Stossel in the WSJ

He takes on Michael Moore head on with his WSJ op-ed:

Patients in countries with government-run health care can’t get timely access to many basic medical treatments, never mind experimental treatments. That’s why, if you suffer from cancer, you’re better off in the U.S., which is home to the newest treatments and where patients have access to the best diagnostic equipment. People diagnosed with cancer in America have a better chance of living a full life than people in countries with socialized systems. Among women diagnosed with breast cancer, only one-quarter die in the U.S., compared to one-third in France and nearly half in the United Kingdom.
Mr. Moore thinks that profit is the enemy and government is the answer. The opposite is true. Profit is what has created the amazing scientific innovations that the U.S. offers to the world. If government takes over, innovation slows, health care is rationed, and spending is controlled by politicians more influenced by the sob story of the moment than by medical science.

His 20/20 special will be shown this Friday.

Comments

Alla
Among women diagnosed with breast cancer, only one-quarter die in the U.S., compared to one-third in France and nearly half in the United Kingdom.

Not to argue for socialized medicine – I have relatives abroad and I am very ambivalent about it, but this argument is flawed.
There is more screening in the US, so more cancers are detected and consequently there is more overediagnosis. Liability issues also drive overdiagnosis higher. Given that overdiagnosed cancer is easy to treat as it wouldn’t have spread anyway, this reduces the ratio of cured cancers/detected cancers. If Stossel adjusted his numbers for overdiagnosis (does he know what it is?), I’d love to know it. It’d be rather difficult to do given how varied the estimates for overdiagnosis are.
The more reliable statistics would be the total number of deaths from breast cancer for, say, every 10,000 women in the population in different countries (adjusted for confounding factors, like having kids early, weight, etc. – I know it is not easy to do). If someone has this data, it’d be interesting to see – I don’t have time now to look for it.
Again, I am not arguing for socialized medicine. In fact, having nice insurance I’d probably stand to lose if we had it. Just pointing an obvious flaw in the argument.
Alla
reduces the ratio of cured cancers/detected cancers
Oops, I meant to say increases the ratio of cured cancers/detected cancers.
Evan
Alla,
It’s obvious that the fastest way to drop a percentage is to increase the denominator, so you are correct that population-adjusted data is the way to go. I have no idea where this is stored but I’m willing to be it exists somewhere.
Anonymous
Alla, I’m confused about what you mean by “overdiagnosed” cancer.
Are you saying there are more false positives in the USA? Are you saying that these false positives are being called cancer?
The patient is not being recorded as having cancer unless there’s a tissue diagnosis of cancer. An abnormal mammogram is not entered into the cancer registry as cancer until a biopsy establishes that it is cancer. I’ve had various imaging studies come back over the years as highly suspicious for cancer (breast, lung, etc.) that came back with a non-cancer tissue diagnosis on biopsy. I do not get calls from the cancer registry about them.
If false positives are a random event, one would think that other countries get the same percentage of false positives we do.
Are you saying that “overdiagnosis” means true cancers that are detected at so early a stage that the patient would likely die of other causes? Like perhaps finding an early prostate cancer in a 95-year-old man?
If you mean by “overdiagnosis” that true positives are being found earlier, making them easier to treat than another country finding the same cancers later, I’m having a hard time understanding why that’s not relevant. If a socialized system can do anything right, one would think it would be able to do primary care and screening right.
And no, I don’t think you need to look at population data necessarily, you look to compare populations with cancer at the same stage. Because I agree, it is not fair to compare survival of one population with advanced cancer against a population with early cancer.
Alla
Anon at 6:10, as far as I know there is only one definition of overdiagnosis as it is used in a zillion published papers in peer-reviewed journals, as well as in the PDQ Summary of Evidence and in the USPSTF Recommendations and Rationale. Yes, by overdiagnosis one usually means early cancers that would’ve never spread in one’s lifetime if remained undetected. I’ve never seen any other meaning of this word.
Obviously, if you do more screening (or if the test is more accurate), you’ll detect more cancer. Some of these extra cases will be overdiagnosis. In addition, there are borderline cases which a US pathologist may be more likely to call cancer because of the liability fears. Some of these may also be overdiagnosis.
Certainly comparing survival at the same stage would show if the treatment is better in the US. But the population study would also show the effect of additional screening in the US. Evan is right in that this data must be published somewhere. I don’t have time to look, but if anybody has it, it’d be interesting…
Evan, when we talk about overdiagnosis increasing the ratio of cured to detected, we are increasing both nominator and denominator by the same number (all overdiagnosed cases are cured). So we are comparing (x+a)/(y+a) to x/y where y>x, x,y,a>0. Trivial to prove that former is greater (ay – ax >0 since y>x)
matthew holt
Stossle is so overblown and so dumb on this as many other topics. Pity because I like the concept of a libertarian on plenty of issues being on prime time.
but the cancer stuff has been thoroughly debunked by Gerald Anderson, Jon Cohn et al. It’s intellectaully vacuous to keep repeating it.
Meanwhile the variation in practice and the use of drugs in cancer care in this country is a disgrace for entirely different reasons that a tax-cutting hawk like Stossel would be appalled about if he spent five seconds trying to understand it!
UroCanswer
The day that Alla can tell me accurately which cancers “wouldn’t have spread anyways” is the day that I will consider this “overdiagnosis” argument. If ever there was a cancer that fits Alla’s claim, it would be prostate cancer. I fully acknowledge that there are many men diagnosed with prostate cancers that will be very unlikely to harm them ever, within their lifetimes. So operating on these men could be construed as a gross overtreatment. Likewise, there are some men with prostate cancer who have occult disease that is not detected by PSA, CT, or bone scan. These men, also, are not well-served with surgery since the cancer has aleady spread (silently). Until a better test comes along, I challenge Alla to prove to me that when he is 68 years old and diagnosed with a low-grade prostate cancer with a moderate PSA elevation, that his cancer is guaranteed not to progress. Otherwise, in my opinion, it’s a gamble with your life. Maybe in my specialty, there is a selection bias and I see all the people that have lost that wager? But I have no doubt that screening programs and earlier detection of cancers decreases cancer-related deaths, but at a certain cost to society. I don’t mean just financial costs, I mean the costs of screening, impact of additional diagnostics, impact of treatments that may not be ideally curative, etc.. The question is what each society’s acceptable cost is.
UroCanswer
anon 6:10,
good example.. clearly an overdiagnosis. That 95yr old man should never have even been biopsied. And probably, his primary care doc shouldn’t even check his PSA in the first place. In this country (USA), this phenomenon is not only being driven by the medical establishment. There is an expectation of active treatment. Due to the type of surgery I specialize in, I get a lot of patients coming to me for second opinions. I spend a lot of time trying to convince many of them to NOT have surgery, because they are 74 years old, and have a faily low-volume, low-risk prostate cancer. This 74yo I’m thinking of looks at me and asks, “how can you be sure my cancer won’t progress in the next 10 years and harm me? My father lived to 98, and I’m fit as a horse myself” I have no good answer other than vague statistics. No test, no crystal ball. I present the options and the risk of surgery. He chooses, and quite frankly, demands.. surgery.
Alla
UroCanswer, the subject of my post (and this thread) was not benefits and risks of screening. The subject here is whether or not the ratio of cured/detected cancer is the right criteria for comparison of European vs American health care as mentioned in this blog entry. The mere existence of the overdiagnosis as well as the fact that one cannot say for sure which cancer will progress shows that this ratio is not valid.
If you are saying that there is no overdiagnosis in mammography only in PSA, feel free to read PDQ summary of evidence on the NIH website as well as USPSTF recommendations and rationale (not just the summary). Feel also free to read this estimate of overdiagnosis from Malmo trial (click on PDF to read the complete article; don’t forget rapid responses as they show an obvious flaw in authors’ math resulting in underestimate). There are other estimates, but this one is based on real data and not just modeling. Given the improvements in technology since the time of Malmo, the numbers are enough to affect the total ratio.
Anonymous
It seems the answer to that is to compare cancer outcome by stage.
Alla
Stage comparison in this case may be affected by stage migration bias – Orac explained it in this post.
So the population-adjusted data would still be most telling. I am sure it exists somewhere, but I need to do some real work now .

Stossel in the WSJ

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