Cancer Mortality Trumps Survival Rates
A recent article in MedPage Today reported on a study in the BMJ (formerly British Medical Journal) about the misconception common among Americans that we have superior 5-year survival rates for most cancers. This, in turn, is thought to justify our aggressive approach to cancer screenings.
Given that Obamacare heightens this perception by making many screenings free, I decided to post the following discussion of this subject from my book, Obamacare – The Good, the Bad & the Missing:
Survival rates are not the measure we should be looking at, since survival rates reflect the percent of patients still living X years after diagnosis (usually 5 years). The more aggressive a country is in screening for cancer – and no country is more aggressive than the U.S. – then the better its survival statistics will look simply because more people are diagnosed early.
Early Diagnosis Doesn’t Guarantee Longer Life
The real test is whether they live any longer due to the earlier diagnoses and the statistical measure for this is cancer mortality, not cancer survival.
Here’s an often-used example: in the U.S., a man may be diagnosed with prostate cancer at age 61 and die at age 67 and be counted as a favorable 5-year survival statistic since he was still alive 5 years after his diagnosis.
Another man in a country with less aggressive use of PSA testing for prostate cancer – a test now in disrepute for screening purposes – may not be diagnosed with prostate cancer until he’s 63 and still die at 67.
However, since he didn’t survive for 5 years after his diagnosis, his case would reflect a negative 5-year survival rate even though both men died at the same age.
An article in The Washington Post quotes the head of the Department of Urology at the University of Kansas and a spokesman for the American Urological Association:
“(It’s) ‘impossible to say’ on the basis of the statistics whether a prostate cancer patient had a better chance of surviving under a ‘capitalist’ or ‘socialist’ medical system. American doctors tend to be more ‘interventionist’ and more likely to advocate surgery than their counterparts in Britain or Canada, where greater emphasis is placed on ‘active surveillance’…’You can’t say that it’s better to have prostate cancer here or in some other country’, with a developed health care system.”
The same article quotes the head of the National Cancer Institute’s Prostate Cancer Research Group:
“When you introduce screening and early detection into the equation, the survival statistics become meaningless.”
“Survival” Means Living Longer…With Disease
In other words, aggressive screening for disease increases survival rates without reducing mortality.
In many instances, this means more people knowing about their disease longer without being any better off for knowing.
Indeed, the stress and expense of treatments that are often fruitless – and, especially with cancer treatments, dangerous - may actually make these patients worse off than those who don’t learn of their disease until later.
This, of course, flies in the face of conventional, simplistic thinking. But there’s nothing simple about our healthcare, or about statistics that are easily manipulated to serve a political (and financial) point. Anecdotal stories about the horrors of socialized medicine, for example, conveniently ignore horror stories in American medicine – as if none existed here.
Our Healthcare Sucks, however, should put that misconception to rest, and you’ll find in it few anecdotal examples – just hard statistics of our broad and consistent underperformance. Anecdotal cases are routinely used by politicians and pundits to “put a face” on a problem, as seen in both political parties’ annual State of the Union addresses that trot out heroes and victims for political gain. But as evidence, they’re essentially meaningless – used more to manipulate than inform.
America’s Cancer Mortality Rates…meh!
So what do mortality statistics say about America’s relative performance in cancer deaths? Comparative mortality rates per 100,000 show that the U.S. rates a “B” for cancer mortality. The U.K. trails with a “C”, while Canada and most of Europe earn “B” ratings”. America’s grade for cancer mortality in the 1960’s, by the way, was an “A”.
This suggests the U.S. does perform fairly well in terms of cancer deaths, although not as good as several “A”- rated countries that spend far less than we do – including several socialized medicine models.
Moreover, when we broaden this comparison to look at deaths from other causes, the U.S. falls to last place among these countries.
Considering we spend roughly twice the average of other developed countries, finishing last in mortality – unvarnished by misleading survival data – is pretty damning testimony to the underperformance of American medicine.
Obamacare May Compound The Problem
And health reform will increase our already aggressive use of screening programs by requiring they be offered free for many Americans, which will further improve our meaningless “survival rates” by detecting disease earlier without necessarily reducing mortality rates.
Increasing screening without increasing primary care physicians means finding more “suspicious” findings – anomalies that may or may not be disease. These patients will then be sent to specialists who will perform interventional procedures that increase medical spending without necessarily improving outcomes.
This is seen in our average cancer mortality rates compared with A-rated countries with less aggressive screening.
Imposing even more aggressive screening programs on a medical infrastructure so heavily skewed to interventional care is a formula for increasing wasteful medical spending without assurance of patient benefit.
Doing so with a better supply of primary care physicians would be a safer and more productive use of limited resources with less risk of overtreatment.
This is but one of many reasons why the expected cost “savings” with Obamacare may prove unlikely.
Putting Screenings In Perspective
None of this is meant to suggest that screenings have no role to play in detecting disease and enabling more effective treatments. My own experience with colonoscopy confirms that some screenings have proven both clinically and cost-effective (see “Medical Uncertainty & Patient Engagement“).
But many screenings lead to overtreatment of dubious findings that may or may not be a threat to one’s health. This overtreatment itself can prove harmful – and not just financially.
It would help patients sort out which screenings are of greatest value for them if we based our claims on honest measures like mortality benefit rather than bogus survival rates that have become little more than a marketing ploy for those who make their livings from the screening industry.
We have enough fear-mongering in American healthcare already (see “America’s Health Scare System“).
 Conference Board of Canada. Health – Mortality Due to Cancer. 2010.
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