Comparative Health Policy and Outcomes of Breast Cancer Care in The United States versus Germany
Cancer is a collection of related diseases where some of the body’s cells begin to divide out of control and spread throughout the body. The normally orderly process of cell division becomes unchaperoned, meaning cells can divide and avoid death with nothing to stop them. Cancer can start anywhere in the body, but for the purposes of this paper, I will be focusing on cancer of the breast. This type of cancer normally begins as a lump in the breast tissue of men and women, and if not detected early, it can quickly spread to other tissues of the body (most commonly the lymph nodes).
You can lower your risk for breast cancer through a myriad of lifestyle factors, but while there is no set cure for cancer, breast cancer is a very treatable disease if caught early. Imaging such as X-rays, mammograms, and tomography are all ways to catch breast cancer, followed by treatment options such as radiation, chemotherapy, or the more drastic mastectomy. Specialists typically needed through the stages of screening, diagnostics, and treatment include gynecologists, imaging technicians, radiologists, oncologists, surgeons, and nurses.
Treatments for women with breast cancer vary depending on the stage they are diagnosed in, with higher survival rates the earlier the cancer is found (as well as some genetic factors that I consider too in-depth for this paper). At stage I, the cancer is still contained in the breast tissue and will normally be treated with breast-conserving surgery along with a check of the nearby lymph nodes, followed by some type of radiation therapy to lessen the chance of the cancer returning. At stage II, the cancer is normally larger than stage I and has spread to a few nearby lymph nodes. This stage will normally be treated with surgery and radiation therapy similar to stage I, but with the addition of chemotherapy. At stage III, the tumor is large and has begun spreading to lymph nodes and nearby tissues. The normal treatment at this stage can either be chemotherapy followed by surgery followed by radiation therapy, or surgery first followed by chemotherapy followed by radiation. Finally, at stage IV, the cancer has spread to various parts of the body and is normally treated with various systemic drug therapies along with surgery and radiation (1).
While the level of prevention, screening, and treatment varies slightly from country to country, so do the health care policies that dictate the responsibility of the patient versus the specialist versus the institution. In this paper, I will be discussing the health care organization differences between United States and Germany when it comes to preventing, screening, and treating breast cancer, as well as the associated outcomes when it comes to remission and mortality rates.
In the United States, breast cancer is the most common type of cancer, with over an estimated 266,000 new cases in 2018 so far (which constitutes over 15% of all new cancer cases), with a median age of diagnosis of 62 years of age. Breast cancer also accounts for almost 7% of all cancer deaths, with over 40,000 deaths reported in 2018 so far, with a median age of death of 68 years of age. It also has a 5-year survival rate of just under 90%. As shown in Figures 1 and 2, while breast cancer diagnoses are fairly consistent between non-Hispanic, white, and black women (followed by minority populations of Asian, Hispanic, and American Indian), black women are much more likely to die from the disease than all other races/ethnicities (2).
In 2014, the percentages of breast cancer diagnoses at each stage were roughly 66% localized (or stage I/II) and 33% regional/distant (or stage III/IV) with the remaining 1% being unstaged (3). The largest determinant of the stage at diagnosis is preventative measures such as routine screening. According to the American Cancer Society, for women with an average risk of breast cancer, it is currently recommended in the United States to have yearly mammogram screening starting at age 45 (with an option to begin at 40), and transition to biennial mammograms starting at age 55.
In the United States, cancer treatments and preventative measures have been affected most recently by the Affordable Care Act (ACA) enacted in 2010. Under the ACA, private insurance companies cannot limit how much they cover during the course of your lifetime. In the past, private insurers could cap their coverage, meaning the patient was responsible for all cancer treatment costs afterwards. Also, preventative screenings, such as mammograms every year or two for women over 40 are now fully covered, meaning the patient does not pay anything. For the actual cancer treatments after the initial diagnosis, out-of-pocket expenses will apply to the patient, but the amount of these expenses will vary depending on the type of insurance program the patient has (if any). The main types of insurance range from private (HMO and PPO), savings accounts (FSA and HSA), and government-sponsored (Medicare and Medicaid).
In terms of biases in the United States, the main three are access, cost, and education. A large part of preventative screening and treatment for breast cancer has to do with having a qualified location that people can get to. In rural, or sometimes even urban areas, these places are not easily accessible. The working hours of these qualified locations may also hinder a person from getting screening or treatment if the location is not open on evenings or weekends. The cost of care is also a large bias in this system. While screenings are now completely covered, most people do not realize that there is a timeline between screening and diagnosis. The mammogram might find an abnormality, but the next steps would include further imaging like ultrasound, as well as biopsies, to determine if the abnormality is cancer or not. These further tests are not covered under the “preventative screening” for insurance companies, and patients will have to pay out-of-pocket for whatever percentage their insurance doesn’t cover. In terms of education bias, there are many people who a) do not know how often they are supposed to be screened, and b) do not realize that screenings are free and/or the steps following are not fully covered.
Socioeconomic status also plays a role in United States cancer care. Wealthier people can afford the best health care plans in the country, meaning more of their costs of treatment will be covered before they have to pay out-of-pocket expenses. Those closer to the poverty line who may be on government-sponsored insurance will have to pay more out-of-pocket expenses to receive the same treatment. This may cause people to have an extremely large financial burden, or not receive treatment at all. One important aspect to note about the United States cancer system is that providers will give any type of treatment they deem necessary to each patient, regardless of cost, which aids to the United States’ healthcare costs increasing.
While racism between patient and provider might not have a large role in United States cancer care, race itself does play a role. As stated earlier, new cases being diagnosed between white and black women is fairly comparable. However, the death rate among black women with breast cancer is much higher. The main reason for this is that black women are far more likely to be diagnosed at a later, deadlier stage. A few factors that are behind this go along with the structural biases of access and socioeconomic status in regards to screening and treatment, but also their higher likelihood of having dense breast tissue, making it more difficult for providers to find the cancer even if they do get their recommended screenings.
Policy-making in terms of United States cancer care has become much more patient-centered in the recent years. There is much more collaboration between specialists when it comes to treatment, and patients have much more say in what treatment they receive. In 2010, the United States spent about $125 billion on cancer care, with breast cancer accounting for 13% of all direct medical spending on cancer (4). With medical treatments shifting from more volume-based to more value-based, the expense of the newest and best technologies used in cancer care also have to be taken into account. This means even more spending per person on treatment and drug costs. Many states have tried to at least pass laws to keep the cost of some life-saving cancer drugs under a certain price, to make them more accessible to all patients.
According to the American Institute for Cancer Research and the World Cancer Research Fund, breast cancer is the most commonly diagnosed cancer in women and the second most common cancer in general (5). There were over 2 million new cases in 2018. Outlined in Table 1 are the top 25 countries with the most prevalent rates for the diagnosis of breast cancer in 2018. The United States and Germany are quite similar in rates of new breast cancer cases.
In contrast to the U.S., the breast cancer screening program in Germany covers mammography screening (at no cost) for all women between the ages of 50 and 69, every two years (6). Although mammography does not provide any prevention for breast cancer, the objective is to detect the cancer at the smallest, earliest stage, providing for the best possible treatment and increasing the chances of survival. The costs are covered by statutory health insurers (i.e. single payer system).
If imaging results show abnormalities, additional imaging or other tests are then required to finalize a diagnosis. This additional imaging may include ultrasound scans or Magnetic Resonance Imaging of the breast, and are often enough to exclude a diagnosis of breast cancer. If such additional testing does not provide peace of mind, typically a biopsy of the breast tissue is required. Breast cancer screening in the German population, yields approximately 2 cancers per 1,000 women screened (Figure 3). This data refers to the actual outcomes of one mammogram. Female participants in Germany’s breast cancer screening program may receive a total of up to ten free mammograms throughout their lifetime. It’s possible that the woman could have abnormal results subsequent to any of their screening mammography tests. While breast cancer screening is paid for on this limited basis, treatment differs from the U.S. in that German patients do not have as much control in their treatment decisions. Similar to the U.S., about 5 out of 6 women who are diagnosed with breast cancer, have developed an invasive tumor. If left untreated, the invasive type of tumor often metastasizes to other areas/organs of the body. About 1 out of every 6 women diagnosed with breast cancer have diseased breast tissue referred to as a ductal carcinoma in situ (DCIS). The DCIS describes the abnormal cells that have developed in the milk ducts. This also means that the breast cancer cells have not spread beyond that area. In some patients, DCIS remains harmless while in others, it advances into an invasive tumor. Because no one can predict how or when the DCIS will remain intact or harmless, patients are usually advised to pursue recommended treatment (7).
When a diagnosis of breast cancer is finalized, treatment depends principally on the progression of the cancer. Most women are counseled to have the tumor surgically removed along with some of the surrounding tissue. Those with advanced stage or larger tumors, may be advised to proceed with removal of the whole breast (mastectomy). Following surgical excision, additional treatment options may include radiotherapy, hormone therapy and chemotherapy. The most appropriate treatment methodology, hinges on the exact diagnosis.
According to a German study of out-of-pocket-payments (OOPS) and the financial burden on German breast cancer patients, they often face payments related to their disease or treatment which are not covered by their health insurance. This study concluded that German cancer patients face relatively high OOPPs during their cancer journey. These payments may burden cancer patients, especially certain subgroups like low-income patients (8).
In Germany, OOPPs are used in the health care system mainly for three reasons. First, they provide some financial relief to the governmental health insurance system by having patients responsible to offset some of the cost. Secondly, they raise the efficiency of medical services by allocating them only to medically justifiable cases (as determined by panels of Medical Necessity experts). Finally, the third, OOPPs help to reduce the risk of “moral hazard” which occurs when individuals access health services without medical necessity, simply because they do not have to pay for the services directly.
Unfortunately, other studies have shown that OOPPs may cause inequities in the use of health care services by German breast cancer patients; the system of overburdening certain subgroups stems from preventing patients from using beneficial medical services or treatment because they simply cannot afford the expense. That same risk group may ultimately change their adherence to established treatment plans by rationing medications, choosing more radical treatments (i.e. mastectomy which would allow them to possibly skip radiation or chemotherapy), or skipping follow up examinations to reduce OOPPs.
Germany’s single payer system covers approximately 87% of the German population. While the balances of patients are covered under other private insurers, all are entitled to medical services under German control. Similar to U.S. health insurers, patients are responsible for health services or treatments that are not covered by insurance and deductibles. There are also other structural biases related to certain threshold caps for any coverage. Financial burdens not only affect patients on an economic basis, but may also influence the psychological well-being. The term “financial toxicity” has been used to describe this combination where patients are forced to opt towards the most economical decision rather than the best treatment decision.
Figure 4 takes a look at how spending on healthcare in the United States compares to other countries that are similarly large and wealthy, such as Germany (based on GDP and GDP per capita). In proportion to the size of its capital, the U.S. spends an unbalanced amount on health care.
As expected, wealthier countries typically spend more per person on health care and the associated costs than countries with lower incomes. However, the U.S. spends more on health care per person than other high income countries. Per person, health spending in the U.S. was over $10,000 in 2016 – 90% higher than Germany (and 31% higher than the next highest-spending country per capita, Switzerland). Typically, other high income countries spend around half as much on health per person than the U.S. does.
In recent years, health spending growth has slowed in the U.S. and Germany, related mainly due to value based practices taking importance over volume based practices. However, while the U.S. has similar public spending, its private sector spending is nearly 5 times that of Germany (Figure 5).
When asking to think of the “perfect balance” of policies between the United States and Germany, Markus Holzhauer, MD, a board certified diagnostic radiologist specializing in mammography working locally at Windsong Radiology Group and a dual citizen of the U.S. and Germany says “The easy answer in theory is the Solidarity Principle, which is the foundation of 90% of healthcare coverage for which the citizens in Germany receive. It only works with a mandate for health insurance coverage because it aims to fundamentally share both the advantages, i.e. prosperity, and the burdens equally and justly among members. When we talk about social solidarity in healthcare, we are talking about providing equity and social solidarity through pooling of risks and funds.”
The U.S. may not yet be ready to create one public health fund with adequate resources to plan for, and effectively meet, health needs of the entire population, not just for a selected few who can afford it…but the debate will continue.