Supplemental Data Table 2A

Appendix 1: Supplemental Methods

Cost variables

Payment claims were pulled from six SEER-Medicare files: hospice, home health, Medicare Provider Analysis and Review (MEDPAR, inpatient), Outpatient Standard Analytical File (OUTSAF, outpatient), National Claims History (NCH, physician/supplier), and durable medical equipment (DME); see Supplementary Table 1 for summary. The combination of SEER-Medicare cost components were different for each file (database variable names are listed in parentheses in uppercase). The sum of these payment variables has been validated to represent the reimbursement rates set by CMS on the basis of resource use (unpublished work, personal communication, Faith M. Asper, Technical Advisor, ResearchDataAssistanceCenter (ResDAC), November 13, 2009).

Medicare patients are responsible for a portion of their hospice and home health benefits (a 5% copay for inpatient respite care and a $5 copay per prescription of outpatient drugs for pain/symptom management); however, the SEER-Medicare claims files for hospice and home healthcare do not contain the necessary patient payment variables (personal communication,Sara Durham, Technical Advisor, Research Data Assistance Center (ResDAC), February 12, 2010). The payment to the service provider for hospice or home healthcare was therefore the combination of the Medicare claim payment amount (PMT_AMT) and the co-insurer payment amount (PRPAYAMT).

Inpatient costs were the sum of the MEDPAR Medicare payment amount (REIMBAMT) plus the MEDPAR total pass through amount (BILTOTPD) [payment by Medicare]; the MEDPAR beneficiary inpatient deductible amount (INPATDED) plus the MEDPAR beneficiary inpatient Part A coinsurance liability amount (COINAMT) plus the MEDPAR beneficiary blood deductible liability amount (BLOODDED) [patient liability]; and the MEDPAR beneficiary primary payer amount (PRIPYAMT) [payment by co-insurer].

Outpatient costs were calculated as the sum of the claim payment amount (PMT_AMT) [payment by Medicare]; the NCH beneficiary Part B coinsurance liability amount (PTB_COIN) plus the NCH beneficiary Part B deductible amount (PTB_DED) plus the NCH beneficiary blood deductible liability amount (BLDDEDAM) [patient liability]; and the NCH primary payer claim paid amount (PRPAYAMT) [payment by co-insurer].

Physician/supplier file costs were the sum of the line payments (which were not available in any of the other Medicare files except for DME): line NCH payment amount (LINEPMT) [payment by Medicare]; the line beneficiary Part B deductible amount (LDEDAMT) plus the line coinsurance amount (COINAMT) [patient liability]; and the line beneficiary primary payer paid amount (LPRPAYAT) [payment by co-insurer].

Durable medical equipment costs were the sum of the line NCH payment amount (LINEPMT) [payment by Medicare]; the line beneficiary Part B deductible amount (LDEDAMT) [patient liability]; and the line beneficiary primary payer paid amount (LPRPAYAT) [payment by co-insurer].

Terminal phase of care

The terminal phase was defined as the month of death to permit distinction between phases of care even in patients with limited survival. Because we had organized the data into calendar months starting from month of diagnosis, we calculated the expected cost for the last month of life using 2/3 of the total cost of the last two calendar months.

Supplemental Table 1.

Cost Category / Data file / Cost component
Medicare or other primary insurer liability * / Patient-Liability **
Hospice and home healthcare / Hospice,
Home health / PMT_AMT: Medicare claim payment amount
PRPAYAMT: Primary Payer Claim Paid Amount / No variable for patient-liability amount
Inpatient / MEDPAR / REIMBAMT: Medicare claim payment amount
BILTOTPD: claim pass-through per diem amount
PRIPYAMT: beneficiary primary payer amount / INPATDED : beneficiary inpatient deductible amount
COINAMT: beneficiary inpatient Part A coinsurance liability amount
BLOODDED: beneficiary blood deductible liability amount
Outpatient / OUTSAF
NCH / PMT_AMT: Medicare claim payment amount
PRPAYAMT: NCH primary payer claim paid amount / PTB_COIN: NCH Part B coinsurance liability amount
PTB_DED: NCH beneficiary Part B deductible amount
BLDDEDAM: NCH blood deductible liability amount
Physician / DME, NCH / LINEPMT: NCH payment amount
LPRPAYAT: beneficiary primary payer paid amount / LDEDAMT: beneficiary Part B deductible amount
COINAMT: coinsurance amount
Durable Medical Equipment / DME, NCH / LINEPMT: NCH payment amount
LPRPAYAT: beneficiary primary payer paid amount / LDEDAMT: Part B deductible amount

* The amount that is not patient-liability is the sum of Medicare reimbursements (payments from Medicare to the service provider) and co-insurance reimbursements (payments from a co-insurer to the service provider [in cases in which Medicare is the secondary insurer because the patient is still primarily insured through his or her employer])

** Patient-Liability is the sum of the deductibles and ‘co-pays’ that are the patient’s responsibility but may be paid in part or whole by employer-sponsored supplemental coverage, Medicaid dual-eligibility, or through patient-purchased Medigap coverage. The portion of the patient liability that the patient pays out-of-pocket at the time of service (vs. the portion that is paid by Medigap coverage purchased by the patient to reduce point-of-service expenses) cannot be determined in the SEER-Medicare files.

Appendix 1: Supplemental Results

Tables3-5 includes results for treatment categories with greater than 10% of patients diagnosed with the histologic type/stage specified based on the proportion of patients in each treatment group at the initial phase. The remainder of patients received the following treatments. Stage I/II NSCLC: 7.5% of patients received Surgery and Radiotherapy, 6.4% received Surgery and Chemotherapy, fewer than 3% received Surgery with Chemotherapy and Radiotherapy (2.9%), Surgery and Chemotherapy (2.4%), or Chemotherapy alone (2.2%). Stage III NSCLC: 8.9% of patients received Chemotherapy alone, 7.8% received Surgery with Chemotherapy and Radiotherapy, 7.6% received Surgery and Radiotherapy, 6.2% received surgery alone, and 2.2% received Surgery and Chemotherapy. Stage IV NSCLC: 3.9% received Surgery with Chemotherapy and Radiotherapy, and fewer than 3% received Surgery and Radiotherapy (2.8%), Surgery and Chemotherapy (1.1%), or Surgery alone (1.1%). Limited Stage SCLC: 6.9% of patients received Surgery with Chemotherapy and Radiotherapy, 5.4% of patients received Radiotherapy alone, 4.1% of patients received Surgery and Chemotherapy, and fewer than 2% of patients received Surgery alone or Surgery and Radiotherapy. Extensive Stage SCLC: 6.9% of patients received Radiotherapy alone, 4.7% received Surgery with Chemotherapy and Radiotherapy, and fewer than 2% of patients received Surgery and Chemotherapy, Surgery with Radiotherapy, or Surgery alone.

Supplemental Data Table 2A. Regression coefficients for average monthly health care costs during the pre-diagnosis and terminal phases.

Cost / Variable / Parameter Estimate / Standard Error / t value / p-value / R2 for model
Total cost,
Pre-diagnosis phase / Constant / -388.031 / 43.26743 / 0.0041
Age / 12.98337 / 0.57055 / 22.76 / <.0001
Year / 12.21647 / 1.07376 / 11.38 / <.0001
Age*Year / NS
Patient-liability,
Pre-diagnosis phase / Constant / -33.75995 / 8.47738 / 0.0178
Age / 1.23328 / 0.11123 / 11.09 / <.0001
Year / 6.53848 / 0.21483 / 30.44 / <.0001
Age*Year / NS
Total cost,
Lung cancer death / Constant / 25580 / 931.2989 / 0.0050
Age / -160.453 / 12.29735 / -13.05 / <.0001
Year / 119.9156 / 23.23658 / 5.16 / <.0001
Age*Year / NS
Total cost,
Cardiac death / Constant / 31509 / 5199.879 / 0.0076
Age / -213.177 / 67.67753 / -3.15 / 0.0017
Year / 376.5375 / 140.1234 / 2.69 / 0.0073
Age*Year / NS

Notes: Linear regression of the form: Monthly Cost = Constant + Age *(Age in years) + Year *(Calendar Year – 1992) + Age*Year *(Age in years)*(Calendar Year – 1992). Terms were included in the final model using a threshold of α = 0.05. Total Cost is the sum of average monthly costs from all sources regardless of payer [Total Cost = Cancer-Attributable Costs + Non-Cancer Attributable Costs = Patient-Liability + Medicare or other primary insurer liability]. Patient-liability is defined as the amount of total health care expenses that are the responsibility of the patient for both cancer attributable and non-cancer health care such as deductibles and ‘co-pays’. Patient-liability may be paid in part or whole by employer-sponsored supplemental coverage, Medicaid dual-eligibility, or through patient-purchased Medigap coverage).

NS – In stepwise regression analysis the  for this variable was not significant to a α = 0.05 threshold and was therefore excluded from the final model (set to zero)

Supplemental Data Table 3A. Regression coefficients for staging phase analysis.

Total cost / Patient-liability
Constant / Age / Year / Age*Year / Constant / Age / Year / Age*Year
NSCLC
Stage I and II
No treatment / NS / NS / NS / NS / 960 +/- 48 / NS / 38 +/- 7 / NS
Radiotherapy / 25,090 +/- 3,036 / -176 +/- 39 / NS / NS / 1,366 +/- 56 / NS / 65 +/- 9 / NS
Stage III
No treatment / NS / NS / NS / NS / 1,055 +/- 55 / NS / 49 +/- 8 / NS
Radiotherapy / 20,747 +/- 2,565 / -88 +/- 33 / NS / NS / 1,435 +/- 42 / NS / 94 +/- 7 / NS
Chemotherapy & Radiotherapy / 17,583 +/- 496 / NS / -431 +/- 70 / NS / 2,899 +/- 437 / -13 +/- 6 / 86 +/- 10 / NS
Stage IV
No treatment / 13,525 +/- 564 / NS / -202 +/- 85 / NS / 1,782 +/- 260 / -11 +/- 3 / 68 +/- 7 / NS
Radiotherapy / 25,371 +/- 2,673 / -149 +/- 35 / 251 +/- 65 / NS / 2,122 +/- 293 / -9 +/- 4 / 115 +/- 7 / NS
Chemotherapy / 22,687 +/- 3,875 / -120 +/- 52 / NS / NS / 3,104 +/- 501 / -20 +/- 7 / 84 +/- 12 / NS
Chemotherapy & Radiotherapy / 26,208 +/- 3,110 / -133 +/- 42 / NS / NS / 3,260 +/- 598 / -20 +/- 8 / 138 +/- 13 / NS
SCLC
Limited Stage
No treatment / 15,548 +/- 1,291 / NS / -534 +/- 192 / NS / 1,168 +/- 122 / NS / 29 +/- 18 / NS
Chemotherapy / NS / NS / NS / NS / 3,300 +/- 650 / -23 +/- 9 / 86 +/- 14 / NS
Chemotherapy & Radiotherapy / 26,912 +/- 3,974 / -114 +/- 54 / -326 +/- 84 / NS / 3,377 +/- 542 / -21 +/- 7 / 102 +/- 11 / NS
Extensive Stage
No treatment / NS / NS / NS / NS / 764 +/- 169 / NS / 89 +/- 26 / NS
Chemotherapy / 25,532 +/- 5,127 / -128 +/- 69 / NS / NS / 2,918 +/- 632 / -21 +/- 8 / 126 +/- 13 / NS
Chemotherapy & Radiotherapy / NS / NS / NS / NS / 1,700 +/- 123 / NS / 76 +/- 12 / NS

Notes: Linear regression of the form: Monthly Cost = Constant + Age *(Age in years) + Year *(Calendar Year – 1992) + Age*Year *(Age in years)*(Calendar Year – 1992). Terms were included in the final model using a threshold of α = 0.05. Total Cost is the sum of average monthly costs from all sources regardless of payer [Total Cost = Cancer-Attributable Costs + Non-Cancer Attributable Costs = Patient-Liability + Medicare or other primary insurer liability]. Net Cancer-attributable cost is defined as the individual patient’s monthly cost of health care incurred in excess of the average pre-diagnosis cost of health care. Patient-liability is defined as the amount of total health care expenses that are the responsibility of the patient for both cancer attributable and non-cancer health care such as deductibles and ‘co-pays’. Patient-liability may be paid in part or whole by employer-sponsored supplemental coverage, Medicaid dual-eligibility, or through patient-purchased Medigap coverage).

NS – In stepwise regression analysis the  for this variable was not significant to a α = 0.05 threshold and was therefore excluded from the final model (set to zero)

Supplemental Table 4A. Regression coefficients for initialtreatment phase analysis

Total costs / Net Cancer-attributable costs / Patient liability
Constant / Age / Year / Age*Year / Constant / Age / Year / Age*Year / Constant / Age / Year / Age*Year
NSCLC
Stage I and II
No treatment / NS / NS / NS / NS / NS / NS / NS / NS / 161 +/- 28 / NS / 16 +/- 4 / NS
Surgery* / NS / NS / NS / NS / NS / NS / NS / NS / 166+/- 16 / NS / 36 +/- 2 / NS
Radiotherapy / 11,513 +/- 1,146 / -81 +/- 15 / NS / NS / 9,388 +/- 1,186 / -60 +/- 15 / -89 +/- 29 / NS / 988 +/- 36 / NS / 20 +/- 6 / NS
Stage III
No treatment / NS / NS / NS / NS / NS / NS / NS / NS / 164 +/- 22 / NS / 14 +/- 3 / NS
Radiotherapy / 8,398 +/- 1,120 / -36 +/- 15 / NS / NS / 7,783 +/- 1,127 / -32 +/- 15 / -74 +/- 28 / NS / 1,021 +/- 31 / NS / 17 +/- 5 / NS
Chemotherapy & Radiotherapy / 14,972 +/- 1,310 / -79 +/- 18 / NS / NS / 15,018 +/- 1,331 / -87 +/- 18 / NS / NS / 2,773 +/- 317 / -21 +/- 4 / 96 +/- 7 / NS
Stage IV
No treatment / 6,717 +/- 1,625 / -46 +/- 21 / NS / NS / 5,713 +/- 1,693 / -44 +/- 22 / NS / NS / 176 +/- 25 / NS / 11 +/- 4 / NS
Radiotherapy / 9,366 +/- 1,160 / -55 +/- 15 / NS / NS / 10,122 +/- 1,178 / -73 +/- 15 / NS / NS / 1,182 +/- 217 / -6 +/- 3 / 20 +/- 5 / NS
Chemotherapy / 12,439 +/- 1,780 / -95 +/- 24 / 256 +/- 44 / NS / 13,434 +/- 1,821 / -114 +/- 24 / 235 +/- 45 / NS / 1,794 +/- 365 / -17 +/- 5 / 97 +/- 9 / NS
Chemotherapy & Radiotherapy / 12,914 +/- 1,415 / -74 +/- 19 / 165 +/- 31 / NS / 13,885 +/- 1,423 / -93 +/- 19 / 159 +/- 31 / NS / 1,630 +/- 297 / -11 +/- 4 / 107 +/- 7 / NS
SCLC
Limited Stage
No treatment / NS / NS / NS / NS / NS / NS / NS / NS / NS / NS / NS / NS
Chemotherapy / 13,644 +/- 2,941 / -93 +/- 39 / 167 +/- 65 / NS / 13,597 +/- 2,983 / -102 +/- 39 / 159 +/- 65 / NS / 478 +/- 67 / NS / 94 +/- 10 / NS
Chemotherapy & Radiotherapy / 15,394 +/- 1,591 / -84 +/- 22 / NS / NS / 16,297 +/- 1,622 / -104 +/- 22 / NS / NS / 2,513 +/- 412 / -19 +/- 6 / 101 +/- 9 / NS
Extensive Stage
No treatment / NS / NS / NS / NS / NS / NS / NS / NS / NS / NS / NS / NS
Chemotherapy / 6,947 +/- 327 / NS / 93 +/- 49 / NS / NS / NS / NS / NS / 1,387 +/- 418 / -12 +/- 6 / 89 +/- 9 / NS
Chemotherapy & Radiotherapy / 7,753 +/- 221 / NS / 136 +/- 33 / NS / 10,839 +/- 1,736 / -50 +/- 24 / 141 +/- 34 / NS / 694 +/- 52 / NS / 115 +/- 8 / NS

Notes: Linear regression of the form: Monthly Cost = Constant + Age *(Age in years) + Year *(Calendar Year – 1992) + Age*Year *(Age in years)*(Calendar Year – 1992). Terms were included in the final model using a threshold of α = 0.05. Total Cost is the sum of average monthly costs from all sources regardless of payer [Total Cost = Cancer-Attributable Costs + Non-Cancer Attributable Costs = Patient-Liability + Medicare or other primary insurer liability]. Net Cancer-attributable cost is defined as the individual patient’s monthly cost of health care incurred in excess of the average pre-diagnosis cost of health care. Patient-liability is defined as the amount of total health care expenses that are the responsibility of the patient for both cancer attributable and non-cancer health care such as deductibles and ‘co-pays’. Patient-liability may be paid in part or whole by employer-sponsored supplemental coverage, Medicaid dual-eligibility, or through patient-purchased Medigap coverage).

NS – In stepwise regression analysis the  for this variable was not significant to a α = 0.05 threshold and was therefore excluded from the final model (set to zero)

* 6 months following surgery month. See Figure 1B
Supplemental Data Table 4B. Regression coefficients for average cost of 30 days including surgery (NSCLC, Stage I/II only)

Cost / Variable / Parameter Estimate / Standard Error / t value / p-value / R2 for model
Total cost** / Constant / 21468 / 2375.646 / 0.0069
Age / 97.58949 / 31.77651 / 3.07 / 0.0021
Year / -282.48 / 52.73172 / -5.36 / <.0001
Age*Year / NS
Patient-liability / Constant / 929.1886 / 26.57613 / 0.043
Age / NS
Year / 58.7427 / 3.81364 / 15.40 / <.0001
Age*Year / NS

NS – In stepwise regression analysis the  for this variable was not significant to a α = 0.05 threshold and was therefore excluded from the final model (set to zero)

Supplemental Data Table 5A. Regression coefficients for continuing treatment phase analysis.

Total Cost / Net Cancer Attributable Cost / Patient-Liability
Constant / Age / Year / Age*Year / Constant / Age / Year / Age*Year / Constant / Age / Year / Age*Year
NSCLC
Stage I and II
No treatment / NS / NS / NS / NS / NS / NS / NS / NS / 263 +/- 44 / NS / 19 +/- 7 / NS
Surgery / 3,323 +/- 294 / NS / -90 +/- 41 / NS / 2,836 +/- 295 / NS / -105 +/- 41 / NS / NS / NS / NS / NS
Radiotherapy / NS / NS / NS / NS / 1,105 +/- 303 / -9 +/- 4 / 16 +/- 7 / NS
Stage III
No treatment / 7,486 +/- 649 / NS / -293 +/- 94 / NS / 6,796 +/- 644 / NS / -310 +/- 93 / NS / NS / NS / NS / NS
Radiotherapy / NS / NS / NS / NS / 13,716 +/- 3,877 / -96 +/- 50 / NS / NS / 1,312 +/- 317 / -11 +/- 4 / 28 +/- 8 / NS
Chemotherapy & Radiotherapy / 10,669 +/- 750 / NS / -309 +/- 102 / NS / 10,219 +/- 742 / NS / -308 +/- 101 / NS / 2,096 +/- 561 / -14 +/- 8 / NS / NS
Stage IV
No treatment / 40,447 +/- 13,931 / -444 +/- 182 / -5,383 +/- 1,905 / 70 +/- 25 / 42,574 +/- 13,862 / -483 +/- 181 / -5,771 +/- 1,895 / 75 +/- 25 / NS / NS / NS / NS
Radiotherapy / 18,928 +/- 5,359 / -148 +/- 71 / NS / NS / 19,876 +/- 5,325 / -168 +/- 70 / NS / NS / 525 +/- 82 / NS / 35 +/- 13 / NS
Chemotherapy / 23,099 +/- 7,085 / -174 +/- 94 / NS / NS / 22,992 +/- 7,116 / -181 +/- 94 / NS / NS / 4,298 +/- 1,079 / -39 +/- 14 / NS / NS
Chemotherapy & Radiotherapy / 21,715 +/- 5,145 / -146 +/- 70 / NS / NS / 23,078 +/- 5,156 / -171 +/- 70 / NS / NS / 2,804 +/- 670 / -25 +/- 9 / 75 +/- 16 / NS
SCLC
Limited Stage
No treatment / NS / NS / NS / NS / NS / NS / NS / NS / NS / NS / NS / NS
Chemotherapy / NS / NS / NS / NS / NS / NS / NS / NS / NS / NS / NS / NS
Chemotherapy & Radiotherapy / NS / NS / NS / NS / 9,590 +/- 742 / NS / -209 +/- 104 / NS / NS / NS / NS / NS
Extensive Stage
No treatment / NS / NS / NS / NS / NS / NS / NS / NS / NS / NS / NS / NS
Chemotherapy / NS / NS / NS / NS / NS / NS / NS / NS / 998 +/- 176 / NS / 68 +/- 26 / NS
Chemotherapy & Radiotherapy / NS / NS / NS / NS / NS / NS / NS / NS / 1,270 +/- 139 / NS / 79 +/- 20 / NS

Notes: Linear regression of the form: Monthly Cost = Constant + Age *(Age in years) + Year *(Calendar Year – 1992) + Age*Year *(Age in years)*(Calendar Year – 1992). Terms were included in the final model using a threshold of α = 0.05. Total Cost is the sum of average monthly costs from all sources regardless of payer [Total Cost = Cancer-Attributable Costs + Non-Cancer Attributable Costs = Patient-Liability + Medicare or other primary insurer liability]. Net Cancer-attributable cost is defined as the individual patient’s monthly cost of health care incurred in excess of the average pre-diagnosis cost of health care. Patient-liability is defined as the amount of total health care expenses that are the responsibility of the patient for both cancer attributable and non-cancer health care such as deductibles and ‘co-pays’. Patient-liability may be paid in part or whole by employer-sponsored supplemental coverage, Medicaid dual-eligibility, or through patient-purchased Medigap coverage).

NS – In stepwise regression analysis the  for this variable was not significant to a α = 0.05 threshold and was therefore excluded from the final model (set to zero)