The Merits of US Cancer Care

Perhaps my readers are unaware of the ongoing debate among US health policy wonks concerning whether American style health care delivery is better for American cancer patients than care available for European cancer patients. Suffice it to say, apologists for the American health care system often cite improvements in cancer survival as evidence that market based health care delivery (the name offered for American health care business) is better than European style health care financing. There is a recent chapter added to this debate, which was reported by Fox News (http://www.foxnews.com/opinion/2010/04/23/tomas-philipson-obamacare-heal...):

April 23, 2010
We Can't Lose Our Global Leadership In Medical Innovation
By Tomas Philipson

Because the most significant components of Obamacare do not take effect for several years, there is still time to reshape it, both to expand affordable safety-net coverage and encourage innovation. But first we must reject the common assumption that the only form of solidarity worth pursuing is universal coverage – the “right” for all citizens, regardless of their means, to access low-cost medical care. Instead, we must emphasize our solidarity with future generations. Whatever short-term benefits in coverage reforms might bring, our children and grandchildren will inevitably pay the price if the U.S. adopts European-style price controls at the cost of the medical innovations that have done so much for the world.

And, here is how the American Enterprise Institute (a conservative think tank) featured the same information by the same author two years ago (http://www.aei.org/article/health/healthcare-reform/private-insurance/cr...):

American Enterprise Institute
February 2, 2010
Critical Diagnosis
By Tomas J. Philipson, Paul Howard

But the U.S. commitment to fighting cancer is second to none. We have recently documented enormous societal gains from the war on cancer. We found that from 1988 to 2000 life expectancy for all cancers combined increased by about four years--translating to about 23 million additional life-years and roughly $1.9 trillion of added social value of cancer care, even after subtracting research costs and spending on medical care for cancer patients.

The U.S. experience greatly contrasts with Europe's, where centralized government funding for cancer care and price controls on new medicines have slowed the battle against cancer, leading to worse outcomes for patients. In a recent study demographers Samuel H. Preston and Jessica Yu documented that the U.S. outperforms almost all European countries in its cancer screening and treatment efforts.

It is important to recognize that innovation and access to care are complementary, not contradictory goals. Rather than opting for an expensive new insurance entitlement that the nation cannot afford, Congress' main objective should be to help those who cannot afford health care, not take over the market for those who can. Stimulating the demand of the low-income uninsured is a laudable goal and is pro-innovation since it raises demand. Restricting care for those who can afford it by using government price controls to strong-arm producers is not. Cancer serves as a great example of the value of the U.S. model over the European model. In health care, as in most other markets, you get what you pay for.

Professor Philipson has recently published an article about cancer care on the website of the journal "Health Affairs" (http://content.healthaffairs.org/content/suppl/2012/04/09/31.4.667.DC1/2...) which is providing new fuel for this flaming controversy. Here is the abstract for the article:

Health Affairs
April 2012
An Analysis Of Whether Higher Health Care Spending In The United States Versus Europe Is ‘Worth It’ In The Case Of Cancer
Tomas Philipson, Michael Eber, Darius N. Lakdawalla, Mitra Corral, Rena Conti and Dana P. Goldman

The United States spends more on health care than other developed countries, but some argue that US patients do not derive sufficient benefit from this extra spending. We studied whether higher US cancer care costs, compared with those of ten European countries, were “worth it” by looking at the survival differences for cancer patients in these countries compared to the relative costs of cancer care. We found that US cancer patients experienced greater survival gains than their European counterparts; even after considering higher US costs, this investment generated $598 billion of additional value for US patients who were diagnosed with cancer between 1983 and 1999. The value of that additional survival gain was highest for prostate cancer patients ($627 billion) and breast cancer patients ($173 billion). These findings do not appear to have been driven solely by earlier diagnosis. Our study suggests that the higher-cost US system of cancer care delivery may be worth it, although further research is required to determine what specific tools or treatments are driving improved cancer survival in the United States.

But, of course, Dr. Philipson's views are disputed, as this report from Reuters points out (http://www.reuters.com/article/2012/04/09/us-cancercare-idUSBRE8380SA201...):

Reuters
April 9, 2012
Is high spending on cancer care 'worth it'?
By Sharon Begley

With the United States spending more on healthcare than any other country — $2.5 trillion, or just over $8,000 per capita, in 2009 — the question has long been, is it worth it? At least for spending on cancer, a controversial new study answers with an emphatic "yes."

Cancer patients in the United States who were diagnosed from 1995 to 1999 lived an average 11.1 years after that, compared with 9.3 years for those in 10 countries in Europe, researchers led by health economist Tomas Philipson of the University of Chicago reported in an analysis published Monday in the journal Health Affairs.

Philipson is a fellow at the conservative American Enterprise Institute and at the Manhattan Institute, served in the administration of President George W. Bush and was a healthcare adviser to Sen. John McCain's 2008 presidential campaign.

Experts shown an advance copy of the paper by Reuters argued that the tricky statistics of cancer outcomes tripped up the authors.

"This study is pure folly," said biostatistician Dr. Don Berry of MD Anderson Cancer Center in Houston. "It's completely misguided and it's dangerous. Not only are the authors' analyses flawed but their conclusions are also wrong."

For the new analysis, Philipson and his colleagues analyzed the survival of cancer patients diagnosed from 1983 to 1999 with any of 13 common cancers, including breast, prostate, colorectal, and leukemias.

Survival means how long a patient lived after being diagnosed. Philipson's team focused in particular on survival gains; that is, how long did patients diagnosed in later years live compared with those diagnosed earlier in the period? Such gains, they argued, show what progress countries made in treating cancer.

While that may seem straightforward, survival data is among the most problematic cancer statistics, Philipson's team acknowledges. In particular, they are plagued by something called lead-time bias.

If a tumor is diagnosed very early in its existence - if it has a long "lead time" - the patient may survive, say, two years if the tumor is very aggressive. If an identical tumor is found in that patient's identical twin later, the twin will survive, say, six months. But the twins die at the same age. The first survived longer with cancer due to lead-time bias, but did not have a longer lifetime.

Crediting medical care with "improving survival" is therefore misleading, cancer experts have long argued. Lead-time bias makes it seem patients live longer, but the only thing that is longer is the number of years they know they have cancer, not their lifespan.

The authors of the "worth it?" study nevertheless base their analysis on survival data. They argue that because U.S. cancer mortality rates fell faster than those in Europe, the survival gains must be real and not an artifact of lead-time bias.

Others call that approach fatally flawed. "Lead-time bias is an issue," said MD Anderson's Berry. "I can see no hint of logic in their statement that 'lead-time bias did not confound our results.'"

Even more problematic, said Berry, is a problem cancer experts have only recently recognized: overdiagnosis. Because cancer screening is much more widespread in the United States than in Europe, especially for breast and prostate cancer, "we find many more cancers than are found in Europe," he said. "These are cancers that tend to be slowly growing and many would never kill anyone."

Screening therefore turns thousands of healthy people into cancer patients, even though their tumor would never threaten their health or life. Counting these cases, of which there are more in the United States than Europe, artificially inflates survival time, experts said.

"As long as your calculation is based on survival gains, it is fundamentally misleading," said Dr. H. Gilbert Welch, a healthcare expert at the Dartmouth Institute for Health Policy & Clinical Practice.

n the new analysis, the survival gains in the United States compared with Europe were greatest for prostate cancer, at more than triple the gains for breast cancer, the cancer with the second-greatest U.S. survival edge. "These are the two cancers where screening has raised the most serious issues about lead-time bias and overdiagnosis," said Welch.

And, here is more from the New York Times about the American tendency to overuse cancer screening (which has been the subject of several blog posts here in the past) (http://www.nytimes.com/2011/10/30/health/cancer-screening-may-be-more-po...) Excerpts:

The New York Times
October 29, 2011
Considering When It Might Be Best Not to Know About Cancer
By Gina Kolata

After decades in which cancer screening was promoted as an unmitigated good, as the best — perhaps only — way for people to protect themselves from the ravages of a frightening disease, a pronounced shift is under way.

Now expert groups are proposing less screening for prostate, breast and cervical cancer and have emphasized that screening comes with harms as well as benefits.

Two years ago, the influential United States Preventive Services Task Force, which evaluates evidence and publishes screening guidelines, said that women in their 40s do not appear to benefit from mammograms and that women ages 50 to 74 should consider having them every two years instead of every year.

This year the group said the widely used P.S.A. screening test for prostate cancer does not save lives and causes enormous harm.

Two recent clinical trials of prostate cancer screening cast doubt on whether many lives — or any — are saved

A new analysis of mammography concluded that while mammograms find cancer in 138,000 women each year, as many as 120,000 to 134,000 of those women either have cancers that are already lethal or have cancers that grow so slowly they do not need to be treated.

Cancer experts say they cannot ignore a snowballing body of evidence over the past 10 years showing over and over that while early detection through widespread screening can help in some cases, those cases are small in number for most cancers. At the same time, the studies are more clearly defining screening’s harms.

In recent years, researchers have found that many, if not most, cancers are indolent. They grow very slowly or stop growing altogether. Some even regress and do not need to be treated — they are harmless.

What should we make of this controversy? First, a response from Dr. Don McCanne, from whom I received links to all of these articles:

This widely-reported study suggests that the high costs for cancer care in the United States are well worth it, providing $800 billion in the value of additional survival gain for prostate and breast cancers alone. A critical review of this study casts great doubt on this conclusion.

The authors purport to show that cancer care in the United States accounts for increased survival time compared to ten selected European nations, and that this benefit is valued at $150,000 per additional year of survival.

It is important to understand the difference between survival and mortality. Survival relates to how long a person lives after the diagnosis of cancer is made. Mortality refers simply to how long a person lives. Lead time refers to how much of a head start a person gets on cancer treatment based on how early in its course it is diagnosed.

Having a survival of five years doesn't mean much if mortality is unchanged. A group of individuals with the same cancer who die at the same time have the same mortality, yet if some have the cancer diagnosed earlier than the others, the five year survival is better for those diagnosed earlier even though the duration of life is not extended.

In this study the authors decided to look at survival rather than mortality in spite of problems with the lead time. They provide an Appendix which purportedly shows that "By analyzing population mortality rates, which are insensitive to lead-time bias, we show that US cancer mortality rates fell faster than cancer mortality rates in the European Union. This must be due to real improvements in cancer survival." Thus they contend that their estimates of survival were reflected in an improvement in mortality.

Having read their Appendix several times, I remain unconvinced of this argument. In fact, contained in their Appendix was the statement, "We examined the average rate of deaths averted over the analysis period 1982-2005 for both prostate cancer and death cancer." Death cancer? The fact that this was published on the Health Affairs website without correction makes me wonder if anyone really read their Appendix critically.

Assuming that it was reviewed (though not by the Health Affairs editors), let's look at Appendix Table 1 which purportedly shows the improved mortality in the United States compared to nine European nations. Of the eleven cancers listed, four showed additional deaths that were supposedly avoided, three showed additional deaths that actually were incurred, and the other four were not statistically significant at a p value of .05. Removing breast and prostate cancer for reasons mentioned below, that leaves only two cancers with additional deaths that were supposedly avoided. Not very convincing evidence for lower U.S. cancer mortality to say the least.

The two cancers that the authors highlighted were breast cancer and prostate cancer. According to H. Gilbert Welch (a highly credible authority from the Dartmouth Institute for Health Policy, and author of "Overdiagnosed"), "These are the two cancers where screening has raised the most serious issues about lead-time bias and overdiagnosis."

Even the authors of the Health Affairs report state, "If US data show both survival gains and mortality reductions, this is likely to reflect real improvements in health; the alternative interpretation requires a scenario in which the diagnosis rate is rising in the US while the actual number of cancer cases is falling." In fact, because of an increase in intensive screening, the diagnosis rate is rising, whereas the very large number of cancers detected that would have remained harmless - especially many of the prostate and breast cancers - in a way might be considered to be a decline since, with no change in survival or mortality, these individuals more appropriately should have been classified with the population group without cancer, and never counted as cancer patients in the first place. Treatment of these harmless cancers certainly should not be counted as having increased cancer survival in the United States.

Regarding the integrity of this study, of some concern is that one of the authors, Mitra Corral, is an employee of Bristol-Myers Squibb, a company that produces cancer drugs and could benefit from the high visibility that Health Affairs gives this article touting the financial benefits of our higher spending on cancer care.

Of greater concern is the background of the lead author, Tomas Philipson, who is associated with conservative think tanks - specifically the American Enterprise Institute and the Manhattan Institute. These and other conservative sources have been dismissing health care reform with the claim that we don't need reform because we have the best health care system in the world. They then use our "superior" cancer statistics to prove it. Because our system is so great, the implication is that we don't need to fix it. Is this policy science, or is it ideological demagoguery?

With reluctance, we might accuse Professor Philipson of allowing his ideology to tarnish his academic purity, but we don't have to. His own words will suffice, "But first we must reject the common assumption that the only form of solidarity worth pursuing is universal coverage – the 'right' for all citizens, regardless of their means, to access low-cost medical care. Instead, we must emphasize our solidarity with future generations. Whatever short-term benefits in coverage reforms might bring, our children and grandchildren will inevitably pay the price if the U.S. adopts European-style price controls at the cost of the medical innovations that have done so much for the world."

My comment:

All of the innovation in the world does American patients little good if the 'market' makes the care financially unavailable. Cancer care currently devastates American patients, first financially and then physically. The overuse of screening, done with the best of intentions, has fooled Americans into believing that a cure for cancer is just around the corner. Dr. Philipson's methods do not stand up to credible scientific scrutiny. What we do in the US is not the best in patient care, it is the best in profit taking for American corporations. And the costs are devastating the families of American cancer patients and at the same time robbing all taxpayers. We must stop pretending the market forces are at work in American health care. The pretense of market forces warps the health care delivery system and leads us to pay more for mediocre, inefficient care.

Dr. Joe Jarvis

Taxonomy: