Higher Symptom Burden Shifts Cancer Care Toward Ancillary Costs, Study Finds

Higher patient-reported symptom burden in the year after a cancer diagnosis was associated with lower spending on cancer-directed therapy and higher spending on ancillary health care services, according to a population-based cohort study published in the Journal of Clinical Oncology.¹

The study evaluated more than 1.7 million symptom assessments through the Edmonton Symptom Assessment System (ESAS) from 285,924 adults with cancer in Ontario, Canada, between 2008 and 2019. The ESAS rates 9 common symptoms—pain, fatigue, nausea, depression, anxiety, drowsiness, appetite, well-being, and dyspnea—from 0 to 10, for a total score of up to 90.

Using the ESAS, the investigators sought to examine whether patient-reported symptom burden was associated with health care resource utilization and costs, with the broader goal of informing patient-centered measures of value in cancer care. Cancer-directed costs included treatments such as chemotherapy and radiation; ancillary costs covered inpatient and outpatient care, emergency department visits, complex continuing care, home care, and inpatient mental health services.

Key Findings

Overall, tiredness, depression, and poor well-being were the most prevalent moderate-to-severe symptoms across cancer types, reported by 37%, 34%, and 33% of patients, respectively. The median total ESAS score was 12 (IQR, 4-25) on a 0-to-90 scale.

The findings showed that symptom burden was associated with health care utilization in different directions depending on the type of resource. Higher symptom scores correlated with lower use of cancer-directed therapies while being associated with increased use of ancillary services. Specifically, each 10-point increase in total ESAS score was associated with a 9.4% decrease in cancer-directed treatment costs and an 18% increase in ancillary health care costs during the subsequent 30 days following ESAS reporting.

Several individual symptoms were associated with particularly large increases in ancillary costs. Severe lack of appetite was associated with an 83.9% increase, while severe poor well-being was associated with an 81.6% increase. Severe pain was associated with an 82.7% increase, severe nausea with an 80.1% increase, and severe drowsiness with a 77.3% increase. Severe tiredness and dyspnea were associated with increases of 71.9% and 68.0%, respectively.

Symptom Burden Varied Across Cancer Types

Of note, symptom burden was not the same across cancer types. Breast, gastrointestinal (GI), and respiratory cancers were the most common cancer types represented in the cohort. Patients with respiratory and head and neck cancers had the greatest overall symptom burden, with median total ESAS scores of 19 (IQR, 9-33) and 17 (IQR, 7-31), respectively.

Health care costs also varied substantially by cancer type; costs were standardized to 2020 Canadian dollars. Median total 30-day costs following an ESAS assessment were C$84,809 for GI cancers, C$80,710 for breast cancers, and C$78,486 for orbit/central nervous system cancers. Median total costs were C$72,335 for head and neck cancers, C$60,725 for respiratory cancers, C$40,727 for gynecologic cancers, and C$38,382 for genitourinary cancers.

Limitations and Implications

The study had several limitations. ESAS assessments were collected in outpatient settings and may not represent patients who were hospitalized, missed appointments, or received care outside the system. The analysis was also limited to the first 12 months after diagnosis and pooled multiple cancer types, stages, and treatment approaches. Because of the retrospective design, the findings demonstrate associations and do not establish that symptom burden directly caused changes in health care costs.

Ultimately, the findings have implications for how value is assessed in cancer care. The investigators noted that total health care spending may not adequately reflect the value of care because the type and direction of spending are important. Lower cancer-directed costs among patients with greater symptom burden, for example, could reflect reduced access to, tolerance of, or engagement in active treatment rather than more efficient care. At the same time, higher ancillary costs may reflect greater downstream health care needs.

The results also support the potential role of routine symptom assessment in understanding patients' experiences during cancer treatment. The ESAS has been used for decades to quantify multiple symptoms and monitor symptom burden over time in patients with cancer and other populations.²

Future patient-centered value measures may therefore need to account for both symptom burden and the composition of health care costs rather than relying on total spending alone. According to study authors Hirpara et al, these measures “will need to be examined across disease sites and phases of care and their usefulness and meaning for patients, clinicians, and health systems evaluated.”

REFERENCES

1. Hirpara DH, Matei AC, Sutradhar R, et al. Association Between Patient-Reported Outcomes and Health Care Resource Utilization: Toward Developing Patient-Centered Value Measures in Cancer Care. J Clin Oncol. Published online September 18, 2026. doi:10.1200/jco-25-02737

2. Hui D, Bruera E. The Edmonton Symptom Assessment System 25 Years Later: Past, Present, and Future Developments. J Pain Symptom Manage. 2017;53(3):630-643. doi:10.1016/j.jpainsymman.2016.10.370