the burden of cancer and cancer care in developed countries is projected to rise due to both higher prevalence and advancing medical technology . in korea , cancer has been the leading cause of death since the year 2000   and cancer incidence is expected to rise from 202,053 in 2010 to 270,809 in 2015 . in other words the societal burden of cancer in korea is substantial and increasing rapidly . cancer care costs vary by the clinical care phase , and a significant portion of the expenditure occurs in the last year of life , consistent with the intensity of care . chastek et al .   noted that terminal cancer patients spent us $ 74,212 on average during their last 6 months of life , which is considerably higher than the average medicare beneficiary s expenditure of us $ 35,156 in the last year of life   ( both in 2009 us $ ) and likely attributable to costly cancer treatments . however , studies on end - of - life medical expenditures for cancer are relatively limited in korea . yi et al .   investigated cancer care costs by the site of cancer and survival time but did not fully explore other possible predictors of costs . focused on the effects of education level on cancer care cost but failed to examine other costdetermining factors , such as comorbidities and survival time . choi et al .   compared cost differences between receiving hospice care and conventional care . however , it focused mainly on comparing medical expenses between a small patient group ( n=529 ) who used hospice care and a comparison group ( n=1,908 ) who did not , and it was limited in terms of estimating cancer care costs in a representative sample . lastly , none of these studies provided a breakdown of spending on the components of cancer care . in the current study , we assess the cancer care cost in the last year of life by treatment component to examine healthcare utilization patterns of terminal cancer patients . in addition to variables that yi et al .   and choi et al .   found to affect the cancer care cost , we incorporated monthly insurance premium level , surveillance , epidemiology , and end results ( seer ) cancer stage , and charlson comorbidty index level into our analysis . we examined each variable s effect on the cancer care cost , including income level , represented by the insurance premium level , which is known to cause inequalities in health care utilization by cancer patients in korea . also , we observed few representative variables of a cancer patient s health care utilization pattern , including the frequency of diagnostic imaging that is non - negligible contributor to the overall cancer care cost . to secure reliable data , we used the korean national health insurance ( knhi ) database . knhi is a nationwide population - based database in which nearly all treatment - related information is available because medical providers are paid on a fee - for - service basis in korea . using this unique data set , we estimated cancer care costs during the last year of life according to patient characteristics and the components of cancer care treatment , which , in turn , enabled us to identify healthcare utilization patterns of the terminal cancer patients . the two major data sources used were the korean central cancer registry ( kccr ) and the knhi claims database . kccr is a nationwide cancer registry program sponsored by the government in which more than 180 hospitals participate . the completeness of registration for 2009 was estimated to be 97.2% of cancer cases . for each patient , the kccr included information on gender , age at diagnosis , date of diagnosis , cancer site , histology , and the seer summary stage . among 878,834 cancer cases in the kccr in 2009 , 72,563 cancer decedents were selected . patients with incomplete death information ( n=1,836 ) and those with no medical claims history ( n=139 ) were excluded , leaving 70,558 patients in the study ( fig . knhi scheme was launched by the government in 1989 as a mandatory universal health insurance program for the whole population , and the knhi database contains claims data for medical services in korea . it includes information on patient gender , age , health insurance premiums , residential area , comorbid diseases , specific surgical procedures , and medical expenditures . cancer patients were classified by tumor type for those with a cancer diagnosis of stomach , lung , liver , colon and rectum , breast , cervix uteri , thyroid , gallbladder , pancreas , bladder , prostate , kidney , esophagus , ovary , leukemia , oral cavity , larynx , melanoma of skin , brain and central nervous system , non - hodgkin s disease , hodgkin s disease , multiple myeloma , testis , corpus uteri , nasopharynx , and other pharynx . this study was approved by the korean national cancer center institutional review board . the requirement for informed consent was waived , because the study was based on routinely collected administrative or registry data . the following patient characteristics were included : gender , age , insurance premium level , residential area , medical utilization , seer summary stage , charlson comorbidity index , survival time , and site of cancer . patient age at death was divided into five categories : < 20 , 20 - 49 , 50 - 59 , 60 - 69 , and  70 years . based on income levels , we identified individuals in the insurance premium categories of below poverty line ( lowest ) , i , ii , iii , iv , and v ( highest ) to create income groups with approximately equal numbers of subjects . knhi contribution was used as a proxy measure for actual household income because it is calculated based on the income , property , and private auto taxes for each household . patients were grouped into three residential area categories of metropolitan , urban , and rural , according to korean zip code . we also used the seer summary stage information within the kccr data which categorizes how far a cancer has spread from its origin . the four categories of summary staging information available in the kccr data are localized , regional , distant , and unknown . regional stage refers to a state where a tumor extends beyond the limits of the organ of origin . distant stage includes tumors that have spread to areas of the body distant from the primary tumor . lastly , cases for which sufficient evidence is not available to adequately assign stage are categorized under unknown . the charlson comorbidity index , which is a single index of comorbidity burden developed to assess the relative risk of a patient s comorbid conditions for determining patient outcome after a critical illness , was used to group patients into four categories according to the index score : 0 , 1 - 2 , 3 - 4 , and  5 ( the most severe ) . survival time was defined as the period from the date of cancer diagnosis to that of death or end of follow - up . the date of diagnosis was obtained from the kccr . for cases in which patients were diagnosed with multiple cancers we classified medical institutions as clinics and small hospitals , general hospitals , tertiary hospitals , or tertiary referral hospitals . clinics are small , private medical facilities dedicated to outpatient services and equipped with up to 30 beds . small hospitals are equipped with more than 30 beds . tertiary hospitals are general hospitals that are usually affiliated with universities , provide a certain quality of care , perform research , and act as teaching institutions . tertiary referral hospitals are those that provide outstanding medical care . patterns of healthcare utilization were also assessed . namely the mean number of inpatient days / visits , outpatient days / visits , and emergency department visits and the use of computed tomography ( ct ) , positron emission tomography ( pet ) , and magnetic resonance imaging ( mri ) were examined . in addition , the components of cancer care costs were examined as follows : identifying costs associated with radiotherapy , chemotherapy , surgeries ( e.g. , resection ) , general tests ( e.g. , lab tests and x - rays ) , diagnostic imaging ( e.g. , ct , pet , mri , angiography , nuclear medicine imaging , and bone densitometry ) , analgesic drugs ( e.g. , morphine and nonsteroidal anti - inflammatory drugs ) , drugs other than analgesics , general costs ( e.g. , fees for physician consultations , inpatient admission , meals , basic treatment such as incisions and dressings ) , rehabilitation , and psychotherapy . the last year of life was defined as the final 12 months of life , and the mean medical cost in the last year of life was calculated by combining the medical claims for each individual . all cost measures were computed as combined insurer and co - payment amounts for each claim and were adjusted to 2009 us $ using an annual average exchange rate of 1,164.5 korean won in 2009 . descriptive analyses were performed for the categories of decedent gender , age , insurance premium level , residential area , seer stage , charlson comorbidity index , survival time , emergency department use , site of cancer , and medical utilization . multiple linear regression analyses were performed to estimate the association between mean cancer care cost during the last year of life and decedent 's demographic and clinical characteristics . to correct for the skewed distribution of the medical cost data , we used the log - transformed mean cancer care cost as the outcome variable . two - sided p - values of  0.05 were considered to indicate statistical significance . the two major data sources used were the korean central cancer registry ( kccr ) and the knhi claims database . kccr is a nationwide cancer registry program sponsored by the government in which more than 180 hospitals participate . the completeness of registration for 2009 was estimated to be 97.2% of cancer cases . for each patient , the kccr included information on gender , age at diagnosis , date of diagnosis , cancer site , histology , and the seer summary stage . among 878,834 cancer cases in the kccr in 2009 , 72,563 cancer decedents were selected . patients with incomplete death information ( n=1,836 ) and those with no medical claims history ( n=139 ) were excluded , leaving 70,558 patients in the study ( fig . knhi scheme was launched by the government in 1989 as a mandatory universal health insurance program for the whole population , and the knhi database contains claims data for medical services in korea . it includes information on patient gender , age , health insurance premiums , residential area , comorbid diseases , specific surgical procedures , and medical expenditures . cancer patients were classified by tumor type for those with a cancer diagnosis of stomach , lung , liver , colon and rectum , breast , cervix uteri , thyroid , gallbladder , pancreas , bladder , prostate , kidney , esophagus , ovary , leukemia , oral cavity , larynx , melanoma of skin , brain and central nervous system , non - hodgkin s disease , hodgkin s disease , multiple myeloma , testis , corpus uteri , nasopharynx , and other pharynx . this study was approved by the korean national cancer center institutional review board . the requirement for informed consent was waived , because the study was based on routinely collected administrative or registry data . the following patient characteristics were included : gender , age , insurance premium level , residential area , medical utilization , seer summary stage , charlson comorbidity index , survival time , and site of cancer . patient age at death was divided into five categories : < 20 , 20 - 49 , 50 - 59 , 60 - 69 , and  70 years . based on income levels , we identified individuals in the insurance premium categories of below poverty line ( lowest ) , i , ii , iii , iv , and v ( highest ) to create income groups with approximately equal numbers of subjects . knhi contribution was used as a proxy measure for actual household income because it is calculated based on the income , property , and private auto taxes for each household . patients were grouped into three residential area categories of metropolitan , urban , and rural , according to korean zip code . we also used the seer summary stage information within the kccr data which categorizes how far a cancer has spread from its origin . the four categories of summary staging information available in the kccr data are localized , regional , distant , and unknown . regional stage refers to a state where a tumor extends beyond the limits of the organ of origin . distant stage includes tumors that have spread to areas of the body distant from the primary tumor . lastly , cases for which sufficient evidence is not available to adequately assign stage are categorized under unknown . the charlson comorbidity index , which is a single index of comorbidity burden developed to assess the relative risk of a patient s comorbid conditions for determining patient outcome after a critical illness , was used to group patients into four categories according to the index score : 0 , 1 - 2 , 3 - 4 , and  5 ( the most severe ) . survival time was defined as the period from the date of cancer diagnosis to that of death or end of follow - up . the date of diagnosis was obtained from the kccr . for cases in which patients were diagnosed with multiple cancers , we classified patients according to the last diagnosis . we classified medical institutions as clinics and small hospitals , general hospitals , tertiary hospitals , or tertiary referral hospitals . clinics are small , private medical facilities dedicated to outpatient services and equipped with up to 30 beds . tertiary hospitals are general hospitals that are usually affiliated with universities , provide a certain quality of care , perform research , and act as teaching institutions . namely the mean number of inpatient days / visits , outpatient days / visits , and emergency department visits and the use of computed tomography ( ct ) , positron emission tomography ( pet ) , and magnetic resonance imaging ( mri ) were examined . in addition , the components of cancer care costs were examined as follows : identifying costs associated with radiotherapy , chemotherapy , surgeries ( e.g. , resection ) , general tests ( e.g. , lab tests and x - rays ) , diagnostic imaging ( e.g. , ct , pet , mri , angiography , nuclear medicine imaging , and bone densitometry ) , analgesic drugs ( e.g. , morphine and nonsteroidal anti - inflammatory drugs ) , drugs other than analgesics , general costs ( e.g. , fees for physician consultations , inpatient admission , meals , basic treatment such as incisions and dressings ) , rehabilitation , and psychotherapy . the last year of life was defined as the final 12 months of life , and the mean medical cost in the last year of life was calculated by combining the medical claims for each individual . all cost measures were computed as combined insurer and co - payment amounts for each claim and were adjusted to 2009 us $ using an annual average exchange rate of 1,164.5 korean won in 2009 . descriptive analyses were performed for the categories of decedent gender , age , insurance premium level , residential area , seer stage , charlson comorbidity index , survival time , emergency department use , site of cancer , and medical utilization . multiple linear regression analyses were performed to estimate the association between mean cancer care cost during the last year of life and decedent 's demographic and clinical characteristics . to correct for the skewed distribution of the medical cost data , we used the log - transformed mean cancer care cost as the outcome variable . two - sided p - values of  0.05 were considered to indicate statistical significance . individuals 70 years of age or older accounted for 52.1% of the patients , and the mean age was 68.0 years ( standard deviation [ sd ] , 13.4 years ) . there were 8,680 patients ( 12.3% ) below poverty line , and the largest percentage ( 28.4% ) was in the highest income class ( v ) . because the study population consisted of decedents , most ( n=22,549 , 32.0% ) were classified under the distant seer summary stage . however , most of the patients ( n=58,728 , 83.2% ) scored  2 on the charlson comorbidity index , suggesting a relatively low level of comorbidity . of the subjects , 35.1% used the emergency department at least once during the last year of life . lung cancer was the most frequent type of cancer ( n=14,070 , 19.9% ) , followed by liver ( n=11,290 , 16.0% ) and stomach ( n=11,044 , 15.7% ) cancers . cancer care costs and healthcare utilization of patients in the last year of life are presented in table 1 . patients younger than 20 years spent the most while those 70 years or older spent the least . the effects of residential area were also examined , revealing that patients living in metropolitan areas had higher costs than those in urban and rural areas . over half of the decedents had survival times of less than 1 year , and those surviving 1 to 2 years incurred the highest costs ( us $ 18,864 ) , whereas patients surviving more than 5 years incurred the lowest costs ( us $ 13,897 ) . patients with leukemia incurred the highest mean medical costs ( us $ 43,219 ) , followed by non - hodgkin s disease ( us $ 28,012 ) , multiple myeloma ( us $ 26,491 ) , testicular cancer(us $ 25,714 ) , and brain and central nervous system cancers ( us $ 24,232 ) . on average , patients were hospitalized for 71 days , spent 40 days equivalent time using outpatient services , visited the emergency department 0.7 times , and underwent ct , pet , and mri 4 , 0.6 , and 0.8 times , respectively ( table 1 ) . the distribution of cancer care costs by the category of service is presented in fig . the majority was attributable to inpatient costs ( us $ 12,385 , 78.8% ) , followed by outpatient costs ( us $ 2,483 , 15.8% ) and drug costs ( us $ 851 , 5.4% ) . 2b presents the distribution of cancer care costs by the type of medical institution . among total cancer care costs ( us $ 1,048 million ) , those at tertiary referral hospitals were the highest ( $ 578 million , 55.1% ) , followed by tertiary hospitals ( $ 347 million , 29.3% ) , general hospitals ( $ 96 million , 9.2% ) , and clinics ( $ 27 million , 2.6% ) , indicating a higher rate of larger hospital use by terminal cancer patients . costs increased steadily as the patient approached death , from $ 644 in the 12th month to $ 2,480 in the last month before death . the highest medical costs occurred 2 months prior to death ( $ 2,665 , 17.0% ) , and 69.5% of the total medical expenditure during the last year of life was spent in the last 6 months . 4 presents cancer care costs by the type of treatment component and survival time . on average , general costs were the highest ( 29.7% ) , followed by other drugs ( 23.8% ) , general tests ( 14.3% ) , chemotherapy ( 11.6% ) , imaging tests ( 6.4% ) , surgery ( 4.7% ) , analgesia ( 4.3% ) , radiotherapy ( 2.9% ) , rehabilitation ( 0.7% ) , and psychotherapy ( 0.1% ) . costs associated with chemotherapy , surgery , radiotherapy , and imaging tests were higher in patients with shorter survival time , although the differences were small . and costs associated with psychotherapy and rehabilitation , which are supportive care services , were very low regardless of patients survival time . the predictors of cancer care costs are presented in table 2 . in our study population higher income level , indicated by the insurance premium , was positively associated with cancer care costs , although insurance premium levels iii and iv showed no statistically significant association . compared with patients living in metropolitan areas , those in urban and rural areas were more likely to have lower costs . as would be expected , having more progressed cancer and higher comorbidity scores were also associated with higher mean medical costs . survival time was positively associated with cancer care costs , although surviving more than 5 years was associated with lower costs , albeit not statistically significantly so . finally , using the emergency department in the last year of life resulted in relatively high costs . individuals 70 years of age or older accounted for 52.1% of the patients , and the mean age was 68.0 years ( standard deviation [ sd ] , 13.4 years ) . there were 8,680 patients ( 12.3% ) below poverty line , and the largest percentage ( 28.4% ) was in the highest income class ( v ) . because the study population consisted of decedents , most ( n=22,549 , 32.0% ) were classified under the distant seer summary stage . however , most of the patients ( n=58,728 , 83.2% ) scored  2 on the charlson comorbidity index , suggesting a relatively low level of comorbidity . of the subjects , 35.1% used the emergency department at least once during the last year of life . lung cancer was the most frequent type of cancer ( n=14,070 , 19.9% ) , followed by liver ( n=11,290 , 16.0% ) and stomach ( n=11,044 , 15.7% ) cancers . cancer care costs and healthcare utilization of patients in the last year of life are presented in table 1 . patients younger than 20 years spent the most while those 70 years or older spent the least . the effects of residential area were also examined , revealing that patients living in metropolitan areas had higher costs than those in urban and rural areas . over half of the decedents had survival times of less than 1 year , and those surviving 1 to 2 years incurred the highest costs ( us $ 18,864 ) , whereas patients surviving more than 5 years incurred the lowest costs ( us $ 13,897 ) . patients with leukemia incurred the highest mean medical costs ( us $ 43,219 ) , followed by non - hodgkin s disease ( us $ 28,012 ) , multiple myeloma ( us $ 26,491 ) , testicular cancer(us $ 25,714 ) , and brain and central nervous system cancers ( us $ 24,232 ) . on average , patients were hospitalized for 71 days , spent 40 days equivalent time using outpatient services , visited the emergency department 0.7 times , and underwent ct , pet , and mri 4 , 0.6 , and 0.8 times , respectively ( table 1 ) . the distribution of cancer care costs by the category of service is presented in fig . 2a . the majority was attributable to inpatient costs ( us $ 12,385 , 78.8% ) , followed by outpatient costs ( us $ 2,483 , 15.8% ) and drug costs ( us $ 851 , 5.4% ) . 2b presents the distribution of cancer care costs by the type of medical institution . among total cancer care costs ( us $ 1,048 million ) , those at tertiary referral hospitals were the highest ( $ 578 million , 55.1% ) , followed by tertiary hospitals ( $ 347 million , 29.3% ) , general hospitals ( $ 96 million , 9.2% ) , and clinics ( $ 27 million , 2.6% ) , indicating a higher rate of larger hospital use by terminal cancer patients . costs increased steadily as the patient approached death , from $ 644 in the 12th month to $ 2,480 in the last month before death . the highest medical costs occurred 2 months prior to death ( $ 2,665 , 17.0% ) , and 69.5% of the total medical expenditure during the last year of life was spent in the last 6 months . fig . 4 presents cancer care costs by the type of treatment component and survival time . on average , general costs were the highest ( 29.7% ) , followed by other drugs ( 23.8% ) , general tests ( 14.3% ) , chemotherapy ( 11.6% ) , imaging tests ( 6.4% ) , surgery ( 4.7% ) , analgesia ( 4.3% ) , radiotherapy ( 2.9% ) , rehabilitation ( 0.7% ) , and psychotherapy ( 0.1% ) . costs associated with chemotherapy , surgery , radiotherapy , and imaging tests were higher in patients with shorter survival time , although the differences were small . and costs associated with psychotherapy and rehabilitation , which are supportive care services , were very low regardless of patients survival time . the predictors of cancer care costs are presented in table 2 . in our study population , older age was negatively associated with cancer care costs . higher income level , indicated by the insurance premium , was positively associated with cancer care costs , although insurance premium levels iii and iv showed no statistically significant association . compared with patients living in metropolitan areas , as would be expected , having more progressed cancer and higher comorbidity scores were also associated with higher mean medical costs . survival time was positively associated with cancer care costs , although surviving more than 5 years was associated with lower costs , albeit not statistically significantly so . finally , using the emergency department in the last year of life resulted in relatively high costs . estimating disease - specific medical costs is of longstanding interest in the fields of health policy and health economics . at the macro - level , such estimates can provide references for budget planning   and are necessary for monitoring the flow of national health expenditures . the estimates of phase - specific medical costs presented in this study may be used to evaluate the cost - effectiveness of cancer control policies . in our study , the average medical cost varied by the decedent s characteristics . those younger than 20 years had the highest mean medical costs , consistent with previous results   showing that lower age was associated with higher cancer care costs . this is associated with the tendency of younger cancer patients to seek more aggressive surgical care and adjuvant treatment   compared with older patients . also , medical costs increased with insurance premium levels , accounted for by high - income patients using inpatient and outpatient care more frequently than those from lower income groups . however , the medical expenditures of insurance premium level groups i and ii were statistically significantly lower than those below poverty line , indicating the underutilization of healthcare services by the near - poor , because income level and healthcare use are generally positively associated . it may also indicate that the near - poor have insufficient access to healthcare services in korea . finally , patient populations in metropolitan areas spent more than those in rural areas , consistent with the previous study by kim and park , who noted higher cancer care costs in urban populations . examining the distribution of expenses by the type of service revealed a disproportionate result , although chastek et al .   reported that inpatient costs accounted for the largest proportion of end - of - life costs in the united states ( 55% ) , we found that this proportion was much higher ( 78.7% ) in the korean population . it is believed that the relative lack of alternative accommodation for terminal cancer patients ( such as home care ) in korea contributed to a higher rate of hospitalization . additional research is warranted to assess hospital utilization patterns in terminal cancer patients in korea . in our analysis , 35.1% of decedents reported a similar rate of emergency department use in korea ( 33.6% ) which is noted to be much higher than that reported in the united states ( 9.2% in 1996 ) and suggesting inadequate functioning of regional medical facilities in korea . it is also noted that establishing a continuing cancer care system based on the family physician setting   may lower the emergency room visit rate . over half of total medical costs incurred at tertiary referral hospitals , which are preferred by patients with serious diseases such as cancer . however , this may represent inappropriate hospital use and unnecessary medical costs , simply because most terminal cancer patients do not require the specialized care provided by tertiary referral hospitals . our study showed that 11.6% and 2.99% of medical costs during the last 6 months of life were spent on chemotherapy and radiotherapy , respectively . this is consistent with the report by chastek et al . , who noted that terminal cancer patients spent 10% and 5% of their medical costs during the last 6 months on chemotherapy and radiotherapy , respectively . the tendency to administer aggressive chemotherapy until the end of life in korea was noted by keam et al . , who showed that as many as 94.6% of patients received chemotherapy during the last 6 months of life , much higher than that reported in the united states ( 33% ) . previous studies   noted that rehabilitation and psychotherapy can make meaningful contributions , even to terminal cancer patients . specifically , yoshioka   noted that almost all study subjects experienced at least some relief from certain types of discomfort , such as pain , dyspnea , and leg edema . according to a report published by the irish cancer society , 9% and 6% of participants surveyed incurred costs for physiotherapy and counseling , respectively . however , patients in the current study spent 1% and 0% of their medical costs on rehabilitation and psychotherapy , respectively , which may indicate underutilization of such services in korea . in our study , on average , patients underwent 4 ct , 0.6 pet , and 0.8 mri scans in the last year of life , representing 6.4% of mean cancer care costs . in comparison , dinan et al .   noted that patients with lymphoma underwent the highest number of imaging procedures , and an average lymphoma patient in 2006 had six ct scans , one pet scan , and one mri within 2 years of diagnosis moreover , using the cost data of this study , yang and czernin   estimated that imaging expenditures in 2006 accounted for 4.6% of overall medicare cancer care costs . considering that our study subjects were terminal cancer patients , who require relatively less diagnostic imaging , and that the hospital utilization pattern was examined over a 1-year period , the use of diagnostic imaging in korea may be excessive ; this should be investigated further . first , we used an administrative claims database , which contains the cost of billed services only , not including costs associated with loss of patient / caregiver productivity / wages , travel to / from treatment , over - the - counter medications , and other cancer - related expenses . however , the results of this study were consistent with previous studies that used knhi claims data , demonstrating high costs during the last year of life for many conditions , including cancer . second , rather than computing expenditures specifically related to cancer care , this study estimated all medical expenditures incurred by patients dying of cancer . however , a previous study   noted that most expenditures incurred by cancer patients during the last year of life were attributable to cancer care . third , in this study we accounted for expenditures for services that are covered by knhi only . therefore , cost estimates of this study do not reflect additional healthcare costs that are not covered by knhi or costs to society due to premature death and lost productivity . despite these limitations , our study was strong in that the study population represented a large segment ( 97% ) of cancer mortality cases in korea in 2009 . to our knowledge , this is the first report to document the breakdown of spending on the components of cancer care during the last year of life in korea . our study results demonstrate that cancer care costs during this time are a significant burden to patients and illustrate the need for further research on costs associated with the components of cancer care . examining possible overutilization and underutilization of healthcare resources will help provide tailored evidence for policymakers in efforts to reduce the burdens of cancer care .
purposethe purpose of this study was to evaluate the cancer care cost during the last year of life of patients in korea . 
 materials and methodswe studied the breakdown of spending on the components of cancer care . cancer decedents in 2009 were identified from the korean central cancer registry and linked with the korean national health insurance claims database . the final number of patients included in the study was 70,558.resultsin 2009 , the average cancer care cost during the last year of life was us $ 15,720 . 
 patients under age 20 spent us $ 53,890 while those 70 or over spent us $ 11,801 . 
 those with leukemia incurred the highest costs ( us $ 43,219 ) while bladder cancer patients spent the least ( us $ 13,155 ) . 
 general costs , drugs other than analgesics , and test fees were relatively high ( 29.7% , 23.8% , and 20.7% of total medical costs , respectively ) . 
 analgesic drugs , rehabilitation , and psychotherapy were still relatively low ( 4.3% , 0.7% , and 0.1% , respectively ) . among the results of multiple regression analysis , few were notable . 
 age was found to be negatively related to cancer care costs while income level was positively associated . 
 those classified under distant surveillance , epidemiology , and end results stages of cancer and higher comorbidity level also incurred higher cancer care costs.conclusionaverage cancer care costs varied significantly by patient characteristics . 
 however , the study results suggest an underutilization of support services likely due to lack of alternative accommodations for terminal cancer patients . further examination of utilization patterns of healthcare resources will help provide tailored evidence for policymakers in efforts to reduce the burdens of cancer care .