QALYs are Back

Despite the ACA not allowing the use of QALY as measures in the delivery of Health Care the academics are flooding the airwaves. In a recent Health Affairs paper by some Dartmouth folks they state:

Compared to Western Europe, for three of the four costliest US cancers—breast, colorectal, and prostate—there were approximately 67,000, 265,000, and 60,000 averted US deaths, respectively, and for lung cancer there were roughly 1,120,000 excess deaths in the study period. The ratio of incremental cost to quality-adjusted life-years saved equaled $402,000 for breast cancer, $110,000 for colorectal cancer, and $1,979,000 for prostate cancer—amounts that exceed most accepted thresholds for cost-effective medical care. The United States lost quality-adjusted life-years despite additional spending for lung cancer: −$19,000 per quality-adjusted life-year saved. Our results suggest that cancer care in the United States may provide less value than corresponding cancer care in Western Europe for many leading cancers. 

I suspect that this is a  move to again eliminate PSA testing and allowing those with prostate cancer just to wait until it mets.

In a recent OncLive piece Dr Benson at Columbia is quoted as follows:

Active surveillance is increasingly employed in men diagnosed with low-risk prostate cancer despite a lack of high-level clinical trial evidence supporting this approach, and physicians should engage in careful patient selection before recommending the strategy, according to Mitchell C. Benson, MD. That note of caution was among the key points that Benson stressed during a presentation on localized prostate cancer that he delivered at the 8th Annual Interdisciplinary Prostate Cancer Congress in New York City.

 The piece further states:

Benson said genetic analysis of the “true biologic behavior” of prostate cancer would eventually help clarify which patients should appropriately be recommended for active surveillance. Gene signature tests that assess risk can be used to help support decisions, he added. As it stands now, Benson said clinicians could improve patient selection by augmenting the standard evaluation through more extensive biopsies. He said a single transrectal ultrasonography should not be used to select patients for active surveillance. “Saturation biopsy improves risk stratification,” he said, adding that he performs an immediate confirmatory biopsy at presentation. Benson and colleagues conducted a study of confirmatory biopsies in 60 patients with low-grade prostate cancer and found that 31.7% (19 patients) would not be candidates for active surveillance based on the results

In MedPage the authors note about the Dartmouth study:

"We are experiencing declines in mortality from cancer in the U.S.," Soneji says. "But those declines are coming at the same pace as in Europe, which is spending a lot less money. Screening, prevention, and treatment have extended life, but that's coming at a much higher cost [in the U.S.] than in Europe." Soneji's paper is at odds with findings in the 2013 Economic Report of the President, which says that the U.S. has realized greater gains in breast and prostate cancer survival compared with Europe, and generated $600 billion in value. That study, Soneji says, does not account for stage of cancer at diagnosis, making conclusions vulnerable to "well-known biases with diagnosis and screening that inflate survival time." That's because in more recent years, cancers are being diagnosed earlier, without corresponding changes in actual dates of death. In other words, he says, it just means people are finding out they have cancer earlier.

One must be very cautious regarding the QALY approach. We have written extensively about this in the past and demonstrated its dangers. Further, we must also pay attention to clinical data, especially from the likes of Benson and others since it deals with facts, not just figures.