On this blog, I’ve often dwelled on the disturbing fact that Americans pay far more for health care per capita than any other nation in the world and yet have a relatively low life expectancy. We spend more, and yet we’re less healthy.
A recent comparison of cancer care in the U.S. and Western Europe reveals just how bad the problem is. The study, published in Health Affairs by Samir Soneji of the Dartmouth Institute for Health Policy and Clinical Practice and JaeWon Yang, a Dartmouth undergraduate, examined spending on and mortality rates from major cancers in the U.S. and 20 Western European countries from 1982 to 2010.
The authors state in their abstract: “Compared to Western Europe, for three of the four costliest U.S. cancers—breast, colorectal, and prostate—there were approximately 67,000, 265,000, and 60,000 averted U.S. deaths, respectively, and for lung cancer there were roughly 1,120,000 excess deaths in the study period. The ratio of incremental cost to quality-adjusted life-years saved equaled $402,000 for breast cancer, $110,000 for colorectal cancer, and $1,979,000 for prostate cancer—amounts that exceed most accepted thresholds for cost-effective medical care.”
It took me a while to digest the study, but let me lay out its implications. Its most benign finding is that the U.S. has achieved lower mortality rates than Europe over the last few decades for three common cancers--breast, colorectal and prostate--at a high cost. From 1982 to 2010, the U.S. spent $435 billion, $325 billion and $434 billion more than Europe on care for breast, colorectal and prostate cancer, respectively. An optimist would say that at least our extra spending is helping people live longer.
But that upbeat conclusion is shattered when you factor in lung cancer, which kills almost as many people as breast, colorectal and prostate cancer combined. Although lung cancer mortality rates in the U.S. have dropped over the past few decades, those rates remain higher than Europe’s. Soneji and Yang estimate that there have been 1,120,000 excess lung cancer deaths in the U.S. compared to Europe from 1982 to 2010.
During this same period, the U.S. spent $406 billion more on lung cancer care—adjusted for population size--than Europe did. Soneji and Yang calculate that for every extra $19,000 spent on a lung cancer patient in the U.S. compared to Europe, that patient loses a year of quality-adjusted life. Americans die more frequently than Europeans of lung cancer even though, according to the World Health Organization, Europeans have higher smoking rates [see comment by Soneji in Addendum].
The excess U.S. deaths from lung cancer swamp its lower mortality rates from breast, colorectal and prostate cancer. If you add together the figures for all four cancers, the U.S. had 729,000 excess deaths from 1982 to 2010 while spending roughly $1.6 trillion more than Europeans (statistics adjusted for population size). Soneji and Yang also found that Americans died at a higher rate than Europeans from leukemia, melanoma and non-Hodgkins lymphoma in spite of spending more per patient.
The only bright spot of the study involves stomach cancer; the U.S. spends only marginally more than Europe on stomach-cancer care and its mortality rates are substantially lower. But stomach cancer may be an anomaly: Soneji and Yang suggest that U.S. food preparation may lead to lower rates of infection by the bacterium Helicobacter pylori, a major trigger of stomach cancer.
The U.S. cancer-care industry badly needs to be reformed.
Addendum: When I asked Soneji about smoking, he responded: “The best historical data is probably the OECD (https://data.oecd.org/healthrisk/daily-smokers.htm). The intensity of smoking may have been higher in the US than Europe (e.g., more packs per day, on average). Another important reason US lung cancer mortality rates are higher is that the stage of diagnosis is more often metastatic lung cancer in the US than in Europe. For example, 36% of British lung cancer patients were diagnosed stage 4 (http://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/lung-cancer/incidence#heading-Five) compared to 57% (Table 15.12, http://seer.cancer.gov/csr/1975_2012/results_merged/sect_15_lung_bronchus.pdf). Soneji also gave me extra data on U.S. versus European spending: “In 2010, the National Cancer Institute estimated the cost of US cancer care was $126 billion (see p. 31, http://progressreport.cancer.gov/sites/default/files/archive/report2011.pdf). For the 12 selected cancers we studied, we estimate the U.S. spent an additional $569 per capita in cancer spending in 2010. Or equivalently, if the U.S. and Western Europe were the same population size, the U.S. spent an additional 80.7 billion dollars in cancer care of the 12 most common cancers in 2010.”
You can find a critique of Soneji’s article here and a critique of that critique here.
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