Those who resist health care reform point to America’s great cancer care – instead, we should protect “the best health care system in the world.” After all, if we’re the best, other countries should change, not us.
Do we really have the world’s best cancer care?
A good indication is the American survival rate for breast cancer, the world’s longest. But what are survival rates?
Survival rates reflect time between diagnosis and death from a condition. It is commonly expressed as “Percentage of patients alive five years after diagnosis.” The higher the percentage, the better the treatment appears.
However, treatment is just one of three aspects influencing survival rate.
The first is an earlier diagnosis that does not alter outcome. Although the disease is detected earlier, the patient dies at the same age. Imagine a patient destined to die at age 50 regardless of treatment. Detecting the disease earlier increases survival rate but makes no difference in life expectancy.
Another aspect of survival rate is over-diagnosis. If a tumor grows too slowly to affect life span, then including patients with these tumors in the studied population extends average survival rate independent of treatment. For example, diagnostic scanning for other diseases incidentally may detect slow-growing prostate cancers that, even if untreated, have no effect on life span. If they are included with more malignant cancers, survival rate increases without any treatment improvement.
Survival rates also reflect normal distribution. There are over 200 types of cancers; most are treated similarly among industrialized nations. If we review survival rates from all cancers throughout the industrialized world, different countries lead in different cancers. Survival rates from head and neck cancers are higher in Canada than in the US. Germany has the highest survival rate in esophageal cancer; Austria in stomach cancers; Belgium in pancreatic cancer; etc.
There is the additional question of statistical versus clinical significance. Our five year survival rate for breast cancer is 83.9%, the highest in the world. The survival rate in Canada is 82.5%. Is this difference clinically significant?
Mortality rate, in contrast, reflects the number of people dying of a disease annually. This statistic eliminates the early diagnosis confusion, though over-diagnosis remains.
An intriguing study recently compared mortality rates from all treatable cancers among the US, the UK, France, and Germany. US mortality rates are better compared to our peers. Perhaps Americans do receive better treatment.
Here’s the catch. When mortality rates are restricted only to patients under 65, the US loses its lead – we are right in the middle. Only when we compare mortality rates among patients over 65 do we excel among our peers. Why? Possibly because Medicare gives older Americans the health care access they lacked when younger.
This age breakdown suggests American medicine possibly offers the world’s best cancer care, but only to patients with access to that care. Access for younger Americans depends critically on wealth. Poor Americans without insurance may not receive the excellent care available to wealthier Americans. At least not until their 65th birthday.
The US may offer the world’s best cancer care. However, we cannot boast of leading in cancer outcomes because access is problematic for non-seniors.
Thus, resisters to reform may be right – America does offer the world’s best cancer care. But advocates of reform are also right – too many Americans are denied this excellent care.
America’s poor health statistics do not reflect on our doctors, nurses, and hospitals (who may be the best in the world), but on our inability to get Americans into the clinics and hospitals where these superb providers practice.
We do not need to reform our health care. We need to reform the barriers to accessing that care.
Samuel Metz is an anesthesiologist.
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