End-of-Life Costs in Cancer Patients: A Systematic Review

Introduction

Health costs in cancer have shown significant growth in recent decades and are an issue of great importance worldwide. ¹ A recent study conducted by All Together Against Cancer movement and the Oncology Observatory, in partnership with the Center for Strategic Studies of Fundação Oswaldo Cruz (Fiocruz), showed that spending on oncology treatment in the Unified Health System in Brazil is approximately 800 million US dollars in 2023, with expenses in the outpatient and hospital areas included. ² Another relevant aspect is that cancer-related expenses represent a significant proportion of health expenses, and aging and population growth are expected to increase the costs of cancer care from $183 billion US dollars in 2015 to about $246 billion US dollars in 2030 in the United States. ³ The estimate of the global economic cost of cancer between 2020 and 2050 is 25.2 trillion US dollars (in international dollars) and considering constant 2017 prices, that is, a value equivalent to an annual tax of 0.55% on global gross domestic product. ¹

According to previous research, it has been observed that the initial year following the diagnosis of cancer and the final year of cancer patients are the periods that are associated with the greatest expenditures and resources in the treatment process.^4,5 Despite the development of palliative care in recent decades and studies indicate that assistance from a team specialized in palliative care promotes better control of symptoms and quality of life, reducing aggressive or obstinate measures, enabling better allocation of resources and lower costs for health systems,^6-8 the appropriate end-of-life care is still difficult to access in low- and middle-income countries ⁹ and is often not offered to patients with advanced cancer without curative possibilities. In this context, assessing costs in end-of-life care is important to identify which resources and expenses have the greatest economic impact on health systems in this period.

The objective of the systematic review was to identify the tangible and intangible costs of an oncology patient at the end of life.

Method

This study was developed according to the structure of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. ¹⁰ The protocol for this review was registered on the PROSPERO platform with the number CRD42023403186. The research comprised steps in accordance with the guidelines provided in the Cochrane Collaboration Manual on Systematic Reviews of Interventions. ¹¹

Data Extraction

Data extraction was performed by SCIS and verified by CEAM and FRCM. The information extracted included: main author, year of publication, country, study objective, type of study, study period, population, inclusion criteria, age range of the population, defined time period for the end of life, oncology diagnosis, definition or description in the study of aggressive measures or active care in end-of-life care, costs considered, identification of direct costs (refer to all resources that are consumed during the treatment or intervention. They can be categorized into medical, and nonmedical), indirect (are related to the consequences of the disease state or health intervention, such as loss of economic productivity due to absence from work or a drop in income) or intangible costs (represent the change in the individual’s quality of life and the consequences of the disease itself, such as pain and suffering), healthcare costing methods (macro-costing or micro-costing), evaluation perspective (refers to who is the payer of the services described in the analysis, most commonly used in cost studies are those related to society as a whole; the patient; the public or supplementary health system; and the health service provider) ¹² and final costs involved. The data presented in Table 1.

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Table 1.

Characteristics of the Studies.

First author (year), setting	Study aim	Study design	Time horizon	Population (n)	Inclusion criteria	Minimum age for inclusion	End-of-life period	Oncological diagnosis
Balasubramanian,I, 2024, Singapore	To understand the type of hospital admissions and inpatient services associated with an increase in inpatient cost in last year of life.	Prospective cohort study	Between July 2016 and March 2018	439 deceased patients	Inclusion criteria for having a diagnosis of a solid metastatic cancer and, being 21 years or above, from two major public hospitals.	Being 21 years or above	The last year of life	Diagnosis of a solid metastatic cancer
Diernberger K, 2023, Scotland	To describe the timing and nature of hospital-based healthcare use and associated costs in the last year of life for patients with a cancer diagnosis.	Retrospective cohort study	Between January 1st 2012 and December 31st 2017	85,732 decedents	Included everyone with a recorded cancer diagnosis in Scotland who died between 2012 and 2017 and was over 60 years of age on their date of death and healthcare data available for a minimum of 365 days prior to death	≥ 60 years of age	The last year of life	Patients with cancer
Mantz, C. A, 2023, USA	To provide an update on the trends in Medicare Part B payments to healthcare providers who provide care for cancer patients during their final six months of life, based on a recent historical period	Retrospective cohort study	Between 2015 - 2019	84,744 beneficiaries	Medicare beneficiaries with a cancer diagnosis in the last 6 months of life during calendar years 2015 through 2019	Age restriction is not present	The last 6 months of life	Patients with cancer
Perdikouri, K, 2023, Greece	To highlight the case of treating EoL cancer patients in a public hospital’s ward of internal medicine in absence of any other relevant settings, e.g. hospital Palliative Care Units or hospices	Retrospective cohort study	Year 2015	135 patients	Deceased cancer patients who were hospitalized in the end of their lives in Spiliopoulio Hospital	Age restriction is not present	Period definition is not present	Patients with cancer
Bjonelv G, 2022,Norway	To describe the complete care pathways of all cancer decedents in Norway during the last six months of life.	Cohort	Identifed all individuals who died in Norway between 2009 and 2013	52,926 people died from cancer in Norway	Diagnosis of cancer documented in Norway between 2009 and 2013 from the Norwegian Causes of Death Registry (CDR)	Age restriction is not present	The last six months	All individuals were linked to the Cancer Registry of Norway (CRN), from which we obtained information about the type (ICD-7 codes) and year (between 1951 and 2013) of their primary cancer diagnosis.
Han K T, 2022, Republic of Korea	To examine patterns of healthcare expenditures in the last year of life in patients with gastric, colorectal, lung, and liver cancer and analyzed whether differences exist in the level of end-of-life costs for cancer care according to economic status.	Retrospective cohort study	Between 2002 to 2015	3083 patients	Information on a sample of around 10% (about 550,000 individuals) of the entire Korean population aged 60 years or above in 2002 with any of the four types of cancer (Gastric, olorectal, lung, and liver) and who died between 2007 to 2015 were observed. To encompass only newly diagnosed patients, a wash out period of 5 years was applied	≥ 60 years of age	The last year of life	Gastric, colorectal, lung, and liver cancer
Kang, D W, 2022, South Korea	To assess healthcare resource utilization and medical costs incurred during best supportive care after the last anticancer drug treatment in patients with terminal cancer	Retrospective cohort study	Between January 1, 2006, to June 30, 2015	2,480 patients	Patients with cancer who were treated with the last anticancer drugs from January 1, 2006, to June 30, 2015, were included to ensure a follow-up period of at least six months	Age restriction is not present	The last 6 months of life	Patients with lung, liver, colon, gastric, pancreatic, gallbladder, and biliary cancers
Awano N, 2021, Japan	To examine recent real-worldmedical costs for patients with lung cancer at our hospital during the last 3 months before death and to compare these costs with those for the first 3 months and those for the first year after first visit.	Retrospective cohort study	Diagnosed between January 1, 2008 and August 31, 2019	In all, 79 patients with small-cell lung cancer (SCLC) and 213 patients with non-small-cell lung cancer (NSCLC) were enrolled in the present study.	Patients who were diagnosed with advanced lung cancer and who died at the Japanese Red Cross Medical Center, Tokyo, Japan, Japan, between 1 January 2008 and 31 August 2019.	Age restriction is not present	The last 3 months of life	Diagnosis of primary lung cancer and pathologically confirmed advanced or recurrent SCLC or NSCLC with stage III and IV disease according to the seventh edition of the American Joint Committee on Cancer staging system
Blayney D W, 2021, USA	To estimate the value of oncology care and compare the value between the different stages of treatment through a transparent report with a reproducible and standardized costing methodology.	Cohort	Diagnosed between 2000-2014, who underwent treatment at SHC through November 1, 2016.	766 were assigned to the relapse and end-of-life cohort	Female patients with breast cancer diagnosed between 2000-2014, who underwent surgery, chemotherapy, or radiation treatment at SHC through November 1, 2016, and who had more than two follow-up visits at SHC within 3 years of their diagnosis.	Age restriction is not present	The relapse and end-of-life episode started with the relapse date and concluded at date of death or the date of last follow-up, whichever was later.	Female patients with breast cancer data extracted from the Oncoshare breast cancer database.
Bylicki O, 2021, France	To identify, at the national level, the incidence of EOL-care aggressiveness and factors associated for Lung Cancer patients. The secondary goals were to analyze the evolution of EOL-care aggressivity indicators according to time period and the economic impact of aggressive EOL care.	Retrospective cohort study	Patients who died in a health care facility between January 1, 2010, and December 31, 2011 (cohort 1); and January 1, 2015, to December 31, 2016 (cohort 2)	79,746 adult Lung Cancer patients identified	All LC patients who died in a health care facility between January 1, 2010, and December 31, 2011 (cohort 1); and January 1, 2015, to December 31, 2016 (cohort 2)	≥ 18 years of age	The last 30 days of life	The analysis included all lung cancer patients with, data extracted from the French National Hospital database, through the International Classification of Diseases, Tenth Revision (ICD-10)
Deeb S, 2021, USA	To examine sociodemographic patterns in the use of interventions and the associated costs of inpatient care among this national cohort in the final days before an in hospital death.	Cohort	Between January 1, 2010, to December 31, 2017.	21,335 patients	Included all patients 18 years and older at hospital admission who had an in-hospital death and a principal diagnosis of metastatic cancer	≥ 18 years of age	The median time from admission to death was 6 days (IQR, 3-12 days)	Diagnosis of metastatic cancer according to diagnostic codes from the International Classification of Diseases
Ito Suffert, S C, 2021, Brazil	To estimate direct medical costs of the last 30 days of oncology patients admitted to an inpatient clinic and to evaluate factors associated with medical costs at the end of life	Retrospective cohort study	Between January 1, 2018 and December 31, 2019	109 patients	included patients aged 18 and older who were diagnosed with incurable cancer and who were admitted to a tertiary hospital in Brazil between January 1, 2018 and December 31, 2019.	≥ 18 years of age	The last 30 days of life	Patients with cancer
Kokkotou, E, 2021, Greece	To estimate the cost of treating patients with lung cancer at their end-of-life (EOL) phase of care in Greece.	Retrospective cohort study	Between 1 January 2015 and 31 December 2018	122 patients	All lung cancer patients who died between 1 January 2015 and 31 December 2018 with at least 6 months follow-up were enrolled in the study.	Age restriction is not present	The last 6 months of life	Patients with non-small-cell lung cancer, specifically adenocarcinoma and squamous, or small-cell-lung cancer (SCLC)
Martins Rozman, L, 2021, Brazil	To identify the sociodemographic and clinical variables that could explain the cost per day of PC for cancer in Brazil.	Retrospective cohort study	Between January 2010 and December 2013	2985 patients	Patients ≥ 18 years of age who received PC between January 2010 and December 2013 at the Instituto do Câncer do Estado de São Paulo (ICESP, São Paulo State Cancer Institute)	≥ 18 years of age	Period definition is not present	Patients with cancer
Rautakorpi, L, 2021, Finland	To evaluate the impact of palliative intervention on the treatment procedures for pancreatic cancer patients during their last month of life.	Retrospective cohort study	Between 2011 and 2016	378 patients	Pancreatic cancer patients deceased during the years 2011–2016 and had a contact to the tertiary care during the last 30 days of life	Age restriction is not present	The last 30 days of life	Pancreatic cancer patients
Fiala M A, 2020, USA	To compare the costs of end-of-life care for patients with myeloma who were enrolled in hospice at end of life to those patients who were not.	Retrospective cohort study	Between 2007 to 2013	2,075 patients	Diagnosed at age 65 or older, received myeloma-directed therapy, had an overall survival > 3 months, and were enrolled in Medicare the month preceding death.	≥ 65 years of age	The last 30 days of life	Patients with myeloma
Li, Z, 2020, China	To examine the associations between health insurance and EOL care in the last six months of life: outpatient visits, emergency department (ED) visits, inpatient services, intensive care unit (ICU) admissions, expenditures, and place of death among the cancer patients.	Retrospective cohort study	Between July 2015 to June 2017	398 patients	Patients diagnosed with cancer who survived more than 6 months after diagnosis and died from July 2015 to June 2017 in urban Yichang, China	Age restriction is not present	The last 6 months of life	Patients with cancer
Chen Y, 2019, USA	To determine how different types of end-of-life care are utilized by each racialethnic group and identify specific areas for potential improvements in equitable care.	Cohort	Surveillance, Epidemiology, and End Results (SEER)-Medicare database for the years 2000–2013	63,375 patients with non-small cell lung cancer(NSCLC) and 26,819 patients with small cell lung cancer (SCLC)	Diagnosed with non-small cell lung cancer (NSCLC) or small cell lung cancer (SCLC) between January 1, 2000, and December 31, 2011, in the analysis	≥ 65 years of age	The last 30 days of life	Non-small cell lung cancer (NSCLC) or small cell lung cancer (SCLC)
Chiang J K, 2019, Taiwan	To evaluate the impact of palliative care on quality indicator (Qis) of EOL cancer care and health care costs for patients with hematological malignancies (HMs) in the final month of life.	Cohort	Between January 1, 2000 and December 31, 2011	724 patients	All patients who had a diagnosis of hematological malignancies with matchingcatastrophic illness certificate (CIC) between January 1, 2000 and December 31, 2011	≥ 20 years of age	The final month of life	Patients with hematological malignancies (HMs)
Karanth, S, 2019, USA	To estimate the racial differences in end-of-life care costs among lung cancer patients, and identifies and quantifies factors that contribute the most to these differences using a statistical decomposition method.	Retrospective cohort study	Between 1991 to 2013	77,082 patients with NSCLC and 13,141 patients with SCLC	Patients diagnosed for the first time with AJCC stage I-IV non–small cell lung cancer (NSCLC) or small cell lung cancer (SCLC), who died at/before December 31, 2013. Only patients 66 years and above, and surviving ≥ 6 months after diagnosis	≥ 66 years of age	The last 6 months of life	Patients with stage I-IV lung cancer
Kyeremanteng, K,2019, Canada	To provide an overview of health outcomes and hospital costs of patients with cancer admitted to The Ottawa Hospital and/or received acute medical services during their final 2 weeks of life.	Retrospective cohort study	Between December 2011 and December 2012	130 patients	Patients must have (1) been diagnosed with terminal cancer, (2) had an emergency visit within 2 weeks of death, and (3) died in the hospital	Age restriction is not present	The last 2 weeks of life	Patients with cancer
Crouch E, 2018,USA	The purpose of this study was to examine rural-urban differences in utilization and expenditures in the last 6 months of life for patients with breast, lung, or colorectal cancer.	Cohort	5% sample of the 2013 Medicare Research Identifiable Files	6,214 patients	To study a full 6 months before death, beneficiaries were restricted to those who had died on or after July 1, 2013, from the 2013 Medicare Research Identifiable Files diagnosed with breast, lung, or colon cancer	Age restriction is not present	The last 6 months of life	Patients with breast, lung, or colon cancer
Deckert K, 2018, German	To identify factors related to inhospital death in German lung cancer patients and analysed resulting costs.	Cohort	Between 2009–2012.	12,457 patients	Patients diagnosed with lung cancer in 2009, with patient-individual three-year follow-up (2009–2012)	Age restriction is not present	The last 30 days of life	Patients with lung cancer
Dover L L, 2018, USA	To describe and compare utilization of hospice care and cancer-directed therapy, risk factors for receiving aggressive care, and impact on overall Medicare expenditures in the last 30 days of life for Medicare beneficiaries 65 years and older with PMBT and SMBT	Retrospective cohort study	Between 2012 to 2015	1323 had a diagnosis of either PMBT (n= 383) or SMBT (n = 940)	Medicare beneficiaries age ≥65 with primary malignant brain tumor (PMBT) or secondary MBT (SMBT) receiving care within a southeastern cancer community network including academic and community hospitals from 2012–2015.	≥ 65 years of age	The last 30 days of life	Patients with malignant brain tumors
Haltia O, 2018, Finland	To explore the resource use and costs of palliative care among end-stage breast, colorectal and prostate cancer patients after termination of life-prolonging oncological treatments, that is, during the palliative care period	Real-life longitudinal register- and questionnaire-based study	Between September 2009 and April 2011	70 patients	Age over 18 years, metastatic disease and patients were to receive no life-prolonging oncological treatments, like chemotherapy or targeted therapies documented in patient records.	≥ 18 years of age	The last 12 weeks of life	Breast, colorectal and prostate cancer
Johnston, E E , 2018, USA	To determine the quantity of and disparities in inpatient utilization in the last year of life of adolescent and young adult (AYAs) with cancer	Retrospective cohort study	Between 2000-2011	12,883 patients	Patients who were 15 to 39 years old at the time of death, had died in 2000-2011, and had an oncologic ICD-9 code during a hospitalization within 6 months of death or had cancer as a death certificate cause of death.	aged 15 to 39 years	The last year of life	Patients with cancer
Accordino M K, 2017, USA	Establish the association between length of time alive with stage IV Breast Cancer and aggressive EOL care, and its associated costs	Cohort	Diagnosed between January 1, 2002 and December 31, 2011, who died by December 31, 2012	4,521 women	Elderly women with stage IV Breast Cancer diagnosed 2002–2011 who died by 12/31/2012	≥ 66 years of age	The last month of life	Histologically confirmed stage IV breast cancer
Bao Y, 2017, USA	To evaluate the association between chemotherapy use by patients with Stage IV pancreatic cancer and health care use and Medicare and out-of-pocket costs in the last 30 days of life.	Retrospective cohort study	Diagnosed between 2006-2011	3,825 patients	Diagnosed with Stage IV pancreatic cancer during 2006-2011 who survived until at least 60 days but died within 12 months of diagnosis	≥ 66 years of age	The last 30 days of life	Diagnosed with Stage IV pancreatic cancer
Hung, Y. N,2017, Taiwan	To investigate health care expenditures and their determinants for cancer decedents in their last year of life over a decade (2001–2010) in Taiwan	Retrospective cohort study	Between 2001 to 2010	339,546 Taiwanese cancer decedents’	The population included all ages and disease groups of cancer patients who died and received health care across all health care systems in Taiwan, between 2001 and 2010	Age restriction is not present	The last year of life	Patients with cancer
Bekelman J E, 2016, USA	To compare site of death, health care utilization, and hospital expenditures in 7 countries: Belgium, Canada, England, Germany, the Netherlands, Norway, and the United States. Determined health care utilization and hospital expenditures during the 180-day and 30-day periods before death	Retrospective cohort study	Identified decedents between January 1, 2010, and December 31, 2010	389,073 patients	Diagnosis of cancer documented within 180 days before death, In Canada, England, Germany, the Netherlands, and the United States	≥ 65 years of age	The 180-day and 30-day periods before death	Cancers were identified in administrative data through International Classification of Diseases, Ninth Revision (ICD-9) or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) diagnosis codes.
Thein, H H, 2016, Canada	Estimate trends in net health care utilization, costs of care attributable to hcc in Ontario, and rate ratios of resource use at various stages of care.	Retrospective cohort study	Between 1 January 2002 and 31 December 2009	2832 patients	Patients 18 years of age and older who were diagnosed with hcc in Ontario between 1 January 2002 and 31 December 2009.	≥ 18 years of age	The last 6 months of life	Hepatocellular carcinoma (HCC)
Wang, H, 2016, USA	To examine the rural-urban differences in Medicare expenditures on end-of-life care for elderly cancer patients in the United States.	Cohort	Year 2008	175,181 elderly adults	Medicare beneficiaries diagnosed with lung, (female) breast, prostate, or colorectal cancer who died in 2008 and were 66 years or older at the time of death	≥ 66 years of age	The last 12 months	Lung, colorectal, female breast, or prostate cancer diagnosis
Wang, J.P., 2016, Taiwan	To compare the patient characteristics, medical procedures, prescriptions, and medical costs for patients with pancreatic cancer who received inpatient palliative care or acute hospital care, and to identify any significant differences between these groups.	Retrospective cohort study	Between January 2003 and December 2006	854 patients	Patients with terminal pancreatic cancer, who had received in-hospital end-of-life care between January 2003 and December 2006.	Age restriction is not present	Period definition is not present	Pancreatic cancer patients
Ashleigh Guadagnolo B, 2015,USA	The aims of this study are to ascertain differences in and costs of end-of-life care among patients dying of cancer in Texas with respect to whether a patient was enrolled in Medicaid and/or Medicare	Cohort	Between January 1, 2000 and December 31, 2008	69,572 patients	Patients who died as a result of breast, colorectal, lung, melanoma, pancreatic, and prostate cancers	≥ 18 years of age	The last 30 days of life	Breast, colorectal, lung, melanoma, pancreatic, and prostate cancers
Bremner K E, 2015, Canada	To compare end-of-life costs in Ontario, Canada, and the United States, using administrative health data.	Cohort	Identifed patitients who died of cancer between 1 January 2001 and 31 December 2005	SEER-Medicare 16,858 patients and Ontario 8643 patients	Included patients with a pathologically confirmed diagnosis of NSCLC who died of cancer between 1 January 2001 and 31 December 2005 at age 65.5 years or older	≥ 65.5 years	The last 6 months of life	Patients with a pathologically confirmed diagnosis of nonsmall cell lung cancer (NSCLC)
Cheung M C, 2015, Canada	Assess whether patients receiving aggressive treatment care near the end of life would use more resources and correspondingly incur greater costs of care in comparison with individuals who did not receive aggressive care.	Cohort	Between January 1, 2005 and December 31, 2009	107,253 patients	Adult patients in end-of-life cancer care in Ontario, Canada who died between January 1, 2005, and December 31, 2009.	≥ 20 years of age	The last month of life	Patients with cancer as the cause of death were identified in the Ontario Cancer Registry.19 International Classification of Diseases, Ninth Revision (ICD9) codes were used to identify the type of cancer death
Du X L, 2015,USA	To examine racial/ethnic and geographical disparities in cancer care and costs during the last 6months of life for lung cancer decedents after the Food and Drug Administration’s approval of expensivebevacizumab in October 2006.	Retrospective cohort study	Between July 2007 and December 2010.	37,393 cases	Patients with lung cancer at allstages who died between July 2007 and December 2010 to allow assessment of the end of life care in the last 6 months after theFDA’s October 2006 approval of bevacizumab for treating lungcancer.	≥ 65 years of age	The last 6 months of life	Patients with lung cancer at all stages
Garrido M M, 2015, USA	To examine associations among advance directives (Ads), quality of life, and estimated costs of care in the week before death	Cohort	Between 2002- 2008	336 patients	Data on patient characteristics and quality of life in the week before death come from the Coping with Cancer cohort of patients with advanced cancer (disease refractory to first-line chemotherapy or distant metastases) and caregivers who were recruited from outpatient clinics in Connecticut, Massachusetts, New Hampshire, New York, and Texas between 2002 and 2008.	Age restriction is not present	The last week of life	Patients with advanced cancer (disease refractory to first-line chemotherapy or distant metastases)
Yu, M, 2015, Canada	To assess the societal costs of end-of-life care associated with two places of death (hospital and home) using a prospective cohort design in a home-based palliative care programme.	Prospective cohort design	Between August 2010 to September 2012	186 participants	Primary caregivers of patients diagnosed with a malignant neoplasm (terminal cancer) who had been admitted to the programme within the last 7 days; caregivers 18 years of age or older; and caregivers fluent in English.	Age restriction is not present for patients	6, 2 and 1 month prior to death	Patients with cancer
Nevadunsky, N S, 2014, USA	To evaluate the association of inpatient palliative medicine consultation with aggressive care interventions at the end of life (ACE) scores and direct inpatient hospital costs of patients with gynecologic malignancies.	Retrospective cohort study	Between June 5, 2005 until February 7, 2010	100 consecutive patients	Patients who were treated during the last year at a single institution and died from their primary gynecologic malignancy were identified from the Gynecologic Oncology Tumor Board Registry.	Age restriction is not present	The last 30 days of life	Patients with primary gynecologic malignancy
Gaertner J, 2013, Germany	To analyze the effects of inpatient PC for cancer patients in the last six months of life	Retrospective cohort study	Between July 1st 2006 and December 31st 2008	11,355 patients	Advanced cancer, death between July 1st 2006 and December 31st 2008, Insured by the BARMER GEK sickness fund from at least January 1st 2005 till death and at least 18 years old at January 1st 2005	≥ 18 years of age	The last 6 months of life	Patients diagnosed with advanced cancer
Hwang. SJ,2013, Taiwan	To analyze differences between hospice care and usual care for geriatric hepatocellular carcinoma (HCC) inpatients in a nationwide survey	Cohort	Between January 2001 and December 2004	729 terminal HCC patients receiving inpatient hospice care and 729 matched controls receiving usual care.	Patients with terminal HCC who were ≥ 65 years old and received their end-of-life care in the hospital between January 2001 and December 2004 were recruited	≥ 65 years of age	Period definition is not present hospice care group (8.0 +/- 7.7 days) usual care group (14.5 – 13.7 days)	Hepatocellular carcinoma (HCC)
Jung, H M, 2010, South Korea	To estimate inpatient and outpatient medical cost per month for patients near the end-of- life and evaluate the cost-saving effect of palliative care.	Retrospective cohort study	Between January to December 2007	656 patients	Patients who died as a result of cancer at Seoul National University Hospital (SNUH) from January 1 to December 31, 2007.	≥ 17 years of age	The last 6 months of life	Patients with cancer

Aggressive or Active Cancer treatments at the EOL care	Considered costs	Direct Costs	Indirect costs	Intangible costs	Health Costing Methods	Perspective	Costs
Aggressive treatments such as surgeries and intensive care unit (ICU) stays	Calculated total cost incurred in all inpatient admissions (gross cost before tax and subsidy), and separately for low-and high-intensity admissions. The cost was adjusted for inflation to 2019 Singapore dollars (SGD) using the consumer price index from the Department of Statistics, Singapore.	Yes	No	No	Macro-costing	Without a detailed description.	Patients incurred a mean total inpatient cost of SGD 26860 in the last year of life, of which 71 percent was incurred in the last 6 months of life. The mean monthly total inpatient cost for the patients in our sample was SGD 2238 during the last year, which increased markedly during the last month of life (SGD5995).
Without a detailed description.	Inpatient and day care: Scottish health service costs include all direct and indirect costs for each care episode within a specific specialty. Outpatient care: the number of outpatient visits per patient in their last year of life, as well as the reasons for each individual appointment.	Yes	Yes	No	Macro-costing	Payer’s perspective.	Headline finding is that inpatient hospitalization accounted for the greatest proportion of costs across all cancer types, and particularly so over the last weeks of life. The variation in healthcare use across cancer types was most pronounced among those with hematological cancer, with costs of £24,358.4 (95% CI [23,454.2-25,262.7]). In the solid tumor group, ovarian cancer had the highest secondary care use and costs of £18,070.3 (95% CI [17,179.4-18,961.3]) in univariate analysis.
Medical oncology, radiation oncology, medical procedures, surgical procedures, anesthesia and pain management, pathology and laboratory, radiology and nuclear medicine and other supplies e services.	Medical oncology, radiation oncology, medical procedures, surgical procedures, anesthesia and pain management, pathology and laboratory, radiology and nuclear medicine and other supplies e services.	Yes	No	No	Macro-costing	Payer’s perspective	The average total Medicare Part B payments per treated beneficiary during the last 6 month oflife increased by 12.0% between 2016 and 2019 (from $14,487 to $16,227), with the greatest absolute cost increase observed for the medical oncology category (from $7030 to $9436 [+34.2%])
Without a detailed description.	The estimated individual patient cost was calculated by pricing all ‘units’ consumed at patient level e.g., medication (pills, ampoules), blood assays, other materials based on current national price lists through a micro costing method. A top down two-step costing approach, including main and auxiliary cost centers, was used to calculate the average overhead cost per patient day; this involved the identification of the ward’s operating costs, e.g., water, heat and energy supplies, and the depreciation prices of building and equipment, telecommunication, maintenance, outsourcing such as disposal, nutrition services, laundry.	Yes	Yes	No	Micro-costing (top down)	Perspective of a hospital (Spiliopoulio Hospital)	The average total cost per case was 2472.14 EUR (SD 1015.10, min 180.13 max 14331.63), with almost equal contributions from individual patients’ and overhead costs (46.21% vs 53.79%). Mean total cost per day was 97.01 EUR (SD 28.88, min 59.52 max 235.23), higher than statutory per-diem fee of 60 EUR.
Describing the complete care pathways of all cancer decedents during their last six months of life.	Healthcare utilization – secondary, primary, and home and community‐based care. Inpatient or outpatient treatments	Yes	No	No	Macro-costing	Payer’s perspective.	On average, the total healthcare costs during the 6 months prior to death summed to NOK379,801, of which 60%, 3% and 37% were in the secondary, the primary and the home- and community-based care setting, respectively.
Without a detailed description.	Healthcare expenditures at end-of-life, calculated based on the sum of inpatient and outpatient costs during the last 12 months of life	Yes	No	No	Macro-costing	Payer’s perspective	The average end-of-life healthcare expenditure was 15,500,000 Korean Won (KRW) (1 USD = approximately 1135 KRW). Total end-of-life expenditures were highest in the ‘high’ economic status group (Mean 16,300,000 KRW, SD 15,100,000), followed by the ‘middle’ (Mean 14,800,000 KRW, SD 12,700,000) and ‘low (Mean 14,000,000, SD 12,800,000) groups.
Healthcare resource utilization included hospitalization, outpatient visits, emergency department (ED) visits, and intensive care unit (ICU) admission	Only total healthcare costs, including co-payment by patients and coverage by the National Health Insurance, were considered in this study, and the nonreimbursed costs were excluded. Inpatient and outpatient costs included the cost of admission (for inpatients only), administration and injection, medication, procedures, lab testing, imaging, and other aspects of the care provided.	Yes	No	No	Macro-costing	Payer’s perspective	The average total medical cost per patient was $6,310, and the per patient per month (PPPM) cost was $3,072. The inpatient cost ($5,705) was approximately 9.4 times higher than the outpatient cost ($605).
Utilization of chemotherapy and immunotherapy, frequent emergency room visits and use of intensive care units (ICUs), long hospital stays and the use of expensive drugs during EOL	The inpatient cost is determined by combining the comprehensive evaluation portion, which comprises fixed costs per day for the disease for which the most medical resources were invested during the hospitalization period, and the performance evaluation portion for surgery and treatment. The medical costs before death and after lung cancer diagnosis were divided into outpatient and inpatient costs and were calculated per month.	Yes	No	No	Micro-costing	Perspective of a hospital (Japanese Red Cross Medical Center)	For both SCLC and NSCLC patients,most EOL medical costs were inpatient costs. The median monthly medical costs of the last 3 months before death were higher than those for the first 3 months and the first year after first visit, during which time both SCLC and NSCLC. Median monthly costs for the last 3 months (×JPY 1 million) for SCLC is 2.06 (interquartile range /IQR 1.25–3.64) and NSCLC is 2.08 (IQR 1.09–3.31). Median monthly costs for the first 3 months (×JPY 1 million) for SCLC is 1,77 (IQR 1.13–3.24) and NSCLC is 1.58 (IQR 0.90–2.53)
Without a detailed description.	Three phases of cancer care: initial (which includes the procedures surrounding diagnosis), survivorship, and relapse and end-of-life care. Included services related to chemotherapy, surgery (including anesthesia evaluation and treatment), radiation therapy, imaging, and laboratory services (including cardiology, tumor markers, laboratory, and anatomic pathology). Other bins included fertility-related services and physical therapy. We included inpatient technical services, inpatient evaluation and management services, and outpatient evaluation and management services	Yes	No	No	Macro-costing	Payer’s perspective.	For the relapse and end-of-life care, the average cost is $17,162 USD (median $10,088 USD), and the average duration is 1,208 (median 786) days.
Chemotherapy administered within the last 14 during the last 30 days of life (DOL); more than one hospitalization within the last 30 DOL; admission to the intensive care unit within the last 30 DOL; and palliative care initiated < 3 days before death.	Economic assessment, limited to direct costs, was done from the French health care payers’ perspective and included hospitalization based on Diagnosis-Related Group tariffs, chemotherapy, radiotherapy, implantable medical devices, and ICU costs. Transportation costs and indirect costs were excluded	Yes	No	No	Macro-costing	Health care payer’s perspective	The mean cost per patient during the last 30 DOL was €8152. Hospitalizations, with a mean of €7288, contributed to 89% of the total costs. Expenditures for patients with or without aggressive EOL care differed significantly: €9480 and €6378, respectively (P < .001), with the difference attributable to hospitalizations (€8080 vs. €6229; P < .001) and ICU admissions (€1063 vs. €92; P < .001). The mean cost increased significantly between the 2 study periods, €7985 vs. V€307 (P < .001), essentially as a result of expenditures for patients receiving aggressive care (€8307 vs. €9277).
Ssystemic therapy, including chemotherapy and immunotherapy, and/or the receipt of invasive mechanical ventilation in intensive care unit, emergency department (ED) admission, during the terminal hospitalization, or enrollment in hospice 3 days or fewer before death.	Total charges billed to insurance, not including professional fees and noncovered charges	Yes	No	No	Macro-costing	Payer’s perspective.	The median total charges were $43 681 (IQR, $17 973-$97 110)
Chemotherapy administered, Intensive care admissions, emergency department visits	Direct medical costs were estimated using the bottom-up micro-costing approach. The real cost (without profit margin) of general medications, hospital supplies, supplies, tests (imaging and laboratory), and blood products were extracted from the patients’ accounts.	Yes	No	No	Micro-costing (bottom-up )	Perspective of a philanthropic hospital that serves patients in the Brazilian public health system (ISCMPA)	The median cost per patient per day related to hospitalization was BRL 119 (73‒181)/United States dollars [USD] 21 (13‒33). The cost of medication was BRL 66 (40‒105)/USD 12 (7‒19), representing 55.46% of costs while that of materials and supplies was BRL 30 (18‒49)/USD 5 (3‒9). In the multivariate analysis, when the limitation of interventions was recorded in the medical record, the median cost is reduced by BRL 50 (USD 9) per patient per day
Overuse of chemotherapy, radiotherapy and monoclonal antibodies/immunotherapy during the last weeks of death	Healthcare resource utilization data, such as hospitalization, therapy (i.e., chemotherapy/immunotherapy, radiotherapy and surgery), and laboratory/imaging tests during the last 6 months before death were also extracted.	Yes	No	No	Macro-costing	Payer’s perspective	During the EOL periods, the mean cost/patient in the last 6, 3 and 1 month were €7665, €3351 and €1009, respectively
Chemotherapy, hospital admissions and dying in a hospital	Clinical consultations, interdisciplinary consultations, hospital admissions, emergency department visits, intensive care unit admissions, surgical procedures, chemotherapy, medications, laboratory tests, medical supplies, hospital supplies, and hospice care.	Yes	No	No	Micro-costing	Perspective of the health care facility (ICESP)	The mean total cost per patient was $12,335 (standard deviation [SD] = 14,602; 95% confidence interval [CI] = 11,803 to 12,851). The mean cost per day per patient was $325.50 (SD = 246.30, 95% CI = 316.60 to 334.30)
Number of the chemotherapy regimens, total dose of the radiotherapy, Radiological examinations and procedures including X-rays, computer tomography (CT), magnetic resonance imaging (MRI), ultrasound examination (US), and other (including stenting and paracentesis), Surgical procedures, Emergency department visits and Hospitalisations in any ward of the university hospital were studied	Number of the chemotherapy regimens, total dose of the radiotherapy, Radiological examinations and procedures including X-rays, computer tomography (CT), magnetic resonance imaging (MRI), ultrasound examination (US), and other (including stenting and paracentesis), Surgical procedures, Emergency department visits and Hospitalisations in any ward of the university hospital were studied	Yes	No	No	Micro-costing	Perspective of a hospital (Turku University Hospital - TUH)	Also, the medical costs in tertiary care were significantly lower for the patients in the Palliative Care Group¼ (PC group) (p < 0.0001). Mean cost varied from 2049 euros in the PC group to 4574 euros in the Standard Care Group (SC) group and median cost from 591 euros in PC group to 3268 euros in SC group (range 1–21.484 euros vs. 1.5–43 603 euros)
Intensive care admissions, emergency department visits, and end-stage treatment regimens	Costs included those paid by Medicare and patient copays during the 30 days preceding death.	Yes	No	No	Macro-costing	Payer’s perspective.	The median cost of care at end of life was $15,870 (range 0- $215,048). The median cost of care for patients who were enrolled in hospice was $9175, compared to $22,921 for those patients not enrolled (p b .0001). After controlling for covariates, hospice enrollment overall was associated with a $13,574 (SE $832; p < .0001) decrease in costs
Outpatient visits, emergency department (ED) visits, inpatient services, intensive care unit (ICU) admissions	Outcomes of interest consisted of EOL healthcare utilization during the last 6 months of life, including number of emergency department (ED) visits, number of outpatient visits, number of hospital admissions and whether a decedent had at least one intensive care unit (ICU) admission, as well as total healthcare expenditures during the last 6 months of life, and Place of death (POD) (in-hospital or home death)	Yes	No	No	Macro-costing	Payer’s perspective	Compared to Urban Resident-based Basic Medical Insurance (URBMI) beneficiaries, New Rural Cooperative Medical Scheme (NRCMS) beneficiaries and Urban Employee Basic Medical Insurance (UEBMI) beneficiaries had ¥15,722 and ¥43,241 higher expenditures.
Without a detailed description.	Decomposed total cost into four mutually exclusive costs: (a) inpatient hospital or skilled nursing facility claims costs (referred to collectively as inpatient costs), (b) outpatient claims costs, (c) hospice claims costs, (d) noninstitutional claims costs for physician and supplier services (referred to collectively as physician services costs), and (e) other costs related to home health services and durable medical equipment	Yes	No	No	Macro-costing	Payer’s perspective.	Total end-of-life costs were significantly higher for all racial-ethnic groups relative to non-Hispanic (NH) white patients, whose average total costs and patient liability costs in the last month of life were estimated to be $9,113 (95% confidence interval [CI], $8,547–$9,717) and $797 (95% CI, $751–$845), respectively, among patients with NSCLC
Undergoing chemotherapy during the last 2 weeks of life, having more than 1 emergency room (ER) visits in the final month of life, being admitted to a hospital at least twice in the final month of life, receiving intensive care unit (ICU) care in the final month of life, receiving cardiopulmonary resuscitation (CPR) in the final month of life, and dying in a hospital	Inpatient service and outpatient service costs listed in his or her claims records	Yes	No	No	Macro-costing	Payer’s perspective (Taiwan’s National Health Insurance (NHI))	The median health care cost per person during the final month of life between the Pal group and the non-Pal group were not significantly different (US$3096 [0-13762] vs US$3900 [0- 43783], P=.315). Similar results were found after separating the Pal group into i-Pal group and h-Pal group.
Emergency room visits, ICU admission, hospital stays, starting new chemotherapy	The “end-of-life care cost” was defined as direct medical cost reimbursed by Medicare during the last 6 months of life.	Yes	No	No	Macro-costing	Payer’s perspective	The average costs of end-of-life care by histologic type for lung cancer patients diagnosed between 1992-2011 who died on or before December 31, 2013 during the last month of life were $16,206.52 for NSCLC and 15,027.46 for SCLC
New or ongoing cancer treatments near death, high number of ED visits or hospital admissions near death, and dying in an acute care setting.	Analyzed the patient interventions received, and length of stay in the hospital.Costs were calculated by multiplying the length of stay by the average costs of a floor bed at The Ottawa Hospital (approximately Can$1128 per day). Hospice costs were determined to be approximately Can$435 per day	Yes	No	No	Micro-costing	Perspective of a hospital (Ottawa Hospital)	Patients were hospitalized, on average, for 7 days and hospitalization costs exceeded the estimated hospice cost by approximately 2.5 times (Can$1 041 170.00 at Can$8009.00/patient vs Can$401 570.00 at Can$3089.00/patient, respectively)
Without a detailed description.	Total Medicare expenditures for inpatient, outpatient, physician, home health, and skilled nursing facility use during the last 6 months of life for patients with breast, lung, or colorectal cancer. Prescription drug claims were not available and were therefore not included in our calculations.	Yes	No	No	Macro-costing	Payer’s perspective.	During the last 6 months of life, median Medicare expenditures were lower for rural decedents for breast cancer ($21,839 vs $25,698), lung cancer ($22,814 vs $27,635), and colorectal cancer ($24,156 vs $28,035; all differences significant at P < .05). In adjusted models, care for rural decedents was less costly than urban decedents for breast, lung, and colorectal cancer, respectively.
Chemotherapy shortly before death, A higher number of hospitalizations	Expenditures for the health insurance company in the last 30 days before death. Total all-cause expenditures for hospitalizations, doctor visits and medications between patients with in hospital death to those who died elsewhere.	Yes	No	No	Macro-costing	Payer’s perspective.	All-cause total costs were significantly higher for patients dying in a hospital (€ 6852 vs. € 3.254, p-value < 0.0001). Hospitalizations made up the biggest part of expenditures and were significantly higher in patients with inhospital death (€ 5895 vs. € 2321, p-value < 0.0001).
Chemotherapy utilization within 30 days of death, late (1–3 days) hospice entry, and lack of hospice care	Hospice care (was defined as any use of outpatient, in-home, or inpatient hospice services), utilization of cancer-directed therapies (systemic therapy, including chemotherapy and immunotherapy administration), and total Medicare expenditures(total reimbursements to providers for all services received within 30 days of death including inpatient, outpatient, physician visit, skilled nursing facility, home health, durable medical equipment, and hospice care)	Yes	No	No	Macro-costing	Payer’s perspective.	The average decrease in Medicare expenditures associated with hospice utilization for patients with PMBT was $−12,138 (95% CI: $−18,065 to $−6210) and with SMBT was $−1,508 (95% CI: $−3,613 to $598).
Life-prolonging oncological treatments, like chemotherapy or targeted therapies	The inpatient costs include treatment costs at communal facilities, tertiary care hospitals or hospice care. The outpatient costs include outpatient visits, home hospital and home hospice care, together with medication, travel and care received at private facilities. Informal care is by definition care given free by family or friends because of a family member’s or friend’s disability or illness. Productivity loss is defined as a reduction of productivity during the days absent from work due to cancer.	Yes	Yes	No	Macro-costing	Payer’s perspective	The costs of the last 60 days of life were €6096 in breast, €6085 in colorectal and €5306 in prostate cancer. Healthcare costs (HCCs) were highest covering 55% of the total costs, followed by informal care costs (27%) and costs due to productivity loss (18%). The last 2 weeks of life contributed to 37% of the healthcare cost.
Cardiopulmonary resuscitation and intubation	Hospital-specific ratios of the cost to charge ([total operating expenses – other operating revenue])/total gross patient revenue) were calculated. The ratio of the cost to charge, multiplied by the charge, was then used to determine costs.	Yes	No	No	Macro-costing	Payer’s perspective	AYAs dying of cancer spent a mean of 40 days (standard deviation [SD], 42 days) in the hospital in their last year of life with a mean cost of $151,072 (SD, $202,562). Most of their admissions and inpatient expenses occurred in the last 6months of life: in the last 6months, they spent a mean of 32 days in the hospital (SD, 34 days) with a mean cost of $124,444 (SD, $175,816).
More than one emergency department visit, more than one hospital admission, greater than 14 days hospitalized, admission to the ICU, admission to hospice within 3 days of death, receipt of IV chemotherapy within 14 days of death, or the use of life-extending procedures (feeding tube placement, ventilation, and/or cardiopulmonary resuscitation), and/or C10 unique physician encounters in the last 6 months of life	Costs of care were calculated from Medicare reimbursement claims from physician, hospital, outpatient, durable medical equipment, and hospice filings between the date of diagnosis and the date of death	Yes	No	No	Macro-costing	Payer’s perspective.	The majority (65.5%) of total costs per-month-alive were related to inpatient care, and inpatient care costs were significantly higher among patients who lived ≤6 months compared to patients who lived 6–12 months and > 12 months ($8923 vs. $3639 vs. $1512, respectively, p\0.001)
Utilization of chemotherapy, receiving health care in hospitals or emergency departments	End-of-life health care utilization and costs were measured over the last 30 days of life and included: dichotomous indicators of having had at least one hospital admission, at least one ED visit, whether the patient received any hospice care, and whether the patient died at a hospital (vs. another place such as home); number of days of hospice care received	Yes	No	No	Macro-costing	Payer’s perspective.	Median Medicare payment in the last 30 days of life were more than $3,000 greater ($12,338.7 vs. $8,907.6), and median patient out-ofpocket (OOP) payment costs more than $750 greater ($1,004.8 vs. $228.5), for patients with vs. without chemotherapy (p<0.001 for both comparisons based on tests of the medians).
This more aggressive care in our participants’ last month of life is shown by overwhelming inpatient care (acute-care hospitalization, ≥2 hospitalizations, ≥14 days of hospitalization), extensive life sustaining treatments ( ≥1 intensive care unit [ICU] admission, cardiopulmonary resuscitation, intubation, and mechanical ventilation support, multiple ED visits, continuation of chemotherapy, and high prevalence of hospital death.	All care settings (inpatient, outpatient, emergency department [ED], and home health) and are based on NHI reimbursement variables in claims datasets adjusted for inflation with the Consumer Price Index (base period 2010 = 100%).	Yes	No	No	Macro-costing	Payer’s perspective	Mean annual EOL care expenditures for Taiwanese cancer decedents increased from 2000 to 2010 from U.S. $49,591 to U.S. $68,773, respectively, with one third of spending occurring in the patients’ last month.
Hospitalizations in acute care hospitals, admissions to ICUs, emergency department visits, or chemotherapy episodes	3 inpatient measures: hospitalizations in acute care hospitals, admissions to intensive care units, and emergency department visits, and 1 outpatient measure chemotherapy episodes	Yes	No	No	Macro-costing	Expenditures paid by insurers (commercial or governmental	In the last 30 days of life, mean per capita hospital expenditureswere highest in Canada (US $10 273), the United States (US $8126), and Norway (US $6625), intermediate in Belgium (US $5840) and Germany (US $4382), and lower in the Netherlands (US $3680) and England (US $3160).
Treatment procedures for patients with hepatocellular carcinoma = noncurative therapy: Percutaneous ablation, chemotherapy, supportive and palliative care	Included family physician visits, specialist visits, ed visits, acute inpatient hospitalizations, same-day surgery, prescription medications, homecare use, and total services (the sum of the numbers for all health care utilization types).	Yes	No	No	Macro-costing	Perspective of the Ontario Ministry of Health and Long-Term Care.	In the end-of-life phase (short-term survivors), mean net costs attributable to outpatient visits and total services significantly increased to $14,220 from $1,547 and to $33,121 from $14,450 (2008–2009 and 2002–2003 respectively).
Enroll later in a hospice program and to use ER services	Inpatient, outpatient, physician services, hospice, home health, skilled nursing facilities (SNF), and durable medical expenditure	Yes	No	No	Macro-costing	Payer’s perspective	On average, elderly cancer patients cost Medicare $51,273, $50,274, $62,815, and $50,941 in the last year for breast, prostate, colorectal, and lung cancer, respectively.
Urinary catheterization, nasogastric tube feeding, central venous catheter insertion, intensive care unit admission, endotracheal intubation, abdominal drainage, hemodialysis, cardiopulmonary resuscitation, total parenteral nutrition, percutaneous transhepatic cholangiography and drainage, chest tapping or intubation, and defibrillation/cardioversion	Examination costs, procedures, surgeries, prescribed drugs, and special medical materials that were used during the admission, and details regarding the doctors’ orders and laboratory tests	Yes	No	No	Macro-costing	Perspective of the Taiwan’s National Health Insurance (NHI) program	The combined daily medical costs were significantly lower for the inpatient palliative care group, compared to those for the acute hospital care group (adjusted mean = 107 US [101–113] dollars/day, vs. 253 [210–308] US dollars/day, respectively; P < 0.001).
Utilization of chemotherapy, emergency room (ER) care, hospitalization, lack of hospice use, and radiation therapy	Total amount reimbursed by Medicaid and Medicare) and included all costs incurred in the 30-day window before death except for outpatient prescription drug costs.	Yes	No	No	Macro-costing	Payer’s perspective.	Adjusted Analyses of All Costs of Care in the Final 30 Days of Life. Coverage x ethnicity, Medicare white = $10,97 and nonwhite = $12,502. Medicaid white = $11,595 and nonwhite = $12,233. Dual white = $10,363 and nonwhite = $13,847. Cancer cause of death; breast $10,758, colon and rectum $10,969, pancreas $10,875, lung $12,179, prostate $9599, melanoma $9896
Chemotherapy use, inpatient hospitalization and in-hospital deaths	Inpatient hospitalizations, emergency room (ER) visits, ambulatory procedures, outpatient infusion chemotherapy, physician services, radiation therapy, and home care services. Services that we included but were not directly comparable included hospice (United States), complex continuing care (Ontario), and palliative care (Ontario).	Yes	No	No	Macro-costing	Public payer perspectives	Mean publicly paid costs in the last 30 days of life for long-term survivors in Ontario and SEER-Medicare were very similar, at US$10,094 and US$10,464 (p = 0.53), respectively. Mean costs for short-term survivors were US$12,836 and US$14,455 (p = 0.11). Inpatient hospitalization accounted for at least 60% of these costs
Chemotherapy administered within 14 days of death, more than 1 emergency department (ED) visit within 30 days of death, more than 1 hospitalization within 30 days of death, or at least 1 ICU admission within 30 days of death.	Costs were calculated for acute hospitalizations, ED visits, ambulatory oncology visits, sameday surgery, complex continuing care (inclusive of palliative care placement), long-term care, home care, physician assessments, certain intravenous chemotherapies, oral medications, and other resources (mental health admissions, dialysis, rehabilitation, and devices).	Yes	No	No	Macro-costing	Payer’s perspective (paid for by the Ontario Ministry of Health and Long-Term Care.)	The mean per-patient cost over the final month was $18,131 for patients receiving aggressive care and $12,678 for patients receiving nonaggressive carecare; the difference was $5453 (P<.0001).
Included the receipt of chemotherapy/targeted biologic, bevacizumab, radiation, growth factors,surgery, hospitalization and mean number of hospitalization, emer-gency department care, hospice care, and costs during the last sixmonths before death	Total health care costs were defined as the sum of amount indollars paid by the Medicare program for inpatient services, outpatient services, physician services, skilled nursing facility, hospice,and durable medical equipment for each patient for last six monthsof life, rather than the amount charged by the care providers.	Yes	No	No	Macro-costing	Payer’s perspective.	The mean totalhealth care cost was $42,749 for the last 6 months of life inpatients with lung cancer, with about $4000 more on average for those who survived beyond 6 months as compared to those who died within 6 months of diagnosis. The costs were higherfor surgery, bevacizumab and, growth factor, which were followedby chemotherapy/targeted therapy, radiation therapy, hospitaliza-tion, emergency department care, and hospice care.
Stay in the ICU, number of days on mechanical ventilation, catheter feeding, chemotherapy, resuscitation, and hospital or outpatient hospice	Considering both the place of death of the patient (intensive care unit [ICU], hospital outside the ICU, nursing home, inpatient hospice and home), and services (length of stay in the ICU, number of days on mechanical ventilation, catheter feeding, chemotherapy, resuscitation and hospital or outpatient hospice reported in the week before death)	Yes	No	No	Macro-costing	Payer’s perspective.	The mean estimated cost of care in the last week of life was $8,110 (SD = $9,957:range $1,022 - $38,819)
Without a detailed description.	Costs were aggregated over three different timeframes of analysis (6, 2 and 1 month prior to death). Outpatient service costs: costs paid by the provincial government, Out-of-pocket costs: costs paid by the patient/family, Third party costs: costs paid by private insurance, Unpaid caregiver time costs: costs of time loss from employment, leisure and household work due to care-giving responsibilities, Hospitalisation costs and Emergency room visit costs:	Yes	Yes	No	Macro-costing	Perspective of societal cost	The estimated total societal cost of end-of-life care was $34,197.73 per patient over the entire palliative trajectory (4 months on average). Results showed no significant difference (P > 0.05) in total societal costs between home and hospital death patients.Looking at costs of end-of-life care by location of death, the average total cost was $37,699.37 for patients who died at home and $29,658.57 for patients who died in hospitals (a difference of $8040.80).
Admission to the intensive care unit (ICU) within 30 days of death, hospital admission more than 14 days in the last 30 days of life, more than one hospital admission during the past 30 days of life, more than one emergency room visit during the last 30 days of life, death in an acute care setting, initiation of a new chemotherapy during the last 30 days of life, last chemotherapy within 14 days of death, and hospice admission less than 3 days before death.	Inpatient direct hospital costs were calculated in dollars for the last 30 days of life from hospital accounting records. Direct hospital cost was defined as combined cost for hospital stay, blood bank, medications, intravenous infusions, laboratory tests, intensive care unit stay, procedures, physical therapy, diagnostic radiology and respiratory therapy.	Yes	No	No	Micro-costing	Perspective of the health care facility (Montefiore Medical Center)	The median direct hospital cost for the last 30 days of life for patients with timely consultation was significantly less, $0 (range $0–$28,019) than for patients who had no/untimely consultation $7729 (range $0–52,720), p = 0.01. This difference persisted in comparison of median direct costs for the last 14 days of life $0 (range $0–$11,008) versus $3935 (range $0–$26,794), p = 0.01.
ICU admission, resuscitation, the number of chemotherapies administered, artificial nutrition	Hospital costs, medication costs, costs for additional medical services such as aids (e.g. hearing aids) or remedies such as massage/physiotherapy.	Yes	No	No	Macro-costing	Third party payer perspective in the German Statutory Health Insurance (SHI).	Total costs were higher for PC patients compared to routine care (21,879 € (±14,351€) vs. 17,885€ (±14,326€); difference 3994€ (95%-CI: [2648€; 18,973€]; p < 0.0001). (differences: hospital costs 2854.1D, medication costs 984.3D, additional medical services and medical aid costs 155.5D)
Urinary catheterization, nasogastric tube feeding, central venous catheter insertion, intensive care unit admission, endotracheal intubation, cardiopulmonary resuscitation, abdominal drainage, hemodialysis, percutaneous transhepatic cholangiography and drainage, chest tapping or intubation, defibrillation/cardioversion, total parenteral nutrition, epinephrine injection, and esophageal balloon insertion, than those in the hospice care group	Costs of examinations, procedures, surgeries, prescribed drugs, and special medical materials used during admission. The corresponding medical order files contained details of doctors’ orders, special medical materials, prescribed drug items, medical procedures, and laboratory tests.	Yes	No	No	Macro-costing	Payer’s perspective	The total medical expenses were significantly higher in the usual care group (adjusted mean = US$326/day, 95% confidence interval = 290–366 in the usual care group versus adjusted mean = US$114/day, 95% confidence interval = 102–128 in the hospice care group, P < 0.001).
Intensive care unit (ICU) admission, ER visits, ventilator use, chemotherapy, surgery, hemodialysis, total parenteral nutrition (TPN) within 2 months of death, and admission days within 6 months of death.	Included hospital charges and outpatient charges, only the direct medical costs	Yes	No	No	Micro-costing	Perspective of a university hospital - Seoul National University Hospital (SNUH)	The total medical cost within 6 months of death for the PCU group was significantly lower than the non-PCU group ($21,591 vs. $29,577, P<0.001).

Results

Characteristics of the Studies

Our data analysis was descriptive of the main characteristics of the studies and presenting a qualitative analysis of the common themes in the studies included in Tables 1 and 2.

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Table 2.

Characteristics of Studies by Periods.

	2010-2019	2020-2024	Total (%)
Number of papers a	26 (60,46%)	17 (39,53%)	43 (100%)
Study setting a
Asia	5 (11,62%)	5 (11,62%)	10 (23,25%)
Europe	3 (6,97%)	6 (13,95%)	9 (20,93%)
North America	18 (41,86%)	4 (9,30%)	22 (51,16%)
South America	0 (0%)	2 (4,65%)	2 (4,65%)
Minimum age for inclusion (years) a
Any age	8 (18,60%)	9 (20,93%)	17 (39,53%)
15 -39	1 (2,32%)	0 (0%)	1 (2,32%)
≥ 17 anos	7 (16,27%)	5 (11,62%)	12 (27,90%)
≥ 60 anos	10 (23,25%)	3 (6,97%)	13 (30,23%)
End-of-life period a
1 month	9 (20,93%)	4 (9,30%)	13 (30,23%)
6 months	7 (16,27%)	5 (11,62%)	12 (27,90%)
12 months	3 (6,97%)	3 (6,97%)	6 (13,95%)
Other period	2 (4,65%)	4 (9,30%)	6 (13,95%)
Various periods	2 (4,65%)	0 (0%)	2 (4,65%)
Not reported	3 (6,97%)	1 (2,32%)	4 (9,30%)
Cancer types a
Any	9 (20,93%)	9 (20,93%)	18 (41,86%)
One	13 (30,23%)	6 (13,95%)	19 (44,18%)
Group	4 (9,30%)	2 (4,65%)	6 (13,95%)
Cost identification method a
Microcosting	3 (6,97%)	5 (11,62%)	8 (18,60%)
Macrocosting	23 (53,48%)	12 (27,90%)	35 (81,39%)
Perspective a
Payer’s perspective	22 (51,16%)	10 (23,25%)	32 (74,41%)
Perspective of a hospital	3 (6,97%)	6 (13,95%)	9 (20,93%)
Perspective of societal cost	1 (2,32%)	0 (0%)	1 (2,32%)
Without descriptionn	0 (0%)	1 (2,32%)	1 (2,32%)
Costs a
Direct	26 (60,46%)	17 (39,53%)	43 (100%)
Indirect	2 (4,65%)	2 (4,65%)	4 (9,30%)
Intangible	0 (0%)	0 (0%)	0 (0%)

^aQualitative variables are presented in terms of absolute and relative frequencies [n (%)].

The oncological diagnoses of the studies analyzed resulted in 18 studies (41,86%) including all types of neoplasms,^15-32 and studies of a specific type of cancer, with eight studies (18.60%) of lung neoplasm,^33-40 three studies (6.97%) of pancreatic neoplasm,^8,41,42 two (4.65%) of breast cancer, ^43,44 two (4.65%) of hepatocellular carcinoma,^45,46 one (2.32%) of hematological neoplasms, ⁴⁷ one (2.32%) of multiple myeloma, ⁴⁸ one (2.32%) of brain neoplasm, ⁴⁹ and one (2.32%) studies of gynecological neoplasms. ⁵⁰ Joint evaluation of a group of solid neoplasms is present in seven studies (16.27%).^51-56

Most of articles (83.72%) describe the concept of aggressive measures or active treatments in end-of-life care.^{8,16,18-28,30-35,37-42,44-50,52,54-56} The main measures described were chemotherapy and emergency room visits associated with hospitalizations. All articles performed direct cost analysis, and four (9.30%) also performed indirect cost analysis.^15,17,29,54 No study evaluated intangible costs. The methodology for identifying health costs was macro-costing in 35 articles (81,39%).^{8,15,16,18,19,22,24-30,32,34-40,42-49,51-56} And micro-costing is mentioned in 8 articles (18.60%)^{17,20,21,23,31,33,41,50} among these, 1 article mentions top-down micro-costing ¹⁷ and 1 presents bottom-up micro-costing. ²⁰

The perspective of the payer was observed in 32 articles (74,41%) of this review, with four studies presenting coverage of National Health Systems involving Ministries of Health.^8,27,30,47 And in the most of US studies (30,23%) the Medicare perspective was used.^{16,28,36,37,40,42-44,48,49,53,55,56} The perspective of hospitals providing health care is present in 9 articles (20,93%) involving public or philanthropic hospitals associated with universities, most of them.^{17,20,21,23,31,33,34,41,50} Only one study highlights the perspective of the society, carried out in Canada. ²⁹ This information is described in Tables 1 and 2.

The period considered for end-of-life care in the economic evaluation of 13 studies (30.23%) was the last 30 days of life,^{20,27,34,36,38,41,42,44,47-50,56} followed by 12 studies (27.90%) analyzing the last 6 months,^{16,18,22,30,31,35,37,39,40,45,52,53} and 6 studies (13.95%) considered the last year of patients’ lives.^{15,24,25,51,55} Six studies considered other periods,^{19,23,28,33,43,54} four studies (9.30%) did not establish a specific period,^8,17,21,46 and two studies (4.65%) evaluated different periods of cohort follow-up to compare costs in end-of-life care.^26,29

The studies selected samples ranging in size from 70 to 339,546 patients. Regarding the age range of patients, 17 studies (39.53%) did not define an age-specific,^{8,16-18,22,23,25,28,29,33,35,38,41,43,50,52,53} 13 studies (30.23%) involved only elderly patients,^{15,26,36,37,39,40,42,44,46,48,49,51,55} and 13 studies (30.23%) involved adolescent and adult patients.^{19-21,24,27,30-32,34,45,47,54,56}

Most of the studies in this review were developed by countries in the Northern Hemisphere, involving 41 studies, representing 95,34% of the total. Twenty-two studies (51.16%) were carried out in North America, seventeen (39.53%) in the United States, ^{16,19,24,26,28,36,37,40,42-44,48-50,53,55,56} and five (11.62%) in Canada.^{23,27,29,39,45} Ten (23.25%) in East Asia,^{8,22,25,31-33,46,51,52} nine (20.93%) in Europe ^{15,17,18,30,34,35,38,41,54} and two studies (4,65%) in South America.^20,21

Quality of Studies

The assessment of the methodological quality and risk of bias of the studies included in this review classified the articles as good and average quality, with 33 articles with a good classification (76.74%)^{16,18,20,21,23-32,34-41,43,45-51,56} and an average classification in 10 articles (23.25%),^{15,17,19,22,33,42,44,52-55} according to Drummond’s check-list for analyzing the methodological quality of economic evaluations presented in Table 3.

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Table 3.

Drummond's Check-List for Assessing Economic Evaluations.

Study	1. Was a well-defined question posed in answerable form?	2. Was a comprehensive description of the competing alternatives given?	3. Was the effectiveness of the programme or services established?	4. Were all the important and relevant costs and consequences for each alternative identified?	5. Were costs and consequences measured accurately in appropriate physical units?	6. Were the cost and consequences valued credibly?	7. Were costs and consequences adjusted for differential timing?	8. Was an incremental analysis of costs and consequences of alternatives performed?	9. Was allowance made for uncertainty in the estimates of costs and consequences?	10. Did the presentation and discussion of study results include all issues of concern to users?	Score (Doran,2008)
Balasubramanian,I, 2024, Singapore	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Good
Diernberger K, 2023, Scotland	Y	N	Y	Y	Y	Y	C	N	Y	Y	Average
Mantz, C. A, 2023, USA	Y	N	Y	Y	Y	Y	Y	N	Y	Y	Good
Perdikouri, K, 2023, Greece	Y	N	Y	Y	Y	Y	C	N	Y	Y	Average
Bjonelv G, 2022,Norway	Y	N	Y	Y	Y	Y	Y	N	Y	Y	Good
Han K T, 2022, Republic
of Korea	Y	N	Y	Y	Y	Y	Y	N	Y	Y	Good
Kang, D W, 2022, South Korea	Y	N	Y	Y	Y	Y	C	N	Y	Y	Average
Awano N, 2021, Japan	Y	N	Y	Y	Y	Y	C	N	Y	Y	Average
Blayney D W, 2021, USA	Y	N	Y	Y	Y	Y	Y	N	Y	Y	Good
Bylicki O, 2021, France	Y	N	Y	Y	Y	Y	Y	N	Y	Y	Good
Deeb S, 2021, USA	Y	N	Y	Y	Y	Y	C	N	Y	Y	Average
Ito Suffert, S C, 2021, Brazil	Y	N	Y	Y	Y	Y	Y	N	Y	Y	Good
Kokkotou, E, 2021, Greece	Y	N	Y	Y	Y	Y	Y	N	Y	Y	Good
Martins Rozman, L, 2021, Brazil	Y	N	Y	Y	Y	Y	Y	N	Y	Y	Good
Rautakorpi, L, 2021, Finland	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Good
Fiala M A, 2020, USA	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Good
Li, Z, 2020, China	Y	N	Y	Y	Y	Y	C	N	Y	Y	Average
Chen Y, 2019, USA	Y	N	Y	Y	Y	Y	Y	N	Y	Y	Good
Chiang J K, 2019, Taiwan	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Good
Karanth, S, 2019, USA	Y	N	Y	Y	Y	Y	Y	N	Y	Y	Good
Kyeremanteng, K,2019, Canada	Y	Y	Y	Y	Y	Y	C	Y	Y	Y	Good
Crouch E, 2018,USA	Y	N	Y	Y	Y	Y	C	N	Y	Y	Average
Deckert K, 2018, German	Y	Y	Y	Y	Y	Y	C	Y	Y	Y	Good
Dover L L, 2018, USA	Y	Y	Y	Y	Y	Y	C	Y	Y	Y	Good
Haltia O, 2018, Finland	Y	N	Y	Y	Y	Y	C	N	Y	Y	Average
Johnston, E E , 2018, USA	Y	N	Y	Y	Y	Y	Y	N	Y	Y	Good
Accordino M K, 2017, USA	Y	N	Y	Y	Y	Y	C	N	Y	Y	Average
Bao Y, 2017, USA	Y	Y	Y	Y	Y	Y	C	Y	Y	Y	Good
Hung, Y. N,2017, Taiwan	Y	N	Y	Y	Y	Y	Y	N	Y	Y	Good
Bekelman J E, 2016, USA	Y	N	Y	Y	Y	Y	Y	N	Y	Y	Good
Thein, H H, 2016, Canada	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Good
Wang, H, 2016, USA	Y	N	Y	Y	Y	Y	C	N	Y	Y	Average
Wang, J.P., 2016, Taiwan	Y	Y	Y	Y	Y	Y	C	Y	Y	Y	Good
Ashleigh Guadagnolo B, 2015,USA	Y	N	Y	Y	Y	Y	Y	N	Y	Y	Good
Bremner K E, 2015, Canada	Y	N	Y	Y	Y	Y	Y	N	Y	Y	Good
Cheung M C, 2015, Canada	Y	Y	Y	Y	Y	Y	C	Y	Y	Y	Good
Du X L, 2015,USA	Y	N	Y	Y	Y	Y	Y	N	Y	Y	Good
Garrido M M, 2015, USA	Y	Y	Y	Y	Y	Y	C	Y	Y	Y	Good
Yu, M, 2015, Canada	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Good
Nevadunsky, N S, 2014, USA	Y	Y	Y	Y	Y	Y	C	Y	Y	Y	Good
Gaertner J, 2013, Germany	Y	Y	Y	Y	Y	Y	C	Y	Y	Y	Good
Hwang. SJ,2013, Taiwan	Y	Y	Y	Y	Y	Y	C	Y	Y	Y	Good
Jung, H M, 2010, South Korea	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Good

Y (Yes), N (No), and C (Can't tell).

Discussion

Our study presents a systematic review with the objective of evaluating observational articles presenting the costs of end-of-life care for oncology patients. A relevant aspect identified is the predominance of studies evaluating costs in end-of-life care in the Northern Hemisphere (95.34%), with more than half of the studies (51.16%) being developed in North America. The scarcity of data in the literature on the costs of end-of-life care in low- and middle-income countries demonstrates a gap in information on the expenses involved in end-of-life cancer care in these countries. Data from the World Health Organization (WHO) highlights that in low- and middle-income countries, the most of people die without access to palliative care and with poorer quality of care. ⁹

In recent decades, the number of articles published on the topic of end-of-life care has increased in the main databases, our results suggest how the theme has been more explored recently, evidence that allows us to structure more consistent public policies aimed at developing end-of-life care. Although our search did not consider the entire year 2024, 17 articles (39.53%) included were published after 2020. Albeit the increase in the volume of studies is extremely positive, the heterogeneity in cost methods and on the definition of the period of end-of-life care highlights the lack of consensus and the gap in the literature. Most of the studies were from a payer perspective (74,41%) and based on macrocosting methodologies (81,39%), which limit the use of the information to evaluate variabilities in the consumption of resources. ⁵⁷ The societal perspective was developed in just one study in Canada, published by Yu et al. in 2015. We did not identify this perspective in more recent studies. ²⁹ An important piece of data presented from society’s perspective was that the average total cost of end-of-life care for all patients (death at home or in hospital) was US$34,197.73 throughout the entire palliative trajectory, which on average presented a duration of 4 months. Public health system costs represented 46.72% of total costs, and private costs represented 53.28%. ²⁹ And the period defined as end-of-life varied across 1 month and years. It eliminates the opportunity to compare studies and cost information for similar clinical conditions.

All studies selected for analysis in this systematic review highlighted direct costs and only 9.3% analyzed indirect costs in an associated manner. The availability of consolidated data and the possibility of analyzing large databases available from Health Systems favor the performance of studies with the perspective of the payer, with analysis of direct costs. However, we know that oncological diseases have a great impact on the lives of patients and their families, ²⁹ causing a reduction in work capacity associated with higher costs of travel for care and medication, absences from work, which are indirect costs, associated with intangible costs related to pain and suffering due to the clinical condition. Direct impacts on quality of life, with reflections and consequences for the perspective of society, and the scarcity of studies in this area identified in this Review indicate a knowledge gap.

Another aspect identified in our study is that heterogeneity was also present in the oncological diagnoses considered in the studies. Oncological diagnosis was explored in 39.53% of the studies included all types of cancer,^15-31 enabling a comprehensive assessment of the costs of the different types of cancer in the population evaluated, 44.18% studies focused on one type of câncer^8,33-50 that allowed the evaluation of specific interventions, Additionally, many studies had small population sizes and were limited to a single institution, ^{17,20,21,23,31,33,41,50} and the biggest samples were identified on the studies based on Medicare administrative data.^{16,28,36,37,40,42-44,48,49,53,55,56}

The studies selected in this systematic review did not present uniformity in the end-of-life periods considering the time horizon, but it is possible to observe that almost 31% of the studies evaluated the last month of life, a fact that can be justified by the evidence that the greatest expenses would be involved in this period. The study by Hung et al., ²⁵ in 2017, evaluating the last year of life, highlighted that a third of the expenses occurred in the last month of patients’ lives. Similar findings observed in the area of cancer treatment indicate a significant increase in expenses during the last weeks.^{15,32,33,51,54}

Considering that health services use a service model focused on maximizing volume measured through productivity, the costs of end-of-life care are significant. ⁵⁸ A change in approach by Palliative Care, focused on a proposal that ‘less is more’^58,59 with emphasis on patient preferences and quality of life, generally promotes greater patient satisfaction, cost avoidance ⁶⁰ and better care quality metrics for the patient and their family^58,59,61-63 A systematic review, conducted by May et al., in 2018, demonstrated in stratified analyses that there was a reduction in costs for cancer (−$4251; 95% CI, −$4664 to −$3837; P < 0.001), these results suggest that palliative care is more effective in changing patterns of care for patients with life-threatening illnesses and that it may be possible for hospitals to reduce costs by implementing palliative care. ⁶⁰

The majority of studies, 76.74%, in the review are of good quality,^{16,18,20,21,23-32,34-43,45-51,55,56} and 23.25% are of average quality.^{15,17,19,22,33,44,52-55} It is important to highlight two points in relation to the assessment of the methodological quality of the studies: criterion 7 was not possible to identify in the analysis of some articles, as the description or reference of costs in relation to the currency of the year of the study, as well as the equivalence with the dollar at the time of the research, was not identified in 20 studies (46.51%) of this review.^{8,15,17,19,22,23,27,28,30,33,38,42,44,46,49,50,52-55} Another significant aspect is that the design of the selected studies did not include a comparator or alternative technology, as described in criteria 2 and 8 of the checklist. As a result, only 16 studies (37.20%) carried out comparisons between conventional hospital care and palliative care, hospital care vs home care or palliative care, or the use of chemotherapy in end-of-life care vs its suspension, thus scoring these criteria.^{8,23,27-31,38,41,42,45-50}

Limitations

New studies on the costs of end-of-life care, presenting a standardization of criteria for economic evaluations, involving a societal perspective, analyzing direct, indirect and intangible costs and also including the pediatric age group, are necessary to understand the resources and costs involved in end-of-life care for cancer patients, for structuring sustainable health policies, with better quality of life and support for patients and their families, through a care process that involves value-based health.

Conclusion

Considering the complexity of the end-of-life care period and the need for consistent data in relation to the care costs involved in this stage of life, the development of more studies, mainly in middle and low-income countries and approaches to indirect and intangible costs, with the perspective of society are of great importance for the development of public health policies and planning of health managers, in accordance with the trend of transforming value-based care, allowing the health care system to create more value for patients and their families.

We believe that future research in this area will be fundamental for the better utilization of healthcare resources. However, we believe that there is a lack of standardization in conducting these studies, such as study design, assessed costs, interval between death and the start of observation, and study perspective. This standardization would be crucial for using the data to develop international guidelines for more efficient end-of-life care.

Supplemental Material

Supplemental Material