Movember vs Pink Ribbon Day, and why it’s not so simple.

Cancer, as a whole, is a reasonably well-funded area of medical research in Western countries. If you are planning on a career in medical research in the West and are concerned about funding prospects, along with neurosciences and cardiovascular diseases, it is a clear winner. I’m going to use American statistics, since the NIH’s published data is far more manageable than the NHMRC’s for this purpose. The five leading medical causes of death in America in 2011, in order, were:

Heart disease: 599,413
Cancers: 567,68
Chronic lower respiratory diseases: 137,353 deaths
Stroke: 128,842
Alzheimer’s Disease: 79,003

The NIH is kind enough to publically report on its research funding by health area each year. Again in 2011, those broad categories received the following amount of funding:

Cancer: $5,448,000,000
Heart disease: $2,049,000,000
Alzheimer’s Disease: $448,000,000
Chronic lower respiratory disease*: $329,000,000
Stroke: $317,000,000

Stroke and Chronic Lower Respiratory Diseases cause around the same number of deaths, and receive a very similar amount of funding. However, in spite of heart disease causing the same number of deaths as cancer, cancer received over two and a half times as much funding. The same funding disparities are seen a level down, between different types of cancer. In 2010, these five cancers were responsible for the highest numbers of deaths in America:

Lung cancers: 158,135 deaths
Colorectal cancers: 52,540 deaths
Breast cancer: 41,360 deaths
Prostate cancer: 28,541 deaths
Lymphomas: 21,502 deaths

Cervical cancer, which we’ve all heard a fair bit about in recent years, killed just 3,922 people. I can’t rank it among all site specific cancers, as the CDC counts some site-specific cancers together in a way which prevents that. However, compared to the other site specific cancers for which they do provide individual data, it is near to the bottom of the list. You should note that this is not due to the HPV vaccine – that will not meaningfully effect the number of deaths until the generation of girls who just received it have retired. Cervical cancer is simply not a very common cause of cancer or cancer-related death.

The funding situation, however, is as follows:

Breast cancer: $824,000,000
Prostate cancer: $362,000,000
Colorectal cancer: $317,000,000
Lung cancer: $223,000,000
Lymphomas: $209,000,000
Cervical cancer: $101,000,000

Per death, this works out to:

Cervical cancer: $25,752 per death
Breast cancer: $19,923 per death
Prostate cancer: $12,684 per death
Lymphomas: $9,720 per death
Colorectal cancers: $6,033 per death
Lung cancers: $1,410 per death

This is striking, right? Cervical cancer is responsible for only a very small number of deaths relative to most other cancers, even in a country where access to screening is probably relatively limited, and yet the NIH funds research on it to an 18-fold greater extent than lung cancer, which kills more people each year than the others combined. Breast cancer receives just over one and a half times the amount of funding per death that prostate cancer does, while colorectal cancer, the second biggest killer, loses out to both.

Now, funding per death and funding per case are different things, because the survival probabilities for some cancers are very much higher than others. The long term survival probability for lung cancer is abominable, and as a consequence, there is only a 1.5-fold difference in funding per case and funding per death. Breast cancer, on the other hand, is very survivable, and as a result, the funding per death is six-fold higher than the funding per case. Whether funding per case or per death seems more salient to you will depend on what you believe the government’s priorities should be when it comes to health funding. I’m more concerned with treating serious diseases which require aggressive treatment, which significantly reduce both the quality and length of life, so I’m more interested in funding per death. If you’re more concerned with larger numbers of people getting less fatal illnesses, you can do your own digging through the pages I link to – the number of new cancer cases by type for the US in 2011 are here, on page 4. Briefly, the funding per case for the above named cancers is as follows:

Cervical cancer: $7,947 per case
Breast cancer: $3,542 per case
Colorectal cancers: $3,128 per case
Lymphomas: $2,780 per case
Prostate cancer: $1,502 per case
Lung cancers: $932 per case

Lung cancer isn’t as far behind in this reading, although it is still a clear loser, and cervical cancer’s astonishing lead has softened somewhat – its per case funding is now 7-fold that of lung cancer’s, rather than 18-fold. Lymphomas and colorectal cancers are still breaking almost even, and breast cancer is now even further ahead of prostate cancer, now by a factor of 2.4 instead of 1.6. Whichever way you slice it, there are significant differences in the research funding for different cancers. People can, and do, read all sorts of political things into these funding disparities, and doubtless there are political elements to it, but even if the case of lung cancer, there are other factors at play.

Firstly, in addition to federal funding for research into a given disease, there will be some combination of federal government expenditure for screening programs, subsidies for diagnosis and treatment, public education campaigns, etc. Chemotherapy drugs can be astonishingly expensive, and how expensive depends on a variety of factors. I haven’t been able to find a good listing of cost per case for treatment between different cancers – if you know of one, holler at me. Regardless, a cancer which attracts a lot of research funding may not consume the same relative amount of funding for treatments, and the research funding isn’t necessarily a good indicator of how much the government spends on that disease as a whole.

It seems likely to me, in Australia at least, that more federal money is spent on anti-smoking campaigns and support than on any other preventative public health education program, with the possible exception of mental health (it’s worth noting that in America these programs are funded by the States, and that funding therefore varies wildly). In addition to this, lung cancer is extremely fatal, and it’s probable that research into new treatments would be aimed at prolonging life, perhaps for just a few months, and reducing side effects, rather than obtaining remission and preventing death from lung cancer entirely. Breast cancer, at the other end of the spectrum, has excellent prognosis when diagnosed early, which is why we have such a well-publicised screening program. Better diagnosis methods and treatments for breast cancer are more likely to provide remissions and additional years or decades of life, something lung cancer treatments can’t offer.

No country has a screening program for lung cancer, as no screening test has been developed – probably a worthwhile area for research funding to be funneled towards, and presumably somebody somewhere is working on a biochemical test. It’s worth noting that in any country, the money spent an anti-smoking programs achieves nothing for non-smoking victims of lung cancer. The stigmatisaion of smoking and the public perception of lung cancer and smoking as inextricably linked presumably plays a role in whatever zero sum game may be occurring in the government’s mind there. In fact, 10-15% of lung cancer cases occur in never-smokers, meaning that conservatively, 16,000 of the lung cancer deaths in the US in 2011 occurred in that group – four times as many deaths as cervical cancer caused. Even if you have the attitude that smokers know what’s coming to them and shouldn’t expect publically funded medical assistance (I position I do not support, since I am not the type of person who would advocate leaving motorcycle riders to bleed out in emergency rooms after accidents while we treat more staid members of the population), the lack of funding for lung cancer research doesn’t only forsake people you think have it coming. It also harms people who have never smoked, and those who took up smoking before the risks were known to them and quit later, and those who live in poorer countries and may never know the risks at all.

The situation between breast and prostate cancer is somewhat more complex. The risk that a 40 year old woman will develop breast cancer before she turns 50 is 5-fold greater than the risk of a man developing prostate cancer over the same period of his life (1.45% vs 0.31%, or 15 per 1,000 vs 3 per 1,000). From age 50 to 60 they are about the same (2.38% vs 2.30%), and from age 60 to 70, men are at two-fold greater risk (3.45% vs 6.62%). Breast cancer therefore presumably affects a greater proportion of people who are still in the workforce, and this may explain some of the keenness of governments to devote money to screening and developing better treatments for it  compared to prostate cancer, which mostly affects men well into their retirement years. I’m not entirely hostile to the various arguments that breast cancer is well-funded due to the position of women in our culture, though I don’t wish to get into them here. I do want to point out that the existence of an effective (some say over-effective) screening program, the age at which risk begins to increase, and the generally good prognosis compared to many other common cancers also play their roles.

Another factor which partially determines the allocation of research funding is the quality of grant applications, and the people making them. It may be the case that certain diseases attract certain types of researchers, and that breast cancer research, for some reason, attracts people who are either very talented, or very good at putting together proposals. In a cynical reading, a well-funded area may attract a greater proportion of researchers who are more than usually concerned with financial security for their research, and who will more enthusiastically allocate the time and resources they need to in order to secure grants. Breast cancer research is developing a reputation as an area which fosters huge, international collaborative projects between very talented people. Lung cancer research, I suspect, is a rather more thankless task, and patient-facing research into a highly fatal disease is likely to be distressing, to say the least. It will presumably attract fewer researchers over all, and probably retain them for shorter periods. It seems likely that the absolute number of exceptional people will be proportionally lower, and that the number of substantial grants awarded will be lower as well.

If this article has seemed somewhat rambling, to some extent that illustrates the point. I am not arguing that breast cancer research is over- or under-funded, or that we should definitely spend more on lung cancer research. Without more information on the total federal government expenditures on each disease, any such argument would be incomplete. The allocation of funding in medical research is a complex business, informed by many factors, on which publically available information is scarce. Simply looking at the figures above does not tell you the whole story, and reading one’s own political explanations into those figures without understanding the disease factors, economic factors, and scientific issues at play is taking a blinkered view. Unless one has access to a great deal of information, the time to look through it in detail, and the background knowledge of a variety of disciplines to analyse it, I think it wise to refrain from taking a particularly strong position.

* Derived from COPD: $108,000,00 + Asthma: $221,000,000, assuming that research funding for chronic bronchitis is negligible as it isn’t listed.

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3 Responses to Movember vs Pink Ribbon Day, and why it’s not so simple.

  1. Peter says:

    Interesting numbers, I would be curious to see a reply from a cancer researcher. Just on your first table though: I would guess that as life expectancies increase in general, cancer and Alzheimer’s are growing as a cause of death relative to heart & respiratory disease — so if you look at projected incidence over the next couple generations of seniors, rather than current incidence, the funding might not seem so out of wack.

    Would also be curious to know how many of those non-smoking lung cancer cases are clearly traceable to asbestos or other remediable environmental factors.

    • Kathryn says:

      Yeah, I imagine that Alzheimer’s research in particular is benefiting from an ageing population. I’m not sure about the lung cancer in non-smokers thing, although I do know that asbestos is far more dangerous to smokers than to non-smokers. It would be interesting to know, though, as environmental factors would of course account for some of them.

  2. Pingback: Moframe Movember | Twenty.oz

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