Value of Cancer Care for Most Tumors Lower in United States than in Western Europe

VBCC - May 2015, Vol 6, No 4 - Economics of Cancer Care
Rosemary Frei, MSc

A reevaluation of the value of cancer care between 1982 and 2010 in the United States versus Western Europe (Soneji S, Yang JW. Health Aff [Millwood]. 2015;34:390-397) paints an entirely different picture from a similar analysis published in 2012 (Philipson T, et­ al. Health Aff [Millwood]. 2012;­­31:667-675). The earlier study found significant improvements in breast and prostate cancer survival in the United States relative to Western Europe, concluding that the high costs in the United States were worth it.

However, the new analysis shows that Americans are getting far less value for their money than Western Europeans are for several tumor types, including prostate cancer. The new study further highlights significant flaws in the earlier study, such as miscalculating the rates of stomach cancer deaths, not including lung cancer in the analysis, and not considering the stage at cancer diagnosis.

Reassessing Value in Cancer Care

Samir Soneji, PhD, MA, Assistant Professor of Health Policy, Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, NH, told Value-Based Cancer Care (VBCC) that some of the conclusions of Dr Philipson and his colleagues are implausible.

“For example, they calculated that there were 224,212 excess stomach cancer deaths in the US compared with Western Europe between 1982 and 2005. But the United States had lower stomach cancer mortality rates than Western Europe throughout the entire period, so the United States could have only averted stomach cancer deaths, not experienced excess deaths,” said Dr Soneji. “And in fact, the greatest number of deaths averted occurred in cancers for which decreasing mortality rates were more likely to be the result of successful prevention and screening than from advancements in treatment.”

Dr Soneji and his colleague analyzed information from the World Health Organization Cancer Mortality Database. The 2012 analysis used survival data from large national cancer registries in the United States and Europe. Dr Soneji noted that survival data can provide inaccurate results if they do not account for cancer stage at diagnosis. Survival times can often be inflated because of earlier diagnosis and overdiagnosis, he said. These do not necessarily affect disease course and mortality, and are more common in the United States, he added.

Furthermore, the earlier study also looked at 10 countries, whereas the new analysis expanded to 20 countries, including countries with higher healthcare spending and similar life expec­tancy increases and population-wide screening as the United States.

In addition, the 2012 analysis focused on 13 cancer types—breast, prostate, colorectal, testicular, soft-tissue, thyroid, stomach, uterine, melanoma, Hodgkin lymphoma, non-Hodgkin lymphoma, acute myeloid leukemia, and chronic myeloid leukemia. The new analysis included all these cancer types (except soft-tissue and uterine) and added cervical and lung cancers.

Both studies calculated excess and averted deaths in the United States versus Western Europe; that is, the surfeit of deaths and the reduction in deaths, respectively, taking into account differences across age-groups in population size, sex proportions, and mortality rates.

Dr Soneji and his colleague also tried to replicate the results of Dr Philipson’s team by looking at the same set of cancer types in the same European countries during the study period of 1982 to 2005. The number of deaths averted and the overall results “varied substantially by cancer type,” they wrote.

New Evidence for Number of US Deaths Averted

Dr Soneji’s analysis showed that in contrast to what was reported in the previous analysis, 78% fewer cases of breast cancer deaths were averted and 60% fewer prostate cancer deaths were averted in the United States. Overall, compared with Western Europe:

  • 621,820 stomach cancer deaths were averted in the United States, resulting in 13,705,501 US life-years saved
  • 4354 cervical cancer deaths were averted, resulting in –41,090 US life-years saved
  • 69,389 breast cancer deaths were averted after 1986 and 2592 excess breast cancer deaths occurred in 1982-1986 and 1990, resulting in overall 66,797 deaths averted
  • 264,632 colorectal cancer deaths were averted
  • 11,759 excess prostate cancer deaths occurred in 1982-1995, and 71,641 prostate cancer deaths were averted after 1995
  • –1,119,599 excess lung cancer deaths, resulting in –28,311,995 US life-years saved.
Dr Soneji told VBCC that the small number of averted breast cancer deaths “is likely due to advancements in breast cancer treatment that were common in both the US and Europe—transatlantic use of similar chemotherapy drugs and surgery.”

However, he noted, the ratio of incremental cost to quality-adjusted life-years (QALYs) saved is high, “because the United States spends substantially more in cancer care costs relative to the number of quality-adjusted life-years saved”; that is, not too many more lives are saved in the United States than in Europe.

Similarly, Dr Soneji said, “While the cost of prostate cancer treatment is much higher in the United States, the United States doesn’t experience many more lives saved. The cost is higher because of more aggressive treatment,” which is costly.

Lives Saved

Stomach and colorectal cancers had the highest numbers of life-years saved in the United States compared with Western Europe, but the cost was significantly higher for colorectal cancer. This is because although there are longstanding and vigorous screening programs in the United States for both types of cancers, the most effective stomach cancer prevention method is to minimize intake of salted or smoked meats (because they contain nitrosamines), which is more widely done in the United States and has a minimal cost to the healthcare system.

Lung and Cervical Cancers

The lopsided results for lung cancer reflect the historically higher lung cancer mortality rates in the United States and the fact that “half of lung cancers are diagnosed at stage 4, so these are very advanced cancers that require extensive, aggressive treatment,” said Dr Soneji.

He and Mr Yang predicted that the death differential will fall in the coming years, in sync with declining smoking rates in the United States.

Cervical cancer had, by far, the lowest ratio of incremental cost to QALYs saved. The explanation, Dr Soneji noted, is that “both sets of countries achieved progress against cervical cancer mortality; this progress has been about equal (so the difference is very small). Yet, cervical cancer care in the United States is more expensive for a variety of reasons—more expensive chemotherapy, more expensive surgery, and more expensive radiation therapy.”

The ACA’s Potential Impact on Cancer

“If greater access to wellness visits and preventive services translates to greater use of these types of medical care, the ACA [Affordable Care Act] may lead to more cancer deaths being averted,” Dr Soneji and Mr Yang wrote.

This can be done because the ACA mandates full coverage of annual wellness visits for the elderly, for example, and it may do so in a cost-effective manner.

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