Key quote: "these are cases we hardly ever get to see at home".
The financial disincentive to seek care is strong.
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.
EDIT: Please do review the replies below, as they offer legitimate questions/doubts about my comment.
I am jaded enough to wonder if it is because the medical industrial complex makes more money off late stage cancers.
My SO has a condition that is a bit hard to pin down. Getting MDs to actually run tests took years of fights. I remember one particular phone call where my SO, myself, the insurance company rep, and the MD were on a 4-way call together. The MD was refusing to run a specific test, as it was not 'needed'. Eventually the insurance person became incredulous on our behalf (a near miracle in itself) and stated that the particular machine that does the test routinely, as part of the standard panel of tests (like, it'll always spit out the pH, salinity, blood-type, etc). As in, the MD knew the results of the test the whole time and refused to tell my SO.
The US system is beyond maddening!
I'll say it until the cows come home, the US 'system' is broken, has been for decades, and will remain so for the future.
Please, vote for people that will make it better.
I naturalized as a citizen elsewhere over US healthcare because I know it is only going to get worse long term. With 2 rare neurological diseases affecting my peripheral nervous system, plus type 1 diabetes (autoimmune and insulin-dependent), I want to stay alive long term, and so that was the best possible choice I could make.
I am extremely well versed in immigration, acquiring citizenships, healthcare systems, and healthcare delivery and logistics, and so if anyone wants help or advice, feel free to email me (see my profile).
Typically getting citizenship in /any/ European Union + European Free Trade Association country (minus Liechtenstein--has an immigration quota) is the best deal for an American.
The reason why? Becoming a citizen of one of these countries confers you EU or EFTA citizenship (let's just call it EU citizenship). Once you become an EU citizen, you have the right to live/work/retire in about 30 different countries. You are also always seen as "The American" with your American educational credentials and American work experience.
So, if you can just spend like 5-10 years in one of those countries (sometimes a less desirable one), get the citizenship, you can then move to somewhere more desired that is much harder to obtain citizenship in--permanently.
Usually the place to go for Americans is Ireland, where you can get citizenship in 5 years. Ireland also permits dual citizenship. Not only can you live/work/retire anywhere in the EU+EFTA: because of ties to the UK, having Irish citizenship gives you rights to live/work/retire in the UK.
Also, pay attention to who is top on this list (5 of the top 10 are in the EU + EFTA):
How healthy will we be in 2040? http://www.healthdata.org/news-release/how-healthy-will-we-b...
A lot of people on here also would get a job easily in Ireland, as they meet criteria for being on the Critical Skills Occupation List: https://enterprise.gov.ie/en/What-We-Do/Workplace-and-Skills...
This means that they do not have to get their employer to do a skilled work test, which means they would otherwise have to prove that they are "not taking away a job from an EU citizen", which is a very high standard to meet.
The problem with Australia, New Zealand, and Canada, is that they have medical inadmissibility clauses in their immigration laws. This means that if you or anyone in your family is expected to (or do) cost more than $19,500 CAD/year, $8,000 AUD/year, or $7,500 NZD/year in medical or social services, or both, as an individual: you and your family are medically inadmissible to those countries and will be denied entry. If you or a family member goes over that threshold at any point, your entire family will be forced to go home and leave, even if working full-time and otherwise fully contributing and integrating into society. I would not be surprised if the UK does something like this post-Brexit.
For example, the third leading cause of death is believed to be preventable medical errors: https://www.bmj.com/content/353/bmj.i2139
This statistic has been corroborated by other studies (search: "third leading cause of death medical errors US"). You cannot evade statistics like that by going to the "best hospitals", or by "having good insurance", or being "able to pay for it".
I nearly died at age 22 from multiple medical errors over the same hospitalization. I am in my early 30s now. It still haunts me. I nearly died from severe diabetic ketoacidosis (blood pH got down to 7.03) from the hospital messing up insulin dosages (I have type 1 diabetes), and then I had to get a central line in my neck for treatment because I was so dehydrated. I got sepsis from the central line placement, which is never supposed to happen. I was not even hospitalized initially for any of the above mentioned reasons!
US life expectancy is expected to go down from #43 in the world in 2016 to #64 in 2040. See: http://www.healthdata.org/news-release/how-healthy-will-we-b...
Then there are things like this: Death or Debt? National Estimates of Financial Toxicity in Persons with Newly-Diagnosed Cancer (42% of newly diagnosed cancer patients exhaust their life assets, with the average losses being $92,098)
Then if you have a rare disease, which 7-8% of the general population collectively has, you often have to rely on orphan drugs (like me). There are 8,000 or so rare diseases. I actually have 2 rare diseases, and one of them is so rare that it will not be cured without personalized medicine.
One of the things which made me give up hope in the US was stuff like this, where very rare diseases become treatable, but the yearly cost of the drug (under contract via insurance) is ~$2 million/year, and it has to be taken for life. This is a new trend, and it makes me distraught.
The $6 Million Drug Claim: https://www.nytimes.com/2019/08/25/health/drug-prices-rare-d...
Currently, the country I am a citizen of (besides the US), is about to have the same lifespan for females as the US (which I am female). The country went through a nasty war with the breakup of Yugoslavia. I am proud of my country, I mean Croatia. I also have the EU to fall back on. With the US, there is very little that can be done to protect me, from a work and insurance perspective.
Things like prior authorization (getting a bureaucrat to give you permission to take this medication), prescription formularies (exclusion lists--you cannot take this medication under any circumstance), and step therapy (you must take a less effective medicine--and fail--before trying a more expensive and more effective medication. This occurs even with serious conditions like cancer and multiple sclerosis), quite literally kill.
I know an American in Japan who is on 3 biologics there. In the US, all 3 would require prior authorization, and 2 of them would be denied, because you can only get authorization to get 1 at a time. He could fight for coverage, via ERISA, through his employer, in court, but he would lose his colon before he would win. Then, when he loses his colon, he cannot sue for damages because of ERISA.
Dude, conversations break down on forums all the time. I use a screenreader and braille to read posts. I read things linearly because of this. It's not like I do not notice a coherent breakdown of conversation as the posts go further down the webpage.
People around the world, who live in highly industrialized countries with guaranteed-issue health insurance coverage (whether it be national/public/private health insurance) go to their doctors at a rate much higher than Americans. We are generally talking about a multiplicative factor on average when comparing the American population to another country’s entire population.
There is a direct relationship between seeing a doctor at a minimum X interval regularly (while in excellent, good, or fair health) versus costs to the /American health insurer/ (or employer paying for the insurance if they are self-insured).
That is why you see ads on TV saying “make sure to schedule your annual checkup with your primary care doctor, brought to you by Aetna!”
Infants go to see a pediatrician at much shorter shorter intervals, which is also due in part to vaccines and the need to check for developmental issues. Young children go in for checkups more frequently than adults to spot developmental issues (parents need to know developmental milestones backwards and forwards--and also log when they occur) along with vaccines. School-aged children generally go in yearly to the pediatrician, where checks on development occur, with the exception for certain vaccines like the HPV vaccine.
No matter what, the first 5 years of life determine a lot in life when it comes to the future, so it is crucial that developmental milestones are being met. If not, these problems can often be resolved with therapy, of various sorts, and children often catch up without issue. It is important that developmental milestones occur at appropriate times at older ages, too. But, there are basic crucial things that must be done for young children like nurturing your child, socializing your child, getting an early start on education, getting top-notch healthcare, etc. that keep the child healthy (also things like personality disorders are often caused by parents not properly socializing their children at a very young age). Investing in the first 5 years of life, as much as possible, has the most potential for a family (also a society) when it comes to their children and their life outcomes. So, it can be argued that parents should have substantial paternity leave so that the human potential of society is fully realized in the future (I am not a parent myself, and I cannot have kids, due to health problems).
Weird side notes. My primary care physician died several years later randomly driving off the expressway into a bridge support pillar. My surgeon was someone I had worked with to develop a surgical simulator. My second oncologist was an asian man with a weird accent. Took several minutes for my brain to register the accent - because he was australian. Life is ... odd.
I had a similar experience: Back when I was swimming laps, another swimmer was an Asian-Australian physician, and I initially had a hard time understanding his Ozzie accent — I surmise that here in Texas I was unconsciously expecting something different from someone with his facial features, so my brain had to parse through the "disparity." (I soon got used to it, of course.)
For context, before we got public health system in australia, the no.1 cause of bankruptcy was medical. Now medical bankruptcy is almost non existent.
Americans famously don't have $400 for emergencies. I don't know if other countries do better, or if there are national plans to help them out in the case of illness, regardless of the costs directly related to the treatment.
Well, no. But clearly bankruptcies usually include multiple financial stresses. More likely, "i got sick, i had medical bills, i lost my job, my car broke down" kind of thing.
Worth noting the (up to) 60% figure i noted was from a harvard study during the GFC. The more conservative figures have tended towards 20-30% for medical bills being the primary cause of bankruptcy. Even then it seems to still be one of the more common (avoidable) causes of bankruptcy.
You are right, it was a long time ago. But the 1975 system was brought in the by the Whitlam government was only universal in that it brought in a single payer system, but not free and not unrestricted. (Before that we had a hodge-podge not unlike the US before the ACA.) After the coup against Whitlam, the subsequent government further restricted or watered that system down, until Hawke brought in a universal healthcare system in 1984, medicare.
Still, with each period of right wing government in australia, we still seem to get a slow death by a hundred cuts to the medicare system (medicare levy, indexation freezes, closing of bulkbilling clinics etc etc etc).
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/)
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.
I’m happy my taxes go towards helping people get out of stage 1 than seeing people live their final days in stage 4.
Germany had all kind of preventative help/medicine when I lived there.
US
Number of deaths: 612,390
Crude rate: 185.0
ASR (World) per 100,000: 86.3
Cumulative risk (0-74): 0
Australia
Number of deaths: 48,236
Crude rate: 189.2
ASR (World) per 100,000: 83.3
Cumulative risk (0-74): 0
These numbers seem fairly close, while other countries have much larger differences. The Australia numbers for incidences are higher, perhaps indicating that they catch it earlier or their population suffers from a naturally higher incidence rate, but that does not equate to significantly lower mortality.
Source: https://gco.iarc.fr/
Medicare would likely save money by having free screenings and yearly bloodwork for all Americans starting at say age 40. The cost of some of these experimental cancer drugs is very very high not to mention surgery/chemo/radiation/etc. Additionally, it would create more incentives to find cheaper/faster/newer tests for these diseases knowing that there will be a HUGE market for them forever. My guess is that after some small number of years, this would actually save Medicare money. Obviously, there is the human upside as well.
Plus California has more people than all of Australia and the worst cancer patients try to go to Stanford, so if expect huge numbers (more than all of Australia even if rates were similar).
[1]https://www.aihw.gov.au/reports/cancer/cancer-data-in-austra...
[1] https://ncci.canceraustralia.gov.au/features/national-cancer...
And no, a general observation of "we don't see stage 4 cancers in Australia, we have to go to the US" is clearly invalidated by this data. There are plenty of stage 4 cancers in Australia.
Take a look at the US Seer data it appears more is diagnosed earlier in the US.[1] 50% are not stage IV and only 2% are unstaged.
On the other hand: intentionally misrepresenting people's statements, and crudely and inappropriately manipulating statistics, sets off my bullshit detector.
Australia has no safety net hospitals, because everyone legally resident in Australia has health insurance. All hospitals in Australia have very high quality of care.
While we (Americans) may have comparable 5 year survival rates, it does not mean that there is not unnecessary death via the American system. There are deaths (mortality) and adverse conditions (morbidities) due to amenable and non-amenable medical errors in all healthcare systems in the world. The unique aspect about American healthcare is that there is another category that is not prevalent in other highly industrialized countries: mortalities and morbidities due to a lack of care (lack of ability to pay for care), which happens easily, even if you have money.
I can assure you that while we may have comparable 5 year survival rates, there’s more to the story here, and that there is so much unnecessary death in the US healthcare system.
I have studied health systems worldwide, country-to-country, via the open-access peer reviewed publications posted on HealthData.org.
I live abroad, basically over the American healthcare situation. I have 2 rare neurological diseases affecting my peripheral nervous system plus type 1 diabetes (autoimmune and insulin-dependent).
Which is, of course, in part, why I’m still married.
Alternatively, for a related experience, since you're on rotation, try going up to your CMO and demanding evidence for some off-the-cuff remark they've made about their own professional choices. Good luck.
As for my personal situation, one of the rare diseases that I have is believed to have caused the autoimmunity that caused my T1D. It is a form of autoimmune autonomic neuropathy, and it showed up 6 months before the T1D diagnosis. We also believe that I am susceptible to other endocrine and neurological immune-mediated diseases through the anti-peripherin antibody. It’s the common denominator relating most of my health problems together, but there is no commercial test available for it at the moment.