I had prostate cancer, 5, 6 years ago. My chance of surviving prostate cancer—and thank God, I was cured of it—in the United States? Eighty-two percent. My chance of surviving prostate cancer in England? Only 44 percent under socialized medicine.Rudolph Giuliani
During the last presidential primaries for the republican party, Rudolph Giuliani, former NYC mayor and prostate cancer survivor, compared the chances of surviving prostate cancer in the US and Europe. The end, obviously, was to criticize the socialized medicine of European countries that was defended by the White House candidate Barack Obama.
The data is quite breath-taking. An American has twice as many chances of surviving prostate cancer than a European does, right? Clearly, Giuliani is not a good epidemiology aficionado. The former NYC mayor used data from the year 2000 that compared the survival rates at 5 years between English and American patients. What he did not know, was the fact that this survival rate is quite useless when you compare two countries where prostate cancer is very differently diagnosed. In the US, PSA screening is common practice, while as in European health services it is not so common (with the permission of urologists...). This screening sets a bias in two senses: a) advances the age of diagnosis (lead-time bias) b) introduces among the diagnosed group patients with non-progressive cancer that will probably die of something else (overdiagnosis bias). Put in other words, the patients in the English group are quite older (they were not detected until they showed symptoms) and their cancers were 'worse' (because all non-progressive cancers, since they are not symptomatic , never get to be detected) .
The data is quite breath-taking. An American has twice as many chances of surviving prostate cancer than a European does, right? Clearly, Giuliani is not a good epidemiology aficionado. The former NYC mayor used data from the year 2000 that compared the survival rates at 5 years between English and American patients. What he did not know, was the fact that this survival rate is quite useless when you compare two countries where prostate cancer is very differently diagnosed. In the US, PSA screening is common practice, while as in European health services it is not so common (with the permission of urologists...). This screening sets a bias in two senses: a) advances the age of diagnosis (lead-time bias) b) introduces among the diagnosed group patients with non-progressive cancer that will probably die of something else (overdiagnosis bias). Put in other words, the patients in the English group are quite older (they were not detected until they showed symptoms) and their cancers were 'worse' (because all non-progressive cancers, since they are not symptomatic , never get to be detected) .
Lead-time bias
Overdiagnosis bias
To sum up, te survival rate at 5 years in both groups is clearly different, but mortality is quite similar. For future campaigns, Mr. Giuliani or someone in his staff should read the excellent article by Gerd Gigerenzer of the Max Planck Institute in Berlin 'Helping Doctors and Patients Make Sense of Health Statistics'. A must, for all those who -willingly or not- deceive everyday our patients and for those who do not want to be deceived.
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