The Economics of Improved Cancer Survival Rates: Better Outcomes, Higher Costs

Carin A Uyl-de Groot; Saskia de Groot; Adri Steenhoek

Disclosures

Expert Rev Pharmacoeconomics Outcomes Res. 2010;10(3):283-292. 

In This Article

Cancer Incidences & Deaths

The average cancer incidence rate for both 19 EU countries and for The Netherlands is shown in Figure 1. The European incidence numbers were not available for each year, therefore, only the available numbers are depicted. All rates are expressed as cases per 100,000 individuals in order to make the results comparable. Rates have been standardized according to the world standard population (1960) in order to reflect the average age structure of the world's population. In The Netherlands, the number of new cancer cases increased by 17% from 1989 to 2007, from 262 to 306 new cancer cases per 100,000 individuals per year. The incidence of cancer in The Netherlands is slightly higher compared with the average in the EU according to data from the Dutch cancer registry and the OECD Health Data.[103,104]

Figure 1.

Incidence and deaths per 100,000 population.
Data from [103,104].

The number of deaths per 100,000 individuals from cancer, both for 19 EU countries and for The Netherlands is also shown in Figure 1. Age-standardized death rates per 100,000 individuals are calculated using the total OECD population for 1980 as the reference population. A downward trend in cancer mortality is visible from 1989 to 2007: in 1989, 195 (209 in The Netherlands) per 100,000 individuals died from cancer in the EU. In 2007, 164 (176 in The Netherlands) per 100,000 people died from cancer in the EU. Thus, over the course of 18 years, an upward trend in the incidence of cancer alongside a 16% decrease in cancer mortality rates can be observed.

Trends in cancer mortality for the EU and The Netherlands are quite comparable (Figure 1). Therefore, The Netherlands can be used as a representative example to show the number of cancer deaths since 1960 (Figure 2). In addition, some major breakthroughs in the treatment of cancer are included in Figure 2 and the year the particular treatment became available in The Netherlands is marked. During the 1960s, an increase in cancer mortality is visible. This increase in total cancer mortality has mainly been caused by the simultaneous increase in lung cancer mortality. Smoking was one of the major drivers of this trend. From the late 1960s until the late 1980s, the mortality rate is relatively constant. A decreasing pattern starts around the late 1980s and early 1990s. From the 1990s, several breakthroughs seem to have had an impact on the cancer mortality rates.

Figure 2.

Malignant neoplasms, deaths per 100,000 in the Dutch population (standardized rates) and new drugs in the treatment of cancer.
Reproduced from [103].

Thus, regardless of the increase in cancer incidence, the probability of surviving cancer has also increased. As a consequence, cancer prevalence has risen. In the following section, three types of cancer will be described in more detail: breast cancer, colorectal cancer and lung cancer.

Breast Cancer

Breast cancer is the most common type of cancer in both Europe and The Netherlands. The 5-year relative survival of breast cancer has increased during the last decades: in The Netherlands, the 5-year survival increased from 80.0% during 1997–2002 to 85.2% during 2002–2007. The survival rates during 2002–2007 were the lowest in Poland (61.6%) and the Czech Republic (75.4%), while they were 90.5% in the USA during these years.[105]

The number of breast cancer deaths per 100,000 females in the EU and The Netherlands are shown in Figure 3. The line related to the Dutch population is relatively constant from the late 1960s until the early 1990s but from 1990 onwards, a decreasing pattern is visible. This pattern is accompanied by an increase in the incidence of breast cancer: in 1989, the incidence of breast cancer was 71.4 per 100,000 females in The Netherlands, but in 2006, the incidence was equal to 93.7 per 100,000 females.[104]

Figure 3.

Breast cancer deaths per 100,000 females in the European Union (19) and The Netherlands in 1960–2007.
Reproduced from [103].

In 2006, the average number of breast cancer deaths per 100,000 females in the EU was 23.1 compared with 27.1 deaths in The Netherlands. Data on the number of deaths in the EU were only available for 13 countries. Only Denmark had higher rates than The Netherlands (28.6 breast cancer deaths per 100,000).[103] However, interpretations should only be made with caution. An explanation could be the high incidence of breast cancer in The Netherlands. Data of 19 EU countries on the incidence of breast cancer were available for 2002. Per 100,000 females, 72.6 new breast cancer cases were diagnosed in the EU compared with 86.7 new cases in The Netherlands.[103] Thus, the incidence of breast cancer is much higher in The Netherlands compared with the other EU countries. The incidence of breast cancer appears to increase continuously in most countries. This trend is mainly influenced by the presence of population-based screening and is due to aging.

Several countries introduced population-based screening in the late 1980s and early 1990s after promising results of several randomized clinical trials. These trials showed mortality reductions of 20–35% among women aged 50–69 years.[4] Since 1989, population-based screening has gradually been implemented in women aged between 50 and 75 years in The Netherlands. The screening has resulted in an increase in the detection of small tumors and metastases have become less common. Compared with the rates in 1986–1988, breast cancer mortality rates in women aged 55–74 years fell significantly in 1997 and subsequent years.[7] Otto et al. suspected that the decline in mortality rates was mainly caused by population-based screening. However, developments in treatment strategies have contributed to improved survival rates as well (e.g., the introduction of taxoids in 1993 and trastuzumab in 1998). One randomized clinical trial showed that the addition of trastuzumab to standard chemotherapy resulted in a significantly lower rate of death after 1 year (22% compared with 33% in the group given chemotherapy alone) in metastatic breast cancer.[8] Trastuzumab is also administered for patients with nonmetastatic breast cancer in The Netherlands and consequently, those patients will have fewer relapses. However, the effect of trastuzumab only holds true for the subpopulation of women with HER2-positive tumors ~30%).

It would be interesting to relate the decreasing number of deaths in the last few decades to specific breakthroughs in diagnosis and treatment. However, during these years, many developments in the field of diagnosis, surgery, radiotherapy and pharmacotherapy have been made. Moreover, these new interventions are often used together. Therefore, it would be difficult to assign this improvement to just one intervention. The improvement in mortality rates is most likely a result of overall better disease management.

Colorectal Cancer

Colorectal cancer is the second most common cancer. The age-standardized 5-year survival rate for Dutch colorectal cancer patients was 56.9% during 1997–2002 compared with a relative survival rate of 58.1% during 2002–2007. The survival rates were the lowest in the Czech Republic and the UK: 46.8% and 51.6%, respectively. In the USA, the relative 5-year survival rate was 65.5% during 2002–2007.[105]

The numbers of deaths caused by a malignant neoplasm of the colon, rectum, rectosigmoid junction or anus are shown in Figure 4. Despite an increase in the incidence of colorectal cancer, a decreasing pattern in the number of deaths is visible, similar to the trend in breast cancer. In 2006, the average number of colorectal cancer deaths per 100,000 individuals in the EU was 19.0 compared with 20.8 in The Netherlands, whereas the average number of deaths was equal to 25.9 deaths in The Netherlands in 1960. The decrease in mortality started as early as the 1970s, long before the introduction of new drugs for the treatment of colorectal cancer.

Figure 4.

Colorectal cancer deaths per 100,000 population in the EU (19) and The Netherlands in 1960–2007.
Reproduced from [103].

The incidence for colorectal cancer in The Netherlands is slightly higher compared with the average in the EU. In 2002, there were 33.6 newly diagnosed individuals with colorectal cancer per 100,000 people in the EU compared with an average of 35.9 in The Netherlands.[103]

Improvements in colorectal cancer outcomes are largely due to advancements in systemic therapy. Progress in surgical management might also explain the decreasing mortality rates. The effects of the introduction of new drugs for the treatment of inflammable bowel disease (Crohn's disease) or changes towards a more fiber-rich diet are not known, but could also have contributed to the decreasing mortality rates. Since 1996, three new cytotoxic drugs (irinotecan, oxaliplatin and capecitabine) and three new monoclonal antibodies (cetuximab, bevacizumab and panitumumab) have been approved for the treatment of colorectal cancer.[9] Before this year, 5-fluorouracil was the only US FDA-approved anticancer drug.[9] The new drugs offer potential benefits but they also bring potential toxicities, for example, neuropathy (a side effect of oxaliplatin), rash (caused by cetuximab) and bleeding (observed with bevacizumab).

In contrast to breast cancer, a population-based screening program for colorectal cancer does not exist in The Netherlands. In several European countries (e.g., Finland, France, Italy and the UK) a screening service has recently been piloted and launched.[4]

Lung Cancer

Lung cancer incidence and mortality rates were among the highest in the world among all cancers but smoking cessation has resulted in record falls, particularly among men. Both in Europe and in The Netherlands, lung cancer was ranked as the third most common cancer in 2006. More cases of lung cancer are diagnosed in men, but the number of women being diagnosed with lung cancer has increased. Lung cancer was responsible for most of the cancer deaths in 2006. The number of lung cancer deaths per 100,000 females and males in the EU and The Netherlands are shown in Figure 5. These numbers include deaths from malignant neoplasms of the trachea, bronchus or lung. The mortality rates for both sexes are shown as they follow different patterns, which was not the case for colorectal cancer. From the early 1980s, the mortality rates for men have been decreasing in both the EU and The Netherlands, whereas the number of female deaths is increasing.

Figure 5.

Lung cancer deaths per 100,000 females and males in the EU (19) and The Netherlands in 1960–2007.
Reproduced from [103].

Trends in lung cancer mortality are closely related to the incidence of lung cancer since many lung cancer patients die from the disease. Simultaneously, the incidence of lung cancer is closely connected to risk factors for the disease, such as smoking.[10] Smoking prevalence has been decreasing in Western countries during recent decades, but these rates dropped faster in men than women.[11] This could explain why mortality rates have been falling in men, but not in women.

The two most common types of lung cancer are non-small-cell lung cancer (~85% of all lung cancer cases) and small-cell lung cancer (~15%). Despite advances in early detection and standard treatment, non-small-cell lung cancer is often diagnosed at an advanced stage and has a poor prognosis. Because of these factors, it has one of the lowest survival outcomes of all cancers.

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