It does not assess the distribution of presentations by stage, it notes a 14% gap of US population coverage (i.e. people entirely unaccounted for in the survival statistics), and if you refer to tables 6 & 7 it's clear that the US overall has slightly worse net 5-year survival rates than Australia for some cancers, and slightly better for some.
In practice, the standard of care available in both countries is very high. It merely remains to present for treatment in time, or whether the system sees you at all.
I must add that focusing on death promotes the repugnant idea that mortality is the only cancer outcome worth assessing. It is not. Taking a moment to considers humans as people, not a pile of potential corpses, will I hope trigger consideration of the quality-of-life consequences of late presentation: people suffering unnecessarily for considerable time, where the incentive for them to suffer instead of seeking treatment is socioeconomic.
Moreover, irrespective of eventual outcome, such cases are more time and resource-intensive, which (along with rent-seeking organisational cliques) is a contributory factor to the fiscal inefficiency of the US health system.
I have trouble seeing the reason for your argument about mortality. This is one paper that looks at 5 year survival across many countries. The authors may have chosen this outcome measure because it is the easiest and most objective outcome measure we have. Other papers can look at disability adjusted life years or quality adjusted life years. Those measures just were not used in this paper.
Trolling in this thread has attempted twisting that to be a statement about outcomes of treatment, including offering up a paper that, as you note, has essentially nothing to say about the histogram of stage-at-diagnosis. One of these even told me (the OP) to "read the OP", then misquoted my own words to me.
I decline to be gaslit by their intentional misrepresentations, straw man restatements, badgering and sealioning; sadly, of course, that just makes the trolls angrier.
Regardless, in Australia fewer will reach that cohort because preventive measures through universal health care are in place. That means widely available cancer screenings will catch malignant tissues before they turn cancerous.
Additionally those screenings will be lower cost than the US model and the patients will have a better quality of life.
Optimizing for those extra 2 months is not a goal we should be striving for.
The problem is as patient's we've never gone through the experience before and are totally unprepared for what it's going to be. From the beginning all we know is that path A ends too soon, and path B has a chance of having a good outcome. We hope beyond what's rational that path B will have an exceptional outcome for us and go down that path. Only later do we realize how painful and miserable the experience can be for everyone.
This is an assertion that you're stating as fact, but it's directly contradicted by both the aforementioned study (it's not true that "fewer people reach that cohort") and by existing domain knowledge about how cancer screening actually works.
As explained below, screening people for cancers earlier actually doesn't improve mortality rates significantly. In fact, survival rates are actually roughly flat when adjusted for detection time, because earlier detection mostly catches cancers that wouldn't actually progress to be fatal in the first place.
> Additionally those screenings will be lower cost than the US model
You have this backwards. Screenings for early asymptomatic cancer are actually the textbook example of gratuitous costs.
But I’m quite confident that we have enough data to establish guidelines on what circumstances to screen. And health insurance coverage shouldn’t be a factor whether to screen or not.
Here are the cancer screening guidelines - https://www.uspreventiveservicestaskforce.org/uspstf/topic_s... - You can see that many of these carry the D recommendation, meaning they should not be done because the harm outweighs the benefit of the screening. Screening only makes sense if the cost of the test is low, the test is very accurate, and the benefit of the treatment you're going to undertake after a positive screen is large.
(1) https://seer.cancer.gov/registries/ (2) https://en.wikipedia.org/wiki/David_Weedon (3) https://www.amazon.com/dp/0702075825/
EDIT: I didn't state that clearly enough in my original comment. I'll leave it unedited and let this reply serve as clarification.
Sure, America's healthcare system is deeply flawed, but it's important to attack it on fair grounds. We can't solve a systemic issue by raising claims and arguments that aren't supported by evidence.
EDIT: Furthermore, identifying early stage cancer is an extremely problematic and difficult field regardless of healthcare system and country. In America, we currently screen asymptomatic healthy adults for breast cancer and colon cancer. We screen people with a smoking history for lung cancer. However, the benefits to overall mortality of these cancer screening tests is controversial.
While in theory identifying stage I cancer should result in improved overall mortality, the data doesn't clearly show that. Take a look at length-time bias (https://en.wikipedia.org/wiki/Length_time_bias). It's possible that a substantial portion of the cancer screening that's done in America (and the stage I cancers found in Australia) selectively identify indolent cancers that are unlikely to be harmful to patients.
I'm claiming that Australian citizens are more likely to bring cancer to their provider when it's still at stage 1, because the citizens do not risk bankruptcy when seeking diagnosis and treatment, resulting in treatment of cancers beginning prior to their reaching stage 4.
This would, if true, create a scenario where:
In Australia, the few stage 4 cancers seen are the cancers that failed treatment at stage 1, stage 2, and stage 3; they are extremely likely to be fatal, as they've already failed essentially every treatment available.
But in United States, the stage 1-2-3 "this is treatable" filtering out isn't occurring, because patients with cancer are waiting for age 65 to seek diagnosis, and so our stage 4 treatment success rate is higher because we didn't treat the treatable cancers earlier in the stages.
Do the above comparisons of AU vs US 'stage 4 survival rates' take into account the successful treatments at stages 1-3 that would presumably be occurring in AU? Do they take into account the incidences of 'this would have been treatable if diagnosed in stages 1-3' that are presumably occuring in US?
EDIT: Do they hold true for each individual type of cancer? Do they hold true when normalized for spending on a given type of cancer as a percentage of all cancer spending?
I'm aware that these are not easy things to compare or assess, and I understand that it's preferable to some to make no statement at all rather than make an approximation that doesn't hold up to a full-power statistical analysis. If someone does know of such a thesis, I suppose my most compact question would be:
"For each type of cancer: Does the Australian health care system tend to diagnose earlier than the United States health care system, provide care at a higher or lower total cost of treatment, with a higher or lower rate of success?"
I understand your argument: you're saying that by treating stage 1–3 patients early on, the stage 4 patients will have a shorter survival. But in the US, stage 4 patients also include many patients that would have been stage 1–3 in a different country, and because these cancers may not be quite as aggressive as the other stage 4 cancers, the 5-year survival will be higher. I'm on board with this part of your argument.
The part that doesn't hold up is patients regularly coming in to their doctors with symptomatic early stage cancer. In early stages, many cancers are completely asymptomatic. Even when we screen completely asymptomatic patients for early stage cancer in the US, we don't actually see clear cut overall mortality benefits. So how is it that these Australians are presenting to their doctors so early on with cancer symptoms?
EDIT: The holy grail of cancer screening has three features:
- Identifies dangerous cancers shortly after they form
- Perfectly separates cancer from non-cancer
- Patients live longer
Medical science itself (regardless of healthcare system and country) can't reliably meet the above three goals. So I'm skeptical that patients having easy access to medical care like in Australia would result in improved cancer survival.
This isn't a trivial problem. These patients are often asymptomatic, and objective physical exam findings are not easy to elicit or entirely non-existent. At this point, the only thing a doctor can do is screen every patient coming through the door for cancer via CT, MR, mammography, colonoscopy, etc., but this doesn't translate into clear cut clinically meaningful benefits that helps patients live longer. You often end up irradiating non-cancer patients and creating new cancers, or you selectively diagnose non-aggressive cancers (length-time bias) and unnecessarily put patients through surgery, chemotherapy, and radiation (i.e. over-treatment). Some fraction of these patients then go on to live shorter lives as a result of the over-treatment. This particular issue we're discussing is more of a medical science problem than a healthcare system problem.
Anecdote from med school: on my surgery rotation, I had a ~70 year-old patient recently diagnosed with early stage colon cancer on a screening colonoscopy. He had undergone chemotherapy and was now about to have the cancerous part of his colon removed. Surgery was a success, and the patient recovered in the hospital for a few days before we sent him home. The day after he goes home, we found out he died from a massive pulmonary embolism, likely a post-operative complication from surgery.
Alternatively, had this patient not had a screening colonoscopy, we never would have found his early stage cancer. Based on his cancer stage, he likely would've lived another 10–15 years without treatment (age ~85-90). Instead, our interventions killed him a few months after diagnosis.
> The records of all births, deaths, and surgeries are known.
Actually, this is not known (at least in the US). There is no central medical database or significant communication between hospital systems. As you can imagine, this is problematic for obtaining meaningful data. In order to answer the questions you raise, researchers have to begin collecting new data prospectively or look retrospectively at the incomplete records contained within their hospital system. The retrospective method is easier and probably more common, but there are serious biases with a retrospective approach, including small sample sizes and non-random sampling (many US hospitals serve specific demographics).
I find this somewhat astonishing and deeply troubling. How can patients or doctors truly make informed decisions if they are not in fact well informed? This is not right at all.
The other party responsible for the lack of centralized data is the EMR vendors (Epic being one of the largest). They're incentivized to lock-in their clients (i.e. hospitals) by making any kind of data sharing at best a pain in the ass and at worst entirely impossible. For large health systems, I've heard the cost of changing EMRs is in the tens to hundreds of millions (USD).
Besides the detriment to research, this does lead to real patient harms. Where I went to med school, there were two major hospitals systems about 5 mins from each other in a major city. I worked in the emergency department at one hospital where I would frequently see patients coming in after car accidents and heart attacks. But often, some of these patients had received all of their care at the hospital 5 mins away. We had zero records for these patients. Meaning, we had to work them up from scratch and any important medical history would be unbeknownst to us. This obviously led to poor care and duplication of medical tests, which can be harmful (e.g. radiation from CTs). And requesting medical records from the other hospital was infeasible in emergencies. Realistically, these records were only available 9a–5p on weekdays via fax at the other hospital's leisure.
Further, 5-year mortality rates can be affected by palliative care philosophy too - do you keep giving chemo to folks who won't recover?
In fact, if you look at the mortality rate for most cancers instead of the 5 year survival rates, they're basically the same across the Australia, the UK and the US.
Prostate cancer in particular is interesting because the US continues to advocate for early screening and PSA antigen tests, but the NHS has found that there's no scientific basis for this, and PSA screening for prostate cancer actually does more harm than good [1]
There's currently no screening programme for prostate cancer in the UK. This is because it has not been proved that the benefits would outweigh the risks.
tl;dr: 5 year survival rates measure, in a lot of cases, the rate of early detection, not cure. At least, that's the inherent bias. Your study uses 5 year survival rates not mortality rates, hence this is illustrating differences in testing philosophy not efficacy. More, early testing is not necessarily better. It's often worse.
[1] https://www.nhs.uk/conditions/prostate-cancer/psa-testing/
[2] https://www.healthaffairs.org/do/10.1377/hblog20150401.04603...
Take a bunch of people over the age of 50 and then screen them for thyroid cancer. Then don't provide them any treatment at all for that thyroid cancer.
You haven't changed when those people die, nor what they die of, but your 5 year cancer survival rates look good because most of these people will live for more than 5 years with their cancer.
And because there are small risks associated with treatment, if you treat large numbers of people you'll harm small numbers of them. Your 5 year survival rates look good, but your all cause mortality looks worse.
That explanation fits what people probably expect, but it's not borne out by the data. The US actually has a higher 5-year survival rate for most common treatable cancers than Australia (e.g. breast cancer, colorectal cancer, prostate cancer).
This has been confirmed by multiple multi-year studies that analyze cancer survival rates across countries (e.g. https://pubmed.ncbi.nlm.nih.gov/29395269/)