Is our high cost of cancer care worth it?

The U.S. spends far more on cancer care than 10 European countries, but according to a new study, it may be “worth it” as “the value of the survival gains greatly outweighed the costs.”

The study, published this week in Health Affairs, found that U.S. spending on cancer care, in 2010 dollars, increased by 49% from 1983 through 1999, from $47,000 per cancer case to $70,000 per case. Meanwhile, in the European countries, spending on cancer care (also in 2010 US dollars) increased 16% from $38,000 per cancer case to $44,000. But the sharp increase in cost seems to come with clear benefits; for patients diagnosed with cancer between 1995 and 1999, average survival from time of diagnosis in the U.S. was 11.1 years, while in Europe it was 9.3 years. These gains were greatest in patients with prostate and breast cancer, as well as chronic and acute myeloid leukemia.

At first glance, this study, which was partially funded by cancer-drug maker Bristol-Myers Squibb, should give ammunition to those stalwarts who continue to insist that America’s health care is the very best that money can buy—at least when it comes to cancer. But despite the findings that the “value of survival” far outweighs the skyrocketing financial costs of cancer care (the National Cancer Institute puts it at $125 billion in 2010)—many questions remain.

First of all, the Health Affairs authors do note some limitations of the study; for example, even though the results suggest that survival gains for U.S. cancer patients have been “worth it” in terms of cost, “this does not imply that all treatments are cost-effective. Additionally, we could not examine the extent to which better outcomes were the result of earlier diagnosis due to screening or newer treatments,” they write. I would add, the data analyzed are more than a decade old—cancer treatments and diagnostic technologies have changed both in cost and efficacy since then. How do we factor in the “value” of a brand new $90,000 cancer drug that keeps a small percentage of very sick patients alive for at most two or three more months?

There are other problems with reading too much into this report.Is our high cost of cancer care worth it?

Here’s something interesting I found in the study: “US mortality rates for cancer are lower than those in Europe, despite higher rates of cancer incidence in the United States.” My first question was why do we have higher rates of cancer incidence in this country? Is it our diet, exposure to pollutants, smoking rates or other environmental or even genetic determinants? None of these seems likely (especially the smoking bit), but there is one major difference. We do a lot more cancer screening in the U.S. than in Europe and this can be a double-edged sword.

While it is true that screening tests like mammography and PSA testing can catch cancers at an earlier, more treatable stage, early diagnosis can also lead to seemingly longer survival times. The researchers explain that they avoided so-called lead-time bias—meaning a person appears to survive longer if they are diagnosed 6 months before another—by comparing changes in mortality rates overall. “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.”

But lead-time bias isn’t the only factor that can skew survival data and the authors leave out a very important factor: In the U.S. where preventive screening is used far more frequently than in Europe, there is also a documented rise in over-diagnosis of cancer. A recent study in the Annals of Internal Medicine  found that over-diagnosis accounted for 15% to 25% of breast cancer cases identified by a large screening program. For example, a woman who is diagnosed with a tiny growth in her breast that is unlikely ever to progress (a so-called pseudo-cancer), or progresses so slowly that she will die of something else, would be counted as one who has been “cured” of cancer through early diagnosis and better treatment in the Health Affairs study. She will have undergone surgery, radiation, and perhaps chemotherapy that cost tens of thousands of dollars—treatment that likely caused physical and psychological harm, but in the end added no “value” in terms of extra life-years.

The same is true for prostate cancer, where some 70% of men diagnosed with a prostate-specific antigen (PSA) test have a low-risk form of the disease. According to a report in the journal Oncology, “over 90% of these men will be treated for their disease at diagnosis although it is estimated that up to 60% of men may not require therapy, even over the long term.” The report adds that a recent cost-effectiveness analysis of PSA screening estimated that the cost of diagnosis and treatment is over $5,227,306 per patient to prevent one death from prostate cancer.

The Health Affairs authors, led by Tomas Philipson, professor of public policy at the University of Chicago and senior economic adviser for the FDA and CMS during the second Bush presidency, do not consider that survival rates might be inflated partially due to this considerable problem of over-diagnosis in the U.S., a country far more enamored with screening mammography and PSA testing than their counterparts in Europe. Instead they find the opposite; “Finally, earlier detection and management associated with increased screening for breast cancer through mammography, and for prostate cancer through prostate-specific antigen testing, in the United States relative to Europe also could have been responsible for improved US patient outcomes.”

There is one more important question about cancer treatment and survival that was not addressed in the Philipson, et. al. study: If you include the pain, suffering and loss of quality of life some cancer patients experience during those extra months of survival, is the cost of care still “worth it?”

To help answer this, I urge you to read a companion story in Health Affairs by Amy Berman, a 51-year-old registered nurse and senior program officer at the John A. Hartford Foundation who was diagnosed with incurable inflammatory breast cancer and has chosen to take a palliative approach to treatment of her disease. She writes;

“Is there a downside to aggressive treatment? You bet. In the case of incurable cancer, it can mean rounds of radiation or chemotherapy, or both, with side effects of crushing fatigue, overwhelming nausea, burned and peeling skin, permanent pain or numbness of fingers and toes, and the cognitive impairment known commonly as “chemo brain.” The ‘treat aggressively’ approach can leave patients bruised and battered, wishing they were dead.”

She adds, “Yes, perhaps, a few months of added life come with it—but at what cost?”

Finally, doctors who treat cancer patients note another, less corporeal “toxic” effect of high-cost cancer treatment in America. Two oncologists from the Duke Cancer Institute wrote in Kaiser Health News last August; “We know that the experience of receiving cancer treatment can result in a physical toxicity, but recent data suggest that cancer treatment might also cause financial toxicity that affects the daily lives of patients and their families.” The Duke doctors cited a study they conducted where they found that although 99% of the mostly older cancer patients were insured (83% with prescription drug benefits), they still paid an average of more than $700 a month for their cancer care out of pocket. Most reported going through their life savings to foot the bill; 11% described cancer care as a catastrophic financial burden.

This begs the question of why are we Americans paying so very much for our cancer care? We won’t really know if it’s “worth it” until we find out which factors are actually responsible for the survival gains over our European counterparts seen in cancer treatment—is it earlier detection? Better chemotherapy drugs? More targeted therapies? Surgical advances? Or are some of our gains really due to over-diagnosis or unwanted treatments that may boost survival a couple of months but destroy a patient’s quality of life?

Naomi Freundlich is a journalist, policy expert and health advocate who blogs at Reforming Health.

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  • http://www.facebook.com/profile.php?id=558041620 Vikas Desai

    There will be no end in sight in regards to overdiagnosis of breast cancer, consider the unstoppable juggernaut that is the susan komen foundation. Pink NFL uniforms, nuff said

  • http://www.facebook.com/macm25 Corey Miller

    seems to be of epidemic proportions!

  • LynnHanessian

            This is a terrific review of the article and weighs some of the many challenges of assess the success of our war on cancer. Of course, an emotionally overwhelming diagnosis must be balanced by reality of options. We have a lot more options, but many come with significant trade-offs. Here is Modern
    Healthcare’s take on the study: http://www.modernhealthcare.com/article/20120414/MAGAZINE/304149991?AllowView=VW8xUmo5Q21TcWJOb1gzb0tNN3RLZ0h0MWg5SVgra3NZRzROR3l0WWRMVGJVUHdGRWxYOU9qTENvK25lK0g4UktMMmxlMDVtbGc9PQ==&utm_source=link-20120414-MAGAZINE-304149991&utm_medium=email&utm_campaign=am

  • Hornblower1810

    The study cites data from 1983 to 1999, an 18 year period.  An increase of 49% during this period represents a 2.12% annualized increase. I would not think of this as  the “the skyrocketing financial costs of cancer care”.  I was shocked it was so low.

  • ChuckPilcher

    Body of article seems not to support the headline. The devil is in the details.

  • http://www.facebook.com/drjoe.kosterich DrJoe Kosterich

    As an observer from afar I wonder how a capitalist society like the USA is not more questioning of the value it gets for the healthcare dollar.The USA spends nearly double the % GDP of most other OECD countries without materially better outcomes.

    • lissmth

       Go get prostate cancer in the UK, Norway or Canada.

      Americans have better survival rates than Europeans for common cancers.  Breast
      cancer mortality is 52 percent higher in Germany than in the United
      States, and 88 percent higher in the United Kingdom.  Prostate cancer
      mortality is 604 percent higher in the U.K. and 457 percent higher in
      Norway.  The mortality rate for colorectal cancer among British men and
      women is about 40 percent higher.

      Americans have lower cancer mortality rates than Canadians. 
      Breast cancer mortality is 9 percent higher, prostate cancer is 184
      percent higher and colon cancer mortality among men is about 10 percent
      higher than in the United States.

      • http://www.facebook.com/drjoe.kosterich DrJoe Kosterich

        OK so why is life expectancy in the USA not higher than other countries?

        • lissmth

           Other factors.  More automobile deaths for one.

          • http://www.facebook.com/drjoe.kosterich DrJoe Kosterich

            Good points. Compared to Australia (where I am) the USA has a 5% greater overall 5 year survival for cancers. This is for double the GDP spend (and the GDP of the USA far exceeds Australia). My question remains does the USA get good value for the money spent?

          • lissmth

            America leads the word in medical technology and innovation.  In reality, we create the stuff and socialized countries use it.  If American went socialized, where would the Canadian prime ministers and the Iranian shahs get their medical treatment?  Indeed, the world gets very good value for what the U.S. spends.

            We also provide national defense for the free world.  If Australia got its butt in the wringer, you know who’d be there.
             
            That “life expectancy” argument depends on who is creating the numbers.  WHO counts deaths in terms of what would be expected for a country.  My state (in the U.S.) counts spending per pupil, not in actual numbers, but in terms of what this state could spend given the level of income.  Same fraudulent computing.  The socialized medicine folk use that argument to argue for government medicine.  The teachers’ unions use the same argument to argue for more money. 

            Other countries statistics are kept differently as well.  It is not an applies to apples comparison. 

      • Sunjay Devarajan

        Where are these statistics from?

  • LBENT

    We treat people, not statistics.  It is impossible, in a one on one basis, to determine a priori what the outcome would have been if not treated.  It used to be thought that low grade thyroid cancer didn’t need aggressive treatment, and then the mortality rates were compared, and guess what, those who were treated by doctors who advocated less than a total thyroidectomy were dying younger from a disease that could be cured. 
    We don’t know the outcomes for all cancers, even ones that “should” behave in an indolent way (e.g. basal cell carcinoma).   And we definitely don’t know what one month, year, or decade of someone’s life could mean.
    My mother was diagnosed with breast cancer at age 42.  Had positive lymph nodes.  Had a 15% chance of 5 year survival.  Had all the treatments.  Lived 20 years disease free.  Then had a secondary leimyosarcoma of the heart.  Had aggressive therapy including heart transplant and live 4 more years–with a reasonably good lifestyle.  (by the way she didn’t “steal”  a heart from someone else. 50% of available hearts are thrown away, orphan hearts, because you need to be within 10% of the body weight of the heart donor and my mother was 115 pounds.  Very few people her size need hearts–it’s usually babies and older obese people).  She died at home.  No heroic measures.  She had fought a good fight.  She had almost a quarter of a century of life that otherwise she might not have had.  She worked, she lived, she loved.  She met all 5 of her grandchildren.  And all of them remember her for the loving person she was.  
    On the flip side, my aunt had metastatic lung cancer and the week she died, when she was 87 pounds, an unscrupulous oncologist gave her chemotherapy.  I found out only after she died.  End of life care can get out of control. 
    Cancer advances is one of the best success stories of American medicine. 

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