Screening, prevention, and treatment have extended life for oncology patients, but at a higher cost in the U.S. than in Europe, research shows.
U.S. spending on cancer care has been increasing more steeply and expensively compared to spending in Western Europe in recent decades, but without a corresponding decrease in cancer deaths, research published in Health Affairs finds. The finding raises questions about whether the U.S. is getting its money's worth for patients being treated for cancer.
Samir Soneji, PhD |
Samir Soneji, PhD, assistant professor at the Dartmouth Institute for Health Policy and Clinical Practice based his report on an analysis of data from the World Health Organization's Cancer Mortality database between 1982 and 2010 for 12 common types of cancer.
"We are experiencing declines in mortality from cancer in the U.S.," Soneji says. "But those declines are coming at the same pace as in Europe, which is spending a lot less money. Screening, prevention, and treatment have extended life, but that's coming at a much higher cost [in the U.S.] than in Europe."
Soneji's paper is at odds with findings in the 2013 Economic Report of the President, which says that the U.S. has realized greater gains in breast and prostate cancer survival compared with Europe, and generated $600 billion in value. That study, Soneji says, does not account for stage of cancer at diagnosis, making conclusions vulnerable to "well-known biases with diagnosis and screening that inflate survival time."
That's because in more recent years, cancers are being diagnosed earlier, without corresponding changes in actual dates of death. In other words, he says, it just means people are finding out they have cancer earlier.
According to Soneji's research, the ratio of incremental cost to quality-adjusted life years saved in the U.S. was $402,000 for breast cancer, $110,000 for colorectal cancer, and $1,979,000 for prostate cancer, "amounts that exceed most accepted thresholds for cost-effective medical care."
The U.S. averted the largest number of deaths for stomach and colorectal cancer. But it "experienced the largest number of excess deaths for lung cancer and non-Hodgkins lymphoma. And only "a modest number" of deaths from breast and prostate cancer were averted.
"We're trying to start a conversation about how we value healthcare, and how we allocate very precious healthcare dollars," Soneji says. "We value these gains in life span, and gains in high quality of life, but without incontinence and disfiguring surgeries that some of these treatments cause."
The biggest relative gains in life expectancy after screening and treatment, he adds, are those we can attribute to screening, as opposed to advances in costly treatments such as chemotherapy drugs.
Colon cancer is an example. It "has achieved faster reductions in mortality than in Europe and at relatively lower cost" in part because of cost-effective colonoscopy screening, "which is far more effective" in detecting true, life-threatening cancers than other screening methods now widely used, far more so than screening mammography or prostate specific antigen testing, he says.
A pre-requisite for an effective screening program is one that "doesn't find things that turn out not to be cancer, like false positives, which are a problem for the medical system and of course for patients who endure considerable distress." And those findings have to lead to treatments that are less invasive, with fewer complications, that "will extend the person's life beyond what would be expected" if the disease were to run its typical progressive course.
Prostate cancer is another example in the other extreme, costing the U.S. much in relation to the number of lives saved, Soneji says.
One surprise, he says, is what the data reveals about lung cancer treatment costs. "The U.S. has always had higher lung cancer mortality rates than Europe. So consequently we've lost lives and we're spending a lot more for lung cancer care than in Europe."
That may change in coming years, he forecasts, because of aggressive anti-smoking campaigns in the U.S., which will result in lower mortality rates than in Europe.
A recent federal policy change requires no-cost lung cancer screenings for adults between the ages of 55 and 77 with a smoking history of at least 30 years or a health problem. Screening is a high-level recommendation from the U.S. Preventive Services Task Force and should result in a reduction in lung-cancer related deaths in future years, Soneji says, "If greater access to wellness visits and preventive services translates to greater use of these types of medical care," and "may do so in a cost-effective manner.