THE ECONOMICS OF CANCER CARE
There is highly complex nature of modern cancer care and the rapid rate of change in both medical technology and drug therapy. These changes are underpinned by extensive investment in new treatments by both drug and medical equipment manufacturers. Clearly, new treatments must be paid for and in general, will cost more than the older technologies they replace. There are exceptions to this – for example, a treatment that improved the cure rate could reduce downstream expenditure on subsequent therapies and so may result in a net decrease in healthcare resource use. Measuring these interdependent changes is clearly complex, hence a lot of health care economic decision-making is focused on the direct acquisition costs of the new technology (which are easy to measure) rather than secondary downstream changes. Frequently with cancer care, these costs are focused near the end of life and result in contentious funding dilemmas.
Economics also impinges on cancer care at a more macroeconomic level than the cost of an individual drug. In general, the developed economies of the world have comprehensive healthcare systems that broadly cover health issues from cradle to grave. Different systems have different pros and cons, but the major difference is between the developed and less developed world. Clearly, if basic infrastructure is lacking, whether or not to buy an expensive new drug is not a relevant discussion for most of the population. It is possible to estimate the size of these effects: Figure 1 shows the interaction between per capita gross national product (pcGNP) and life expectancy in years.
As can be seen, there are some countries with very low income and as would be expected, low life expectancy. However, there are others with pcGNP of less than $1,000 per year but where life expectancy exceeds 65 years. These countries include places like Egypt, Trinidad, and China. Common features of these countries are an integrated public health system and good perinatal care. Conversely, there are countries with pcGNP of more than $2,000 with the life expectancy of fewer than 60 years. The problem here appears to be high levels of HIV infection. Thus in broad terms, how rich a country it will affect, not surprisingly, the quality of healthcare and life expectancy, but also other factors play an important part. Some of these factors can be readily influenced by factors within the control of governments – overall organization to get maximum impact from resources, public health campaigns, and so on. Conversely, at the upper end of the spectrum, once a certain level of national income is reached, there is very little further gain possible, with an apparent ceiling of life expectancy in the high 70s. Whether this will change in the future with improving technology remains to be seen.
If we move on to examine the effects of national income on cancer, we see another interesting effect. As wealth increases, so does the risk of developing cancer. This is partly an effect of lengthening life expectancy – if you don’t starve or die young from infection, you have a much better chance of living to relative old age and getting cancer. Other factors are also at play: for example, once national income exceeds around $5,000 per person, cancer occurs at a rate of 250–400 cases per 100,000 people per year – see Figure 2.
However, there are a number of countries with income in this bracket but with a cancer rate of less than one-third of this rate, all in the Middle East. This has been attributed to widespread adherence to more traditional, less Westernized lifestyles despite rising national income. Conversely, there is a cluster of countries with Western-style high cancer rates but income of less than $5,000 per head. These turn out to be former Soviet bloc states that seem at first glance to have the worst of outcomes – Western diseases at developing world incomes. On closer inspection, however, the picture is less gloomy – the low income is real but the high cancer rates reflect long life expectancy due to well-organized healthcare systems. The recent discussions about the relative merits of ‘socialized medicine’, and in particular the NHS and the US system, highlight the need for dispassionate analysis. Whilst it is true that there are differences in some outcomes between the US and UK, overall life expectancy is very similar for all countries with well-developed healthcare systems – despite recent US Republican talk of NHS ‘death panels’, the truth is that Western healthcare is pretty good at keeping most of its citizens alive into old age.
Whilst all of this is true at the level of state funding when cancer therapy tends to hit the press is when access to a new therapy is denied someone, usually presented as a variant of the staple news story of ‘patient refused life-saving drug by faceless bureaucrat’. This is the origin of the Republican allegations about NHS death panels (in truth, of course, US patients with no healthcare will also be denied the same treatment by a different set of bureaucrats or perhaps their bank manager). Why do these stories occur in some of the wealthiest countries in the world? What are the likely future trends in funding and costs?