American Cancer Care Beats the Rest

You don't want socialized medicine if you're really sick

"Your accomplishment of [universal access] is the envy of every U.S. citizen who understands what you've done," Sen. Edward Kennedy (D., Mass.) told a Canadian audience in 1996. This week, a major international study confirms that Mr. Kennedy is right to stay at home for his own cancer care: U.S. medicine bests the cancer treatment available to people in 30 other countries.

The Concord study compares five-year cancer survival rates for several malignancies: breast cancer in women; prostate cancer; colon and rectal cancer in women and men. Combining the efforts of some 100 researchers, drawing data from almost two million cancer patients in 31 countries, the study, to be published in the August issue of The Lancet, is groundbreaking.

Who's on top? Arguably Cuba, which records the best overall outcomes for breast cancer and colorectal cancer (in women), and seems to beat U.S. health care in three out of the four categories. The study's authors -- who apparently hold higher standards than filmmaker Michael Moore -- disregard these results owing to data quality issues.

The study finds that the U.S. leads in the field of breast and prostate cancer. France excelled in women's colorectal cancer and Japan in men's colorectal cancer. The news isn't all good here: great discrepancies exist between white and African-Americans. That said, the United States clearly leads other nations in overall survival.

These results aren't completely surprising. Though international comparisons are hard to make, Lancet Oncology published last August a comparison of American and European care, and the U.S. fared better in 13 of the 16 cancers studied.

Americans don't usually hear good news stories about health care. Mr. Moore favorably reviewed British, French and even Cuban health care in the movie "Sicko," showing satisfied patients and happy, chic docs. Paul Krugman wrote last year in the New York Times that: "there's very little evidence that Americans get better health care than the British." Cancer care there is different than here. Take for instance the country whose health-care system Mr. Krugman likes so much. The Lancet Oncology study finds that five-year survival rates for cancer in men, for example, are 45% in England (slightly higher in Wales, lower in Scotland) but 66% in the U.S.

Why do the British lag behind American survival rates? Screening standards are different. In the United States, internists recommend that men 50 and older get screened for colon cancer; in the National Health Service in the United Kingdom, screening begins at 75. And British patients wait much longer to see specialists. A Clinical Oncology study of British lung cancer treatment found in 2000 that 20% "of potentially curable patients became incurable on the waiting list." Novel drugs offered here often aren't available there; for instance, Avastin, a drug for advanced colon cancer, is prescribed more often in the U.S. than in the UK, by some estimates as much as ten-fold more.

A drug called Temodal is the U.S. standard of care for Sen. Kennedy's type of brain cancer. In Britain, a government body charged with funding decisions -- the euphemistically named NICE, or National Institute for Health and Clinical Excellence -- ruled in 2001 that Temodal wasn't worth the money as a first-line treatment; in 2007, they partially lifted the prohibition. Patients can still get the drug, they just need to pay out of pocket -- for all their cancer care. The National Health Service recently ruled that if patients opt out of one type of care (say by getting Temodal), they opt out of all publicly funded care.

Two cheers, then, for American health care and better cancer outcomes. Rising costs, however, threaten to undermine the economy. Not surprisingly, our debate is shifting to a discussion of getting better value from our health dollars. Just last week, the U.S. House of Representatives held hearings on this topic (full disclosure, I was a witness). Former Sen. Tom Daschle and his co-authors speak at length about "value" in their new book, "Critical: What We Can Do About the Health-Care Crisis." Given his potential role in a future Democratic administration, the book may lay out the first outline of ObamaCare.

What's to be done? Mr. Daschle talks up the idea of a federal health-care board charged with "recommending coverage of those drugs and procedures backed by solid evidence. It would exert influence by ranking services and therapies by their health and cost impacts." The inspiration? Mr. Daschle cites Britain's NICE. The Congressional Budget Office is slated to release a paper on this topic later this year.

Given the Concord results, the CBO may want to hold off on that effort. Value -- like in the other five-sixths of the economy -- will come from competition and choice, not a government committee. But the federal government can take a leadership role in promoting competition. How? By creating greater transparency of prices, releasing more Medicare information on complications and outcomes, encouraging hospitals and clinics to standardize their health records, and slashing regulations that discourage competition. Together, these efforts would make it easier for American patients to seek out excellence. And that seems as American as apple pie and good cancer care.

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British hip and knee patients face delays due to emphasis on cheap cataract surgery

Thousands of patients could be facing unnecessary delays for hip and knee operations because the NHS is concentrating too much on cataract surgery, an expert has warned. More fiddling in response to targets. Cost instead of clinical need becomes the criterion for doing a procedure

The eye surgery has made up almost one fifth of all "extra" operations carried out using the additional cash ministers have pumped into the health service in recent years, figures show. As a result there has been a significant fall in waiting times for the procedure. But recent evidence suggests that surgeons could be carrying out cataract operations unnecessarily early on some patients, according to The King's Fund, the independent health think tank which collated the statistics.

Waiting times for other operations, in particular hip and knee replacements, have not fallen so fast, said John Appleby, the organisation's chief economist. "In reducing these waiting times we have done the easier operations and left the more difficult ones to last," he said.

The King's Fund calculates that of an estimated 605,000 "extra" operations carried out between 1998 and 2005, 115,000 were for cataracts. "I think that if you looked back from 1998 to now that many people would be surprised just how many of these extra procedures have been one operation, cataracts," Mr Appleby said. "Although the number of other operations being performed have increased as well, the figures show they have not risen nearly as much as cataract operations." He added: "There is also evidence that now some people are being admitted with rather good vision who would normally not be admitted for the operation so soon."

The think tank estimates that while a cataract operation costs the NHS around $1200 to $1400, the cost of a hip or a knee replacement is around 10 times that, at between $12,000 and $14,000.

Although cataracts can ultimately cause blindness some patients do not require surgery for months or even years after their initial diagnosis. Ministers have set a target that no patient should wait more than 18 weeks for treatment by the end of this year. Government spending on the NHS has more than doubled to $180 billion since the turn of the century.

A spokesman for the Department of Health said: "In England, by the end of December 2008, no patient will have to wait more than 18 weeks from the time they are referred by their GP for any treatment unless they choose to do so, or it is clinically appropriate. "Latest figures show the majority of patients are already being seen within 18 weeks and that the NHS nationally has achieved its milestones for March 2008.

"The increase in supply of cataract services has enabled the NHS to massively reduce waits for cataract surgery. Average waiting times for cataract operations 10 years ago were as long as 2 years, now it is around 3 months. The number of cataract operations have also nearly doubled in the last ten years. Ultimately, commissioning decisions are a matter for local primary care trusts."

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