Tackling the Impact of Cancer on Health, the Economy and Society

When cancer was first written about, in an ancient Egyptian textbook from 3 000 BC, it was said that there was no treatment (American Cancer Society, 2018[1]). But as the medical sciences developed, and with the invention of anaesthesia, cancer became operable in the 19^th century. Other inventions, including x-rays and mustard gas, lead to the development of radiation and chemotherapy treatment. As the field of cancer treatment continued to develop, more and more people now survive their cancer diagnosis. In just two decades, between 1995 and 2014, the proportion of people alive five years after their lung cancer diagnosis (5‑year survival rate) increased from 10% on average across 7 OECD countries, to 19% (Figure 4.1) (Arnold et al., 2019[2]). In the same period, the 5‑year survival rate of colorectal cancer has gone from 52% in 1995, to 66% in 2014.

But despite overall improvements, there remain considerable differences between countries in survival rates (Figure 4.2). On average in the OECD and EU, around 60% of people survive for five years after their colon cancer diagnosis, but this varies two‑fold, from 35% in Colombia to 72% in Cyprus. There is more than seven‑fold variation in lung cancer survival rates across OECD and EU countries, ranging from 5% in Chile to 33% in Japan. Survival rates for breast cancer are higher on average and there is only 1.3‑fold variation across OECD and EU countries. Nevertheless, in Colombia and Lithuania only 7 in 10 women survive for five years after being diagnosed with breast cancer, while 9 in 10 women survive in the United States and Cyprus. These intercountry differences highlight that much more can be done, and should be done, to increase cancer survival rates.

The OECD SPHeP NCDs model was used to evaluate the potential impact of reducing variation in cancer survival rates (Box 4.1). It is estimated that, if all countries improved their screening, diagnosis and treatment of cancer, to the point at which they achieved the best possible 5‑year survival rates observed within the OECD and EU, this would save over 201 000 premature deaths due to cancer per year in the OECD, and 89 000 premature deaths in the EU. This is a quarter of all premature deaths due to cancer (25% and 26% in the OECD and EU, respectively). Countries with lower survival rates, including Mexico and Colombia, would see even greater reductions in cancer premature mortality if they achieved the best survival rates (Figure 4.4). Countries with a high baseline cancer premature mortality rate, including Central and Eastern EU Member States (MS), would also see the greatest improvement in these rates.

For mouth and throat cancer, around four in ten premature deaths (41%) could be avoided if the highest survival rates were to be attained across the 43 OECD and EU countries (Figure 4.5). Improved survival rates would also prevent around one in three premature deaths due to cervical cancer (36%) and skin melanoma (31%). However, in absolute terms the impact on lung cancer is the largest, with 61 000 premature deaths avoided every year – nearly 30% of the total impact – followed by 33 000 premature deaths due to colorectal cancer.

As premature mortality decreases, the average life expectancy is estimated to increase in all countries, and by half a year in OECD and EU countries (0.46 and 0.51 years respectively) (Figure 4.6). Countries with the greatest improvement in premature mortality rates also see the greatest impact on life expectancy.

Improved cancer survival would increase the size and output of the workforce. In the OECD, it is estimated that the equivalent of 270 000 additional full-time workers (105 000 in the EU) would be available due to increased employment. Improved cancer survival does mean that the workforce would include more people living with cancer and older people who are more likely to have other non-communicable diseases (NCDs). As a result, there would also a reduction in workforce output due to increased absenteeism, presenteeism, and early retirement. However, these impacts do not outweigh the increased employment. Based on annual wages, per capita output would increase by EUR PPP 10 in the OECD and EU on average – including an increase of EUR PPP 16 due to employment (Figure 4.7). In total, improved cancer survival rates would increase the workforce output by EUR PPP 7.3 billion in the OECD – equivalent to more than half the annual gross domestic product of Malta (EUR PPP 2.7 billion in the EU).

An important factor driving differences in survival rates is the quality and timeliness of cancer care (Arnold et al., 2019[4]). Early diagnosis improves survival chances: on average in the United Kingdom, a lung cancer diagnosed at stage one has a 5‑year case fatality rate of 43%, compared to 97% when an otherwise similar case lung cancer is diagnosed at stage four (Crosby et al., 2020[5]; Office for National Statistics, 2019[6]). Delays in cancer treatment are also associated with increased case fatality rates: patients with colon cancer, head and neck or bladder cancer whose surgical treatment is delayed by one month are 6% more likely to die compared with those without this delay. Patients with breast cancer have an 8% increased risk of death (Hanna et al., 2020[7]; BMJ, 2020[8]). The availability of, and access to, effective diagnostics and treatments can also influence outcomes.

To ensure everyone has the same chance of survival, no matter where they live, countries should continue to improve the access to as well as the quality and timeliness of cancer care. This includes 1) more effective screening, 2) investing in programmes for early diagnosis, and 3) more effective treatments.

Screening plays a pivotal role in the fight against certain cancers. The WHO includes screening for cervical, breast and colorectal cancer on their Best Buys for NCDs list (WHO, 2022[9]) (WHO, 2023[10]), and several countries are also exploring the potential of lung cancer screening (Box 4.2). The purpose of screening is to identify those individuals who have a disease, but do not yet have symptoms, so that an early treatment or intervention can be offered to improve chances of survival. Screening is different to early diagnosis, because screening invites people without symptoms to undergo testing, whereas early diagnosis aims to detect conditions as early as possible in people with symptoms (WHO Regional Office for Europe, 2020[11]).

While the characteristics in terms of target population and frequency vary, most OECD and EU countries have programmes for breast, cervical and colorectal cancer screening in place (OECD, 2023[13]; OECD, 2024[12]). However, there are considerable differences in screening rates across countries: breast cancer screening rates vary four‑fold, from 20% in Mexico to 83% in Denmark (Figure 4.8).

Screening coverage also varies considerably within countries. In the EU, nearly 80% of women with tertiary education had participated in cervical cancer screening in 2019, versus only 61% of women with lower secondary education or less (Eurostat, 2023[14]). In some countries, for example in Romania, this inequality was even larger, with three times more women with high education than low education having a cervical smear test. Screening rates also varied across income groups: women with a low income were twice as likely to miss out on breast cancer screening compared to women with a high income. Finally, people living in rural areas also had a significantly lower likelihood of receiving breast and colon cancer screening than those living in urban areas (OECD, 2024[12]).

To improve screening uptake, it is important to understand what the drivers and barriers to participation are. For colorectal cancer screening, barriers range from a lack of knowledge and not feeling screening is personally necessary; active aversion to screening (fear, discomfort, disgust or not wanting to know); and contextual barriers of the healthcare system such as practical constraints or poor relationships with healthcare professionals (Le Bonniec et al., 2023[15]). Younger people, women, people with a lower level of education, lower income and ethnic minorities are less likely to participate in colorectal screening (Wools, Dapper and Leeuw, 2016[16]). Increasing awareness, particularly among socially vulnerable populations is key to address some of these barriers (Box 4.3).

There are various ways in which screening invitation and delivery can be improved to increase screening uptake. Invitation by a general practitioner (GP) letter rather than another authority, letters with fixed appointments rather than open invitations (Box 4.4), and personalised invitations compared to standard invitations were all more successful in encouraging uptake (Staley et al., 2021[17]). Reminders have also been shown to increase uptake, with reminders delivered by letter or email even more effective than phone call or text message. Facilities with flexible appointment times and with female providers were shown to have higher uptake of breast and cervical cancer screening (Plourde et al., 2016[18]). For women who are uncomfortable seeing a health worker for a cervical smear test, self-testing can help. HPV self-testing was found to be effective in increasing uptake among lower socio‑economic groups in France (Sancho-Garnier et al., 2013[19]).

Once people have symptoms, the outcome of their disease can be improved through early diagnosis and timely access to appropriate treatment. Early diagnosis refers to the detection patients with symptoms at the earliest possible stage so they have the best chance for successful treatment (WHO, 2017[22]; OECD, 2024[12]). This includes the access to medical care delay (“access delay”), the delay in time from visit to diagnosis (“diagnosis delay”), and the delay between diagnosis and receiving treatment (“treatment delay”).

Access delays can be reduced by increasing awareness of the initial signs of cancer among patients. A study in the Netherlands found that while many people recognise changes in bowel habits, changes of a mole and breast lumps as signs of cancer, less than half recognised dysphagia (difficulty swallowing) as a potential symptom of cancer (Sijben et al., 2024[23]). A study in the United Kingdom found that only 51% of women correctly identified nipple rash as a symptom of breast cancer (Green, Lloyd and Smith, 2023[24]). Access delay can also be reduced by addressing barriers to seeking access, such as not wanting to make a fuss, waiting to see if a symptom will pass on its own, or difficulties making an appointment with the doctor (Green, Lloyd and Smith, 2023[24]) (Boswell et al., 2023[25]).

Reducing diagnosis delay involves increasing awareness of the initial signs of cancer among healthcare workers, improving accessibility and affordability of diagnostic services, and improving the referral process from first to secondary and tertiary levels of care (WHO Europe, 2010[26]). Clinicians can also be supported in making a cancer diagnosis, for example through electronic clinical decision support tools (eCDSTs) (Box 4.5).

Improved referral from primary care through to specialist oncology care can reduce treatment delays. Several countries such as Denmark, Ireland, Latvia, Lithuania, Poland, Slovenia and Sweden have developed fast track referral mechanisms (OECD, 2024[12]). Latvia introduced fast-track access for people with cancer (called the green corridor) in 2016. It is paid in full by the state budget and aims to streamline diagnosis and treatment decisions for suspected cancer cases by requiring specialist consultation and diagnostic examination within ten working days of the date of referral (OECD, 2024[12]). Access to cancer care improved, and the proportion of people diagnosed at early stages increased from 50% in 2015 to 55% in 2017 (OECD, 2023[30]; OECD, 2024[12]).

High-quality cancer diagnosis and treatment is crucial to ensure better outcomes. Advancements in cancer treatment have long been a focal point of medical research and innovation. However, policymakers should ensure that these advancements become available to the public. In addition, to deal with increasing drug cost (Box 4.6) and care for a rising number of people with cancer in a sustainable way, countries need to seek effective and efficient ways of delivering high-quality cancer care.

There are various options to increase access to effective treatment. The use of generics and biosimilars can help reduce costs. Collaborative Health Technology Assessment (HTA) can bring new medicines to patients quicker. The availability of companion diagnostics and Next Generation Sequencing (NGS) technologies is key to unlocking precision medicine and providing targeted therapies to patients. Finally, the establishment of Comprehensive Cancer Centres (CCCs) can streamline efforts towards better patient management.

The use of generics and biosimilars can help lower prices for oncology treatment when the originator product has gone off patent or lost market exclusivity. The steep increase in the number of new cancer medicines in the past two decades means that the opportunities to achieve savings through the use of generics and biosimilars will rise in the coming years (Godman et al., 2019[36]).

However, there are significant differences across countries in the share of 19 biosimilars for three reference medicines (bevacizumab, rituximab, trastuzumab) that has public reimbursement/coverage. In Estonia, all biosimilars are used in hospitals, while in Malta only three biosimilars (16%) – one for each reference medicine – are available (OECD, 2024[12]).

The mean time from EMA approval to public reimbursement/coverage of biosimilars also exhibits great variation between countries, ranging from around 200 days in Spain to between 700 and 835 days in Greece, Iceland, Latvia, Lithuania and Slovenia, and almost 1 400 days in Cyprus. Countries with a higher share of publicly reimbursed/covered biosimilars tended to have shorter time periods between EMA approval and public reimbursement/coverage (OECD, 2024[12]).

Different policies exist to stimulate the utilisation of generics and biosimilars when they become available in clinical practice (Hofmarcher, Berchet and Dedet, 2024[32]; Vogler et al., 2021[37]). This includes pricing policies of various forms, such as internal reference pricing, where medicines with identical or similar active substances are clustered into groups and a common price is defined for all medicines within those groups. Prices of generics/biosimilars might also be linked to the price of the originator product through a system where mandatory discounts apply to generics/biosimilars which might increase with the number of generics/biosimilars entering the market. The price of the originator product might also face a mandatory price cut upon market entry of generics/biosimilars (Godman et al., 2019[36]; Moorkens et al., 2017[38]).

Oncology research is highly active and new, more effective treatments for cancers are constantly emerging. Between 2004 and 2022, 152 new cancer medicines were granted centralised marketing authorisation by the European Medicines Agency (EMA) (Hofmarcher, Berchet and Dedet, 2024[32]). However, access to new medicines is unequal across countries, both in terms of overall access to cancer medications and in terms of the time taken to access these medicines. When looking at the reimbursement of cancer medicines with a high clinical benefit that received marketing authorisation after 2016, Germany, the Netherlands, Bulgaria and Sweden covered 85% of more, while Cyprus and Latvia only covered a small proportion of indications (both 31%) and Malta covered none (Hofmarcher, Berchet and Dedet, 2024[32]). The total time between EMA marketing authorisation and reimbursement/coverage decision ranged from less than 100 days in Germany and Sweden to over 1 100 days in Cyprus, Latvia and Lithuania (Hofmarcher, Berchet and Dedet, 2024[32]).

Collaborative health technology assessment (HTA) at a multinational level could help improve timely access to cost-effective medicines. The number of new cancer medicines has been increasing over the last decade, upping the workload for HTA agencies and pricing and reimbursement bodies. Joint evaluations of (relative) effectiveness of selected cancer medicines by regional co‑operations, such as BeNeLuxA and FINOSE, have already been done. The joint European HTA applicable for cancer medicines from 2025 should be used as an opportunity to decrease work at the national level with the assessment of (relative) effectiveness rather than result in a duplication of work (Hofmarcher, Berchet and Dedet, 2024[32]). Additionally, value frameworks such as the European Society for Medical Oncology (ESMO)-Magnitude of Clinical Benefit Scale (MCBS) can offer additional support in the prioritisation of access to cancer medicines and assist in the HTA process (OECD, 2024[12]).

There has been an increase in the development of targeted therapies for cancer: of the 42 approvals of new cancer medicines between 2020 and 2022, 34 approvals (81%) concerned targeted therapies (Hofmarcher, Berchet and Dedet, 2024[32]). Targeted therapies are designed to act on specific genetic features of the cancer. For example, about 40% of people with colorectal cancer have KRAS gene mutations, and so may respond better to a type of cancer treatment specifically designed for that mutation (Zhu et al., 2021[39]).

However, to be able to effectively use these new treatments, governments need to ensure access to their companion diagnostic. A companion diagnostic identifies whether a patient has a certain genetic feature, and would benefit from a specific targeted treatment. Fewer than half of EU countries currently have an automatic link between the coverage/reimbursement decision for a medicine and its companion diagnostic, meaning that it is possible that a treatment is covered by insurance while its companion diagnostic is not (Hofmarcher, Berchet and Dedet, 2024[32]).

Increasing access to companion diagnostics can be cost-saving in the long-run. The French National Cancer Institute tested EGFR biomarkers in 16 724 lung cancer patients and found that only about 10% of patients would have responded to the available treatments at that time (gefitinib or erlotinib). The cost of running these test was less than EUR 2 million, versus an estimated savings of EUR 69 million from not treating the 15 000 nonresponding patients with that medication (Draghia-Akli, 2012[40]; Gill et al., 2020[41]).

A next step in ensuring access to innovative cancer treatments is through the use of next generation sequencing (NGS) technology. NGS sequences millions of DNA fragments at the same time, allowing clinicians to test for multiple genetic mutations rather than testing one‑by-one (Kamps et al., 2017[42]). This way they can identify which personalised treatments would work for a specific patient. Research looking at the use of NGS in patients with lung cancer, colorectal cancer or melanoma in France found that 20% of patients had a change in the care pathway following the NGS results (Coquerelle et al., 2020[43]).

CCCs, which combine comprehensive, multidisciplinary care with research and education, can provide high-quality cancer care. In Europe, the Organization of European Cancer Institutes (OECI) and the European Academy of Cancer Sciences have established complementary quality accreditation systems to test the clinical and research excellence of CCCs (Oberst, 2019[44]). A benefit of these centres is increased collaboration in innovative clinical trials. For example, in Finland, four CCCs are working together on a clinical trial to determine the efficacy and toxicity of targeted anticancer drugs (OECD, 2023[45]; ClinicalTrials.gov, 2023[46]).

A flagship measure of Europe’s Beating Cancer Action Plan is to establish an EU Network of national Comprehensive Cancer Centres, with the aim of increasing patient access to high quality diagnosis, care and innovative treatment across the EU (European Commission, 2021[47]). At present, the number and coverage of accredited centres varies considerably in the EU, with some countries not having any accredited centres yet and others, such as Finland, having almost full coverage (Leemrijse et al., 2021[48]). The Joint Action for Creation of National Comprehensive Cancer Centres and EU-Networking (CraNE) in Europe will help to link CCC networks in the EU (CraNE, 2023[49]).

There is a clear case for continuing to improve cancer care, and various ways in which policymakers can do so. Longer lifespans will increase healthcare cost. Even if there is no additional expenditure associated with the improved treatment outcomes (an unlikely scenario), healthcare cost will go up as more people survive: people will live for longer, they can get cancer again and they can incur cost for other diseases.

In the scenario where all countries improve cancer care and attain the best possible survival rates observed within the OECD and EU, per capita health expenditure will increase by EUR PPP 35 per year on average in the OECD, even without additional per case costs (EUR PPP 37 in the EU) (Figure 4.11). This includes EUR PPP 24 per capita in costs related to cancer treatment, as well as EUR PPP 10 for the treatment of other diseases. This is a 1.1% increase in overall health expenditure on average in the OECD, or a total of EUR PPP 52 billion – equivalent to the total annual health budget of Belgium (EUR PPP 17 billion and 1.3% in the EU).

This increase in health expenditure comes on top of the expected rise due purely to population ageing. As shown in Chapter 3, between 2023 and 2050 per capita health expenditure on cancer in the OECD is estimated to increase by 67% due to population ageing (59% in the EU). Improved survival rates could add another 15% to this (16% in the EU). In addition, there may be increased per-case cancer cost needed to achieve the higher survival rates, higher treatment and drug prices, as well as increased cost to deliver physical, psychological, and supportive care to a growing number of cancer survivors (Box 4.7).

As the trajectory of cancer treatment costs continues to rise, it becomes increasingly evident that the most effective approach lies in prioritising prevention strategies. While advancements in cancer treatment have undoubtedly improved patient outcomes, the financial burden associated with managing the disease places significant strain on healthcare systems worldwide. By shifting our focus towards preventive measures, such as promoting healthier lifestyles and increasing vaccination, we not only have the potential to curb escalating costs but also to significantly alleviate the physical, emotional, and financial toll experienced by individuals and society.

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