The results of this study, plus the coverage gaps still in existence among those states that have declined to expand Medicaid under the ACA, raise the question of whether mortality due to treatable cancer in the United States is higher than it could otherwise be.— Kenneth L. Kehl, MD
The global economic crisis beginning in 2008 was associated with substantial public health effects, especially with respect to mental health.1–3 Nevertheless, there is also evidence of a paradoxical association between recessions and reduced all-cause mortality, in part because of reductions in motor-vehicle accidents, cardiovascular deaths, and morbidity related to chronic liver disease.4–6 The impact of economic downturns on patients with cancer, therefore, is an important question for epidemiologists, policymakers, and oncologists.
As reviewed in this issue of The ASCO Post, Maruthappu et al conducted an ecologic study to assess the impact of the recent crisis on cancer mortality among middle- and high-income countries.7 They found that rising unemployment was associated with durably increased all-cancer mortality, but this association was stronger for those cancers deemed “treatable” (breast, prostate, and colorectal cancers) than for those deemed “untreatable” (lung and pancreatic cancers). Controlling for universal health coverage eliminated these associations. They also found that the economic crisis was associated with more than 250,000 excess cancer deaths, concentrated among treatable cancers and countries without universal health care. Furthermore, increasing public expenditure on health was associated with decreased cancer mortality, specifically among treatable cancers.
Although the authors could not eliminate the possibility of residual confounding in this observational study, their findings reinforce the potential negative impact of economic upheaval on patients with cancer, particularly when access to health care depends on employment. The estimated excess in cancer mortality, although relatively small as a percentage of the population in the developed countries in this analysis, would rank on the same order of magnitude as some of the most severe recent natural disasters.8 This analysis was also restricted to relatively developed countries with reliable mortality data; therefore, it is likely the estimate would have been even higher if it additionally included less-developed economies.
The classification of cancer histologies in this analysis into treatable and untreatable tumor types also serves as a stark reminder of the benefits, as well as the limitations, of well-organized cancer-care delivery systems. Improvements in health-care delivery are likely to be most impactful in the context of diseases for which highly effective prevention and treatment strategies exist, whereas clinical research remains among the most urgent needs of patients with “untreatable” cancer.
Important Questions Raised
The association between public expenditures on health and reduced cancer mortality raises important questions, especially in light of the increasing concern within developed nations about the cost of health care in general and cancer care in particular.9,10 It is tempting to attribute this finding to an association between public expenditures and the presence of universal health care, but in this study, the authors identified an association that did not depend on the existence of such a system. This relationship between increased cancer-care spending and improved outcomes has also been reported previously11; for a cancer-care system to be sustainable in a societal context, it therefore remains important to identify which expenditures are of highest value in improving patient outcomes.
Relevance to U.S. Health-Care System
The findings of this study are directly relevant to the health-care system of the United States. Although health insurance rates have improved substantially following the Affordable Care Act (ACA),12,13 millions of people remain uninsured14; indeed, the United States was classified in this study as one of the nations without universal health coverage.
The results of this study, plus the coverage gaps still in existence among those states that have declined to expand Medicaid under the ACA, raise the question of whether mortality due to treatable cancer in the United States is higher than it could otherwise be. Studies of the impact of Medicaid coverage, including the Oregon Medicaid experiment, have identified increased utilization of health care, including cancer screening and other preventive care, among newly insured patients15; however, there have been limited effects on hard outcomes, such as cardiovascular disease.16 Additionally, in studies using the National Cancer Data Base, outcomes for patients with Medicaid have been similar to those for uninsured patients.17–20 Therefore, the impact of health reform in the United States on clinical outcomes for patients with cancer remains an important research question. ■
Disclosure: Dr. Kehl reported no potential conflicts of interest.
1. Clair A, Reeves A, Loopstra R, et al: The impact of the housing crisis on self-reported health in Europe: Multilevel longitudinal modelling of 27 EU countries. Eur J Public Health. May 23, 2016 (early release online).
7. Maruthappu M, Watkins J, Noor AM, et al: Economic downturns, universal health coverage, and cancer mortality in high-income and middle-income countries, 1990–2010: A longitudinal analysis. Lancet. May 25, 2016 (early release online).
17. Fedewa SA, Etzioni R, Flanders WD, et al: Association of insurance and race/ethnicity with disease severity among men diagnosed with prostate cancer, National Cancer Data Base 2004–2006. Cancer Epidemiol Biomarkers Prev 19:2437-2444, 2010.
Unemployment increases are associated with rises in cancer mortality; universal health coverage seems to protect against this effect.— Mahiben Maruthappu, MA, and colleagues
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