Survival rates are not the same as mortality rates – ctd.

A reader writes:

I’m curious what portion of the very real 2x spent on healthcare over most developed nations you think might be attributed to this technology-driven early-detection longer-maintenance phenomenon? Big percentage? Or small?

Aren’t there ethical boundaries that medical professionals consciously do not cross because they know if they detect a tumor (for instance) and there is no reasonable treatment for it, they really shouldn’t be pushing the screening? If so, the scenarios you share with us (on this topic) must be accompanied by “treatments” that actually derive some benefit for the patient. But if mortality rates aren’t changed that much, is the only benefit the ever-intangible “peace of mind?”

These are excellent questions.  I wish I could quote you a source or an actual number, but it’s not that easy.  I know good estimates of wasted money say we spend hundreds of billions of dollars more than expected on outpatient care alone.  It’s not small.

Moreover, the tragedy is that this is actual waste.  We could spend this money on things that really work.  Or save it.  But we spend a lot on things that don’t really do much good.

The ethics aren’t as simple as I wish, though.  You see, I work at the population level.  And at the population level, survival rates fail for the reasons I posted before.  But most doctors work at the patient level, and there, you need that statistic.  All a patient cares about when you’re in the room with them is “how long can I expect to live?”  To answer that, you need a survival rate.  You need to know how long from diagnosis the average person will live.  So most physicians understand survival rates and think they are the most important thing.  That’s not because they are unethical.  It’s just the world they live in.

But at a population level (where I live), you don’t want to use survival rates because they can’t be compared across systems for the reasons I described before.  They aren’t a measure of “quality”.  They are a measure of patient-level expectations.

As to the rest of your question, there can be benefits above cure.  Some people may derive satisfaction by “knowing” they have cancer.  Personally, I would only want to know if something could be done with that knowledge to better my outcomes.  Sometimes that is true; sometimes it is not.  Sometimes treatment causes harm, and if benefits aren’t clear, we shouldn’t be doing it.  See Avastin.

It is never as clear cut as we would like it to be as to whether we are diagnosing too early.  The most obvious example is the rush towards personalized genetic testing.  What to do with the knowledge that you have a propensity for a disease you may be able to do nothing about – and may never get – is an ethical issue many are struggling to solve.  But some people want to do it anyway.  It’s a personal decision, and one that likely we will need to leave to individuals.  This isn’t much different than what you bring up above.  If doctors and patients decide together to do earlier and earlier testing, I don’t think I should be able to tell them they can’t.

I can, however, say that it’s not very cost-effective.  I can say that maybe we shouldn’t have to pay for it when others want it.  And I can say that while it may increase survival rates, it isn’t necessarily improving mortality rates.

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