Facing the difficult issues when it comes to high quality cancer care

Facing the difficult issues when it comes to high quality cancer careIt has been a long slog since we started our war on cancer here in the United States in 1971.

At times I am not certain that this has been so much of a war as opposed to a series of skirmishes that occasionally have produced incredible moments of optimism. But there have been a fair share of frustrations as well along the way. Our science and our care have made significant progress, but sometimes we find ourselves asking, “What have you done for me lately?”

I think it is important to reflect on the progress that we have made on several fronts in detecting cancer earlier, treating it more effectively and providing quality of care for those who find themselves caught in the jaws of illness, especially for those whose journey has not been successful.

The screening dilemma

When I talk about the prevention and early detection of cancer I remind people of the state of affairs we found ourselves in back in the 1970s: we had precious little to offer in the way of early detection, save for the Pap smear in cervical cancer. We were convinced that if we only could find cancer earlier we would be able to save lives.

Mammography for breast cancer, screening for bowel cancer and PSA testing for the early detection of prostate cancer came along, and while research demonstrated that we could effectively find breast and colon cancer earlier and save lives, we weren’t quite as rigorous when it came to prostate cancer.

Fast forward 40 years or so, and we find ourselves on the horns of several dilemmas where we can find many cancers much earlier than before, and we can even find cancers we never anticipated or intended to look for, as is the case with incidental cancers that are found on CT scans.

But finding all of these cancers has left us with another dilemma, namely whether we are really helping all those people where the cancer may never have caused difficulty during their lives.

We are still not able for the most part to separate the more indolent cancers from those that are more aggressive. As we find more cancers, that has become an increasingly important distinction. For now, suffice to say – especially for prostate cancer – we are probably treating many more people with aggressive therapies that they really don’t need.

Countries around the globe in the developed world struggle with the dilemma. Here in the United States, screening for cancers is widely available and readily accepted as effective, even when the science raises serious and important questions about that effectiveness. As a result, many people are treated with expensive therapies that at best may not do them any good, and in fact may do harm.

Undoubtedly some people are helped, but we can’t say for certain who they are. And then there are the unfortunate folks whose disease develops quickly between screenings, or when the cancer may be so aggressive that even detection on screening doesn’t do a whole lot to alter the course.

Treatment arms race

On another front in this “war” we have a treatment arms race under way in the US and that is the increasing cost of techniques, procedures and medications. For example, proton beam machines designed to deliver very high doses of radiation in very precise dimensions are flourishing.

Forget that there is no real evidence – except in very specific instances where cancers may impinge on vital structures or in certain pediatric cancers – that they really make a difference. Robotic surgical devices have captured the eye of the public who believe that they are magical and “gee whiz,” yet the number of proven advantages are limited.

The United Kingdom has generally adopted a more restrained approach to cancer care. There is at least some level of review, based on measures of effectiveness, which limits proliferation of these devices. The decisions that are made are not universally accepted, but that is the trade-off in a national health scheme that provides more care to more people at lower cost. It would lead to a revolt in the United States.

There is no doubt that we folks on this side of the ocean are going to have to face a harsh reality that we cannot continue on our current path. It is not sustainable. The UK is going to have to decide how to get more technology and more expensive drugs to people in the face of limited budgets, and the reality that newer treatments are potentially effective while being incredibly more expensive than the drugs they replace.

The targeted therapies that we have developed, and the targeted therapies we will develop, as a result of our increasing knowledge of what makes a cancer cell a cancer cell may well be a Godsend. They may turn some cancers from killers to chronic diseases, much as has happened with chronic myelogenous leukaemia, where imatinib overnight changed the face of a very bad situation. But they are proving to be very, very expensive.

No matter which system of health care we live in – the fee-for-service system in the United States where everyone has to find the funds to pay for their share of treatments, or the more global care offered by the National Health Service in the UK – we are going to have to figure out how to pay for it. Progress is real, but it is incredibly expensive.

Ordinary people – and that includes almost all of us in both countries – can’t afford this stuff.

The value question

So that brings us to the basic question of what we value in health care and how we pay for it.

At one end of the spectrum, patients and families in the United States want access to the treatments we desire when we believe we need them. At the other end of the spectrum, the UK has made the decision to cover everyone, but you want the system to work better than it does.

Neither world is perfect.

The value question goes one step further when it comes to comparing the two systems. Here in the US, politicians, doctors and people in this country are constantly telling us how we have the best health care in the world.

Never mind that that claim is hard to support: we spend much more money per capita than anywhere else in the world, while our longevity – the length of our years – doesn’t come anywhere close to what other developed countries experience. We have tens of millions of people without health insurance, and millions more without adequate insurance to pay for the care they need, especially if they develop cancer.

While it is true that in the US we can provide people with lots of care with lots of advanced technologies if they become sick, we don’t do a decent job of preventing them from getting sick in the first place and we certainly don’t provide everyone with access to basic, high-quality, high-value care when they do get sick.

And then there are the folks who tell us how much better the results of treatment are here in the United States for cancer compared to the UK. The reality is that the differences can be less than perceived.

How one uses and reports statistics – such as how long someone survives after a cancer diagnosis as to opposed measuring the actual numbers of deaths per 100,000 people - can paint very different pictures.

Just because cancers are found earlier doesn’t mean that more people survive. They may just live longer with their disease but the death rates may be the same, not to mention that – as noted above – we may find many cancers through “early diagnosis” that would never have caused harm or death.

A recent article in a major health care journal proclaimed that people in the United States lived longer with their cancer than their unfortunate counterparts in the UK, thus justifying the loads of money we spend on cancer care. A couple of years ago one of our presidential candidates who has prostate cancer proclaimed that the poor men with prostate cancer in the UK don’t live long because they don’t get screened, and they don’t get the high-tech care we offer here.

The point was made to underline the failings of national health insurance compared to the excellent care here in the United States. It was wrong. It quietly went away as an issue.

What these folks have missed is that we probably find a lot more cancers here than you do there. That’s because we screen a lot more folks than you do there. But it is not so clear that you fare worse. Your cancer patient population probably represents the tip of the iceberg above water, while we are finding many cases below the water line who appear to live longer but really don’t. Their disease is simply found earlier.

And I would find it hard to say that people who get expert cancer care in the UK get inferior treatment from inferior doctors than those people would get in the United States. They may not get as much care, and it may not be as fancy. But I suspect your doctors are every bit as diligent as those in the United States. That has been the case for decades and I don’t think that has changed recently.

Hard decisions

So both our countries struggle with our realities, our fiscal constraints, our societal perceptions, and the limitations that both systems bring to the table. We share the same knowledge about cancer care, but we make different value judgements. And in the end I suspect there isn’t much difference.

(I am certain I will hear from those who disagree, which is fine with me. But always remember it is important to support perceptions with facts, and sometimes facts can be manipulated to support one position or the other.)

What is immutable is the fact that both our countries are going to have to come to grips with some very difficult issues when it comes to providing high quality cancer care. Those decisions won’t be easy, whether it relates to how we prevent and detect cancer early, or what treatments we choose to offer, or when we decide more treatment is futile. The UK has a long history of paying attention to quality of life, pain management and hospice care. Our politicians call that “death panels”. You call it compassion.

As I look into my crystal ball, I suspect that over the next number of years we are going to become a lot more like you than most people can imagine or want to imagine. Whether that is “good” or “bad” will always be in the eyes of the beholder. But it is a change we have to consider.

There may be some in the UK who look to the US and our latest, cutting-edge technology, with a tinge of envy about what we do when it comes to providing health care (actually, more often “sick care”) here in the United States. The problem is we can’t afford to keep doing it.

Clearly, at some point in the not too distant future, we in the US are going to have to make some difficult decisions about how we use the limited resources available for health care and provide greater access to those in need. I suspect there are some lessons you have learned and decisions you have made in the UK that we could benefit from.

That, my friends, would be an interesting turn of events.

J. Leonard Lichtenfeld is deputy Chief Medical Officer for the national office of the American Cancer Society. He blogs at Dr. Len’s Cancer Blog.

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