicine, 328(15): 10921096.
Malin, J. L. (2010), ‘Wrestling with the high price of cancer care: should we control costs by individuals’ ability to pay or society's willing to pay?’, Journal of Clinical Oncology, 28(20): 32123214.
McNeil, C. (2007), ‘Sticker shock sharpens focus on biologics’, Journal of National Cancer Institute, 99(12): 910914.
Medpac (2010), Report to Congress: Medicare Payment Policy, March 2010, Washington, DC: Medpac.
Meropol, N. J.Schulman, K. A. (2009), ‘Cost of cancer care: issues and implications’, Journal of Clinical Oncology, 25(2): 180186.
Meropol, N. J., Schrag, D., Smith, T. J., Mulvey, T. M., Langdon, R. M., Blum, D., Ubel, P. A.Schnipper, L. E. (2009), ‘American Society of Clinical Oncology guidance statement: the cost of cancer care’, Journal of Clinical Oncology, 27(23): 38683874.
Mukherjee, S. (2010), The Emperor of All Maladies: A Biography of Cancer, New York: Scribner.
Mullins, C. D., Montgomery, R.Tunis, S. (2010), ‘Uncertainty in assessing value of oncology treatments’, Oncologist, 15(Supplement 1): 5864.
Nadler, E., Eckert, B.Neumann, P. J. (2006), ‘Do oncologists believe new cancer drugs offer good value?’, Oncologist, 11(2): 9095.
Neumann, P. J., Sandberg, E. A., Bell, C. M., Stone, P. W.Chapman, R. H. (2000), ‘Are pharmaceuticals cost-effective? A review of the evidence’, Health Affairs, 19(2): 92109.
Neumann, P. J., Palmer, J. A., Nadler, E., Fang, C.Ubel, P. (2010), ‘Cancer therapy costs influence treatment: a national survey of oncologists’, Health Affairs, 29(1): 196202.
Pearson, S. D.Bach, P. B. (2010), ‘How Medicare could use comparative effectiveness research in deciding on new coverage and reimbursement’, Health Affairs, 29(10): 17961804.
Ramsey, S.Schickedanz, A. (2010), ‘How should we define value in cancer care?’, The Oncologist, 15(Supplement 1): 14.
Rawlins, M. D.Chalkidou, K. (2011), ‘The opportunity cost of cancer care: a statement from NICE’, Lancet Oncology, 12(10): 931932.
Schnipper, L. E., Meropol, N. J.Brock, D. W. (2010), ‘Value and cancer care: toward an equitable future’, Clinical Cancer Research, 16(24): 60046008.
Schrag, S. (2004), ‘The price tag on progress – chemotherapy for colorectal cancer’, New England Journal of Medicine, 351(4): 317319.
Schrag, S.Hanger, M. (2007), ‘Medical oncologists’ views on communicating with patients about chemotherapy costs: a pilot survey’, Journal of Clinical Oncology, 25: 233237.
Schickedanz, A. (2010), ‘Of value: a discussion of cost, communication, and evidence to improve cancer care’, Oncologist, 15(Supplement 1): 7379.
Shih, Y. C.Halpern, M. T. (2008), ‘Economic evaluations of medical care interventions for cancer patients: how, why, and what does it mean?’, CA: A Cancer Journal for Clinicians, 58(4): 231244.
Smith, T. J.Hillner, B. E. (2010), ‘Concrete options and ideas for increasing value in oncology care: the view from one trench’, Oncologist, 15(Supplement 1): 6572.
Smith, T. J.Hillner, B. E. (2011), ‘Bending the cost curve in cancer care’, New England Journal of Medicine, 364(21): 20602065.
Slevin, M. L., Stubbs, L., Plant, J. J., Wilson, P., Gregory, W. M., Armes, P. J.Downer, S. M. (1990), ‘Attitudes to chemotherapy: comparing views of patients with cancer with those of doctors, nurses, and general public’, British Medical Journal, 300: 14581460.
Soares, M. (2005), ‘Off-label indications for oncology drug use and drug compendia: history and current status’, Journal of Oncology Practice, 1(3): 102105.
Sox, H. (2009), ‘Evaluating off-label uses of anticancer drugs: time for a change’, Annals of Internal Medicine, 150(5): 353354.
Sullivan, R., Peppercorn, J., Sikora, K., Zalcberg, J., Meropol, N. J., Amir, E., Khayat, D., Boyle, P., Autier, P., Tannock, I. F., Fojo, T., Sideroy, J., Williams, S., Camporesi, S., McVie, J. G., Purushotham, A. D., Naredi, P., Eggermont, A., Brennan, M. F., Steinberg, M. L., Ridder, M. D., McCloskey, S. A., Verellan, D., Roberts, T., Storme, G., Hicks, R. J., Ell, P. J., Hirsch, B. R., Carbone, D. P., Schulman, K. A., Catchpole, P., Taylor, D., Geissler, J., Brinker, N. G., Meltzer, D., Kerr, D.Aapro, M. (2011), ‘Delivering affordable cancer care in high-income countries’, Lancet Oncology, 12(10): 933974.
Sulmasy, D. P. (2007), ‘Cancer care, money, and the value of life: whose justice? Which rationality?’, Journal of Clinical Oncology, 25(2): 217222.
Szabo, L. (2008), ‘Study: many cancer patients forgoing care because of cost’, USA Today, October 13.
Tangka, F. K., Trogdon, J. G., Richardson, L. C., Howard, D., Sabatino, S. A.Finkelstein, E. A. (2010), ‘Cancer treatment cost in the United States. Has the burden shifted over time?’, Cancer, 116(14): 34773484.
Temel, J. S., Jackson, V. S.Billings, J. A. (2010), ‘Early palliative care for patients with metastatic non-small-cell lung cancer’, New England Journal of Medicine, 36(8): 733742.
Tol, J., Koopman, M., Cats, A., Rodenburg, C. J., Creemers, G. J. M., Schrama, J. G., Erdkamp, F. L. G., Vos, A. H., van Groeningen, C. J., Sinnige, H. A. M., Richel, D. J., Voest, E. E., Dijkstra, J. R., Vink-Borger, M. E., Antonini, N. F., Mol, L., van Krieken, J., Dalesio, O.Punt, C. J. A. (2009), ‘Chemotherapy, bevacizumab and cetuximab in metastatic colorectal cancer’, New England Journal of Medicine, 360: 563572.
Ubel, P. A., Jepson, C., Baron, J., Hershey, J. C.Asch, D. A. (2003), ‘The influence of cost-effectiveness information on physicians’ cancer screening recommendations’, Social Science and Medicine, 58(8): 17271736.
Virgo, K. S., Vernava, A. M., Longo, W. E., Kissling, M. E., Lin, J. C.Johnson, F. E. (1995), ‘Cost of patient follow-up after potentially curative colorectal cancer treatment’, Journal of the American Medical Association, 273: 18371841.
Wong, U., Hamilton, O., Egleston, B., Salador, K., Murphy, C.Meropol, N. J. (2010), ‘Understanding how out-of-pocket expenses, treatment value, and patient characteristics influence treatment choices’, The Oncologist, 15: 566576.
Wright, A. A., Zhang, B., Ray, A., Mack, J. W., Trice, E., Balboni, T., Mitchell, S. L., Jackson, V. A., Block, S. D., Maciejewski, P. K.Prigerson, H. G. (2008), ‘Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment’, Journal of the American Medical Association, 300: 16651673.
Zhang, B., Wright, A. A., Huskamp, H. A., Nilsson, M. E., Maciejewski, M. L., Earle, C. C., Block, S. D., Maciejewski, P. K.Prigerson, H. G. (2009), ‘Health care costs in the last week of life: associations with end-of-life conversations’, Archives of Internal Medicine, 169: 480488.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Health Economics, Policy and Law
  • ISSN: 1744-1331
  • EISSN: 1744-134X
  • URL: /core/journals/health-economics-policy-and-law
Please enter your name
Please enter a valid email address
Who would you like to send this to? *


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed