5 ms·

> The reason they rarely get to see stage 4 cancer in Australia is because their health care system would rather treat it when it’s at stage 1, and patients are

> The reason they rarely get to see stage 4 cancer in Australia is because their health care system would rather treat it when it’s at stage 1, and patients are able to seek that treatment without fear of bankruptcy; but in the US, public health care isn’t generally available until you’re 65, leading to a huge spike in “I couldn’t afford to see a doctor sooner” stage 4 cancers. 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/ https://pubmed.ncbi.nlm.nih.gov/29395269/)

floatingatoll 6y ago
My comment doesn't discuss survival rates at all. Perhaps there has been a misunderstanding? I said that, for Australia's health care system, treating cancer at Stage 1 is cheaper than treating it at Stage 4. Could you talk more about how you went from treatment costs to survival rates? EDIT: I didn't state that clearly enough in my original comment. I'll leave it unedited and let this reply serve as clarification.
- sxg 6y ago
  The other commenter is pointing out the flaw in your argument. You're claiming that Australians are less likely to see stage IV cancer than Americans due to a worse healthcare system in America. As the other commenter states, that's a very believable argument that fits the narrative about America's healthcare system. However, the data doesn't support that claim. If Australians truly see fewer cases of stage IV cancer because of a better healthcare system, then we should expect to see higher 5-year survival rates for those cancers in Australia. As the other commenter brought up, 5-year survival rates are higher in America than Australia for the most common cancers. So it's unlikely that your original argument is correct. 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 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.
  - floatingatoll 6y ago
    > You're claiming that Australians are less likely to see stage IV cancer than Americans due to a worse healthcare system in America 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?"
    - sxg 6y ago
      > 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 successful treatment of cancers prior to their reaching stage 4. 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.
josho 6y ago
From the abstract the US has 0.7% higher survival rate than Australia. Which I wouldn’t be surprised turns out to be within the margin of error. 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.
- bumby 6y ago
  It’s hard to go through the actual study on my phone to find the appropriate context for that statistic but keep in mind cancer is a disease that will cause a drug to get a standing ovation at a presentation for increasing life expectancy 2 months. In that context, seemingly small improvements matter
  - josho 6y ago
    That reminds me. A loved one died of cancer. All involved would have preferred that they died in 6 months instead of 2.5 years. Because the final 2 years of their life was filled with painful treatment that left everyone involved stressed, anxious, and saw a loved one slowly decline. Optimizing for those extra 2 months is not a goal we should be striving for.
    - Sebguer 6y ago
      I'm sorry, but who in this scenario was forcing them to receive the treatments?
      - josho 6y ago
        Fair question. 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.
inopinatus 6y ago
The very study referenced above undermines the claim it is supposed to support. 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.
- jac241 6y ago
  The 14% gap in US population coverage is from Illinois, Nevada, Arizona, North and South Dakota, Maryland, and Kansas not providing data to this registry. Canada is only at 76.5% of their population included. If you're going with the premise that people in the US present with higher stage cancers like other posters in this thread, then it paints US cancer care in an even better light that they are able to have comparable 5 year survival despite their average cancer presenting later and having a worse prognosis. 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.
  - inopinatus 6y ago
    Quite so. My entire point is an anecdote relating one doctor's observations re. proportion of late presentations and their availability for study, and attaches that to a comment on US socioeconomic incentives. 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.
arcticbull 6y ago
America has higher 5-year survival because America tests earlier and more often than most other countries. That's likely attributably to a lawsuit-happy society and liability fears. However, that doesn't necessarily impact your likelihood of dying from the disease much of the time. This is called early detection and overdiagnosis bias [2]. 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. This is just a misinterpretation of the data. 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/ https://www.nhs.uk/conditions/prostate-cancer/psa-testing/ [2] https://www.healthaffairs.org/do/10.1377/hblog20150401.046038/full/ https://www.healthaffairs.org/do/10.1377/hblog20150401.04603...
- jac241 6y ago
  Maybe the urology society pushes for PSA tests but the USPTF - https://www.uspreventiveservicestaskforce.org/uspstf/topic_search_results?topic_status=All&category%5B%5D=15&searchterm=prostate https://www.uspreventiveservicestaskforce.org/uspstf/topic_s... - the set of guidelines that medical students in the US are taught do not recommend PSA screening.
DanBC 6y ago
> The US actually has a higher 5-year survival rate 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.

floatingatoll 6y ago

My comment doesn't discuss survival rates at all. Perhaps there has been a misunderstanding? I said that, for Australia's health care system, treating cancer at Stage 1 is cheaper than treating it at Stage 4. Could you talk more about how you went from treatment costs to survival rates? EDIT: I didn't state that clearly enough in my original comment. I'll leave it unedited and let this reply serve as clarification.

sxg 6y ago
The other commenter is pointing out the flaw in your argument. You're claiming that Australians are less likely to see stage IV cancer than Americans due to a worse healthcare system in America. As the other commenter states, that's a very believable argument that fits the narrative about America's healthcare system. However, the data doesn't support that claim. If Australians truly see fewer cases of stage IV cancer because of a better healthcare system, then we should expect to see higher 5-year survival rates for those cancers in Australia. As the other commenter brought up, 5-year survival rates are higher in America than Australia for the most common cancers. So it's unlikely that your original argument is correct. 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 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.
- floatingatoll 6y ago
  > You're claiming that Australians are less likely to see stage IV cancer than Americans due to a worse healthcare system in America 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?"
  - sxg 6y ago
    > 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 successful treatment of cancers prior to their reaching stage 4. 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.

josho 6y ago

From the abstract the US has 0.7% higher survival rate than Australia. Which I wouldn’t be surprised turns out to be within the margin of error. 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.

bumby 6y ago
It’s hard to go through the actual study on my phone to find the appropriate context for that statistic but keep in mind cancer is a disease that will cause a drug to get a standing ovation at a presentation for increasing life expectancy 2 months. In that context, seemingly small improvements matter
- josho 6y ago
  That reminds me. A loved one died of cancer. All involved would have preferred that they died in 6 months instead of 2.5 years. Because the final 2 years of their life was filled with painful treatment that left everyone involved stressed, anxious, and saw a loved one slowly decline. Optimizing for those extra 2 months is not a goal we should be striving for.
  - Sebguer 6y ago
    I'm sorry, but who in this scenario was forcing them to receive the treatments?
    - josho 6y ago
      Fair question. 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.

inopinatus 6y ago

The very study referenced above undermines the claim it is supposed to support. 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.

jac241 6y ago
The 14% gap in US population coverage is from Illinois, Nevada, Arizona, North and South Dakota, Maryland, and Kansas not providing data to this registry. Canada is only at 76.5% of their population included. If you're going with the premise that people in the US present with higher stage cancers like other posters in this thread, then it paints US cancer care in an even better light that they are able to have comparable 5 year survival despite their average cancer presenting later and having a worse prognosis. 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.
- inopinatus 6y ago
  Quite so. My entire point is an anecdote relating one doctor's observations re. proportion of late presentations and their availability for study, and attaches that to a comment on US socioeconomic incentives. 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.

arcticbull 6y ago

America has higher 5-year survival because America tests earlier and more often than most other countries. That's likely attributably to a lawsuit-happy society and liability fears. However, that doesn't necessarily impact your likelihood of dying from the disease much of the time. This is called early detection and overdiagnosis bias [2]. 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. This is just a misinterpretation of the data. 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/ https://www.nhs.uk/conditions/prostate-cancer/psa-testing/ [2] https://www.healthaffairs.org/do/10.1377/hblog20150401.046038/full/ https://www.healthaffairs.org/do/10.1377/hblog20150401.04603...

jac241 6y ago
Maybe the urology society pushes for PSA tests but the USPTF - https://www.uspreventiveservicestaskforce.org/uspstf/topic_search_results?topic_status=All&category%5B%5D=15&searchterm=prostate https://www.uspreventiveservicestaskforce.org/uspstf/topic_s... - the set of guidelines that medical students in the US are taught do not recommend PSA screening.

DanBC 6y ago

> The US actually has a higher 5-year survival rate 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.