Commentary: Medicine: A Cold Look at the Cost of Saving Lives
By Catherine Arnst
How much is a year of life worth? This may seem like a question that should never be asked--and in the U.S., it rarely is. But as ever more expensive medical treatments and tests are introduced, our society will have to face this issue head on. "In the current health-care environment, ignoring cost is no longer tenable," says Dr. David Atkins, science adviser to the U.S. Preventive Services Task Force, a panel of medical experts.
A study in The Journal of the American Medical Association sheds light on one important area. Doctors from Johns Hopkins University School of Medicine analyzed the cost-effectiveness of a sophisticated lung cancer test called spiral computed tomography (CT) scanning. The conclusion: It may be more accurate than other options, but for society, it's not worth the very high price.
That same verdict might easily be applied to any number of new medical procedures. Ductal lavage, a test that analyzes breast cells to assess a woman's risk of developing breast cancer, can cost $700 and is a rough gauge at best; Gleevec, a new leukemia drug, costs $12,000 per year but does not cure the disease; and the Abiomed artificial heart, in tests for patients suffering end-stage heart failure, is expected to cost $100,000 for the device alone.
Spiral CT scans are at the nexus of the cost-benefit conundrum. The technology spirals low-dose X-rays around the body as a patient is transported through a metal tube. Studies have found that CT scans are vastly better than conventional X-rays at detecting tumors when they are small and easy to treat. But the scans also produce far more false-positive results, leading to many unnecessary biopsies. Plus, a CT scan costs about $500 vs. $50 for an X-ray.
Is it worth it? By one measure, yes. Using a computer model, the Johns Hopkins team estimated that if 100,000 current or former heavy smokers were scanned once a year, starting at age 60, there would be 553 fewer lung cancer deaths over 20 years--a 13% reduction. But there also would be 1,186 unnecessary biopsies because of false-positive readings. Add it all up, and the screening program would cost $116,300 per year of life saved for current smokers and $2.3 million per year for former smokers. The researchers concluded this was too high a price.
That may sound unfair to lung cancer patients. After all, the U.S. spends billions on screening for breast and prostate cancer even though there is no proven survival benefit for the two most widely used tests. And lung cancer kills more people each year than breast and prostate cancer combined.
But lung cancer summons considerations that complicate the equation. Because 90% of its victims are current or former smokers, they face far more health problems than the general public. "I'd hate to see an attitude develop that smokers deserve what they get," cautions Dr. Michael A. Grodin, director of medical ethics at Boston University. Yet there's no denying that smokers who survive lung cancer are at high risk of death from other tobacco-related diseases. And lung cancer, although it strikes 170,000 people annually in the U.S., doesn't use up many health-care dollars because some 80% of its victims die within a year or two of diagnosis. CT scans that help keep some of these patients alive would perform an enormous medical service, but the cost may not be tolerable.
So far, no medical body recommends routine lung scans, and most insurance plans won't cover them. As more patients pay for the scans on their own, however, pressure will mount on insurers to pick up the tab. That's the history of prostate and breast screening. Both tests are widely used--and covered--though the jury is still out on the benefits.
The National Cancer Institute hopes to avoid the same ad hoc adoption of CT scans. It's conducting a large clinical trial to determine if the test improves the chances for surviving lung cancer, but no conclusion will be reached for seven years. Doctors should urge patients who request a CT scan to enter the trial.
In the meantime, Washington must start debating just how the nation should spend its health-care dollars--because we truly cannot afford to duck this issue any longer.
Arnst covers science and medicine.