This is a puzzle that every process (healthcare, education) without a clear-cut metric for measuring success suffers from. Everyone "teaches to the test (metric)" when their livelihoods depend upon it. We need metrics that measure how well metrics "get at the true truth". But no doubt someone will figure out how to game that system ... I guess we need to ultimately trust our doctors and teachers.
1
Prof. Carroll neglected another problem with either mortality or survival studies - by definition, they must be based on older treatments, as the patients in the newer treatments aren't far enough long to impact either survival or mortality.
The new treatments not only decrease mortality, but increase survival AND QALY. In breast cancer, for example, many women are spared chemotherapy, and its resulting impact on QALY, because of new advances in tumor testing that can more accurately pinpoint who will benefit from chemotherapy as a treatment modality.
Any discussion of the limitations of any cancer treatment has to at least mention the caveat of changes in treatments over time.
The new treatments not only decrease mortality, but increase survival AND QALY. In breast cancer, for example, many women are spared chemotherapy, and its resulting impact on QALY, because of new advances in tumor testing that can more accurately pinpoint who will benefit from chemotherapy as a treatment modality.
Any discussion of the limitations of any cancer treatment has to at least mention the caveat of changes in treatments over time.
The main premise of the article is wrong so any discussion about it would be futile at best.
The standard is neither the survival or the mortality rate. The first can be terribly distorted and has been exposed since 2007 when it was presented to a seminar at the National Congress on the Under and Uninsured held in Washington, D.C. Stated as done here it shows the ability to present facts which are not.
The mortality rate is based on the number of people who died. It is a body count and like those counts of North Vietnamese killed and wounded showed a win but only the climax is real. 54,000 Americans also died.
The way to describe and compare disease expenses is to compare the amount of money spent to prevent the disease against that expense to treat it.
America can reduce the number of deaths due to lung cancer by ending the addiction to smoking and using tobacco. Compare that expense to that of treating a woman diagnosed as having lung (or breast) cellular dysfunction (cancer) and then decide which is better. Add in the expenses of having a sick woman. a mother, ill. Add to that the added expenses that accure to other members of the family caused by the unhealthy reaction (stress) to unwanted cancer.
The 1% and the 99% are getting the shaft. Brain cancer treatment leads nowhere as Ted Kennedy learned. Steve Jobs would have been smart to find ways to prevent liver cancer than making stockholders richer. Ask their families.
Life isn't/shouldn't be measured by an abacus
The standard is neither the survival or the mortality rate. The first can be terribly distorted and has been exposed since 2007 when it was presented to a seminar at the National Congress on the Under and Uninsured held in Washington, D.C. Stated as done here it shows the ability to present facts which are not.
The mortality rate is based on the number of people who died. It is a body count and like those counts of North Vietnamese killed and wounded showed a win but only the climax is real. 54,000 Americans also died.
The way to describe and compare disease expenses is to compare the amount of money spent to prevent the disease against that expense to treat it.
America can reduce the number of deaths due to lung cancer by ending the addiction to smoking and using tobacco. Compare that expense to that of treating a woman diagnosed as having lung (or breast) cellular dysfunction (cancer) and then decide which is better. Add in the expenses of having a sick woman. a mother, ill. Add to that the added expenses that accure to other members of the family caused by the unhealthy reaction (stress) to unwanted cancer.
The 1% and the 99% are getting the shaft. Brain cancer treatment leads nowhere as Ted Kennedy learned. Steve Jobs would have been smart to find ways to prevent liver cancer than making stockholders richer. Ask their families.
Life isn't/shouldn't be measured by an abacus
1
We can also reduce breast cancer deaths by kicking addiction to tobacco (and alcohol). Indeed -- we can reduce alot of cancer suffering and associated expenditures if we adopted diet and lifestyle habits intended to stave off Type II Diabetes & Heart Disease. Breast cancer risk is not uniform across the population and plenty of the risk is a lifestyle factor: obesity, smoking, alcohol consumption, having children late (or not at all.)
Anyone afflicted with cancer has been dealt a very bad hand, but medicine has been remarkably consistent about prevention, exercise and keeping weight down. We're not getting the shaft, so much as their pleas are falling on deaf ears.
Anyone afflicted with cancer has been dealt a very bad hand, but medicine has been remarkably consistent about prevention, exercise and keeping weight down. We're not getting the shaft, so much as their pleas are falling on deaf ears.
The author has just described our system of medicine in the United States.
It is a system built on profit for the pharmaceutical drug blitz, hospitals
( now with billboards for brain surgery), clinicians, surgeons, therapists, medical equipment mfgs. and not a system based on patient care. Pure money extraction to the max.
Put the patient in charge of paying the providers instead of Mr. raise your premium to cover losses insurance company, and guess what, medical costs would plummet.
The patient that is being treated today is the insurance company. Why? They pay the bill................ Congress pays attention to lobbyists. Why? They pay the bills. America never changes.
It is a system built on profit for the pharmaceutical drug blitz, hospitals
( now with billboards for brain surgery), clinicians, surgeons, therapists, medical equipment mfgs. and not a system based on patient care. Pure money extraction to the max.
Put the patient in charge of paying the providers instead of Mr. raise your premium to cover losses insurance company, and guess what, medical costs would plummet.
The patient that is being treated today is the insurance company. Why? They pay the bill................ Congress pays attention to lobbyists. Why? They pay the bills. America never changes.
Western doctors are very good at making a lot of money off of cancer. They are really not very good at solutions or cures. Until the west develops viral phage therapy, there will be little progress.
The most important take home message from the article is to talk about health care costs in the US first.
My word! Next they may notice that people in their 60's and 70's are dropping like flies. That just because the older generation is living longer doesn't mean we will be.
They all grew up on organic food, many grew up in the country on farms doing physical labor, they were never exposed to chemicals when they were young.
They all grew up on organic food, many grew up in the country on farms doing physical labor, they were never exposed to chemicals when they were young.
1
Every life is priceless, but as a matter of public policy cost must be considered. I'll worry about the contradiction when we stop throwing lives away for lack of money to pay for basic medical care and throwing money away on drugs of marginal effect and treatments of marginal effect.
The FDA needs stiffer standards for drug approval with clinical effects considered (not required today). Using drugs off label is experimental and needs to be documented. We need single payer, eliminating the 21% takeout by insurance companies or alternative regulation. Medicare should bargain for drug prices. All that just for a start.
Most important of all, we need informed patients and families. As a biologist I can look at the research but we need popularizations that explain outcomes in terms everybody can understand so they can make decisions about their own lives.
The FDA needs stiffer standards for drug approval with clinical effects considered (not required today). Using drugs off label is experimental and needs to be documented. We need single payer, eliminating the 21% takeout by insurance companies or alternative regulation. Medicare should bargain for drug prices. All that just for a start.
Most important of all, we need informed patients and families. As a biologist I can look at the research but we need popularizations that explain outcomes in terms everybody can understand so they can make decisions about their own lives.
4
This article raises very valid points if one is concerned solely with current economic analysis. But does the author really believe that there is no value in being able to diagnose a cancer 4 years earlier due to a new diagnostic procedure? Perhaps we cannot yet take advantage of this knowledge, but someday if a new treatment does arise, this ability to make an early diagnosis could pay off hugely.
This also helps to illustrate another very important issue ignored by the writer - the value of research for future treatments and outcomes that we cannot yet measure. And two important points - we cannot predict which areas of research will end up with huge practical implications, and by it's nature, research needs examine a wide range of topics without knowing which will be the most valuable. Second, even patient treatment regimes are part of the research process, clinical research. Until they are tried, we don't know if they work, even if the basic preclinical research supports it.
This also helps to illustrate another very important issue ignored by the writer - the value of research for future treatments and outcomes that we cannot yet measure. And two important points - we cannot predict which areas of research will end up with huge practical implications, and by it's nature, research needs examine a wide range of topics without knowing which will be the most valuable. Second, even patient treatment regimes are part of the research process, clinical research. Until they are tried, we don't know if they work, even if the basic preclinical research supports it.
This is fantastical thinking though. "We might, therefore we should." In the meantime, there are real costs, measured in lives, of that sort of money we could be spending elsewhere -- like, say, poverty reduction or general improvements to nutrition, or to maintenance healthcare like checkups, vaccine development, fitness programs, etc.
The study of economics is to acknowledge that our resources are limited. Money represents the time of scientists, beds at hospitals, clinical work, nursing hours. If our ultimate goal is to decrease our actual mortality rate, then your hopes for some magical breakthrough must be set aside for concrete things we can take that we know for certain will improve our quality of life.
The study of economics is to acknowledge that our resources are limited. Money represents the time of scientists, beds at hospitals, clinical work, nursing hours. If our ultimate goal is to decrease our actual mortality rate, then your hopes for some magical breakthrough must be set aside for concrete things we can take that we know for certain will improve our quality of life.
1
If I may add this slight addendum. The difficulties addressed in the article regarding the costliness of over-diagnoses of cancers is telling. For example, I think that the current state-of-the-art in prostate cancer results in a dichotomy approaching 30% of cases are malignant but 70% of diagnosed cases are benign, or do not affect life expectancy. Thus at a cost of each additional QALY of $2,000,000 for prostate cancer these false cases should actually raise the cost of this disease per QALY added. For example, since: [ 0.30 x X = $2,000,000; where X = ($2,000,000/0.30); or X = $6,666,667]; perhaps the cost of each QALY is closer to $6,666,667 than the $2,000,000 cited in the article. Also, this same amorphousness surrounds cases of breast cancer but the proportion of benign cases is less than 70%. But errors in the diagnosis of breast cancers include: the diagnostic tool can itself cause the cancer to be detected. The move to digital diagnostic methods results in clearer images because of higher frequency and shorter wavelength radiation. Thus, more energetic tissue altering radiation is delivered to the patient. Comparative benchmarks or baselines need to be developed digitally for comparative purposes to detect tumor growth. The establishment of benchmark images may require repeated exposure to more potent radiation. Thus, the cited references to questions regarding the correct frequency of mammograms, and their initiation and ending dates. 4/17 Sat 5:36 pm
1
I have lung cancer; have had it for about three years now. At 85 I figure that maybe I'll make it to 88 or so. And that would be with continuing (oral drug) treatment.
I really don't care about survival rates or mortality rates or anything else at this point. It it is terribly imporant for the actuaries to have the appropriate measure to, say, justify funding protocals, all well and good.
As for me, I'm just rolling best I can with what Medicine has managed to do for me.
Naf
I really don't care about survival rates or mortality rates or anything else at this point. It it is terribly imporant for the actuaries to have the appropriate measure to, say, justify funding protocals, all well and good.
As for me, I'm just rolling best I can with what Medicine has managed to do for me.
Naf
7
Another fundamental issue with survival: statistically, "survival" is measured as a time to event. The most common way of judging whether a new treatment improves "survival" is to look at median survival, that is, the time at which 50% of each group has reached the event (death, tumor progression, etc.) But buy the end of the study, all patients in both groups might have died. Thus, in a survival analysis, if the time to event is prolonged, even by a few weeks, by an intervention, then the intervention will be superior, in a "statistically significant" (p<0.05) way. Unfortunately, those who get the treatment still die, but half of them live a few weeks or months longer. However, since cancer treatments are often quite toxic, their quality of life is impaired. The extra weeks they receive are often of poor quality. These are fundamental problems with survival analysis and the effect of any intervention on disease is much better tested with odds ratio for death at a certain time point or QALYs added, since enhancing well-being is the objective of medicine.
2
For every ailment the medical industry (usually big pharma) will come up with a 'treatment'. However there is no lower limit on the effectiveness of these 'treatments' - if its an incurable disease and there is an .0001% chance that the biased, noisy data might indicate that this treatment very slightly works, then the FDA will approve it. Then the pharmaceutical companies can charge a virtually infinite amount of money for it. There is barely any money for independent research into the effectiveness of these treatments, nor into real research into real cures. We have to put our foot down and stop shoveling money to pharmaceutical companies for unproven, marginal benefits. But every time we try to set such limits patients cry "How can you put a $$ amount on my life!". Full disclosure, I am such a patient. I want to see our money go to real research for real cures and not big pharma hype.
9
Agreed that the economic opportunity cost or medical triage alternatives of acting against breast cancer reduce the funds for acting against prostate cancer. Thus, the need for an overall prioritization scheme in medical treatments. And, especially with lung cancer, the most effective treatment option is to simply eschew tobacco usage. The five-year survival rate is only 16.8% because: 1) The lungs are full of circulatory arteries, veins, and capillaries that are used to exchange, via hemoglobin found in red blood cells, CO2 for O2. Since O2 is vital to the body's metabolic processes, the alveoli in the lungs are very efficient at helping to maximize the diffusion of O2 across this O2/CO2 diffusion gradient. The surface area of the alveoli available for this exchange, and also a mutagen target, is also increased by the many folds and undulations within the lung tissue helping to maximize this surface area. 2) Given this large surface area, by repeated exposure to this acrid smoke, an underlying gene sited on a chromosome can undergo an initial mutation. Then via mitosis, this initial genetic mutation is transcribed into other cells' metabolic pathways. Next, given this circulatory rich environment, the growing cancerous tumor can be well nourished via this rich circulatory lung environment. The development of new circulatory components to feed tumors is termed angiogenesis, and occurs very vigorously in the lungs. Often, death soon follows. Wed, Apr 15, 2015, 11:21 am
1
It seems to me that the question of the economics of health care cannot be examined in isolation. What exactly are the costs of allowing the continued sale of cigarettes and other corporate interests at the expense of public health interests? The pollution of air, water and land resources effect
public health - are we figuring these issues into the calculations? This at the same time that we have an enormous military budget that dwarfs all else. I think this needs to be part of the discussion.
public health - are we figuring these issues into the calculations? This at the same time that we have an enormous military budget that dwarfs all else. I think this needs to be part of the discussion.
7
To say that my life as a breast cancer patient is overpriced at $400,000 a year is a perfect example of what this country has become. Is my life less valuable than a prisoner jailed for murder? What is the cost to keep him alive? Ask my children, my husband, my brothers, my sisters and my friends if I am worth it. I wonder what portion of that cost is due to the greed of pharmaceutical companies and some physicians who inflate their fees in order to break even with the costs they face due to the AHCA.
If we listen to this rubbish, next we'll be testing infants for cancer genes, claiming their lives will be a financial drain on our society and forcing parents to sign a release. What happened to the value of a life at any cost? There IS no price we can put on one. I am glad I don't have to rely on the author for my care at any age or stage!
If we listen to this rubbish, next we'll be testing infants for cancer genes, claiming their lives will be a financial drain on our society and forcing parents to sign a release. What happened to the value of a life at any cost? There IS no price we can put on one. I am glad I don't have to rely on the author for my care at any age or stage!
1
You totally miss the point. Money spent in one direction can't be spent in another. Hence your children have to forgo much for what in the end is for actually very little other than the emotional delays (well sort of) as death is, at best, only slightly postponed. We as a society (and not your family) spend a big wad of cash, but in the end no one really gets anything from that spending other than the medical industry.
Far better to spend a fraction of that $400k on palliative care that actually improves your dying (yes that is what is happening), and then the rest on on giving you family cleaner air to breath, cleaner water to drink, fewer chemicals to start the cancers in the first place.
But if you can pull together the $400k from your own resources fine, but don't you go off on the ACA and promulgating "death panels" etc myths.
Far better to spend a fraction of that $400k on palliative care that actually improves your dying (yes that is what is happening), and then the rest on on giving you family cleaner air to breath, cleaner water to drink, fewer chemicals to start the cancers in the first place.
But if you can pull together the $400k from your own resources fine, but don't you go off on the ACA and promulgating "death panels" etc myths.
6
Professor Carroll makes a faulty, biased argument.
1) Instead of pitting patients with one disease against another, like when he says that the money spent on a patient with breast cancer could go to another disease, Dr. Carroll could investigate who determines the cost of the drugs and coverage where dollars are spent overall in health care. Biotech firms, pharmaceutical companies, and health care insurance companies price their medications and health coverage. and choose to cover certain ailments over others. A patient does not decide how much money a biotech firm or health care agency spends on executive bonuses, marketing, and advertising, or other expenditures which don't necessarily help prevent, cure, or treat illnesses. Presently, costs of care is determined by what the market allows.
The rate of certain cancers are rising so clearly we do need to continue to invest funds in prevention as well as treatment. Many people live with Diabetes and HIV, so there is hope that certain cancers may be able to treated as a chronic conditions. Ultimately, we can decide to invest in prevention and treatment of cancer and other illnesses simultaneously, but it may require cutting back on heath care industry executive compensations, bonuses, and salaries.
1) Instead of pitting patients with one disease against another, like when he says that the money spent on a patient with breast cancer could go to another disease, Dr. Carroll could investigate who determines the cost of the drugs and coverage where dollars are spent overall in health care. Biotech firms, pharmaceutical companies, and health care insurance companies price their medications and health coverage. and choose to cover certain ailments over others. A patient does not decide how much money a biotech firm or health care agency spends on executive bonuses, marketing, and advertising, or other expenditures which don't necessarily help prevent, cure, or treat illnesses. Presently, costs of care is determined by what the market allows.
The rate of certain cancers are rising so clearly we do need to continue to invest funds in prevention as well as treatment. Many people live with Diabetes and HIV, so there is hope that certain cancers may be able to treated as a chronic conditions. Ultimately, we can decide to invest in prevention and treatment of cancer and other illnesses simultaneously, but it may require cutting back on heath care industry executive compensations, bonuses, and salaries.
4
Not mentioned: basic medical costs are so grossly inflated in the US vs. western Europe, and the differential cost of each QUALY gained for cancers in the US will always be negative vs. western Europe. A colonoscopy in the US costs about $10,000; in Switzerland, about $300.
14
Why no citations or footnotes? The same problems with the five year survival rate were well articulated 15 years ago by Welch et al., JAMA, 2000 as well as by a review committee charged with evaluating the measurement of progress against cancer, who published their recommendations in JNCI in 2000. These statistics remain commonly produced and reported by cancer registries alongside the more meaningful stage-specific ones. Most professionals use those to understand changes over time and have done so for decades!
2
The statements you can click contain citations.
But mortality rate has its own issues as well -- specifically, that the overall population mortality rate is always 100%. So if the mortality rate for cancer goes down, does that mean that we are treating cancer more effectively? Or does it mean that we are treating other diseases less effectively?
There is no single perfect metric that provides "the" answer for any single disease. On a society-wide or global basis, the best metric is likely lifespan, because of course that's what all this spending is trying to improve in the end. But don't know how you use that to target the impact of a single disease.
There is no single perfect metric that provides "the" answer for any single disease. On a society-wide or global basis, the best metric is likely lifespan, because of course that's what all this spending is trying to improve in the end. But don't know how you use that to target the impact of a single disease.
7
If the mortality rate for a cancer went down, that would mean we had cured a number of individuals and they would increase the mortality rate of another cause.
Huge difference between QALY and lifespan: a quality year with loved ones vs 12 months in a bed with tubes and respirators.
Huge difference between QALY and lifespan: a quality year with loved ones vs 12 months in a bed with tubes and respirators.
8
The article argues only that we rethink the balance between the cost and the benefit of cancer care as seen first from the patient's point of view, then from the point of view of public health. I think that is a fair consideration. However, our system will result in injustice to the poor if we begin to limit the funds spent per patient to prolong that individual's life. Guess who is not going to get the treatment and the extra year or two of qualify life?
3
In the US for sure, in Europe there is universal health care.
An extensive article in Sci. American on mortality rate changes over the last FIFTY years showed large improvement in infant mortality and heart related deaths, but minimal change with cancer. While I believe progress has been made to improve quality of life and extend the lives impacted, and certainly "cures" for a variety of cancers are extremely challenging, when considering the billions (is it hundred of billions?) spent on cancer research, their results have been poor, regardless of what "measuring stick" is used.
12
Very interesting article. But it's missing discussion of the age factor, as though we're all of the same age. As we age into our 70s and beyond, chronic health problems start to pile up. How is one to think about submitting to cancer therapy at an advanced age without considering its effects on the quality of remaining life? What would one or two years of extended life mean if one had to spend some part of it dealing with the aftermath of therapy on top of other problems? That wouldn't mean much to me, especially since no one can tell me what might be the duration or quality of my life on the other side of therapy.
I am now 78 yrs old and bear my share of chronic problems. While not debilitating, every year they get a little more limiting. I cheer for younger people who have better physical (and maybe psychological) resources than I do and elect to take head-on the scourge of cancer. But that battle is no longer for me. I have had a happy and productive life, and I smile at the thought of my estate passing, without being plundered by our healthcare system, to my heirs and beneficiaries.
Let's face it: in too many cases, administering chemotherapy is tantamount to conducting excruciating experiments, the results of which cannot be known in advance. Rather than roll the dice, just leave me at home and keep me pain free where I can enjoy my beautiful, familiar surroundings until my eyes close for the last time.
I am now 78 yrs old and bear my share of chronic problems. While not debilitating, every year they get a little more limiting. I cheer for younger people who have better physical (and maybe psychological) resources than I do and elect to take head-on the scourge of cancer. But that battle is no longer for me. I have had a happy and productive life, and I smile at the thought of my estate passing, without being plundered by our healthcare system, to my heirs and beneficiaries.
Let's face it: in too many cases, administering chemotherapy is tantamount to conducting excruciating experiments, the results of which cannot be known in advance. Rather than roll the dice, just leave me at home and keep me pain free where I can enjoy my beautiful, familiar surroundings until my eyes close for the last time.
53
You have an excellent point. Not every life is equally valued by the holder of that life. In cancer care, as in all choices, the patient should be free to choose how much treatment to endure. That said, I do wonder what would or will happen if you actually get cancer? My mother thought she wanted to die until she was about to die and then she definitely did not want to!
4
Is one man's fear of dying as "valuable" as the esteem another person's community has for her, or the potential productivity of yet a third person still in their youth? We can, do, and frankly *must* set limits for public spending on any individual's health care, but we'll never arrive at a formula that can meet all the criteria advanced by religions, family members, ourselves, and the IRS.
3
Yes. Missing the age factor indeed.
Getting into what constitutes quality of life is fraught with difficulties. For that reason, in terms of basic fairness, we should weight younger people's lives more heavily than older people's lives. Older people have had their opportunities.
Getting into what constitutes quality of life is fraught with difficulties. For that reason, in terms of basic fairness, we should weight younger people's lives more heavily than older people's lives. Older people have had their opportunities.
2
I am not sure what to make of these numbers at all. Does the mortality rate measure the age at which people die of the disease? Does the survival rate take into account the stage at which the cancer was detected? The age of the patient?
As for the theory that some lumps might never develop into cancer, how would we even know that if we stopped detecting them in the first place?
As for the theory that some lumps might never develop into cancer, how would we even know that if we stopped detecting them in the first place?
2
The ones that don't grow quickly are often missed by manual exams... again and again... because they aren't growing quickly enough to be felt and therefore aren't invading the body in a dangerous way. Detecting these with mammography etc. does mean you can monitor them, but if you do regular self-exams you'll feel them if they start to grow. Of three breast cancer occurrences my mom has faced, only the ductal carcinoma in situ (DCIS) was detected by screening before she felt it manually. The others (estrogen-receptive) grew so fast between her six-month screenings that she found them herself. She feels she survived cancer 3 times, but the DCIS might never have become a problem.
5
DEWC,
If they hadn't detected the DCIS, would she have been so scrupulous in doing self exams to begin with?
Plus, how do you know that there is no disposition to additional breast cancer in people with DCIS? What if she had only been going for biannual mammograms? Is the moral of the story to do less mammography, or perhaps even more for some patients? Not everybody can detect lumps easily. They are now recommending 3D mammography for women with dense breast tissue. Plus, there is also ultrasound.
We don't know enough yet to know which cancers will spread, and which women are at the most risk, but we can't learn unless we continue to monitor these things.
Dr. Carroll's attitude reminds me of the high handed approach doctors used to have in the old days. If there are limits on the data they are making decisions on, he doesn't really say what they are. Plus, what are the QALY's based on? Is the patients age taken into account. I would say an extra year for someone in their 40s or 50s should be worth several years for someone in their 80s - no matter what the "quality" of life. Cancer, not heart disease, is the #1 killer of people in middle age.
If they hadn't detected the DCIS, would she have been so scrupulous in doing self exams to begin with?
Plus, how do you know that there is no disposition to additional breast cancer in people with DCIS? What if she had only been going for biannual mammograms? Is the moral of the story to do less mammography, or perhaps even more for some patients? Not everybody can detect lumps easily. They are now recommending 3D mammography for women with dense breast tissue. Plus, there is also ultrasound.
We don't know enough yet to know which cancers will spread, and which women are at the most risk, but we can't learn unless we continue to monitor these things.
Dr. Carroll's attitude reminds me of the high handed approach doctors used to have in the old days. If there are limits on the data they are making decisions on, he doesn't really say what they are. Plus, what are the QALY's based on? Is the patients age taken into account. I would say an extra year for someone in their 40s or 50s should be worth several years for someone in their 80s - no matter what the "quality" of life. Cancer, not heart disease, is the #1 killer of people in middle age.
1
A friend of mind worked for the Department of Defense. One of her projects was to do analysis on whether it was cost effective to do a certain safety change on fighter aircraft. The cost of the change was found to be more than it cost to compensate the families of the dead pilots. Emotional costs were not a consideration.
My friend quit that job not much later. It isn't always about money.
My friend quit that job not much later. It isn't always about money.
10
I've heard reports that Russia did a similar analysis regarding whether to curb smoking in its population, and determined that having smokers die at a relatively young age (about the time they'd retire) saved the national coffers a bundle.
At least in that situation the smokers have a choice to avoid the risk.
At least in that situation the smokers have a choice to avoid the risk.
2
Well, it's about money when it's about money, that's the problem.
It's not about money-- especially when it's other peoples money! If the choice is about spending all of my money, it is not so easy, especially when one is old. If it's about spending somebody else's money, it's a lot easier.
It's not about money-- especially when it's other peoples money! If the choice is about spending all of my money, it is not so easy, especially when one is old. If it's about spending somebody else's money, it's a lot easier.
1
The article and comments made me think about what choices I might make if diagnosed with the rarely curable ones like brain, pancreatic or lung cancers. Would I want to see thousands spent for a month or two of a longer life or would I choose the big sleep.
12
I worry that the take home message of this editorial will be "we have spent so much money on cancer and for what?"... and that would be a disservice.
1. First, survival isn't everything. In breast cancer, randomized trials have shown that lumpectomy+radiation produces the same survival as mastectomy--but it costs more. Yet, giving women the choice to keep their breast has been a major advance.
2. There is zero mention of randomized controlled trials. The beauty of such trials is that they can counteract the effect of many biases, including lead time bias. In stage I-III breast cancer, several treatments (tamoxifen, Herceptin) have significantly increased the cure rate. We are not talking about a year or two. For an individual woman, we are talking about being cured "for life" or dying of breast cancer recurrence. Sadly recurrences can sometimes happen even with treatment, but I would hate for people to come away with misconceptions about the value of certain treatments.
3. A big part of QALY is cost. In the U.S. for the same treatment, including drugs, tests, doctor and nurse visits, etc, we pay far more than other countries. Does that mean we shouldn't pay for a highly effective treatment if one if available? I would argue that the message should not be "this is money we can't spend on other treatments" but instead "why does the same treatment cost so much more in the U.S. and what are we willing to do for it to cost less?"
1. First, survival isn't everything. In breast cancer, randomized trials have shown that lumpectomy+radiation produces the same survival as mastectomy--but it costs more. Yet, giving women the choice to keep their breast has been a major advance.
2. There is zero mention of randomized controlled trials. The beauty of such trials is that they can counteract the effect of many biases, including lead time bias. In stage I-III breast cancer, several treatments (tamoxifen, Herceptin) have significantly increased the cure rate. We are not talking about a year or two. For an individual woman, we are talking about being cured "for life" or dying of breast cancer recurrence. Sadly recurrences can sometimes happen even with treatment, but I would hate for people to come away with misconceptions about the value of certain treatments.
3. A big part of QALY is cost. In the U.S. for the same treatment, including drugs, tests, doctor and nurse visits, etc, we pay far more than other countries. Does that mean we shouldn't pay for a highly effective treatment if one if available? I would argue that the message should not be "this is money we can't spend on other treatments" but instead "why does the same treatment cost so much more in the U.S. and what are we willing to do for it to cost less?"
22
Amen about treatment costs. Our health care system is entirely too money driven with every entity trying to get theirs. I was shocked at the secrets and lies I discovered during my own experience of breast cancer. Doctors and facilities effectively work for insurance companies who tell them what they can and cannot do. Doctors protect their sources of income. Patients' insurance payments keep the wheels turning and then they get caught in the middle. We all need to educate ourselves a lot more about how things actually work. I wrote my experience into a story posted at
http://mammogramsanddcis.blogspot.com (mammograms and dcis)
Reading it will not be a waste of your time.
http://mammogramsanddcis.blogspot.com (mammograms and dcis)
Reading it will not be a waste of your time.
9
I can't tell what the author is recommending. Don't treat, don't screen, don't invoke American exceptionalism? What I do note in the comments are the paucity of the voices of us actually undergoing cancer treatments. Yes, cancer is expensive but only through treating it can lessons for the population as a whole be learned. My oncologist told me when I asked that one component of my treatments had improved 5 year survival rates 50% after it became a standard therapy for my type of disease. Thank you, Big Pharma and thousands of dedicated doctors, nurses, researchers, et al. With all the "victim blaming" in this thread, I'm wondering if Susan Sontag ever wrote, "Illness as Metaphor." And stop monetizing my life.
14
*Somebody* has to monetize the cost of your treatment. You choose treatment instead of a few new Porsches if you're rich. You choose treatment instead of funding your child's education if you're upper-middle class. You choose treatment instead of worrying what it will do to costs for others in your insurance pool if you're average middle-class. You choose treatment and mortgage your house and deplete your retirement account. You choose treatment and leave your bills unpaid at the hospitals for them to absorb. You choose food and electric and forego treatment. It costs money. Paying for it means making choices.
12
None of this is "victim blaming". The enormous medical costs this society is experiencing is a proper subject of public debate and policy.
7
As an MPH student I understand the QALY numbers and the opportunity costs of screening. However, we also need to consider the costs of cancer care when the cancer is caught at a late stage including medical costs, pain and suffering, caregiver health costs related to caregiving and a long list of others.
I agree that lead time bias cam be an issue for screening programs. That's why the National Lung Screening Trial resulting in a 20% reduction in MORTALITY for lung cancer with LDCT is such compelling evidence that we finally have a screening test that will make a dent in the mortality rate as well as the 5 year survival rate. It's time to get behind this evidence based gold standard screening test and start saving lives.
I agree that lead time bias cam be an issue for screening programs. That's why the National Lung Screening Trial resulting in a 20% reduction in MORTALITY for lung cancer with LDCT is such compelling evidence that we finally have a screening test that will make a dent in the mortality rate as well as the 5 year survival rate. It's time to get behind this evidence based gold standard screening test and start saving lives.
8
It's time we recognized the napalm approach to cancer therapy is about as effective as it was in Vietnam. I have breast cancer and let me assure you... I want my kids to have that 400,000 and enjoy it. I can forego an extra year of life, especially given the barbaric nature of the so-called "treatments." NO WAY am I giving one cent of my money to Big Pharma.
16
1
Hurray for you! I read all these statistics and think, "But WHAT a year!"
Cancer was scary because it killed, quickly, apparently healthy people. The achievement of modern cancer treatment is to keep you alive till you're really really sick.
And of course, every year, month, week and day gets added to the precious statistics that keep people sucked in to this pathetic scrabble after a little more time.
I would rather accept swift death from cancer, to taking 18 years to die as my mother did, one brain cell at a time. of dementia.
Cancer was scary because it killed, quickly, apparently healthy people. The achievement of modern cancer treatment is to keep you alive till you're really really sick.
And of course, every year, month, week and day gets added to the precious statistics that keep people sucked in to this pathetic scrabble after a little more time.
I would rather accept swift death from cancer, to taking 18 years to die as my mother did, one brain cell at a time. of dementia.
Wow! So many comments completely missed the point of this article. Aren't people ashamed of quoting anecdotal evidence?
6
Talking about this issue in terms of money creates the illusion that the only problem with the current system is the dollar cost. If it were just cheaper to screen and medicate all those patients for every anomaly, it would be OK, right?
How about we address the non-monetary harm of these policies.Mass screening and subsequent follow-up, if the end result is largely the same would seem to be a net harm, depending on ones perspective. If detection and treatment won't alter the end much, I'd rather be left alone until symptoms make the choice easier. Over diagnosis and over treatment don't just harm the financing of healthcare, they decrease quality of life by medicalizing the symptomless and subtracting well-being from those who feel OK.
Less absolute recommendations, and more discussion of trade-offs might help some patients dial back on this and enjoy their lives with less anxiety.
How about we address the non-monetary harm of these policies.Mass screening and subsequent follow-up, if the end result is largely the same would seem to be a net harm, depending on ones perspective. If detection and treatment won't alter the end much, I'd rather be left alone until symptoms make the choice easier. Over diagnosis and over treatment don't just harm the financing of healthcare, they decrease quality of life by medicalizing the symptomless and subtracting well-being from those who feel OK.
Less absolute recommendations, and more discussion of trade-offs might help some patients dial back on this and enjoy their lives with less anxiety.
24
Thank you. I was getting ready to write something similar.
2
The cost of a QALY reflects the high cost of the American medical system, which is the real issue here. The British medical system is the #1 ranked system in the world, and it is the also the least costly of the medical systems in the western world. I wonder, what is the cost of a QALY for the different cancers in the British system?
Plus, do these costs not decline over time?
Plus, what are you suggesting, stop trying? And who decides who gets treatment and who doesn't? I guess that would be a job for Sarah Palin's death panels.
Plus, do these costs not decline over time?
Plus, what are you suggesting, stop trying? And who decides who gets treatment and who doesn't? I guess that would be a job for Sarah Palin's death panels.
6
Or Hillary Clinton's....
Whoever is going to be President, we know it won't be Sarah Palin, right?
Whoever is going to be President, we know it won't be Sarah Palin, right?
2
I'm disappointed to read, that according to this article, my Oncologist treated me not because I was a person but rather for the sake of any economic gain that may be had for keeping me alive. Thanks for putting me in my proper place, relative to what really matters in this country.
9
Good lord. Medical doctors aren't supposed to be paid?
He treated you because you are a person and because you were sick, and he deserves to be paid for his services.
What, your grocer provided you and your family food in exchange for money, not for the "sake of economic gain that may be had for keeping you alive"?
One gets so tired of people who hate their own country and society. Of course, if one was truly tired of it, then one wouldn't read NYTimes commenters, I guess....
He treated you because you are a person and because you were sick, and he deserves to be paid for his services.
What, your grocer provided you and your family food in exchange for money, not for the "sake of economic gain that may be had for keeping you alive"?
One gets so tired of people who hate their own country and society. Of course, if one was truly tired of it, then one wouldn't read NYTimes commenters, I guess....
3
I found this article troubling yet equally informative and necessary because it is imperative that this dialogue continues because of what's at stake - a life.
The cold and calculating timbre of the information presented stopped me in my track because I wondered - are the core issues of cancer in either the medical or political fields predominately about money than actually trying to eradicate the disease? When did cancer become a business first instead of an illness?
My mother died 33 years ago from lung cancer 4 months after being diagnosed. She never smoked and pretty much lived her life like Euell Gibbons - ate healthy and did everything in moderation. Her older brothers also died of cancer, each of a different type, all before she was diagnosed. She was shocked to learn that she had cancer because she assumed since her older brothers had it, she would be spared. I recall suggesting to her, ever so gingerly, that I thought her math was somewhat flawed. I believe she possessed a particular cancer gene which was systemic to her family.
Early detection would not have saved my mother and its accuracy is not 100% ironclad. However, it can be an effective tool. Friends of mine are alive because their cancers were discovered from early detection.
The reasoning behind the ongoing debate of cost factor of various treatments vs. the survival rate would change dramatically if those participating had a spouse, a child or a parent with cancer.
The cold and calculating timbre of the information presented stopped me in my track because I wondered - are the core issues of cancer in either the medical or political fields predominately about money than actually trying to eradicate the disease? When did cancer become a business first instead of an illness?
My mother died 33 years ago from lung cancer 4 months after being diagnosed. She never smoked and pretty much lived her life like Euell Gibbons - ate healthy and did everything in moderation. Her older brothers also died of cancer, each of a different type, all before she was diagnosed. She was shocked to learn that she had cancer because she assumed since her older brothers had it, she would be spared. I recall suggesting to her, ever so gingerly, that I thought her math was somewhat flawed. I believe she possessed a particular cancer gene which was systemic to her family.
Early detection would not have saved my mother and its accuracy is not 100% ironclad. However, it can be an effective tool. Friends of mine are alive because their cancers were discovered from early detection.
The reasoning behind the ongoing debate of cost factor of various treatments vs. the survival rate would change dramatically if those participating had a spouse, a child or a parent with cancer.
9
I am just like your mother. Diagnosed with lung cancer at age 41 - I am a never smoker who's never lived or worked with smokers, a fitness instructor (regular exerciser), healthy eater, etc.
You say early detection would not have saved your mother. Perhaps. BUT - if the medical system had paid any attention whatsoever to the fact that never smokers can and do get lung cancer, we might have more treatments today. Instead, lung cancer has just been pretty much written off as a death sentence for the past 50+ years, almost any money set aside for the disease spent on anti-tobacco campaigns which may have helped some smokers but also served to perpetuate the stigma of lung cancer and suffering of those afflicted (the vast majority of lung cancer patients today are either never smokers like me, or already long-time non-smokers, so the use of the money in this way not only doesn't help, but hurts us).
I understand there has to be some cost/benefit analysis done in medical care. But sometimes, even if you can't save the patient today, efforts made & knowledge gained in trying to do so will help many future patients. There may have been no saving your mom 33 years ago, but I sure wish someone had tried. Things might look a lot different for me today if they had.
lisa.ericgoldman.org
You say early detection would not have saved your mother. Perhaps. BUT - if the medical system had paid any attention whatsoever to the fact that never smokers can and do get lung cancer, we might have more treatments today. Instead, lung cancer has just been pretty much written off as a death sentence for the past 50+ years, almost any money set aside for the disease spent on anti-tobacco campaigns which may have helped some smokers but also served to perpetuate the stigma of lung cancer and suffering of those afflicted (the vast majority of lung cancer patients today are either never smokers like me, or already long-time non-smokers, so the use of the money in this way not only doesn't help, but hurts us).
I understand there has to be some cost/benefit analysis done in medical care. But sometimes, even if you can't save the patient today, efforts made & knowledge gained in trying to do so will help many future patients. There may have been no saving your mom 33 years ago, but I sure wish someone had tried. Things might look a lot different for me today if they had.
lisa.ericgoldman.org
1
There have been the expected comments from those who say a cancer they know about -- either their own or a loved one's -- has been kept in check by some of these expensive therapies. But to this untrained observer, it seems that it is never clear why some cancers go into remission and others don't respond. Sure there are studies showing that treatments give a certain number of added months or years of life, but with individual cases, like those cited, it may just be pure luck, that this cancer was going to travel this route no matter what the therapy, or the expense. That is certainly the lesson learned about early detection of breast cancer. For decades the idea was to catch it before it spread. But little did we know that it had already decided on its own whether or not it would spread -- all our treatments had little to do with it.
16
Neoplastic diseases (cancers) are nearly universal in humans. In most people, they are held in check by immune systems, such that those diseases never come to the attention of the individuals afflicted. Autopsies for unrelated causes of death reveal internal scars caused by neoplasms that have waxed and waned without complaints during the lives of those individuals.
14
Those of us diagnosed with advanced and metastatic lung cancer are especially grateful for those "expensive therapies" and screening with low dose CTs. Lung cancer screening with LDCT can catch lung cancer early, while it is 85% curable (the majority of LC patients are diagnosed when the cancer is already metastatic and has a 4% survival rate). Lung cancer screening with LDCT reduces MORTALITY by 20% according to the HUGE NLST study. Targeted therapies (like the one I take) and immunotherapies are helping metastatic cancer patients live longer. I had chemo plus radiation, and progressed within two months; I had more chemo, followed by more radiation, and progressed within two months; I then started on a targeted therapy trial, and in two months my cancer had disappeared. I have had No Evidence of Disease for over two years. Clinical trials show 80% of patients with my lung cancer mutation respond to this drug. Other cancer patients who literally were at death's door now have either stable disease or no evidence of disease thanks to precision medicine, and live relatively normal lives for months or years. They have time to help small children grow up. They have time to enjoy life with family and friends. Yes, we're all going to die eventually. Medicine is supposed to be about helping sick people live longer with less discomfort. If cancer patients are deemed unworthy of such life-prolonging treatments, who else will we eventually choose not to treat?
5
Perhaps we need to talk about another issue that is also an uncomfortable conversation - the millions of dollars squandered in the American healthcare system on what are, to a great extent, diseases of poor choices: type 2 diabetes, obesity, heart disease, and fatty liver.
These chronic illnesses are a major factor in the US's high healthcare spending in comparison to other developed nations. And, unlike cancer, which can strike anyone these are illnesses that should never have been.
These chronic illnesses are a major factor in the US's high healthcare spending in comparison to other developed nations. And, unlike cancer, which can strike anyone these are illnesses that should never have been.
9
Obesity is in fact a major cause of many cancers. And cancer doesn't "strike" people - 50% of cancers could be prevented by changing lifestyles. Your point is great - but include cancer in those chronic diseases of poor choices.
10
Yes, obesity can be related to cancer and obviously smoking is the major cause of lung cancer, but a recent study found most cancers are caused by random mutation.
10
Please read the responses to that very flawed article in Science.
2
mortality rates also have problems. If thumb cancer struck at 60, in a country in which malnutrition caused death at 50 the mortality rate for thumb cancer would be zero.
ImmunoOncology will change these rates over the next 5 years thanks to the economic system's support of pharmaceutical company R&D in the US.
ImmunoOncology will change these rates over the next 5 years thanks to the economic system's support of pharmaceutical company R&D in the US.
1
The sum of all mortality rates over enough time is 100%. So any time we make progress on mortality from any cause, we automatically make the aggregate mortality from all other causes go up, even if nothing has gotten worse with any of them.
3
Actually, your statement is false. If I actually reduce the mortality
rate in some disease, I in effect, increase the total population, thereby
reducing the mortality rate of ALL causes. What you're alluding to is the
% of people who ultimately die of a given disease. This is not
a RATE of dieing.
rate in some disease, I in effect, increase the total population, thereby
reducing the mortality rate of ALL causes. What you're alluding to is the
% of people who ultimately die of a given disease. This is not
a RATE of dieing.
The author says,"Over the same period, the United States had more than 1.1 million more deaths from lung cancer than Western Europe." Does this statement refer to equal populations? If not, how can we tell whether the U.S. or Western Europe has a higher mortality rate?
4
The author does a good job explaining the difference between survival rates and mortality rates from cancer. But it's still unclear how much progress has been made against cancer from treatment. What reduction in mortality does the 67,000 lives not taken by breast cancer between 1982 and 2010 represent? Is it a 5% reduction? 10%? Spending $400,000 for each additional year of life does seem exorbitant, especially when we could save many more using that money for preventative public health measures. The biggest killer is still lung cancer, and anti-smoking campaigns are an effective way of preventing those deaths.
11
The biggest cancer killer is still lung cancer, but anti-smoking campaigns are a TERRIBLE way of preventing those deaths. Did you know that the vast majority of newly diagnosed lung cancer patients are either never smokers (like me) or long time non-smokers?
I hate smoking, and I have no problem with anti-tobacco campaigns. But, I cannot afford to see another dime of the paltry amount of funds set aside for lung cancer spent on them, especially when they perpetuate the stigma that lung cancer patients caused their own disease and don't deserve any improvements in treatment.
lisa.ericgoldman.org
I hate smoking, and I have no problem with anti-tobacco campaigns. But, I cannot afford to see another dime of the paltry amount of funds set aside for lung cancer spent on them, especially when they perpetuate the stigma that lung cancer patients caused their own disease and don't deserve any improvements in treatment.
lisa.ericgoldman.org
1
A relevant read on where the money is going and how it is spent in some cases.
http://www.redpepper.org.uk/held-hostage-by-big-pharma-a-personal-experi...
http://www.redpepper.org.uk/held-hostage-by-big-pharma-a-personal-experi...
Our country is about to spend $1 trillion over the next three decades on a new generation of nuclear weapons. Why are we parsing health care spending without looking at reasonable alternative avenues of funding? Nuclear deterrence does not work, and makes us less safe, not more. We can find better use for the trillion dollars we will spend over the next three decades on weapons we can never use...and which we had better never use. How about the cost of treating cancer caused by radiation from nuclear war?
33
What is omitted from the discussion is the question of support for research. At present, because of budget cuts only 9% of NIH grant proposals are being supported. This is clearly a false economy that Congress refuses to deal with. Every advance in cancer treatment since 1948 came about because someone came up with a good idea and someone else proved that it was of value.
8
Thank you for explaining this so clearly. Two thumbs up!
1
Better treatment and earlier diagnosis both increase survival rates, but the author is wrong to say that prevention does - since the person was never diagnosed with the disease, they cannot be said to have survived it. Prevention effects show up only in mortality rates.
12
such an important discussion when we look at our healthcare system. Wasting healthcare dollars on mammograms that do nothing to improve mortality rates, but do increase spending on radiology and unnecessary procedures but continuing because a bunch of people claim that "my early mammogram saved my life" even though all evidence suggests it did not. same with diagnosing every 70 year old man with prostate cancer even though the first thing you learn in medical school is that EVERY man gets prostate cancer if he lives long enough but most never get close to killing you. If we want an efficient and effective healthcare system, our decisions need to be based on science, not wishes or protecting ones charity turf (see breast cancer foundations and early mammogram lobbying). It is not whether ther eis any effect, but if spending dollars on that goal is better use of funds than spending it on vaccines, or other actually useful preventative medicine or treatment.
24
There's a serious unaddressed issue here that undercuts Carroll's argument. While survival rates are prone to lead-time and over-diagnosis bias, mortality rates are indifferent to age of death. For example, treatment methods could slow the rate of tumor growth so that the average lifespan of those who contract and die from lung cancer increases from 62 to 67. The same relative number of people may have contracted and died from the disease; but survived longer. That would be an immense improvement. But it wouldn't register as an improvement in mortality rates, because the exact same proportion would be dying from lung cancer.
Moreover, improvements might continue apace with all the major disease-based causes of death - heart disease, stroke, diabetes, etc. Same diseases, same relative proportions of deaths each year due to each disease, but everyone is living 10 years longer. The mortality rate, however, would remain the same.
The best measures will be of the relative improvement due to treatment (in terms of both survival and quality of life), which are only crudely correlated with mortality rates. Carroll's objection to survival rates doesn't show that survival rates are a bad measure. They show that better benchmarks are needed. Survival rates need to be benchmarked against the stage of the disease immediately before treatment - such as the size of a tumor (in volume or estimated cell counts) and its rate of growth - not the date of diagnosis or first treatment.
Moreover, improvements might continue apace with all the major disease-based causes of death - heart disease, stroke, diabetes, etc. Same diseases, same relative proportions of deaths each year due to each disease, but everyone is living 10 years longer. The mortality rate, however, would remain the same.
The best measures will be of the relative improvement due to treatment (in terms of both survival and quality of life), which are only crudely correlated with mortality rates. Carroll's objection to survival rates doesn't show that survival rates are a bad measure. They show that better benchmarks are needed. Survival rates need to be benchmarked against the stage of the disease immediately before treatment - such as the size of a tumor (in volume or estimated cell counts) and its rate of growth - not the date of diagnosis or first treatment.
30
In addressing what you call the author's simplistic analysis, you fall into simplistic thinking of your own. There can be a true "survival extension," which is what you are alleging. So sure, someone might still die from breast cancer, but they lived longer than they otherwise would have because of treatment, which is a gain. If that were clearly happening, I would likely agree with you, but at least with breast cancer, that doesn't seem to be what is in fact happening. Those who die from breast cancer are not living longer -- they might be diagnosed earlier, but their treatment is not giving them additional years of life. There are women who benefit from treatment and screening, and these women are usually cured of breast cancer, and die from some other cause (like a neighbor of mine, who died from lung cancer, and not breast cancer that she had 20 years before she died). But there are not enough of these women to change the needle on the overall mortality rate from breast cancer. That does tell us that screening is not having the desired impact, which is to find cancer early enough to cure it.
9
First of all, let's make one thing clear: each and every one of us will die. Mortality rates are a ridiculous metric by which to measure the success or failure of cost effectiveness and cancer care. To reduce extended survival to "quality adjusted life" is to take the very person to whom that extended survival means the most out of the conversation (the cancer patient).
Last week I marked ten years since my diagnosis with NSCLC. At stage IV, my five year survival stats are at 4%. As an individual, I pay no attention to the numbers. A combination of traditional therapies and three phase I clinical trials have gotten me this far and I enjoy every single moment of my quality adjusted life.
The value of my extended survival? Priceless.
Last week I marked ten years since my diagnosis with NSCLC. At stage IV, my five year survival stats are at 4%. As an individual, I pay no attention to the numbers. A combination of traditional therapies and three phase I clinical trials have gotten me this far and I enjoy every single moment of my quality adjusted life.
The value of my extended survival? Priceless.
39
No society can afford to have all its members on "extended survival." Someone must make a choice. Thankfully, many prospective patients choose not to become patients, or even to remain patients. Death with dignity.. priceless.
15
It is no surprise that your situation colors how you view the article, but mortality rate is not ridiculous metric. At a minimum, the US can't claim to outperform Europe on healthcare by simply catching cancer earlier with no effect on mortality rates. While I am happy you are getting treatment, we do need to discuss what treatments we will fund - the vast majority of Americans, without cancer, are railing against the high cost of healthcare. More people should read Atul Guwande's book, Being Mortal, to better understand their treatment options.
3
I'm truly happy for you beating the odds and deeply enjoying the gift of unexpected years of life.
Please understand, however, that your life-saving treatment did, in fact, have a price. If you were able to completely afford it from your own savings and no more than the $$ (plus interest) you contributed to medical insurance over the years, then you were able to be treated without impacting anybody else (generally speaking). If, though, you drew extensively from the insurers' reserves, that money is now not available for somebody else to get a lifesaving treatment. Or, the other people covered by your insurer(s) will have to forego something else to pay increased premiums. And if you have a stack of medical bills you are unable to pay, your years of life gained do in fact exact a price on others (taxpayers) who may already be making difficult financial trade-offs in their own lives. As a society, we have chosen to bear some of the cost of helping those suffering from misfortune, but society cannot do this indefinitely. The cost of cancer drugs and treatment WILL force hard decisions regarding what 2 or 200 extra months of life are "worth"... but those months are assuredly NOT "priceless".
Please understand, however, that your life-saving treatment did, in fact, have a price. If you were able to completely afford it from your own savings and no more than the $$ (plus interest) you contributed to medical insurance over the years, then you were able to be treated without impacting anybody else (generally speaking). If, though, you drew extensively from the insurers' reserves, that money is now not available for somebody else to get a lifesaving treatment. Or, the other people covered by your insurer(s) will have to forego something else to pay increased premiums. And if you have a stack of medical bills you are unable to pay, your years of life gained do in fact exact a price on others (taxpayers) who may already be making difficult financial trade-offs in their own lives. As a society, we have chosen to bear some of the cost of helping those suffering from misfortune, but society cannot do this indefinitely. The cost of cancer drugs and treatment WILL force hard decisions regarding what 2 or 200 extra months of life are "worth"... but those months are assuredly NOT "priceless".
3
From the article... "The researchers found that the survival gains seen in the United States equated to more than $550 billion in additional value, more than the difference in spending."
Who benefitted from the $550 billion added value? Was it the makers of the cancer drug or the cancer patients?
Who benefitted from the $550 billion added value? Was it the makers of the cancer drug or the cancer patients?
22
With better genomic data and less costly DNA analysis, scanning for cancer is going to be focused much more in the future on those with the gene mutations associated with cancers, which is the largest risk factor. Given false positives in testing as high as 97% in the case of PSA for prostate cancer, this could eliminate a lot of over treatment. Of course, we should never under estimate the profit motive driving testing and treatment, so change will occur incrementally.
After genetic risk, preventable behavior is the next biggest opportunity. That would include stronger incentives for smoking cessation and healthy lifestyle.
Better research and action on environmental hazards, that is less hampered by false science promoted by industry groups, will continue to reduce cancer risk.
HD truck emissions of cancer causing particulates have been reduced by 96% for current models, compared to two decades ago. Reduced use of estrogen treatment for menopause, increased HPV vaccination, less pesticide use, fewer coal burning emissions and a host of other opportunities will win the "war on cancer" far more cost effectively than most current or future treatments.
After genetic risk, preventable behavior is the next biggest opportunity. That would include stronger incentives for smoking cessation and healthy lifestyle.
Better research and action on environmental hazards, that is less hampered by false science promoted by industry groups, will continue to reduce cancer risk.
HD truck emissions of cancer causing particulates have been reduced by 96% for current models, compared to two decades ago. Reduced use of estrogen treatment for menopause, increased HPV vaccination, less pesticide use, fewer coal burning emissions and a host of other opportunities will win the "war on cancer" far more cost effectively than most current or future treatments.
28
While we're at it, if only we were "less hampered" by a wide range of false narratives promoted by industry groups. But of course we wouldn't want to trample on the "protected speech" of such "people."
There is no exaggerating the extent of the lunacy masquerading as legal doctrine.
There is no exaggerating the extent of the lunacy masquerading as legal doctrine.
Cancer is among the most costliest illnesses anyone can have. So is diabetes, kidney disease, or any other illness that requires ongoing care. Yet we have in America, not a health care system but a wealth care system. If you can afford the illness you will receive the care. If you cannot afford the illness you will receive no care or poor care. Fragmented care is a guarantee because our doctors do not communicate well with each other. There is no central repository for our medical information. We do not have a single payer universal access health care system. We have a for profit wealth care system that penalizes those who are too sick to fight the denials, those who did not save enough to cover co-pays, deductibles, going outside the HMO to see experts not on the panel if so indicated. In other words, the system is rigged against the patients and their families.
Our choices in any sort of medical care are made for us by where we live, how much we've been able to save, the sort of insurance offered to us or what we can afford to purchase. Our choices are not made by what is realistic in terms of what we need. That goes for cancer and every other medical illness/event in our lives. Even the way we die.
Our choices in any sort of medical care are made for us by where we live, how much we've been able to save, the sort of insurance offered to us or what we can afford to purchase. Our choices are not made by what is realistic in terms of what we need. That goes for cancer and every other medical illness/event in our lives. Even the way we die.
54
"If you can afford the illness you will receive the care."
If you ask for the care, which not everyone does. When it's time to go, it's time to go. Many, many Americans have left, by their own choice, without spending every one of their last dollars to stick around another day. Needless to say, they also have not wasted the community's assets, either. And, that's the only reason why we're not all bankrupt.
If you ask for the care, which not everyone does. When it's time to go, it's time to go. Many, many Americans have left, by their own choice, without spending every one of their last dollars to stick around another day. Needless to say, they also have not wasted the community's assets, either. And, that's the only reason why we're not all bankrupt.
1
Andy Hain, that's your answer to hen3ry's eloquent, spot-on indictment of the "wealth care system" here in the richest country on the planet? Give us a break.
No responsible person will advocate that everyone should be treated for every malady every time. Yet surely there's a better answer to holding down costs than treating only those who can afford to pay or have fancy insurance.
No responsible person will advocate that everyone should be treated for every malady every time. Yet surely there's a better answer to holding down costs than treating only those who can afford to pay or have fancy insurance.
10
For better or worse, many people have come to fear CANCER as the ultimate monster to slay. It doesn't seem to matter if you are 90 and diagnosed with lung cancer or 45 and almost bedridden from getting 3rd line of treatment for breast cancer. If the treatment can buy us 3 months or more, most people seem to go for it. Every life matters and in theory, you can't put a price on it but in healthcare, we must. There isn't an endless pot of money to spend on cancer care. There are other pressing health problems besides cancer that need the money. One just needs to read about "free health fairs" that are held in this country. You would think we are a third world country.
59
Price does matter. We spend an obscene amount of money on people who have terminal cancer, particularly when they've run out of treatment options. Spending millions of dollars on extending someone's life for a few months, is a very poor use of resources and is ultimately unsustainable.
30
Sage, of course. So should the wealthy have those options?
Should billionaires be spending their wealth on projects such as this? http://www.washingtonpost.com/sf/national/2015/04/04/tech-titans-latest-...
Should billionaires be spending their wealth on projects such as this? http://www.washingtonpost.com/sf/national/2015/04/04/tech-titans-latest-...
1
Aggressive cancer screening saves few lives and is a leading reason why our healthcare costs are so high.
Spread the word loud and clear -- the Emperor (of all Maladies) is wearing no clothes.
Spread the word loud and clear -- the Emperor (of all Maladies) is wearing no clothes.
15
My wife is one of those 67,000 saved from early detection of breast cancer and the use of clinical studies/research and the use of hormone inhibiting drugs. She is an amazing woman, wife, daughter and mother who is actively engaging and shaping the lives of our three children who will be entering the world as adults soon! The ripple effect of the $400,000.00 per person invested can not be understated as she approached her 5 year survival mark in May of this year on me her children, her family and all of our community.
The economic engine of cancer research, development, treatment, therapy and pharmacology should not be underestimated either! As a percentage of the overall economy (and i do not consider the overly aggressive inclusion of treatment for noncancerous conditions that have of late been included in cancer treatment) this ripple effects of such investment is substantial in all the communities of this country. There was a recent article in the NYT addressing the effect of healthcare economics on women and the lifting of their economic status in nursing and other aspects of the healthcare industry.
The economic engine of cancer research, development, treatment, therapy and pharmacology should not be underestimated either! As a percentage of the overall economy (and i do not consider the overly aggressive inclusion of treatment for noncancerous conditions that have of late been included in cancer treatment) this ripple effects of such investment is substantial in all the communities of this country. There was a recent article in the NYT addressing the effect of healthcare economics on women and the lifting of their economic status in nursing and other aspects of the healthcare industry.
19
There are lots of ways to create an 'economic engine', many of which are not a total waste of resources. We are talking here about spending billions for no net improvement in outcomes, unless you are looking at the balance sheets of the medical industry.
5
Increasing survival rates without affecting mortality rates is clearly an illusion.The real question is why this is so.
5
because we have been sold the myth of earlier detection leads to better outcomes. while that may be true in some cases it is not in all. that is why the US has such a higher rate of breast and prostate cancer diagnoses, with longer survival rates but the same mortality as other countries. who cares if you diagnose me with prostate cancer at age 88 if I am going to die of a heart attack in 2 years no matter what. if everyone were to die at age 90, and you didn't check someones birth date till they hit 87, survival rates would be 3 years. if you checked birth dates at birth, survival rates would be 90 years. But everyone is still dying at 90.
9
If you detect the onset of thumb cancer five years earlier, as the author points out, the survival rate improves. But the author ignores the fact that the mortality rate also lowered because we have now one more person added to the (denominator) total population with cancer and so the mortality rate (conditional probability, actually) will also drop. So both numbers will show improvement. It's odd that the author doesn't point this out.
1
I think you misunderstood one point.
"Mortality rates are determined by taking the number of people who die of a certain cause in a year and dividing it by the total number of people in a population."
The total number of population does not mean total population with cancer.
"Mortality rates are determined by taking the number of people who die of a certain cause in a year and dividing it by the total number of people in a population."
The total number of population does not mean total population with cancer.
9
The denominator does not change as the person's life ends at the same date in both cases--only the survival rate changes.
why don't we discuss going to a single payer health care system? It will reduce health care costs by half.
Also Nixon's war on cancer isn't going too well, is it. Physicians have over promised and under delivered. Perhaps it is time to give the money to other diseases where progress has been made.
Also Nixon's war on cancer isn't going too well, is it. Physicians have over promised and under delivered. Perhaps it is time to give the money to other diseases where progress has been made.
38
There's been HUGE progress made on cancer. The trouble is that 'cancer' isn't a disease, but a multitude of diseases. During the Nixon period, anybody who got a Non-Hodgkins Lymphoma had a good chance of dying from it. Today? It's the easiest cancer to treat.
If that isn't progress, nothing is.
If that isn't progress, nothing is.
19
There have been many programs on TV recently explaining the new effective treatments for cancers. These effective cancer treatments begin to become available to the general public maybe in 18 month to 2 years. PBS, Cancer, the Emperor of all Maladies; HBO, Killing Cancer; 60 Minutes also had 2 segments about 2 weeks ago. One set of treatments give cancer engr’ed viral infections like measles, a cold, polio, etc., and they kill the cancers. Another set of treatments is really beyond me, they prohibit a critical cancer protein but…, and another is they find anticancer cells made by the body’s defense systems but are outnumbered by cancer, grow them outside the body and put them back in much greater numbers, and the last but not least is to do a number of these treatments together maybe with radiation and/or chemo.
2
This is such a difficult issue. Population-based statistics have no meaning to a family surrounding a loved one on his/her deathbed. Is it worth society spending an extra 50 or 100 thousand dollars per day for this patient to survive/suffer a few more days with tubes dangling everywhere? To the family losing a loved one, probably yes. To the suffering patient, who knows? Having more end of life options like physician assisted death will probably save more money than limiting testing and early treatment as a way to bend the cost curve. Society should be willing to pay for a few more years of living as a trade off against a few more days of dying.
11
If we can afford it. But I think the limited money any society has may be spent in better ways
Hard to believe the author is a physician who actually treats patients. He seems to think more like a bean-counting numbers cruncher. The key issue here is NOT cost but rather that real progress in treating cancer has been greatly exaggerated by confusing survival rights with long term mortality rates. It is an absolute scandal that, with all our advanced biology and biotechnology, so little progress has been made against this disease. Either there are gross incompetencies in the research process, or big pharmaceutical companies are more interested in continuing to reap the vast profits they now make from their lengthy, incredibly expensive, and in most cases, ultimately ineffective therapies. (These two possibilities are not mutually exclusive).
9
I don't read the author to suggest that we just stop doing what we are now doing. The issue is, where should resources and efforts be directed in the future. Look at it from the perspective of those who are still dying from a disease like breast cancer. I have a friend whose cancer was detected and treated early (age 39) but who still died at the age of 43. It seems clear enough that continuing to beat the bushes to emphasize early screening has given us as much advantage as we can hope for without making other advances, like differentiating between tumors or figuring out why some cancers are so resistant to current treatment.
I completely agree with your assessment. The author of this article comes across more like an accountant than a physician.
1
When to comes down to the consideration of whether the cancer survival rate is cost effective, it depends on whose survival you are talking about, and therein lies the problem.
13
For patients and potential patients -- most of us - what we demand in treatment may come down to understanding what the last year(s) of life are going to be like. And this has to factor in the patient's general heath, age, other conditions, etc.
I do think this article should have included more of an an explanation of the factors involved in determining QALY - or link.
So I 'll suggest an NIH article on measuring health, at http://www.ncbi.nlm.nih.gov/books/NBK53336/ which adds the concepts of DALY - Disability adjusted life years, and HRQoL - Health Related Quality of Life.
And the wikipedia def. of QALY:"a measure of disease burden, including both the quality and the quantity of life lived."
In order to drive home the message of the costs of extending life span as the sole goal of treatment, it's important to show that each expensive hour may also be not one a patient would want to live. QALY is meant to show "value for the money" spent by the health system, but to get away from the fear that it's a formula to be used to withhold treatment, it's important to make the message personally relevant.
I do think this article should have included more of an an explanation of the factors involved in determining QALY - or link.
So I 'll suggest an NIH article on measuring health, at http://www.ncbi.nlm.nih.gov/books/NBK53336/ which adds the concepts of DALY - Disability adjusted life years, and HRQoL - Health Related Quality of Life.
And the wikipedia def. of QALY:"a measure of disease burden, including both the quality and the quantity of life lived."
In order to drive home the message of the costs of extending life span as the sole goal of treatment, it's important to show that each expensive hour may also be not one a patient would want to live. QALY is meant to show "value for the money" spent by the health system, but to get away from the fear that it's a formula to be used to withhold treatment, it's important to make the message personally relevant.
10
I was disappointed that the author didn't include a discussion of age-adjusted mortality rate: if the age at which patients die from a disease increases, then treatments may be effective in extending life, if not in staving off eventual death from the disease. But I'm pleased that the chirpy story of "increased survival rates" -- at 5 years after diagnosis -- is finally getting the scrutiny and criticism it deserves.
56
These are valid scientific concerns.
But, of course the solution that will be offered is obvious,
and always has been, no matter how often people like
Obama say otherwise:
Death panels
But, of course the solution that will be offered is obvious,
and always has been, no matter how often people like
Obama say otherwise:
Death panels
4
Are there "Death Panels" for people with no insurance?? In your world, of course there are: everybody who does not participate in paying for an uninsured person.
How about for the wealthy GOPer *with* insurance but whose insurance has run out? Who is the "Death Panel" then? Well, it is the entire (GOP) insurance company!
Somehow it would seem that "Death Panel" is a catch-all for "I do not like Obama and want to scare others into hating him, too."
Obama is not my favorite person in the world, but Obama Care is a lot better than the GOP "death panels" who would have 45,000,000 people live and die (!!) without medical care.
How about for the wealthy GOPer *with* insurance but whose insurance has run out? Who is the "Death Panel" then? Well, it is the entire (GOP) insurance company!
Somehow it would seem that "Death Panel" is a catch-all for "I do not like Obama and want to scare others into hating him, too."
Obama is not my favorite person in the world, but Obama Care is a lot better than the GOP "death panels" who would have 45,000,000 people live and die (!!) without medical care.
23
Here is my opinion on these statistics -
It is either 100% or zero. All the rest is guesswork.
It is either 100% or zero. All the rest is guesswork.
1
Prof. Carroll correctly points out the biases in survival rate statistics, but leaves out the biases in mortality rate statistics. It would have been good to understand biases in both. Ultimately, both survival and death are the results of more complex interactions of underlying health (a person with lung cancer may or may not die depending on other health factors), early diagnosis, and type of treatments available. Comparing overall statistics of such complex processes is always fraught with difficulties.
10