The Freakonomics of Chemotherapy

In Super Freakonomics, Levitt and Dubner paint a bleak view of the value of chemotherapy. Is their view cynical and fatalistic? Or is it clear and realistic?

The authors acknowledge the effectiveness of chemotherapy in treating leukemia, lymphoma, Hodgkin's disease and testicular cancers, but they label it "remarkably ineffective" overall, citing the following statistics:
- Although the 5-year survival rate for all cancer patients has been shown to be 63 percent, barely 2 percent of survival is attributable to chemotherapy. For multiple myeloma, soft-tissue sarcoma, melanoma of the skin and cancers of the pancreas, uterus, prostate, bladder and kidney, chemotherapy had zero discernible effect.

- A typical chemotherapy regime for non-small-cell lung cancer, which kills more than 150,000 Americans each year, costs $40,000, but only extends life by an average of 2 months.

- Cancer patients make up 20 percent of Medicare patients, but consume 40 percent of the Medicare drug budget.

- More than $40 billion is spent each year worldwide on cancer drugs.
If chemotherapy is so ineffective, why is it so widely prescribed? According to the authors, major reasons include:

- a natural response to financial incentives (Oncologists typically derive more than half their income from selling and administering chemotherapy drugs.)

- an attempt to inflate survival rates (A few extra months of life, expressed as a percentage, can look quite impressive.)

- an over-belief in the efficacy of chemotherapy

- a promise of hope for recovery or extending life

The observations made in Super Freakonomics cast light on some of the struggles inherent in reforming America's health system. Even if chemotherapy can be proven to be ineffective, its use is unlikely to be curtailed greatly.
The government will find it difficult to impose limits on constituents that put a "death squad" label on panels that evaluate efficacy and allocate resources.

Manufacturers of chemotherapeutic agents will not simply abandon incentives that promote chemotherapy. Their lobbyists will lean hard on legislators.

Oncologists want to save lives. Patients are willing to endure chemotherapy's toxic rage to overcome cancer. Families cling to it in desperation. And we all know cancer survivors who attribute their priceless second lease on life to their treatment regimen. Chemotherapy is hope.

With the advent of companion diagnostics, chemotherapy may one day be as effective as we hope and believe it should be. Oncologists would be able to match individual patients with the chemotherapy drug(s), dose and timing that works best for their specific biological makeup. They would also avoid chemotherapy when it would have little or no effect.

In the meantime, as I look at chemotherapy—and healthcare in general—in economic terms, it reminds me of a saying that is attributed to John Wanamaker. (Revisions are mine.)

"Half the money I spend on [healthcare] is wasted; the trouble is I don't know which half."

— Tom DeSanto

Source: Super Freakonomics, Steven D. Levitt and Stephen J. Dubner, HarperCollins 2009, pp. 84-86. Image: www.canceractive.com