August 08, 2018
3 min read

Adolescents treated at pediatric cancer centers incur higher costs

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Photo of Paul Nathan 2018
Paul Nathan

Adolescents with cancer treated at pediatric institutions had greater health care use and higher costs than those treated at adult institutions, according to a Canadian population cohort study.

“This study is part of a larger body of work that has assessed the costs of caring for children and adolescents with cancer, and compared them between two Canadian provinces — Ontario and British Columbia,” Paul Nathan, MD, MSc, clinician investigator and the director of the aftercare program in the division of hematology/oncology at The Hospital for Sick Children, told HemOnc Today. “We were particularly interested in looking at the costs for adolescents and young adults (AYA) because AYA with a cancer are a vulnerable group of patients, often failing to find an ideal ‘medical home’ in either pediatric or adult institutions.”

Nathan and colleagues identified 1,356 Ontario adolescents aged 15 to 17.9 years diagnosed with cancer from 1995 to 2010 from provincial cancer registries. The researchers compared heath care resource use and costs — in 2012 Canadian dollars — for 691 adolescents (median age at diagnosis, 17 years; 51.5% female) treated in adult institutions and 665 adolescents (median age, 16 years; 45.3% female) treated in pediatric institutions.

Cancer diagnoses included leukemia (n = 176), lymphoma (n = 394), central nervous system tumor (n = 134), bone and soft tissue sarcoma (n = 201), germ cell tumor (n = 161), thyroid carcinoma (n = 147) and other cancers (n = 143).

Adolescents treated at pediatric centers appeared more likely to be younger, to be male and to have died during follow-up.

Investigators compared health care use and costs at four phases to address the fact that some patients may not have contributed data to the entire care trajectory. The phases included prediagnosis (60 days before diagnosis), initial (360 days after diagnosis), terminal (360 days before death for those who died before Dec. 27, 2011) and continuing (time between initial phase and terminal phase or end of observation).

Hospitalization rates appeared higher for those treated at pediatric centers during the prediagnosis (14.9% vs. 6.9%; P < .001), initial (95.1% vs. 73.3%; P < .001) and continuing phases (43.2% vs. 34.4%; P = .002) compared with those treated at adult centers. However, during the terminal phase, hospitalization rates appeared similar between the two groups (96.1% vs. 96.3%).

Adolescents treated at pediatric centers appeared more likely to visit an ED during the prediagnosis (38.2% vs. 22.9%; P < .001) and initial (66.9% vs. 48.9%; P < .001) phases than those treated at adult centers.


For all cancer types, median initial phase costs per 360 days appeared higher for those treated in pediatric institutions (eg, leukemia: $153,926 vs. $102,418; P < .001; lymphoma: $65,025 vs. $19,846; P < .001).

“There are disparities in outcomes depending on where these patients are treated and, as shown in this study, there also are disparities in the costs of care,” Nathan said. “As cancer care providers continue the work of developing AYA-focused oncology programs, it is important to balance these factors to determine the most effective and cost-effective models for caring for AYA with cancer.”

The limitations of the study included inability to account for psychosocial services, outpatient medications and complementary/alternative medicine; the lack of a multivariable model; and potential confounders.

“These findings should not be viewed in isolation,” Nathan said. “Yes, the costs of caring for AYA in pediatric institutions were considerably higher than care in adult institutions, but there is evidence that for many cancers, outcomes are better when AYA patients are treated in pediatric centers, or on pediatric protocols.”

Further research needs to be done before these findings could be generalized to the United States, Helen M. Parsons, MD, MPH, and colleagues wrote in an accompanying editorial.

“Nathan and colleagues present several important contributions to our understanding of how the treatment setting contributes to variations in treatment and care across the cancer continuum,” they wrote. “However, more work is required to fully demonstrate the role of the treatment setting in AYA health care utilization and outcomes outside of Ontario. Given the critical differences in health care delivery and payment between Canada and the United States, it is important that similar studies be conducted in the United States to confirm these findings in other populations.” – by Cassie Homer

For more information:

Paul Nathan, MD, MSc, can be reached at The Hospital for Sick Children, 555 University Ave., Room 9402 Black Wing, Toronto, ON M5G1X8, Canada; email:

Disclosures: The authors report no relevant financial disclosures.