FIG. 12:  A number of data sets have shown that surveillance is a toxic financial situation for patients.  Figure 12 shows results from a 4-year interval in the Surveillance, Epidemiology, and End Results (SEER) Program–Medicare-linked database.^[14]  Among almost 7000 patients, 60% did not have complete surveillance, meaning that only 40% of patients had complete surveillance, stratified by care pathways. The primary reasons for lack of surveillance were the huge costs and financial toxicity.  Patients were less likely to have complete follow-up and surveillance if they were older, lived in an urban environment, were black, or had low-risk cancer. 

The right half of the Figure shows data from a later report, looking at over 20,000 SEER-Medicaid patients whose care was delivered by 940 clinicians.^[15]  Again there was large variability in cost in the management of the disease, with much of this burden coming from the follow-up of patients.  Clinicians have different risk criteria for managing and following patients, and the result was a 3-fold difference in expenditure per patient, ranging from $2800 for low-treatment intensity providers to $7100 for high-treatment intensity providers.  Of note, however, the difference in costs was associated with no difference in benefit or survival.