October 31, 2007
Update: A test case for the media
My earlier post about Paul Krugman’s attack on Rudy Giuliani’s health-care ad has attracted critical comments that are making similar points. I argued that Giuliani’s numbers were wrong and that his claims were misleading, but that cancer survival rates are indeed higher in the United States (especially for those with health insurance) than for NHS patients in England. Here is one of the comments disagreeing with that post, which states criticisms that others have also made in a fairly clear and comprehensive way.
Mr. Crook’s criticisms of Paul Krugman are not even internally consistent, much less supported by fact.
1. The statement "If you are a man with prostate cancer, it may not matter very much whether your cancer is diagnosed early, or whether you live in Britain or America" implies that the survival rates are very similar.
2. The further implication is that Mr. Crook knows the true incidence in each country, which are clouded by differences in diagnostic methodology. In reality, there may be real differences in incidence due to differences in the environment, nurture, genetic variation, and so on. Therefore, the true incidence in each country is unknown.
3. Mr. Crook provides no citations for his assertions, while Mr. Krugman does.
4. The debate over whether PSA antigen testing affects survival is not settled, as a review of recent literature will confirm.
5. Since Mr. Crook asserts that diagnosis is much better in the United States than in the UK, it is disingenuous to shift from overall survival rates to 5-year survival rates. The Ezra Klein reference is clearly to overall mortality.
I was very disappointed by this piece, especially considering the nice promotion this site received from Brad DeLong.
Yes: thank you, Brad, for the nice promotion. Now, as to the criticisms of the post, there is some confusion over terminology here, to which I have no doubt contributed. The standard measure of the effectiveness of cancer treatment is five-year survival rates, often abbreviated in the literature to "survival rates". Whenever I said "survival rates" in my original post, I meant "five-year survival rates".
The five-year survival rate is the proportion of people still alive five years after being diagnosed with cancer. It is a flawed measure, as I tried to explain, and prostate cancer is probably the best example of how it can mislead. Early detection increases the five-year survival rate, but in the case of prostate cancer does not much reduce mortality, because prostate cancer develops so slowly that its victims tend to die of something else first. Mortality rates for that cancer are about the same in both countries. Five-year survival rates are far higher in the United States–so the claim that "survival rates" (ie, five-year survival rates, the usual meaning of that term) are higher for prostate cancer in the US is not "just plain false", as Paul stated. It is in fact true. Misleading, as I tried to explain, but true.
Well then, why not look just at mortality rates? Because mortality rates vary with incidence. If mortality rates for certain cancers are lower in America, that may be because the incidence of those cancers (driven by factors other than efficacy of treatment) is lower. Changes in mortality rates over time tell you something about a country’s whole cancer-control regime. By themselves, cross-country comparisons of mortality rates say little about the quality of treatment. Why not look at mortality rates adjusted for incidence? One problem here is that we only have figures for recorded incidence, not actual incidence. The US is good at detecting prostate cancer early. It records vastly higher incidence of the disease than Britain. Since the disease has about the same mortality in both countries, you might conclude that US treatment was vastly superior. That would be wrong, because America’s incidence figures are inflated (or you could say that Britain’s are suppressed) by differences in screening.
Careful assessments of the efficacy of cancer treatment need to take five-year survival rates, mortality, recorded incidence and a host of other complications and confounding influences into account. Reliance on the five-year survival rate alone is rightly criticised–and the case of prostate cancer shows why–but it remains the standard measure. And on that measure, overall US cancer treatment scores better than Britain’s.
Enough metric crunching. I said that the politically salient question is this: if you have cancer, would you rather be an American with health insurance or a Brit without private insurance, forced to rely on the NHS? I said the answer was obvious. If anybody with professional experience of the two systems thinks I’m mistaken about that, I’d love to hear from you.
>> I said that the politically salient question is this: if you have cancer, would you rather be an American with health insurance or a Brit without private insurance, forced to rely on the NHS? <<
It seems Rawls asked the more pertinant question. In a state of uncertainty over your citizenship, which system would you prefer to be universal?
Posted by: trevelyan | October 31st, 2007 at 11:19 pm | Report this commenttrevelyan: I agree that this is an interesting question and a better question. But I doubt that it is more to the point politically: the voters in next year’s election know they are Americans.
Posted by: Clive Crook | October 31st, 2007 at 11:35 pm | Report this commentThank you for the gracious and complete reply.
Alas, I still think Krugman had the right of it. You are correct that 5-year survival rates is the standard measure applied to cancer. But to which measure were the two men actually referring? Krugman was clearly referring to mortality: the Ezra Klein reference is unambiguous.
What Gratzer (and, via Gratzer, Giuliani) is citing is unclear– and almost certainly wrong. The National Cancer Institute (seer.cancer.gov/statfacts/html/prost.html) lists the 5-year relative survival rate as 98.4%. That measure corrects for causes of death other than cancer. My guess is that Gratzer is using raw survival rates. Since the median age of diagnosis is 68, and the median age at death is 80, that would be a highly improper measure.
So, you may well be correct on how Krugman and Giuliani (and the rest of us) should be arguing quality of care, but I think Krugman is correct on what actually got said.
Posted by: Charles | November 1st, 2007 at 2:17 am | Report this commentThanks Charles. Your point is well taken: I don’t know where Giuliani/Gratzer got their numbers either. Remember that in my first post I did give the ad “the edge for deception”. But I’m not letting Paul off the hook because he left his readers (and I’m guessing deliberately) with the impression that US cancer treatment is no better than in the NHS, which is wrong.
I think that the chief deception in what Rudy said was the implication that universal coverage has to mean “socialized medicine”, as in the NHS. No leading Democrat is calling for that–a good thing, in my view. Paul, on the other hand, presumably regrets it. Until he started praising Hillary’s plan, I had understood him to believe that private insurance was the root of all that is wrong with US health care.
Posted by: Clive Crook | November 1st, 2007 at 10:36 am | Report this commentFair enough… but I would suggest that it’s safer not to extrapolate or try to read minds. Krugman did a post on Rudy Giuliani’s ad about prostate cancer, not on cancer in general nor even about whether the NHS is better or worse than the mixed American system. Good journalistic practice would, I believe, also suggest dropping an e-mail query to him to examine the suspicion that he was deliberately misleading his readers.
As for the issue of insurance, it’s a major cost driver. With US governmental and current account budgets so badly out of balance, broadening insurance is essentially impossible without cost reduction. While there are means to cut costs by, for example, more aggressive policing of end-of-life care and creative use of physician’s assistants and nurses (not to mention avoiding unnecessary wars and levee failures), the administrative costs of the private system are the nail sticking up.
Posted by: Charles | November 1st, 2007 at 3:02 pm | Report this commentI’m a Brit, with health insurance, in America. Would I rather have cancer here or in Britain? In Britain. Why? Because my health insurance expires in a year’s time (I’m on COBRA). At that point, if I have cancer, I’m effectively uninsurable. My care from the point of diagnosis to the point at which my insurance expires will no doubt be wonderful. But then, I’m on my own. And there’s no way I can afford the cost of cancer care out of my own pocket.
Posted by: Felix | November 1st, 2007 at 8:12 pm | Report this commentReally, your last comment is the most dubious of all. As Felix says, why would you compare a Brit under the NHS with an privately-insured American?
Moreover, the trend in private insurance premiums in the U.S. is as unsustainable as public health care spending. Under present circumstances, the private system will survive by shifting bad risks to the public sector, and leaching subsidies out of public coffers in the bargain.
Would it make sense for a randomly-selected person in the U.K. to prefer the U.S. system to his/her own?
Posted by: MaxSpeak | November 2nd, 2007 at 2:51 pm | Report this commentFelix: I agree, of course: if your insurance is going to expire in a year then the choice is simple. Lack of certainty that one’s health insurance will stay current is one of the reasons why many Americans favour universal coverage and like the look of the Democrats’ reforms. For this and other reasons, I support universal coverage (though not through single-payer), as I have often argued elsewhere. My point here is simply that Americans with insurance can expect better cancer care than Brits who have to rely on the NHS. That is not so far from the point Giuliani was making. It is a point that some health reformers in America still apparently wish to deny.
MaxSpeak: Comparing standards of care for Americans with insurance, and standards of care in the NHS, is relevant if Americans with insurance (the majority) are being told that standards of care in an NHS-style single-payer system would be as good or better. Privately insured Americans are the ones who need to be convinced that they will gain, or anyway not lose, from health reform. This is better done by emphasising that reform will not import an NHS-like system, rather than by pretending that an NHS-like system would be as good for the fortunate insured majority. The Democratic presidential candidates have taken this point to heart. They are not proposing single-payer–and a good thing too. But some American health reformers continue to resist the idea that the NHS is worse than what most Americans (admittedly at much higher cost) currently have.
Posted by: Clive Crook | November 5th, 2007 at 6:29 am | Report this comment