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Cancer and the world economy (Please read this, Vice President Biden!)
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I was interested to see a report in The Lancet noting that there was a significant spike in cancer deaths associated with the financial crash from 2008 to 2010.
On a proportionate level, the spike was not huge, but an increase of more than a quarter of a million deaths certainly is worthy of investigation and comment.
Maruthappu and colleagues studied what they termed “treatable” and “untreatable” cancers and assessed the impact of the economic downturn on outcomes in both groups, comparing results in nations with universal health coverage and those without a safety net system.
They found this effect was only seen in the treatable malignancies, such as breast, colon and prostate cancers. There was no increment in cancer deaths for patients with advanced cancers of the lung or pancreas, presumably because current outcomes were not good enough to be impacted by the economy. Further, they documented this effect only in nations without universal coverage. Finally, the study showed improved cancer mortality statistics were associated with increased public health expenditure.
Possible explanations
What might be reasonable explanations for this observation?
One possibility is random fluctuation, although an increment of this magnitude in a 3-year period does not really suggest a random blip. Observer error — with a series of clerical workers simultaneously coding or listing incorrectly — also seems very unlikely, notwithstanding my concerns about the GIGO (garbage in, garbage out) principle in the acquisition of big data, whether applied to health care or international banking and financial estimates.
In most instances, there is a lag period between cause and effect in carcinogenesis. One usually finds lag periods measured in decades between the onset of cancer and previous significant exposure to radiation, smoking, asbestos, industrial exposure, sunlight or other known carcinogens.
Were there any potentially carcinogenic effects worldwide that occurred suddenly and that might explain this worldwide phenomenon? The Chernobyl disaster occurred 30 years ago, but the pattern of radiation exposure does not really fit with the diffuseness of the current observation.
Similarly, it seems unlikely that the nuclear accidents Tokaimura in 1999 and Fukushima Daiichi in 2011 would explain sudden increases in global cancer deaths in this period. An analogous comparison also fails to support a sudden, synchronous increment of exposure to other carcinogens on a worldwide basis.
John Sweetenham, MD, HemOnc Today’s Chief Medical Editor for Hematology, and I have recently written editorials on the adverse impacts of poverty, lack of health insurance, geographical isolation and other sociocultural factors on cancer survival. Disparities of care are sufficiently important to the health of our nation that I feel no need to apologize for returning to this theme after such a short interval.
Siran M. Koroukian, PhD, Paul M. Bataki, MS, MD, and I have previously shown substantially reduced survival from curable cancers among newly enrolled Medicaid patients compared with long-term recipients of Medicaid and patients with private health insurance. The group with private insurance had substantially better survival overall.
The President’s Cancer Panel some years ago also documented similar economically based adverse effects on cancer treatment access and outcomes.
More recently, fiscal toxicity has become a major issue for patients receiving expensive cancer treatments, partly due to treatment costs, and also because health insurers are increasingly sharing costs with patients via the copay mechanism. This impact is felt by both insured and uninsured patients, and it may ultimately create a similar contribution to a decline in cancer treatment outcomes. An important fact that is poorly understood by the voting public is that it is illegal for health care systems to unilaterally waive copayments for the uninsured and underinsured.
Making an impact
So where does this leave us?
It is noteworthy that the impact appears to have been documented most clearly in nations that do not have universal health care insurance. Thus, an easy explanation is that loss of employment and income (and associated loss of health insurance), in association with a worldwide economic downturn, may explain reduced participation in, or reduced access to, screening programs and delay of attention to symptoms or of treatment for established diagnoses.
The Maruthappu study focused on cancer deaths — it is easy to secure social and demographic information on a worldwide basis for cancer incidence and death rates — but it would seem important to assess whether other potentially lethal disorders were similarly associated with increased death rates during this period.
I have some concerns about the “moonshot” rhetoric and the latest “war on cancer.” Although I fully understand the benefits of an increased national focus on cancer research and treatment, I am not personally convinced that the absence of hypothesis-driven targets and the leveraging of multiple high-profile meetings with “experts” necessarily will represent an improvement on the status quo. No doubt, the potential increase in federal funding could help a great deal, but government leadership of the research agenda may be akin to physician leadership of the space race or the automobile industry.
However, what today’s topic illustrates is that there is an important place for government in cancer treatment — namely, developing a sensible, financially robust, bipartisan approach to a national safety net for potentially lethal diseases with high associated treatment costs, thus offering the best known standards of care to all of our patients.
To be clear, this is no panacea, as it is well established that socioeconomic gradients persist for cancer outcomes in nations that have universal coverage, but it would improve our national cancer mortality figures in a meaningful way.
In addition, government must develop a more sensible, pragmatic and outcome-driven approach to refining the difference between costs and price of medical, hospital and pharmaceutical care based on the best level-one and level-two evidence, as well as common sense. This will demand education of the general public, a redefinition of the health care understanding and expectations of the general consumer community, and a careful review of direct-to-patient marketing in this space.
I hope Vice President Joe Biden’s health staffers read this. It might act as a primer for how to make an impact on cancer deaths in the United States in the time frame that they have set for the newest oncology war.
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References:
Koroukian SM, et al. Cancer. 2012;doi:10.1002/cncr.27380.
Maruthappu M, et al. Lancet. 2016;doi:10.1016/S0140-6736(16)00577-8.
President’s Cancer Panel 2009-2010 Annual Report. America’s demographic and cultural transformation: Implications for cancer. NCI. Available at: deainfo.nci.nih.gov/advisory/pcp/annualReports/pcp09-10rpt/pcp09-10rpt.pdf. Accessed May 31, 2016.
For more information:
Derek Raghavan, MD, PhD, FACP, FRACP, FASCO, is HemOnc Today’s Chief Medical Editor for Oncology. He also is president of Levine Cancer Institute at Carolinas HealthCare System. He can be reached at derek.raghavan@carolinashealthcare.org.
Disclosure: Raghavan reports no relevant financial disclosures.