International Differences in Mortality at Older Ages Dimensions and Sources (2010) / Chapter Skim
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9 Low Life Expectancy in the United States: Is the Health Care System at Fault?--Samuel H. Preston and Jessica Ho
9 Low Life Expectancy in the United States: Is the Health Care System at Fault?--Samuel H. Preston and Jessica Ho
Pages 259-298
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Life expectancy at age 50 in the United States ranked 29th highest in the world in 2006 according to the World Health Organization (2009)
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men and women in life expectancy at age 50 among 21 countries of the Organisation for Economic Co-operation and Development (OECD) would improve sharply (Preston, Glei, and Wilmoth, Chapter 4, in this volume)
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In particular, in the second half of the chapter we investigate comparative mortality trends for prostate cancer and breast cancer. We document that: • effective methods of screening for these diseases have been developed relatively recently; • these diagnostic methods have been deployed earlier and more widely in the United States than in most comparison countries; • effective methods are being used to treat these diseases; and • the United States has had a significantly faster decline in mortality from these diseases than comparison countries.
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International comparisons of cancer survival rates show a distinct advantage for the United States. Using cancer registry data, researchers from the Eurocare Working Group compare 5-year survival rates for cancers of 12 sites that were diagnosed between 1985 and 1989 (Gatta et al., 2000)
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An updated analysis reached similar conclusions. Based on period survival data for 2000-2002 from 47 European cancer registries, 5-year survival rates were found to be higher in the United States than in a European composite for cancer at all major sites (Verdecchia et al., 2007)
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Such a pattern would not be observed if lead-time bias were the only factor at work, that is, if early detection conferred no advantage. INTERNATIONAL STUDIES OF CARDIOVASCULAR DISEASE In contrast to cancer, nations do not have registries for heart disease and stroke.
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They calculate in-hospital 7-day and 30-day survival rates for patients newly admitted with ischemic stroke. For both men and women ages 65-74, the U.S.
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Survival rates following a heart attack are somewhat above average in the United States, whereas survival rates following a stroke are comparable to those of comparison countries. The evidentiary basis for international comparisons of the treatment of cardiovascular diseases is much weaker than in the case of cancer.
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In view of the studies that show that the United States does relatively well in treating cardiovascular disease, it seems inaccurate to attribute its high death rates from these causes to a poorly performing medical system. And these diseases contribute a majority of their set of amenable deaths, rendering the totality of amenable causes problematic.
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80 60 40 20 0 R C E A LD AN EU P BR E T SA S N N A AU H FR ES O SW R AU IT JP FI N U D C C G G N FIGURE 9-2 Age-standardized death rates at ages 50+ from pneumonia, 2000-2004. NOTE: AUS = Australia, AUT = Fig9-2.eps = Canada, CHE = Switzerland, Austria, CAN DEU = Germany, ESP = Spain, FIN = Finland, fill = France, GBR = Great Britain, patterned FRA GRC = Greece, ITA = Italy, JPN = Japan, NLD = the Netherlands, NOR = Norway, SWE = Sweden, USA = United States.
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As noted earlier, disease prevalence is higher in the United States than in a European composite for cancer, heart disease, stroke, chronic lung disease, and diabetes (Thorpe et al., 2007a)
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. CASE STUDY I: PROSTATE CANCER Accounting for 31,000 deaths in 2000, prostate cancer was, after lung cancer, the second leading cause of cancer deaths among U.S.
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. However, the American Cancer Society and the American Urological Association recommend that the PSA test should be offered annually to men over age 50 with at least a 10-year life expectancy.
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aOf the two sources of U.S. data presented in Table 9-2, the data from the Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System are less reliable because they are based on a telephone survey with a low response rate.
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Half were invited for biennial PSA testing, with 10,000 men serving as passive controls for whom diagnosis of metastatic prostate cancer was monitored by using the Swedish Cancer Registry. The risk of being diagnosed with metastatic (i.e., advanced)
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. In summary, radical prostatectomy was found to reduce prostate cancer mortality and risk of metastases, although no further increase in benefit was observed 10+ years after surgery.
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conducted a systematic review of studies published between 1986 and 2006 on hormone therapy for nonmetastatic prostate cancer. They extracted survival probabilities for men with localized or locally advanced prostate cancer receiving immediate hormone therapy as adjunct to radiation therapy, adjunct to radical prostatectomy, or stand-alone therapy.
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The 5-year relative survival rates in the United States increased from 71 to 83 percent between 1984-1986 and 1987-1989, whereas European rates improved from 55 to 59 percent during the same period (Post et al., 1998)
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Prostate Cancer Mortality Population-level data on mortality have one distinct advantage over data on survival rates among those newly diagnosed: they are not subject to lead-time bias. If one country is diagnosing cancer sooner than another but early diagnosis does not alter the clinical course of the disease and delay or prevent death, then that country will enjoy no advantage in mortality as a result of its earlier diagnoses.
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mortality and incidence of advanced-stage prostate cancer concluded that two-thirds of the decline in mortality between 1990 and 1999, and 80 percent of the decline in distant-stage incidence, was attributable to expanded PSA testing (Etzioni et al., 2008)
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LOW LIFE EXPECTANCY IN THE UNITED STATES TABLE 9-3 Coefficients of Negative Binomial Regression Predicting the Log of the Number of Deaths from Prostate and Breast Cancer Coefficient (standard error) Variable Prostate Cancer Breast Cancer Constant –10.37*
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. In contrast to prostate cancer, there are important behavioral risk factors for breast cancer.
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. The IARC concluded that there is sufficient evidence from randomized trials that offering of mammography to a treatment group reduces breast cancer mortality in women ages 50-69, by an average of 25 percent.
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Breast Cancer Treatment In OECD countries, the large majority of cases of breast cancer are treated surgically. Surgery is often supplemented with some combination of radiotherapy, hormone therapy, and chemotherapy (i.e., adjuvant therapy)
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. After 20 years of follow-up in a randomized trial, Fisher et al.
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The Early Breast Cancer Trialists' Collaborative Group summarized the results of 55 randomized controlled trials involving more than 37,000 women. Compared with a placebo, adjuvant tamoxifen resulted in annual reductions of 26 percent in recurrence and 14 percent in death.
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Variations in stage and type of tumor, age of patient, type of surgery, and other factors make it impossible to reliably compare the few national or regional data that exist. Breast Cancer Survival Several studies have compared international survival rates from breast cancer.
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(2002) found that European breast cancer patients diagnosed in 1985-1989 had significantly lower 5-year relative survival rates than American patients (73 versus 82 percent)
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. We hypothesize that the United States has had a faster decline in breast cancer mortality than the comparison countries because it took better advantage of technological advances in screening and treatment.
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20.0 18.0 16.0 14.0 12.0 10.0 00 04 02 0 6 0 4 6 8 8 94 92 2 8 8 8 8 8 9 9 9 20 20 20 19 19 19 19 19 19 19 19 19 19 Year FIGURE 9-4 Age-standardized death rates from breast cancer, 1980-2005.
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. Thus, the United States has experienced a significantly faster decline in breast cancer mortality than comparison countries.
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. Survival in men with nonmetastatic prostate cancer treated with hormone therapy: A quantitative systematic review.
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breast cancer mortality: A Bayesian approach. Journal of the National Cancer Institute Monograph, , 30-36.
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breast cancer incidence, survival, and mortality rates. Journal of the National Cancer Institute, , 1571-1579.
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. Effects of radiotherapy and sur gery in early breast cancer: An overview of the randomized trials.
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. Breast cancer screening: A summary of the evidence for the U.S.
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. Monitoring the decrease in breast cancer mortality in Europe.
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. Adjuvant radiotherapy and chemotherapy in node-positive premenopausal women with breast cancer.
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. The full potential of breast cancer screening use to reduce mortality has not yet been realized in the United States.
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. Prevalence of self-reported screening mammography and impact on breast cancer mortality in Austria.
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