Andrea Miyahira: Hi, I'm Andrea Miyahira with the Prostate Cancer Foundation. I'm here at ASCO 2025 with Dr. Dee of MSKCC, a resident physician, to discuss a recent study that he also co-published in JAMA Oncology, looking at the global health care system and what factors are important for influencing cancer patient outcomes. So Dr. Dee, thanks for joining us today.

Edward Christopher Dee: Thank you for having me.

Andrea Miyahira: So describe this study, what were the major questions that you were looking at and how did you go about answering those questions?

Edward Christopher Dee: Absolutely. So in this study we asked, what health systems at the macroscopic level could be associated with better cancer outcomes when we look at pan-cancer analyses, when we look at cancer on a macroscopic scale as possible?

So our outcome variable was based on the GLOBOCAN data set. That's a WHO-sponsored aggregator of National Cancer Databases that essentially consolidates the epidemiology of cancer throughout every country in the world. They've identified 185 countries and territories, and then pick the best cancer registries from each of those countries, and then develop estimates that we're able to use in big epidemiologic studies.

This group publishes GLOBOCAN, which is one of the main references for cancer incidence and mortality throughout the world. But what we thought was interesting was, well, we could use a proxy for survival, which is a variable called the mortality to incidence ratio, which is just dividing the age-standardized mortality by the age-standardized incidence, that gives us a sense for roughly what cancer outcomes look like in each country.

And then we looked at important metrics that help to define cancer systems throughout the world. We looked at GDP per capita, we looked at the Universal Health Index or the UHC index, we looked at gender inequality index, and multiple other covariates to build these multivariable models.

One of the simplifications that we had to do was given that it ultimately is a relatively small sample size of about 120 with complete data for the multivariable analyses, we relied on linear models. So to do this study, we first did univariable analyses between the health system covariables that we picked out, and the mortality to incidence ratio for pan cancer outcomes.

And we found essentially that everything was associated. Greater GDP per capita was associated with improved mortality to incidence ratio. Increased gender inequality was associated with worse mortality to incidence ratio.

And we said, OK, we'll take everything that was significant on univariable analysis and put it into a multivariable model. And we found that even adjusting for all of these important covariates and adjusting for multicollinearity, we found that the two most strongly associated factors were number one, GDP per capita, we thought of that as almost a positive control, but number two, universal health care index, UHC index.

Again, we can't draw causal associations, but what this tells us is that the closer a country moves towards universal health care, towards providing access to people regardless of ability to pay, cancer outcomes actually get better.

What was also interesting is that in a subset analysis by sex, we found that the gender inequality index approached significance and was associated with worse mortality to incidence ratio for worse gender inequality only for female patients, which again, makes sense, but is also in a sense a sad reality of the way the world is.

Obviously, this study boils down really, really complex interactions into relatively simple models, but what it tells us is a lot about directionality. What this tells us is that when people think of UHC, they think of primary care, they think of vaccination, they think of pediatrics. But what we're showing and this is quite novel is that universal healthcare and health systems at large have an important role to play for cancer.

I like the idea of thinking of what our group does as kind of comparative cancer systems, and I think this is the first study and hopefully many, that lays the foundation for looking at cancer systems across countries.

What can we learn from each other? What can the Philippines, where I'm from, learn from India? What can we learn from Canada? What can the US learn from Brazil? How do we engage these countries and these cancer systems in conversation with each other?

Andrea Miyahira: Yeah, that's really interesting. So you found that universal health care was one of the most important factors that's associated with cancer mortality?

Edward Christopher Dee: Absolutely.

Andrea Miyahira: So in the US we don't have universal health care, so how did the US compare with other countries that have a similar GDP when it comes to cancer patient outcomes?

Edward Christopher Dee: The US did OK. It was upper middle of the pack within high resource countries. And I think that's because the US in many ways leads in terms of the advances in technology, but isn't the most equitable on various kinds of intersectional layers of the population in the US.

Equity is not just race. Equity is socioeconomic status. It's educational attainment. It's proximity to a cancer center. These are all really important variables that really many intelligent people have studied and continue to study. But I think the US, by merit of its history, by merit of its size, suffers from a sense of inequity, and that plays out in cancer outcomes in multiple, multiple studies.

Andrea Miyahira: And how about other countries that differ in different GDPs and different other factors, what can they do to improve their cancer patient outcomes?

Edward Christopher Dee: I think the first point is that GDP per capita and a country's human development index and wealth, that's not destiny. What this tells us is that there are multiple levers that could be toggled, that could be modified to help improve cancer outcomes at large.

We know that there's a tsunami of cancer diagnoses coming. The early onset colorectal incidence increases are making headlines this week, but we know that in 2040, approximately 30 million cancer diagnoses are expected in that year alone and 15 million deaths, so we know we have to start planning for this. We know we need to bank resources to catch these things.

But I think what's important is that in the setting of the rising incidence and global burden of cancer is that there are variables that are modifiable. I think number one is really the idea of universal health care. We thought that was a really powerful finding in our research.

And this is a modifiable factor. This is ultimately something that is for some countries a gift of history, for others it's an aspirational thing, but it's a policy level thing. It's something that countries can actually legislate.

Again, I'm from the Philippines, and there have actually been significant efforts to move towards universal health care. It's being passed into law and the implementation has been slow, but it's going there, and I think that bodes well for cancer care in countries that are not as resourced, for example, as the US or Canada.

I think the second piece that's really important is that there's a lot to be said for international exchange and countries actually talking to each other, not just within particular regions or within economic strata, but also across the board, and that's something that our group hopes to push forward in conversation.

Two examples of countries that have done really well despite not being the wealthiest per capita are Brazil and Malaysia. These are countries that we call them middle income countries, but they're not the wealthy Denmarks of the world, the Canadas of the world, and yet these countries are able to have really, really good cancer outcomes, especially considering the fact that there's still a lot of poverty in these countries.

So again, GDP is not destiny. And these countries with strong legislation that protects patients with cancer, that provides access, have done really well, and other countries can learn from that.

Andrea Miyahira: So were you able to look at prostate cancer specifically and--

Edward Christopher Dee: Yeah, this is actually a really--

Andrea Miyahira: --what factors were associated with mortality?

Edward Christopher Dee: This is actually a really interesting substudy that we did. We just published it in The Prostate. This was published by-- sorry, this was presented at ASCO GU earlier this year, but using a similar methodology.

In a separate prostate cancer-specific study, obviously just looking at male patients, we found that in addition to universal health, which recapitulated the JAMA Oncology study, we found that radiotherapy facilities per unit population and surgical workforce per unit population were both significantly associated with better prostate cancer outcomes.

Obviously, but I think an important finding that we're glad was published because this tells us that multidisciplinary care has such an important role to play in cancer outcomes. The study identified radiation and surgery as really important factors for prostate cancer. As a radiation oncologist, very happy to find those results.

But I think what this tells us is that health systems strengthening also includes professional development, and a critical element of that is training and retaining clinicians throughout the different disciplines.

Perhaps a little kumbaya hope is that this finding can encourage even more cross-disciplinary collaboration between surgeons, radiation oncologists, medical oncologists, and everybody else who takes care of patients, and that that collaboration can move cancer outcomes for the better.

Andrea Miyahira: OK, thank you. And considering that Medicare and access to health care are issues in this country and in the United States, are there any economic messages that clinicians and researchers can bring to our policymakers to really convince them that improving access is really, really vital and something that should be protected and legislated?

Edward Christopher Dee: I think there are a lot of things. I think number one is really the humanitarian cause. All of us in health care understand that health care is a human right. I hear that's a bit of a controversial statement these days, and we owe it to our patients to be able to advocate for them.

But I think another piece that's really important as well is that it is economical to provide early access to care for people not just in cancer, but throughout the disease spectrum. We know that preventive medicine is actually really cost-effective.

But also specific to cancer, we know that in many ways the different validated screening paradigms for prostate cancer, for breast cancer are cost-effective. We know that the vast majority of health expenses happen when people have progressive disease, and so providing early, effective, and efficient access to care can actually reduce overall costs at a health system level.

And I think that probably falls second in my mind to really the humanitarian need for improved access, but we see it at a national level as well. You get countries that spend far less than the US with similar or better cancer outcomes. Why is that? Because they provide early access to patients.

These countries are not perfect. The US is extremely strong and is the world leader in technologies, but in terms of health systems, there's a lot to learn. There's a lot to learn from preventive medicine, from providing screening, early treatment care that does not push people into financial catastrophe, that improves access and can mitigate costs at a system level.

Andrea Miyahira: OK, thank you, and do you have any final take-home messages for our viewers?

Edward Christopher Dee: Absolutely. I think our hope is that people will continue to ask these questions. There's so much more that can be done. And I think especially speaking to the research community, engaging economists, health care systems, policy scientists. This is how I think we should move things forward.

What we've tried to do in our work is to incorporate patient advocates in our authorship, and I think they bring invaluable expertise in terms of what patients actually care about. But I think having perspectives, not just from a bunch of radiation oncologists and surgeons and medical oncologists, but from actual policy people, from economists, from statisticians, from patients, that can really move research forward, especially the kind of research that is so focused on people, on health systems. And I think ultimately, that's how we can help quantify and help define a way forward, number one.

I think the second message is that-- this part is actually probably the harder part-- that we have to work together to translate these research findings into actual change. What does that mean to advocate for one's patients? That's the more dangerous, more difficult, and perhaps more rewarding part of what hopefully we'll all be able to do together.

Andrea Miyahira: OK, well, thank you so much, Dr. Dee, for your important work and for sharing this with us today.

Edward Christopher Dee: Awesome. Thank you, again.