Yesterday, senator Mitch McConnell (R) introduced more anti-healthcare-for-all talking points on the Senate floor, a transcript of which was posted at the Washington Post.
Most people...in the US [like] the quality of cancer care that’s available here...the fact is, America boasts some of the highest cancer survival rates in the world...But it could very well change if the U.S. adopts a government-run health care system along the lines of the one some are proposing.
A recent study comparing US cancer survival rates with other countries found that, on average, US women have a 63% chance of living at least five years after a cancer diagnosis compared to a 54% rate for women in Britain. As for men, 66% of American males survive at least five years while 45% of British men do.
It's no mystery why Americans have higher cancer survival rates than their counterparts in countries like Great Britain. Part of the reason is that Americans have greater access to the care and the medicines they need. And they don't want that to change. All of us want reform, but not reform that denies, delays, or rations health care.
No mystery? Really? Better access to care? Including the more than 40 million uninsured?
Does the United States have the best cancer care "in the world?" It is a much more complicated question than McConnell would make you believe.
Why 5-Year Survival Rates Aren’t the Best Measure
Let’s assume McConnell’s rates are accurate (they aren’t). What do they tell you? Not much. For one thing, 5-year survival rates depend on many factors other than treatment, including (a) site of the cancer; (b) time of diagnosis (eg, early, late); (c) age at diagnosis; and (d) genetic or morphological factors.
Controllable treatment-related factors that influence survival include: (a) access to clinical trials; (b) access to healthcare; (c) adherence to treatment; (d) types of medications; (e) aggressive or nonaggressive treatment approach (some of which is determined by patient preference; and (f) skill of the surgeon. Here is what one study has to say on the matter:
The differences in survival are due to a variety of reasons, Dr. Verdecchia and colleagues write. They include factors related to cancer services — for example, organization, training, and skills of healthcare professionals; application of evidence-based guidelines; and investment in diagnostic and treatment facilities — as well as clinical factors, such as tumor stage and biology.
Prostate cancer and 5-year survival
In 2007, Rudy Guiliani tried to use his story of prostate cancer survival to spur opposition to a government-sponsored healthcare plan. Much like McConnell, he intimated that 5-year prostate cancer survival rates were so much better in the US than Europe that he might have died under socialized medicine.
At the time, he claimed to get his facts from an article that quoted the Commonwealth Fund, a private healthcare think tank. The Commonwealth Fund shot back that 5-year survival rates aren’t really the best measure of treatment efficacy:
The survivability figures tell us little about the differences in the quality of treatment received by prostate cancer patients in the United States and Britain...about 25 men out of 100,000 are dying from prostate cancer every year in both the UK and the US.
Until recently, early PSA prostate screening was widely pushed in the United States, based on the theory that early detection prevents deaths. Europe did not jump on this bandwagon for multiple reasons: (a) Prostate cancer typically grows slowly and many never become symptomatic or life-threatening; (b) There was (and is) no solid evidence that treating early stage prostate cancer saves many lives; and (c) The treatment for early stage prostate cancer can leave men impotent and/or incontinent.
A recent study concluded that to save 1 life, 45 men would have to get unnecessary surgery that could leave them impotent/incontinent. Europe instead takes a watch-and-wait approach, treating prostate cancer only when it becomes symptomatic or seems aggressive.
For argument’s sake, let’s say every man survives 10 years from the time his prostate cancer starts. If you catch it after 3 years in the US, the man will live 7 years, becoming another statistic in the 5-year survival rate. If you are in England, and do not get your cancer detected until the 6th year, you survive 4 more years—missing the 5-year mark. But both men die of cancer after 10 years.
Prostate cancer is the second leading cancer among men, and the much higher rate of early prostate cancer cases detected in the US skews 5-year cancer survival statistics for men (accounting for more than half of the disparity) and overall in this country’s favor. In addition, many American men are living with horrible adverse effects they did not need to endure. Is that better healthcare?
US 5-year survival not best in all cancers
McConnell neglected to mention that other countries have higher rates of survival for specific types of common cancers.
The highest survival rates were found in the U.S. for breast and prostate cancer, in Japan for colon and rectal cancers in men, and in France for colon and rectal cancers in women.
The highest survival rates for gastrointestinal cancer are found in Japan. This may be because Japan has higher rates of this type of cancer, giving their surgeons more experience treating it. Their surgeons appear to be more skilled at excising the tumors. The lower rate of obesity in the Japanese may also be a factor, because it makes surgery easier. It could also be due to unidentified genetic factors; it is known that the Japanese respond better to treatments for lung cancer than other races, for example.
Different studies calculate different rates
Here is a classic example from the EUROCARE study:
The age-adjusted 5-year survival rates for all cancers combined was 47.3% for men and 55.8% for women, which is significantly lower than the estimates of 66.3% for men and 62.9% for women from the US SEER program.
Using the SEER survival rate of 62.9% for US women, the study notes that it calculated an overall survival rate for women in Sweden of 61.7. The rate for women in Europe overall was 59.7%--higher than the 55.8% this study calculated for women in the US.
Most of the statistics quoted on 5-year survival rates in the US are based on the SEER database. This database encompasses statistics for about 10% of the population and does not capture people who die of cancer but never had their disease diagnosed or treated.
It would be interesting to know what the statistics are on the number of people in the United States who die of cancer without ever seeing a doctor. It would be impossible to know. Death could be attributed to embolism, which is common in cancer patients. The rate of autopsy is very low in the United States, and nobody really tracks how many cancers nationwide are diagnosed at autopsy.
In a study that used state-by-state databases of cancer statistics, the rate of 5-year survival in the US was lower than the widely quoted numbers reported by SEER. This is likely because SEER may be failing to capture pockets of people in areas with greater healthcare disparity and poorer outcomes:
The data presented here confirm suggestions that cancer survival in the SEER Program areas (10% population coverage during the 1990s) was higher than in other parts of the country. By contrast, regional variation in survival in Australia and Canada was much less marked than in the USA.
Most studies note that in the US, the difference between cancer mortality in blacks and whites is sharp. Some people who oppose a public plan argue this is due to genetic differences. It is true black women are more likely to have aggressive types of breast cancer, but the main reason for disparity is that black people have less access to healthcare and when they do get healthcare, tend to receive worse care:
Racial disparities in cancer treatment, which are not explained by clinical factors, lead to worse outcomes in blacks. Analysis of SEER data suggested that some racial differences in treatment and cause-specific survival persist after adjustment for poverty. By contrast, the racial difference in survival from colorectal cancer was almost absent in patients managed under the equal-access, integrated health-care Veterans’ Affairs system.
So, in the United States some people get great cancer care and other people get really bad cancer care or none, depending on their race, their level of education, where they live, and if they can afford care. In Canada, the level of cancer care might be slightly lower than the best care in the United States, but it is better than the worst care in the United States. In addition, the level of care is even across the entire population because of universal access.
This study does not agree with McConnell that the US has the best cancer care for many cancers. Cuba actually beats the United States, although the researchers expressed concern Cuba might be overreporting its success but it should be noted Cuba has a high number of doctors. Here are 5-year survival rates for various countries:
Breast cancer:
Cuba – 84.
US – 83.9
Colon cancer:
Japan – 63.0 men, 60.1 women
US – 60.1 men, 60.1 women
Top 3 Countries In Order For
Colorectal survival: Women - Cuba, France, USA; Men – Japan, Cuba, USA
Colon: Women – Cuba, France, USA; Men – Japan, USA, Cuba
Rectum: Women – France, Cuba, USA; Men- Cuba, Japan, USA
Patient choices
Patient choices have a strong effect on outcomes. In the US, there is an increasing trend to get prophylactic breast and/or ovary removal in women who have cancer-causing genes. This is not the case in Europe. Women in Europe are also less likely to have complete mastectomy than women in the US and more likely to elect more conservative (but less effective) surgeries.
Do oral anti-cancer medications have an effect?
There are several oral anti-cancer medications approved in the United States. There are more approved in some European countries, and even more approved for use in Japan. These are as effective as most intravenous treatments and cheaper to administer.
In the US, oral treatments cost much more than in other countries because insurance companies include chemotherapy costs in the doctor visit but let oral medications fall under prescription coverage. In Medicare Part D, patients hit the "donut hole" with their first cancer prescription. Doctors in the US markup intravenous chemotherapy treatments; they cannot with oral treatments, so prescribing one could mean lost revenue (though I would never suggest oncologists would put financial concerns over patient wellbeing). Some US doctors prescribe intravenous agents for patients who simply cannot afford copayments for the oral treatments.
Cost is not an issue under "socialized" medicine so patients may be more likely to get oral therapies. It is well known that patients are less likely to adhere to prescribed oral treatments—even patients with cancer. This is especially true when they are hit with financial hardships. They may skip pills, wait to refill prescriptions, etc. This could certainly lead to differences in survival rates, if one country uses oral treatments more than another.
Caveat
I am not saying the US does not have the best cancer care in the world--it very well may. But does it matter if you are one of the millions of people without access to it?
You may recall that a Federal Court of Appeals recently ruled it was okay to fire people who cannot work due to cancer:
The 8th Circuit cited one of its earlier opinions that found that the Americans with Disabilities Act did not cover illnesses like cancer.
If Federal Courts say people with cancer are not "disabled," what is to stop Medicare/Medicaid from giving them coverage under disability provisions?
One of the studies referenced herein did note that US patients with private insurance fared better regarding survival than patients under Medicare, even when age-adjusted. But age-adjusting does not adjust attitudes toward cancer treatment, likelihood to seek diagnosis (young people are more likely to seek treatment) and other factors like income disparities that might affect care.
The US healthcare system leads to a disruption in continuity of care because it is employment based. This may be actually hurting cancer survival rates, which might be better if we had a public option:
When insurance is tied to employment, you may have to switch doctors when you change jobs. In the past three years, says Karen Davis, president of the Commonwealth Fund, 32 percent of Americans have had to switch doctors.
So much for getting to see a doctor "of your choice."
Conclusions
It is true that cancer patients in Europe are often denied access to newer medications. NICE has more stringent cost/benefit requirements before approving a treatment.
This may seem bad, but sometimes everyone must sacrifice a little for the benefit of all. NICE does not deny treatment that saves or significantly improves lives--only access to medications that may grant 1 month or so of life or reduce tumor size but shows no survival benefit. I would sacrifice a month of life to know that my children will grow up to always have healthcare when they need it. Would you?
To summarize, 5-year survival rates are not good predictors of the effectiveness of cancer care. Statistics on survival do not include people who die from cancer but never get treatment—which includes many uninsured in the US. There are many reasons why statistics on survival might differ between countries that have nothing to do with who pays for care. Arguments like McConnell’s (which is based on an article by Dick Morris) try to manipulate the facts about cancer to score political points. Like cancer, the story is much more complex than it seems.
UPDATE: I know, it's long enough as it is. But Dave in RI made an excellent point. The majority of people with cancer in the United States are the elderly and many are covered under Medicare. As Dave pointed out, if republicans believe cancer care is so excellent in this country (and it may be), perhaps credit should be given to the government-run Medicare for ensuring that its enrollees are getting access to good care.