In his February speech to Congress, President Obama vowed that his administration would seek a cure for cancer, renewing President Nixon’s declaration of war on cancer almost four decades ago. Over these decades, have we won any battles? And if so, how?
Yes, we have won some battles, mostly since the early ’90s. The U.S. cancer mortality rate has fallen 14 percent since 1992. The mortality rate in Maine, though higher than the national average, also has fallen 14 percent.
Since Nixon declared the War on Cancer, spending on cancer research has risen fivefold, after correcting for inflation. And spending on cancer treatment — surgery, radiation and chemotherapy — has also risen fivefold, to $75 billion a year.
Should we connect the obvious dots and say that these huge spending increases provided exactly the weapons we most needed to fight cancer?
Not on your life. To the contrary, a close look at the facts shows that the most effective anti-cancer weapons often are the least expensive.
David Cutler, a Harvard economist who looked closely at the facts, found that cancer screening is our most effective weapon. The three screens with the biggest benefits are mammograms for breast cancer; colonoscopy for colorectal cancers; and the PSA test for prostate cancer, though the effectiveness of PSA testing is still controversial. Cutler concluded that these three screens account for 35 percent of the total decline in cancer mortality.
Screening is so effective because early detection is critical: If a cancer is discovered after spreading beyond its initial site — such as the breast in the case of breast cancer — it is difficult or impossible to cure. If a cancer is discovered early, before it spreads, then treatment can be targeted precisely at the initial site and is likely to be more effective and relatively cheap.
The second-most effective weapon, Cutler found, is changes in behavior, especially smoking reduction. Since 1965, the proportion of adults who smoke regularly has fallen by half, leading to fewer new cases of lung cancer. Reduced smoking, Cutler concluded, accounts for 23 percent of the reduction in cancer mortality.
These weapons, screening and changes in behavior, are not very costly. Most of the new screening tests are relatively cheap and efforts to reduce smoking — public health messages and regulation of tobacco company advertisements — have not been expensive.
Treatment by contrast is relatively ineffective and very costly, according to Cutler. Improvements in surgery, radiation, and chemotherapy have indeed contributed to survival, but treatment usually adds months rather than years to patients’ lives. Treatment improvements for three major cancer types reduced mortality by only 20 percent.
Because treatment yields small additions to life expectancy, yet is costly, treatment that extends life by one year is costly. Cutler estimated that the treatment needed to add a year to average life expectancy costs $140,000 for colorectal and breast cancer and $400,000 for prostate cancer. Lung cancer treatment, though costly, does not improve survival chances at all.
Still, Cutler’s conclusions about treatment are uncertain, as he himself admitted. And obviously treatment sometimes does add many years to a patient’s life — though often because screening caught the cancer early.
Further, Columbia University economist Frank Lichtenberg found that drug therapy is very effective. According to Lichtenberg, new drugs have added a full year to cancer patients’ life expectancy and these drugs usually cost less than $3,000 over a lifetime.
Yet, despite their differences, Cutler and Lichtenberg both found that the most effective anti-cancer weapons have low costs.
President Obama seems to agree. In his February speech, he said that preventive care deserves special emphasis, because it is “one of the best ways to keep our people healthy and our costs under control.”
These findings about cancer should help shape our policies toward other social problems. A careful look beneath the surface may show that big spending to solve big problems is often ineffective. We should examine carefully all the weapons in our arsenal, to discover whether some inexpensive ones are the most effective.
Goliath’s huge spear was indeed the biggest weapon on the battlefield, but he was felled by a boy with a slingshot and five stones. Goliath should have looked for inexpensive weapons.
Edwin Dean, an economist and seasonal resident of Vinalhaven, writes monthly about economic issues.