Apr 16 2012
Cancer care in the U.S. versus Europe: Is more necessarily better?
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18 Responses to “Cancer care in the U.S. versus Europe: Is more necessarily better?”
??? Super Methusalahs?
I have often thought that the high US health costs are also caused by the litigious tendencies of US patients. It makes going to the doctor a kind of lottery. If the doctor makes a mistake, you hit the jackpot. So part of the ‘health costs’ are lawyer’s fees. These jackpots are paid for by insurance companies that (1) require large premiums and (2) demand that the doctors protect themselves by ordering all kinds of tests. All these extra precautions also cost a lot. And of course, part of all those large premiums are kept by the insurance companies themselves – who pay lawyers to protect themselves against having to pay all those jackpots.
Offit has described how all this litigation nearly wiped out all vaccine makers, and raised the costs of vaccinations by a factor 30. I guess the astronomical costs of other forms of health care to a large degree is caused by the same kind of legal harassment.
Am I wrong? Am I seeing a non-existent conspiracy of lawyers?
Something I find hard to understand is that judging a doctor, i.e. deciding whether s/he has done something wrong from a scientific or medical point of view is done by civil courts rather than disciplinary courts.
I did pick what the most likely fatal flaw in this study is likely to be just from reading the abstract, but I’m going to give the credit to the bloggers on SBM for their expert teaching skills.
On the other hand, I didn’t pick it before being primed to look for it, but for that I blame myself for being a less than perfect student.
“Am I wrong? Am I seeing a non-existent conspiracy of lawyers?”
Our fearless leader, who just happens to be a lawyer, says you are wrong. He was supposed to have a study done to prove it, too. Well, you can just take him at his word.
Also, this study only compares survival of those diagnosed with cancer, whom actually receive comprehensive care. I would be interested to see (which is, unfortunately, neigh impossible) how survival rates per unit of total population compares: arguably, in countries with established social healthcare you will probably have fewer people dying due to undiagnosed or untreated cancers.
Another potential surrogate to get at the same information might be stage at diagnosis for cancers that aren’t routinely screened for. Presumably, in a health care system where fewer people have access to high quality care, cancers will tend to be diagnosed at a more advanced stage. (Looking for stage in cancers that are screened for would only tend to show which country screens more aggressively, not so much how well cancers are treated.)
I actually don’t care one whit about length of survival after diagnosis. I care only about the mortality rate, followed by the morbidity rate. (Which is also to say I would trade prevention for a certain amount of diagnosis and treatment, if it were possible, but that’s for another day.) Morbidity rate goes up with overdiagnosis, of course, and overtreatment may hasten death from other causes, and so higher morbidity can be countervailing in part against a lower mortality rate. A decent analysis would look at all of these questions.
[...] Cancer care in the U.S. versus Europe: Is more necessarily better? Great piece deconstructing a cancer study. Also the only article I can remember on the health debate that points out the real question is how care will be rationed since all systems involve rationing. Share this:TwitterFacebookTumblrLinkedInRedditEmailLike this:LikeBe the first to like this post. This entry was posted in commentary, Links and tagged lost phone by local.god. Bookmark the permalink. [...]
I still do care about survival, but it is in a different context: comparing treatments in randomized studies. The randomization helps to make sure one arm of the study is not stacked with overdiagnosed people. Comparing two screening methods is harder. Some folks have been comparing “death due to cancer type X”, rather than all deaths, and accepting that as a sufficient demonstration. I think it is a good sign, but not total proof. Trouble with using survival for all: takes so many subjects. Since only a few percent are affected by the cancer you were screening for, it’s hard to find a difference for all subjects if you only helped the affected people a little bit. Takes time too: we want to count how many people we are giving second cancers, ideally. In wanting the perfect, I might be being the enemy of the good here – not sure.
Heartily agree with cervantes willingness to spend on prevention. Franklin was mistaken: A penny saved is more than a penny earned.
Good article.
Something that I don’t see pointed out often, which I’ve thought from time to time, is that lead time bias isn’t a neutral thing or a purely academic error in thinking. It’s not just that it means there is no difference to real survival; it means you’re spending more years of your life [i]as a cancer patient[/i], with all the baggage that comes with that.
@David Gorski –
Super great post with graphical support. Very nice.
You don’t seem to as many comments with this type of thing in comparison to some of your other style of posts, but you are stimulating more brains.
- pD
errr, that is. . .
“You don’t seem to generate as many comments . . . ” (sorry)
“there are two ways to study how well different countries are doing in terms of cancer care. ”
Wouldn’t a simple method using mortality data be to compare rates of various cancers in various countries correcting for incidence and then compare the age at death from those cancers? Presumably the sample sizes would be large enough to average out different ages at onset. It certainly wouldn’t be conclusive but it would use easily obtainable data and might provide some interesting pointers for additional research.
“resistance to … the Affordable Care Act (PPACA), … has been fueled by two things: (1) resistance to the mandate that everyone has to buy health insurance, and (2) the parts of the law designed to control the rise in health care costs”
In other words, resistance has been fueled by the very things that give PelosiCare (sorry but Nancy Pelosi did the heavy lifting) any hope of doing some good. Some mechanism is necessary to get the healthy into the system; think Social Security – it relies on today’s workers financing the retirement of yesterday’s workers. If SCOTUS holds the mandate unconstitutional the only alternative is a healthcare tax supporting universal basic care (not a bad idea in my estimation but one unlikely to become law anytime soon).
That quote by Aaron Carroll is great. I’m going to have to share that with a few people, and bookmark this for future discussions on cancer screening. Thanks for another accessible read on the subject.
Interestingly NZ has just released their findings on cancer rates.
http://www.otago.ac.nz/wellington/otago031532.pdf
They use mortality rates throughout.
@Mark P
Interesting report from the Kiwis. It mostly concerns itself with socioeconomic variables and survival rates. But it is clear that the raw age at death and the cancer diagnosed information exist in the raw data. It would be interesting to compare that with age at death from similar cancers in a couple of other countries. As Dr. Gorski pointed out, focusing on survival years from diagnosis may say more about screening procedures and diagnostic sensitivity than about actual efficacy of treatment.
Of course there are a bunch of confounders using simple age at death for a given cancer: diet, exercise, environmental carcinogens, etc. But still a simple age at death from X would still be interesting. If the average age of death from, say, colon cancer in several similar countries with differing health care models clusters around 62, who cares if survival from diagnosis is 10 years or 10 minutes? Such data would suggest that countries spending markedly more for colon cancer diagnosis and therapy aren’t getting much bang for their extra bucks. Alternatively, if higher spending countries saw colon cancer deaths at a much older age it would suggest some real benefit to the higher spending.
As far as I know the US is one of the countries with most expensive health care cost, I know several people with critical ills like cancer that prefer to travel to another countries to get an appropiate treatment that they can afford.
So sad, as these people are really desperate to get a chance to survive. Great post, very informative.
[...] [...]
Here is a source for mortality statistics, http://www.deathriskrankings.com/Default.aspx
This source has an interactive feature. I would suggest the following settings:
1) Click on Death Comparison Rankings
2) Select Primary comparison, US to Europe
3) Select Secondary comparison Age
4) Select Sex Female
5) Select Cause of death, Cancer: Breast (requires scrolling)
6) Click on submit
Then you will receive 1 year mortality rates by age group for breast cancer, comparing US to Europe. It is interesting that the US has an equal (0) or higher mortality rate than Europe until age 40. The result has implications that can be used in arguments based on observational statistics, but still lack scientific vigor.
It should also be noted that there are significant differences in breast cancer prevalence related to ethnicity. That could account for the lower mortality rate in Japan. http://www.cdc.gov/cancer/breast/statistics/race.htm
The controversy over the USPSTF recommendations on mammography had several sources, not just the failure to understand overdiagnosis. My gripe centers on the panels moving from standard methods of making decisions from scientific data (estimating mortality reduction from RCTs, and evaluating cost per year of life saved), to incorporating computer models for deriving data used in an Efficient Frontier analysis. The traditional methods are explicitly used in the supporting article prepared by the “Oregon Evidence-based Practice Center”, in Appendix C1 of the evidence supporting article. Computer models are rife with pitfalls. The framework of the decision from the Efficient frontier analysis was ad hoc, and bore little relationship to the original applied mathematical model. But those methods received little scrutiny as a new way to make decisions from scientific evidence.
Overdiagnosis of breast cancer is more of a problem today for several reasons. We now detect more DCIS and smaller invasive tumors that may never have continued to grow or metastasize. Treatment has improved, so a larger percentage of breast cancers detected by palpation will now survive. We are also screening more women above age 75 than we ever have before (or at least compared to 25 years or more ago). However it does not represent the problem of overdiagnosis to the general public to fail to mention that overdiagnosis also occurs with detecting breast tumors by palpation (although the USPSTF specifically defines overdiagnosis as only referring to cases detected by screening mammography, slightly different than defined here). Based on the more recent RCTs, it is reasonable to say that 90% to 95% of invasive breast cancers detected b y screening mammography in the age group between 40 and 50 would have grown and become detectable by feeling a lump. A high percentage of comedo type and high nuclear grade DCIS would also have grown and eventually be felt as well.
While overdiagnosis can be used as an argument to justify cessation of screening if the patients life expectancy is less than 10 years, it is a weak argument to justify not screening between age 40 and 50.
One other argument about autopsy studies and estimating the prevalence of breast cancer: Many of the breast cancers counted in the autopsy series would be too small to detect by regular screening mammography. Specimen radiographs used in autopsy series are not limited by radiation exposure issues or problems with the thickness of the breast tissue. Consequently specimen radiographs can be much more sensitive for small tumors than screening mammography.