Original Article| Volume 64, ISSUE 5, P449-460, November 2022

Download started.


End-of-Life Costs of Cancer Patients With Alzheimer's Disease and Related Dementias in the U.S.

  • Xingran Weng
    Address correspondence to: Xingran Weng, DrPH, MSW, Department of Public Health Sciences, A210, Penn State College of Medicine, 90 Hope Drive, Suite 2200, Hershey, PA 17033, USA.
    Department of Public Health Sciences, Penn State College of Medicine (X.W., C.S., L.J.V.S., L.W.), Hershey, Pennsylvania, USA
    Search for articles by this author
  • Chan Shen
    Department of Public Health Sciences, Penn State College of Medicine (X.W., C.S., L.J.V.S., L.W.), Hershey, Pennsylvania, USA

    Division of Outcomes, Research and Quality, Department of Surgery, Penn State College of Medicine (C.S.), Hershey, Pennsylvania, USA
    Search for articles by this author
  • Lauren J. Van Scoy
    Department of Public Health Sciences, Penn State College of Medicine (X.W., C.S., L.J.V.S., L.W.), Hershey, Pennsylvania, USA

    Department of Medicine, Penn State College of Medicine (L.J.V.S.), Hershey, Pennsylvania, USA

    Department of Humanities, Penn State College of Medicine (L.J.V.S.), Hershey, Pennsylvania, USA
    Search for articles by this author
  • Marie Boltz
    Ross and Carole Nese Penn State College of Nursing (M.B.), University Park, Pennsylvania, USA
    Search for articles by this author
  • Monika Joshi
    Division of Hematology-Oncology, Department of Medicine, Penn State Cancer Institute (M.J.), Hershey, Pennsylvania, USA
    Search for articles by this author
  • Li Wang
    Department of Public Health Sciences, Penn State College of Medicine (X.W., C.S., L.J.V.S., L.W.), Hershey, Pennsylvania, USA
    Search for articles by this author



      End-of-Life (EOL) care consumes a substantial amount of healthcare resources, especially among older persons with cancer. Having Alzheimer's Disease and Related Dementias (ADRD) brings additional complexities to these patients’ EOL care.


      To examine the Medicare expenditures at the EOL (last 12 months of life) among beneficiaries having cancer and ADRD vs. those without ADRD.


      A retrospective cohort study used 2004–2016 Surveillance, Epidemiology, and End Results-Medicare data. Patient populations were deceased Medicare beneficiaries with cancer (breast, lung, colorectal, and prostate) and continuously enrolled for 12 months before death. Beneficiaries with ADRD were propensity score matched with non-ADRD counterparts. Generalized Estimating Equation Model was deployed to estimate monthly Medicare expenditures. Generalized Linear Models were constructed to assess total EOL expenditures.


      Eighty six thousand three hundred ninety-six beneficiaries were included (43,198 beneficiaries with ADRD and 43,198 beneficiaries without ADRD). Beneficiaries with ADRD utilized $64,901 at the EOL, which was roughly $407 more than those without ADRD ($64,901 vs. $64,494, P = 0.31). Compared to beneficiaries without ADRD, those with ADRD had 11% higher monthly expenditure and 7% higher in total expenditures. Greater expenditure was incurred on inpatient (5%), skilled nursing facility (SNF) (119%), home health (42%), and hospice (44%) care.


      Medicare spending at the EOL per beneficiary was not statistically different between cohorts. However, specific types of service (i.e., inpatient, SNF, home health, and hospice) were significantly higher in the ADRD group compared to their non-ADRD counterparts. This study underscored the potential financial burden and informed Medicare about allocation of resources at the EOL.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Pain and Symptom Management
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Institute of Medicine.
        Dying in America: Improving quality and honoring individual preferences near the end of life.
        The National Academies Press, Washington, DC2015
        • Brauner DJ
        • Muir JC
        • Sachs GA.
        Treating nondementia illnesses in patients with dementia.
        JAMA. 2000; 283: 3230-3235
        • Lopez RP
        • Guarino AJ.
        Uncertainty and decision making for residents with dementia.
        Clin Nurs Res. 2011; 20: 228-240
        • Williams KN
        • Herman RE.
        Linking resident behavior to dementia care communication: effects of emotional tone.
        Behav Ther. 2011; 42: 42-46
        • Müller-Spahn F.
        Behavioral disturbances in dementia.
        Dialogues Clin Neurosci. 2003; 5: 49-59
        • Miller SC
        • Mor V
        • Wu N
        • Gozalo P
        • Lapane K.
        Does receipt of hospice care in nursing homes improve the management of pain at the end of life?.
        J Am Geriatr Soc. 2002; 50: 507-515
        • Urban RR
        • He H
        • Alfonso R
        • Hardesty MM
        • Goff BA.
        The end of life costs for Medicare patients with advanced ovarian cancer.
        Gynecol Oncol. 2018; 148: 336-341
        • Margolis B
        • Chen L
        • Accordino MK
        • et al.
        Trends in end-of-life care and health care spending in women with uterine cancer.
        Am J Obstet Gynecol. 2017; 217: 434.e1-434.e10
        • Chen Y
        • Criss SD
        • Watson TR
        • et al.
        Cost and utilization of lung cancer end-of-life care among racial-ethnic minority groups in the United States.
        Oncologist. 2020; 25: e120-e129
        • Legler A
        • Bradley EH
        • Carlson MD.
        The effect of comorbidity burden on health care utilization for patients with cancer using hospice.
        J Palliat Med. Jun 2011; 14: 751-756
        • Huang HK
        • Hsieh JG
        • Hsieh CJ
        • Wang YW
        Do cancer patients with dementia receive less aggressive treatment in end-of-life care? A nationwide population-based cohort study.
        Oncotarget. 2017; 8: 63596-63604
        • Mariotto AB
        • Enewold L
        • Zhao J
        • Zeruto CA
        • Yabroff KR.
        Medical care costs associated with cancer survivorship in the United States.
        Cancer Epidemiol Biomarkers Prev. 2020; 29: 1304-1312
        • Kelley AS
        • McGarry K
        • Gorges R
        • Skinner JS.
        The burden of health care costs for patients with dementia in the last 5 years of life.
        Ann Intern Med. 17 2015; 163: 729-736
        • American Society of Clinical Oncology
        Potential approaches to sustainable, long-lasting payment reform in oncology.
        J Oncol Pract. 2014; 10: 254-258
        • Roderburg C
        • Loosen SH
        • Kunstein A
        • et al.
        Cancer patients have an increased incidence of dementia: a retrospective cohort study of 185,736 outpatients in Germany.
        Cancers (Basel). 2021; 13
        • Banegas MP
        • Yabroff KR
        • O'Keeffe-Rosetti MC
        • et al.
        Medical care costs associated with cancer in integrated delivery systems.
        J Natl Compr Canc Netw. 2018; 16: 402-410
        • Bremner KE
        • Yabroff KR
        • Coughlan D
        • et al.
        Patterns of care and costs for older patients with colorectal cancer at the end of life: descriptive study of the United States and Canada.
        JCO Oncol Pract. 2020; 16: e1-e18
        • Brown ML
        • Riley GF
        • Schussler N
        • Etzioni R.
        Estimating health care costs related to cancer treatment from SEER-Medicare data.
        Med Care. 2002; 40 (IV-104-17)
        • Courtier N
        • Milton R
        • King A
        • et al.
        Cancer and dementia: an exploratory study of the experience of cancer treatment in people with dementia.
        Psychooncology. 2016; 25: 1079-1084
        • Gorin SS
        • Heck JE
        • Albert S
        • Hershman D.
        Treatment for breast cancer in patients with Alzheimer's disease.
        J Am Geriatr Soc. 2005; 53: 1897-1904
        • Gupta SK
        • Lamont EB.
        Patterns of presentation, diagnosis, and treatment in older patients with colon cancer and comorbid dementia.
        J Am Geriatr Soc. 2004; 52: 1681-1687
      1. National Cancer Institute. SEER-Medicare: Brief Description of the SEER-Medicare Database. Available from Accessed August 21, 2020.

      2. National Cancer Institute. ICD-O-3 SEER Site/Histology Validation List. Available from Accessed October 20, 2020.

        • Wang H
        • Qiu F
        • Boilesen E
        • et al.
        Rural-urban differences in costs of end-of-life care for elderly cancer patients in the United States.
        J Rural Health. 2016; 32: 353-362
      3. National Cancer Institute. SEER-Medicare: Medicare Claims Files. Available from Accessed August 21, 2020.

      4. U.S. Bureau of Labor Statistics. Databases, Tables & Calculators by Subject. Available from Accessed October 11, 2021.

      5. Chronic Condition Data Warehouse. Condition categories: Alzheimer's disease and related disorders or senile dementia. Available at: Accessed August 21, 2020.

        • Wang SY
        • Hall J
        • Pollack CE
        • et al.
        Trends in end-of-life cancer care in the Medicare program.
        J Geriatr Oncol. 2016; 7: 116-125
        • Krieger N
        • Chen JT
        • Waterman PD
        • Rehkopf DH
        • Subramanian SV.
        Race/ethnicity, gender, and monitoring socioeconomic gradients in health: a comparison of area-based socioeconomic measures–the public health disparities geocoding project.
        Am J Public Health. 2003; 93: 1655-1671
        • Henry KA
        • Sherman RL
        • McDonald K
        • et al.
        Associations of census-tract poverty with subsite-specific colorectal cancer incidence rates and stage of disease at diagnosis in the United States.
        J Cancer Epidemiol. 2014; 2014823484
      6. U.S. Census Bureau. Census Bureau Regions and Divisions with State FIPS Codes. Available at: Accessed October 28, 2020.

      7. National Cancer Institute. Documentation for the Patient Entitlement and Diagnosis Summary File (PEDSF). Available from Accessed October 28, 2020.

      8. U.S. Department of Agriculture. Rural-Urban Commuting Area Codes. Available from Accessed January 23, 2022.

      9. National Cancer Institute. Attachment A for the SEER-Medicare PEDSF file: SEER research data record description cases diagnosed in 1973-2015. Available from Accessed August 21, 2020.

      10. National Cancer Institute. SEER Cause of Death Recode 1969+ (03/01/2018). Available from Accessed November 18, 2020.

      11. National Cancer Institute. Comorbidity SAS Macro (2021 version). Available from Accessed February 5, 2022.

      12. Kosanke J, Bergstralh E. Match 1 or more controls to cases using the GREEDY algorithm. Available at: Accessed March 29, 2021.

      13. SAS Institute Inc. Example 98.4 Greedy Nearest Neighbor Matching. Available at: Accessed April 2, 2021.

        • Rosenbaum PR
        • Rubin DB.
        The central role of the propensity score in observational studies for causal effects.
        Biometrika. 1983; 70: 41-55
        • Rosenbaum PR
        • Rubin DB.
        Reducing bias in observational studies using subclassification on the propensity score.
        J Am Stat Assoc. 1984; 79: 516-524
        • Rosenbaum PR
        • Rubin DB.
        Constructing a control group using multivariate matched sampling methods that incorporate the propensity score.
        Am Stat. 1985; 39
      14. Yang D, Dalton J. A unified approach to measuring the effect size between two groups using SAS®. Available at: Accessed May 10, 2022.

        • Zeger SL
        • Liang K-Y
        • Albert PS.
        Models for longitudinal data: a generalized estimating equation approach.
        Biometrics. 1988; 44
        • Lee J
        • Choi JY.
        Texas hospitals with higher health information technology expenditures have higher revenue: a longitudinal data analysis using a generalized estimating equation model.
        BMC Health Serv Res. 2016; 16: 117
        • Du XL
        • Parikh RC
        • Lairson DR.
        Racial and geographic disparities in the patterns of care and costs at the end of life for patients with lung cancer in 2007-2010 after the 2006 introduction of bevacizumab.
        Lung Cancer. 2015; 90: 442-450
      15. SAS Version 9.4. SAS Institute Inc, 2013
        • Lin PJ
        • Zhu Y
        • Olchanski N
        • et al.
        Racial and ethnic differences in hospice use and hospitalizations at end-of-life among medicare beneficiaries with dementia.
        JAMA Netw Open. 2022; 5e2216260
        • Leniz J
        • Yi D
        • Yorganci E
        • et al.
        Exploring costs, cost components, and associated factors among people with dementia approaching the end of life: a systematic review.
        Alzheimers Dement (N Y). 2021; 7: e12198
        • Alzheimer's Association
        2020 Alzheimer's disease facts and figures.
        Alzheimer's Dement. 2020;
        • Shepherd H
        • Livingston G
        • Chan J
        • Sommerlad A.
        Hospitalisation rates and predictors in people with dementia: a systematic review and meta-analysis.
        BMC Med. 2019; 17: 130
        • Lyketsos CG
        • Steinberg M
        • Tschanz JT
        • et al.
        Mental and behavioral disturbances in dementia: findings from the Cache County Study on Memory in Aging.
        Am J Psychiatry. 2000; 157: 708-714
        • Hirakawa Y
        • Chiang C
        • Aoyama A.
        A qualitative study on barriers to achieving high-quality, community-based integrated dementia care.
        J Rural Med. 2017; 12: 28-32
        • Duncan I
        • Ahmed T
        • Dove H
        • Maxwell TL.
        Medicare Cost at End of Life.
        Am J Hosp Palliat Care. 2019; 36: 705-710
        • Hopman P
        • Heins MJ
        • Korevaar JC
        • Rijken M
        • Schellevis FG.
        Health care utilization of patients with multiple chronic diseases in the Netherlands: differences and underlying factors.
        Eur J Intern Med. 2016; 35: 44-50
        • Christina A
        • Nguyen AB
        • Michael E
        • et al.
        Comparison of healthcare delivery systems in low- and high-income communities.
        Am J Accountable Care. 2019; 7
        • Bazargan M
        • Bazargan-Hejazi S.
        Disparities in palliative and hospice care and completion of advance care planning and directives among non-hispanic blacks: a scoping review of recent literature.
        Am J Hosp Palliat Care. 2021; 38: 688-718
        • LoPresti MA
        • Dement F
        • Gold HT.
        End-of-life care for people with cancer from ethnic minority groups: a systematic review.
        Am J Hosp Palliat Care. 2016; 33: 291-305
        • Caba Y
        • Dharmarajan K
        • Gillezeau C
        • et al.
        The impact of dementia on cancer treatment decision-making, cancer treatment, and mortality: a mixed studies review.
        JNCI Cancer Spectr. 2021; 5: pkab002
        • Nowrangi MA
        • Lyketsos CG
        • Rosenberg PB.
        Principles and management of neuropsychiatric symptoms in Alzheimer's dementia.
        Alzheimers Res Ther. 29 2015; 7: 12
      16. National Cancer Institute. Measures that are Limited or not Available in the Data. October 27th, 2021. Available from Accessed December 14, 2021.

        • Yabroff KR
        • Mariotto A
        • Tangka F
        • et al.
        Annual report to the nation on the status of cancer, part 2: patient economic burden associated with cancer care.
        J Natl Cancer Inst. 2021;
        • Halpern SD.
        Goal-concordant care - searching for the Holy Grail.
        N Engl J Med. 2019; 381: 1603-1606