Cost of ovarian cancer by the phase of care in the United States

Abstract

Background:

Ovarian cancer is associated with delayed diagnosis and poor survival; thus, interest is high in identifying predictive and prognostic biomarkers and novel therapeutic agents.

Although the costs of ovarian cancer care are likely to increase as newer, more effective, but more expensive treatment regimens become available, information on the current costs of care for ovarian cancer—across the care continuum from diagnosis to the end of life—are lacking.

Objective:

This study aimed to estimate real-world mean and median costs of ovarian cancer care within the first 5 years after diagnosis by patients’ phase of care, age, race/ethnicity, and geographic region.

Study Design:

We performed a retrospective cohort study of ovarian cancer patients diagnosed between January 1, 2015 and December 31, 2020. We used claims data from Optum’s de-identified Clinformatics^® Data Mart database, which includes inpatient, outpatient, and prescription claims for commercial insurance and Medicare beneficiaries nationwide. Cost of ovarian cancer care were calculated for the start of care (ie, the first 6 months), continuing care (ie, period between the initial and end-of-life care), and end-of-life care (ie, the last 6 months) phases and reported in 2021 U.S. dollar amounts. Ovarian cancer care costs were stratified by age, race/ethnicity, and geographic region. Due to the skewed nature of cost data, the mean cost data were log-transformed for modelling. Ordinary least-squares regression was conducted on the log costs, adjusting for patient categorical age, race/ethnicity, and geographic region.

Results:

A total of 7913 patients were included in the analysis. The mean cost per year for ovarian cancer care was >$200,000 during the start of care, between $26,000 and $88,000 during the continuing care phase, and >$129,000 during the end-of-life care phase. There were statistically significant associations between age and costs during each phase of care. Compared to younger patients, older patients incurred higher costs during the continuing care phase and lower costs during the end-of-life care phase. Geographic differences in the costs of ovarian cancer care were also noted regardless of the phase of care. There were no associations between cost and race/ethnicity in our cohort.

Conclusions:

Ovarian cancer care costs are substantial and vary by the phase of care, age category, and geographic region. As more effective but expensive treatment options for ovarian cancer become available with potential survival benefit, sustainable interventions to reduce the cost of care for ovarian cancer will be needed throughout the cancer care continuum.

Tweetable statement:

Costs of ovarian cancer care are substantial and vary by the phase of care, age, and geographic region. Effective cost management strategies are urgently needed as new therapeutic agents become available.

Introduction

More than 58% of patients with ovarian cancer are diagnosed at an advanced stage, which confers a poor prognosis.¹ The standard of care for newly diagnosed advanced ovarian cancer includes tumor cytoreductive surgery and platinum-based chemotherapy.² However, given that 70% of patients with advanced ovarian cancer experience recurrence and eventually die of the disease, there have been heightened interests and efforts in the pursuit of more effective diagnostic and therapeutic strategies.³ Cancer drug prices have been identified as a primary driver of the increasing cost of cancer care.^4,5 Patients who received bevacizumab as part of their primary management strategy experienced higher total costs than those without it ($171,468 vs $104,482 in 2017 U.S. dollars; p<0.001).⁵ Different drug administration modalities have also been associated with differences in the cost of care, with intraperitoneal/intravenous chemotherapy being more costly than standard or dose-dense intravenous chemotherapy ($121,761 vs $105,047 vs $115,099; p<0.001).⁵ An early report on the cost of ovarian cancer care based on claims data from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database from 1999 to 2003 found that the mean net cost of care was highest during the first year after diagnosis and the last year of life.⁶

Given recent advances in the availability and breadth of novel therapeutic agents for ovarian cancer treatment, along with the rising cost of cancer care and associated financial toxicity,^5,7–13 current cost estimates are needed. Accordingly, the objective of this study was to estimate the current real-world cost of ovarian cancer care among American individuals by their phase of care. A secondary objective of this study was to aggregate the cost of ovarian cancer care by age category, race/ethnicity, and geographic region to identify potential patterns in the cost of ovarian cancer care.

Materials and Methods

Data Sources

We performed a retrospective study of individuals with ovarian cancer using data from Optum’s deidentified Clinformatics^® Data Mart (CDM) database, which contains data derived from administrative health claims from patients from all 50 U.S. states since January 1, 2007. The CDM includes inpatient, outpatient, and prescription claims for both commercial insurance and Medicare Advantage with Part D members. Standard pricing algorithms are applied to CDM to account for differences in pricing across health plans and provider contracts and reflect allowed payments across all provider services. This standardization of prices enables consistent comparisons across patients, data sources, and geographic areas. The MD Anderson Cancer Center institutional review board approved this study and waived informed consent because data were deidentified. STROBE reporting guidelines were utilized.

Study Patient Identification

The eligibility criteria for inclusion in this study are illustrated in Figure 1. We identified patients with a diagnosis code for ovarian cancer between January 1, 2015 and December 31, 2020. Following the method for identifying incident ovarian cancer developed by Huepenbecker and colleagues,¹⁴ patients were required to have had either platinum-based chemotherapy or debulking surgery within 6 months of ovarian cancer diagnosis and to have had no diagnosis codes for ovarian cancer within the 6 months before the index diagnosis code. In addition, patients were required to have continuous health insurance coverage for 6 months before and at least 6 months after the index diagnosis code and to be at least 18 years old at the time of diagnosis. Lastly, patients with less than $1 in total claims per year for a phase of care were excluded from the analysis for that phase of care. Treatments and diagnoses were defined using the International Classification of Disease Ninth or Tenth edition diagnosis codes and Current Procedural Terminology codes (Supplemental Table 1).

Figure 1.

Flow chart for cohort selection (created with BioRender.com)

Study Measures and Statistical Analysis

The primary outcome of this study was the cost of ovarian cancer care by the patient’s phase of care. To identify a patient’s phase of care, we considered the 5 years after the index ovarian cancer diagnosis, or until death or end of continuous coverage. Patient costs beyond 5 years from diagnosis were not captured. We defined the phases of care as the start of care phase (ie, the first 6 months after diagnosis), the end-of-life care phase (ie, the last 6 months before death), and the continuing care phase (ie, the period between 6 months after diagnosis and 6 months before death). Notably, not all cancer patients contribute time to all the phases of care. Any months of continuous health insurance coverage within 6 months of a patient’s date of death but after the index diagnosis were considered part of the end-of-life phase. For patients with 12 or fewer months between index diagnosis and the date of death, any remaining months of continuous insurance coverage between the end-of-life phase and index diagnosis were assigned to the start of care phase. For patients with more than twelve months of continuous coverage, the patients with 6 months after the index diagnosis code were assigned to the start of care phase. All remaining months of continuous coverage were assigned to the continuing care phase.

We denoted the first 6 months after the index diagnosis as the start of care phase and distinguished it from the continuing care phase to account for the higher upfront costs associated with initial diagnostic evaluations and debulking surgery. The first 6 months after an ovarian cancer diagnosis typically correspond to the time for cytoreductive surgery and treatment with chemotherapy before and/or after surgery.¹⁵ After the first 6 months (start of care phase), patients will either be on maintenance therapy or in surveillance. However, care for ovarian cancer is variable and influenced by many factors.

For simplicity and consistency, time is reported in years instead of months for all phases of care. The costs of care for ovarian cancer per year were calculated as a weighted average of the patient costs for each phase, weighted by the number of years each patient contributed to that phase. These costs were also calculated by categorical age, race/ethnicity, and geographic region within each phase of care. Box plots were generated to graphically represent the distribution of costs within these demographic categories.

Due to the heavily skewed nature of cost data, it was necessary to log-transform the mean cost data for modelling. Ordinary least-squares regression was carried out on the log costs, adjusting for patient categorical age, race/ethnicity, and geographic region. Results from these least-squares models are presented as exponentiated regression coefficients with associated 95% confidence intervals (CIs), which can be interpreted as a multiplicative change in the costs relative to the reference category. Forest plots were generated to graphically display these results. Additional sensitivity analysis was conducted to check the fit of age as a continuous covariate, which would be necessary for future economic evaluations.

Secondary analysis included stratifying ovarian cancer care costs by age category (using SEER-defined categories of 18–25, 26–30, 31–35, etc.) and race/ethnicity (Asian, Black, Hispanic, White, and Unknown) by phase of care. The CDM database uses the following racial categories: Asian, Black, Hispanic, White, and Unknown. Hispanic ethnicity is categorized as a race in the CDM database.

Ovarian cancer care costs were defined as the sum of all reimbursed costs from primary and secondary insurance providers and cost-sharing from patients. Ovarian cancer care costs included inpatient, outpatient, and prescription claims associated with ovarian cancer care. All costs are reported in 2021 U.S. dollars in the CDM database. Data analysis was done using SAS Enterprise Guide 7.1.

Results

A total of 7913 patients were identified and included in the analysis. Table 1 illustrates the number of patients with ovarian cancer contributing to each phase of care by demographic characteristics and the mean cost of ovarian cancer care per year. A total of 7549 patients contributed years to the start of care phase, 6926 patients to the continuing care phase, and 2471 patients to the end-of-life care phase.

Table 1.

Demographic characteristics of patients and the mean yearly cost of ovarian cancer care by phase of care (N=7,913)

	Start of Care Phase			Continuing Care Phase			End-of-life Phase of Care*
Demographic	n (%)	Years contributed	Mean cost per year	n (%)	Years contributed	Mean cost per year	n (%)	Years contributed	Mean cost per year
Categorical Age
18 – 25	57 (0.8)	27.4	$292,898.80	51 (0.7)	107.5	$26,037.33	24 (1.0)	12.5	$ 534,514.89
26 – 30	44 (0.6)	21.6	$246,205.02	36 (0.5)	50.5	$32,044.19
31 – 35	91 (1.2)	43.7	$253,257.13	82 (1.2)	164.6	$52,010.11
36 – 40	152 (2.0)	73.4	$281,619.27	139 (2.0)	305.0	$66,014.19
41 – 45	272 (3.6)	130.8	$274,109.42	257 (3.7)	510.8	$68,885.33	43 (1.7)	23.2	$418,957.38
46 – 50	421 (5.6)	203.0	$281,048.90	384 (5.5)	833.7	$72,446.59	58 (2.3)	32.7	$376,767.09
51 – 55	539 (7.1)	259.5	$269,989.87	495 (7.1)	1084.4	$66,967.88	84 (3.4)	39.6	$367,669.00
56 – 60	698 (9.2)	337.2	$279,258.18	643 (9.3)	1349.7	$81,268.66	142 (5.7)	91.8	$292,525.21
61 – 64	641 (8.5)	306.1	$281,735.34	576 (8.3)	1029.3	$88,333.10	140 (5.6)	94.9	$262,107.24
65 – 70	1584 (21.0)	747.9	$300,184.29	1451 (21.0)	3362.3	$73,299.89	569 (22.8)	361.2	$246,369.13
71 – 75	1418 (18.8)	669.7	$297,873.96	1305 (18.8)	2983.2	$75,202.18	612 (24.5)	480.3	$172,977.18
76 – 80	923 (12.2)	436.3	$308,533.06	875 (12.6)	1868.7	$75,690.39	418 (16.8)	332.0	$155,333.33
81 – 85	506 (6.7)	235.5	$280,183.27	461 (6.7)	976.0	$64,719.21	273 (10.9)	212.4	$137,930.70
86+	203 (2.7)	89.9	$251,979.20	171 (2.5)	265.7	$68,236.63	132 (5.3)	76.5	$132,572.83
Race/Ethnicity						.
Asian	253 (3.4)	121.6	$291,798.11	221 (3.2)	468.1	$68,981.70	69 (2.8)	50.2	$236,487.46
Black	823 (10.9)	386.5	$282,842.69	727 (10.5)	1427.5	$84,090.37	312 (12.5)	201.0	$223,339.42
Hispanic	849 (11.2)	404.6	$286,394.08	772 (11.1)	1641.6	$70,852.44	247 (9.9)	207.5	$188,135.63
White	5277 (69.9)	2507.6	$290,197.13	4891 (70.6)	10777.4	$72,965.49	1733 (69.5)	1208.5	$201,128.09
Unknown	347 (4.6)	161.8	$292,691.70	315 (4.5)	576.9	$70,127.20	134 (5.4)	89.8	$213,646.33
Geographic Region						.
Northeast	931 (12.3)	439.5	$275,466.63	859 (12.4)	1828.0	$69,673.34	326 (13.1)	165.3	$304,839.93
Midwest	1659 (22.0)	789.4	$274,302.43	1532 (22.1)	3348.8	$76,607.97	555 (22.2)	282.5	$266,500.19
South	3152 (41.8)	1489.7	$276,431.80	2879 (41.6)	5861.9	$75,320.20	1038 (41.6)	652.2	$225,393.34
West	1785 (23.6)	853.2	$331,482.44	1642 (23.7)	3817.6	$70,170.24	572 (22.9)	654.4	$129,119.80
Unknown	22 (0.3)	10.2	$340,897.79	14 (0.2)	35.0	$61,473.00	4 (0.2)	2.5	$342,442.22

^*For the end-of-life phase, age 18 – 40 were collapsed into a single category due to low cell counts.

The mean cost per year was calculated using a weighted average with the number of years contributed by each patient as the weights.

Initial care was the first 6 months following diagnosis with ovarian cancer. End of life was defined as the last 6 months of life after diagnosis. Continuing care is defined as the period between initial care and end-of-life care. In cases where patients lived <6 months, time was preferentially assigned to the end-of-life phase then the start of care phase. Patients do not contribute years to all the phases of care. For simplicity, time is reported in years.

All costs are reported in 2021 U.S. dollars.

The mean cost of care per year for the start of care phase was highest for patients aged 76–80 years ($308,533.06), patients with unknown race/ethnicity ($292,691.70), and those with unknown geographic region ($340,897.79). Patients aged 61–64 years, Black, and received care in the Midwest had the highest mean cost of care per year for the continuing care phase ($88,333.10, $84,090.37, and $76,607.97, respectively). For the end-of-life care phase, the mean cost per year was highest among 18–40 year olds ($534,514.89), Asian ($236,487.46), and those with unknown geographic region ($342,442.22). Similar trends were noted for the median costs of ovarian cancer care per year per patient (Figure 2).

Figure 2.

Box plots of costs of ovarian cancer care per year by patient demographics. Log scale was used due to the right-skewed nature of the cost data by outliers. A, Costs of ovarian cancer care per year in the start of care phase. B, Costs of ovarian cancer care per year in the continuing care phase. C, Costs of ovarian cancer care per year in the end-of-life care phase.

Figure 3 shows the exponentiated regression coefficients and 95% CIs of the log costs of ovarian cancer care by patient demographics based on ordinary least-squares regression, adjusted for categorical age, race/ethnicity, and geographic region. For the start of care phase, costs were significantly lower for ages 26–30 years (exp[β]=0.79, 95% CI 0.62–0.99) and 86–90 years (exp[β]=0.84, 95% CI 0.74–0.95) compared to 56–60 years. Compared to receiving care in the West, the costs were significantly lower in the Northeast (exp[β]=0.87, 95% CI 0.81–0.93), Midwest (exp[β]=0.89, 95% CI 0.84–0.93), and South (exp[β]=0.88, 95% CI 0.84–0.92). We found a significant effect of age on the cost of care for the continuing care phase (Figure 3B). Overall, older patients incurred more costs than younger patients. Compared to patients with ovarian cancer who received care in the West, those treated in the South and Midwest incurred higher costs for the continuing care phase (exp[β]=1.21, 95% CI 1.11–1.32 and exp[β]=1.19, 95% CI 1.08–1.31, respectively). Lastly, for the end-of-life care phase, age was inversely associated with costs of care, with older patients incurring lower costs (Figure 3C). Cost during the end-of-life phase were higher in the Northeast (exp[β]=3.63, 95% CI 2.95–4.47), Midwest (exp[β]=3.22, 95% CI 2.71–3.83), and South (exp[β]=2.13, 95% CI 1.86–2.44) compared to the West. There were no statistically significant associations between race/ethnicity and cost regardless of the phase of care.

Figure 3.

Forest plots showing the exponentiated regression coefficients and 95% confidence intervals of the log costs of ovarian cancer care by patient demographics based on ordinary least-squares regression adjusted for categorical age, race/ethnicity, and geographic region. The results can be interpreted as a multiplicative change in costs relative to the reference category. A, Start of care phase. B, Continuing care phase. C, End-of-life care phase.

A more granular assessment of mean yearly costs for ovarian cancer care by combinations of age category and race/ethnicity for each phase of care is presented in Supplemental Table 2–4. This level of granularity would be necessary for other ovarian cancer-related health economics assessments and cost minimization interventions. These results are accompanied by model parameter estimates and sensitivity analysis for standardized continuous age (Supplemental Table 5). The sensitivity data for age standardization as a continuous variable is necessary because age is presented as a categorical variable in all the regression models.

Comment

Principal Findings

This retrospective study estimated the real-world costs of ovarian cancer care within the first 5 years after diagnosis by the phase of care based on a national sample of 7913 Medicare and commercially insured patients. We also demonstrated trends in the cost of ovarian cancer care by different patient demographic variables. Fewer patients contributed to the cost of ovarian cancer care during the end-of-life phase compared to the other phases of care. Compared to younger patients, older patients incurred higher costs during the continuing care phase and lower costs during the end-of-life care phase. Geographic differences in the costs of ovarian cancer care were also noted regardless of the phase of care.

Results in the Context of What is Known

Consistent with other studies,^5,6,16 we found that the highest mean cost per year for ovarian cancer care was incurred during the initial 6 months following diagnosis and was >$200,000 in 2021 U.S. dollars depending on patients’ age, race/ethnicity, and geographic region. Bercow et al.¹⁶ and Suidan et al.⁵ also reported high costs during the first year of ovarian cancer treatment. The high initial costs of care could be attributed to the cost of diagnostic procedures, including imaging studies and tissue specimen biopsy, as well as initial treatment with cytoreductive surgery and chemotherapy.^12,17

Similar to Yabroff et al.,⁶ we also report high end-of-life care costs, which are likely driven by inpatient medical services and supportive care services necessary to provide symptom management and comfort toward the end-of-life.¹⁸ It has been reported that at least 20% of patients with solid tumors receive chemotherapy within 2 weeks of death,¹⁹ contributing to end-of-life care expenses. Shared medical decision-making regarding end-of-life planning and proactive management of expectations are essential for promoting quality end-of-life experiences and managing care costs. In a longitudinal multi-institutional cohort study involving 325 patients with advanced cancer, only 31.2% of patients reported having end-of-life discussions with their providers, which was associated with lower rates of aggressive interventions and a 35.7% lower cost compared to patients who did not have these discussions.²⁰

Clinical Implications

With newer but costlier therapies in development or under investigation, data on the current costs of ovarian cancer care are needed to inform high-quality, value-based care for the increasing number of women who are living longer with ovarian cancer and consequently are exposed to such costs for a longer time. Our study provides average yearly costs of ovarian cancer care by phase of treatment, age category, and race/ethnicity during the first 5 years following diagnosis. We provided data with this level of granularity to support patients and providers in their tailored treatment decision-making process.

We found variations in the cost of ovarian cancer care by geographic region and age likely due to differences in facility costs, provider costs, and healthcare utilization driven by patients’ medical comorbidities, values and preferences, socioeconomic status, and health literacy level.^21,22 In our cohort, older patients incurred higher costs during the continuing care phase and lower costs during the end-of-life care phase. Younger cancer patients have been reported to seek more aggressive surgical care and more adjuvant treatment than older patients,^23–25 which may be a driver of higher costs among younger individuals during end-of-life care.

Although other studies have reported racial differences in cancer care and outcomes,^26–28 we found no significant associations in race/ethnicity and the cost of ovarian cancer care. The racial/ethnic subgroups in the CDM are not disaggregated and may be conflated by other variables not assessed in our analysis due to the lack of availability of such data, including healthcare utilization and the care delivery setting.

Knowledge of associations between cost of care and demographic variables could allow clinicians to identify patients who are likely to experience high cost burden from ovarian cancer care. Early identification of these individuals coupled with strategies to manage the costs of care, such as early referral to financial counselors, might offset the implications of medical debt on quality of life and ovarian cancer care outcomes.

Research Implications

Patients with advanced ovarian cancer typically experience relapse and receive multiple lines of treatment over months to years.²⁹ The resulting expenses can lead to financial toxicity.^30,31 Patients with high medical debt depend heavily on their social networks, withdraw from long-term savings accounts, file for bankruptcy, and delay or defer recommended treatment, among other austerity measures.^32,33 These coping mechanisms are not sustainable and may impact the overall quality of life.^34,35 We recognized the need for current representative information on ovarian cancer care costs for health economics assessments. Accordingly, our study provides important insight into the costs of ovarian cancer care by different demographic variables necessary for designing and implementing tailored, effective policy and sustainable programs to address the economic burden associated with ovarian cancer care.

Strengths and Limitations

One strength of this study is that we used the algorithm created by Huepenbecker et al. (2022) for our cohort selection due to the reported overall algorithm sensitivity of 89.9%, positive predictive value of 93.8%, and specificity and negative predictive value of >99.9% for identifying incident epithelial ovarian cancer cases.¹⁴ In figure 1, the majority of patients were excluded in step one due to not having had platinum-based chemotherapy or tumor debulking surgery within six months of diagnosis. The exclusion of these 29,284 patients likely represents the removal of patients with prevalent cancer, leaving incident cases. In addition, cost data include inpatient, outpatient, and drug expenses incurred by both commercially and publicly insured patients across the ovarian cancer care continuum from diagnosis to the end of life. We included the average healthcare costs for individuals at least 18 years old due to the reported differences in patterns of care between younger and older patients with cancer.^23–25

Our study was limited by data availability. We did not stratify cost by clinical variables, such as stage of ovarian cancer or the type of treatment, because of lack of data. The cost by treatment was addressed previously by our study team.^5,9 In addition, the results of this study are only applicable to the commercially insured and Medicare beneficiaries included in the CDM database and may not reflect the entire U.S. ovarian cancer population. This study may have limited external validity to Medicaid, uninsured and self-paying individuals. The medical expenditure reflected in the CDM is based on a standardized pricing algorithm, which may not reflect the actual costs of services received by patients. The CDM cannot guarantee that all laboratory tests are represented due to differences in laboratory chains and contractual relationships with insurers. Lastly, pharmacy claims could be duplicated due to multiple prescriptions for the same drugs. Despite these limitations inherent to the CDM,³⁶ claims data represent real-world consumer behaviors and provide a robust estimate of care costs for insured individuals.

Claims data provide information on health services reimbursed by insurers, which are within the purview of healthcare payers and policymakers. Given that our results are comparable to those based on other health claims databases,^5,6,16 it is undeniable that the costs of care for ovarian cancer are substantial and have direct and indirect implications for patients and society. Although we included overall healthcare costs among patients with ovarian cancer, our analysis did not capture indirect costs that contribute to financial toxicity in cancer survivors, such as lost wages, travel for care, and the psychosocial and quality of life disutility of cancer diagnosis and treatment; these factors would reflect even higher costs of care.

Conclusions

We found that the costs of care for ovarian cancer are substantial and vary by phase of care, age category, and geographic region. We report that the average yearly costs of care for ovarian cancer were highest in the start of care and end-of-life phases of care and lowest in the continuing care phase. Patients with ovarian cancer experience considerable economic burdens. Because effective screening is not available to decrease the incidence of ovarian cancer, future research should focus on strategies to enhance the management of ovarian cancer care expenses and improve high-quality, value-based care.

Supplementary Material

Supplement Table 1 ICD CPT

Supplemental Table 1. International Classification of Disease Ninth (ICD-9) or Tenth (ICD-10) edition diagnosis codes and Current Procedural Terminology (CPT) codes used in this study.

Supplement Table 2 Start of care

Supplemental Table 2. Mean yearly costs for ovarian cancer care by age and race/ethnicity (start of care phase)

Supplement Table 3 Continuing Care

Supplemental Table 3. Mean yearly costs for ovarian cancer care by age and race/ethnicity (continuing care phase)

Supplement Table 5 Model Estimates

Supplemental Table 5. Model estimates for continuous age sensitivity analysis.

Supplement Table 4 End of Life

Supplemental Table 4. Mean yearly costs for ovarian cancer care by age and race/ethnicity (end-of-life phase)

AJOG at a Glance.

A. Why was this study conducted?

This study aimed to estimate real-world costs of ovarian cancer care within 5 years after diagnosis by patients’ phase of care, age, race/ethnicity, and geographic region.

B. Key Findings

The mean cost per year for ovarian cancer care was >$200,000 during the start of care, $26,000–$88,000 during continuing care, and >$129,000 during end-of-life care. Age was significantly associated with costs during the continuing care and end-of-life care phases. Geographic differences in the costs of ovarian cancer care were noted regardless of the phase of care. There were no associations between cost and race/ethnicity.

C. What does this add to what is known?

The costs of ovarian cancer care are substantial and vary based on patients’ age, geographic region, and phase of care.