Is There an Ideal Healthcare System for Treating Cancer?

Liam Davenport


September 24, 2019

Government-subsidized healthcare versus private, out-of-pocket insurance. Treatment value versus access to new drugs. Fee-for-service reimbursement versus salaried physicians.

When it comes to treating cancer, different countries' healthcare systems often serve as laboratories for new ideas. And seen in a different light, they are also a reflection of a country's values and priorities.

Each year at the European Society for Medical Oncology (ESMO) Congress investigators present research comparing and contrasting cancer outcomes of various healthcare systems around the world. While certain characteristics, such as high-volume hospitals, are associated with improved outcomes, it is much more difficult to compare complex health systems.

As part of our coverage of this year's ESMO Congress, Medscape spoke with several experts about their national healthcare systems' approaches to patient care in order to determine what is and isn't working in terms of increasing access, improving outcomes, and reducing costs. Is there a best healthcare system for cancer patients?

A Worldwide Tour of Cancer Care

When taking a global view of cancer care, the sheer heterogeneity of the systems jumps out at you.

The United Kingdom and Portugal have national health systems that are free at the point of use, whereas cancer care in Italy and Spain is completely reimbursed. In Germany, patients are required to have health insurance, with only some cancer drugs fully reimbursed by the national health system.

In Asia, outside of economic giants like Korea, Japan, or Hong Kong, many countries "struggle with costs, and most healthcare systems do not have a system of reimbursement," says Ravindran Kanesvaran, MD, from the National Cancer Centre Singapore and ESMO Asia-Pacific policy committee chair.

Canada has a publicly funded, universal healthcare system, although how care is delivered varies depending on the jurisdiction.

These countries share the concept of a national healthcare system driving cancer care, but things are different in the United States.

The United States has "a very complex system" held together by guidelines and recommendations, says B. Ashleigh Guadagnolo, MD, MPH, professor in the department of radiation oncology at The University of Texas MD Anderson Cancer Center in Houston.

That sentiment was underscored by a 2019 report from the National Academies of Sciences, Engineering, and Medicine,[1] for which Guadagnolo was a committee member. The authors stated that US cancer care involves "more than a dozen federal agencies, 65 states and territories, and many private organizations... [with] no uniform way of coordinating the efforts and priorities of these diverse stakeholders."

Guadagnolo says the result is that "there continue to be large cancer-related health inequities" that require a specific US national cancer strategy.

Access Is a Global Problem

Having a national health system does not guarantee access to cancer care, however.

While the United Kingdom's National Health Service is "a huge asset," its tremendous size means that ensuring every patient gets the latest or best treatments is "a challenge," says Emlyn Samuel, from the charity Cancer Research UK.

The United Kingdom's National Institute for Health and Care Excellence, which determines which treatments should be funded, also plays a crucial role, but the time required for a cost-effectiveness analysis can leave patients waiting for drugs. The Cancer Drugs Fund was created to give patients access to promising new treatments while evidence is still immature, but it has not been without controversy. Patient access to a drug relies on it being funded by the local health authority, which can create a so-called postcode lottery.

In Portugal, private health insurance was rare a decade ago, but now around 40% of the population has some sort of coverage. Plugging the gap with private health insurance does not always work, however, says Fatima Cardoso, MD, director of the breast unit at Champalimaud Clinical Centre, Lisbon, Portugal. Cardoso is co-chairing a special session at ESMO called "Universal health coverage and cancer: What you and your country need to know."

"Patients don't think that they're going to have cancer, so they take the least expensive [insurance plan] that doesn't have a sufficient level of reimbursement," she says. "I can see two patients who are very similar, have a similar type of tumor, and would need a similar treatment, but I may have to decide differently because one has very good health coverage and the other one doesn't. For an oncologist, that is extremely difficult to face."

Cardoso adds that issues about access affect every single country. She believes that even in Nordic countries, where you would expect better and perhaps more homogeneous coverage, there are inequalities in access to care that are getting wider.

In Asian countries with well-funded healthcare systems, Kanesvaran explains that there are lengthy delays over drug approval because governments are cautious about spending on expensive drugs, companies "don't put in the applications," and Asian patients are rarely included in international trials. This means that access to drugs other than "relatively cheap chemotherapies" can be patchy, he says.

China and Japan have tackled the issue by developing their own cancer drugs, including immunotherapies, although Kanesvaran says that these are "few and far between."

Bridging Inequalities in Outcomes

In surveying data from 2.4 million patients from several countries, the International Cancer Benchmarking Partnership found that cancer survival was persistently higher in Australia, Canada, and Sweden; intermediate in Norway; and lower in Denmark, England, Northern Ireland, and Wales.[2]

This was particularly the case in the first year after diagnosis, which Samuel says stresses the importance of diagnosing cancers early.

"We know that if a patient is diagnosed at stage I or II, then their chances of surviving cancer are drastically improved. One of the reasons we lag behind those other countries is because we tend to diagnose at a later stage," he says.

To address these disparities, Cardoso believes that there needs to be a shift away from chasing after the newest and most expensive drugs.

"The most important and relevant cancer treatments are actually not expensive at all," she says. "Every single country, rich or poor, should be very careful not to waste resources."

Samuel agrees, pointing out that Cancer Research UK funds "a lot of research into optimizing radiotherapy or surgical treatments, which are not just better for the patient but also better for the health system."

Cardoso believes that the ESMO Magnitude of Clinical Benefit Scale[3] and the American Society of Clinical Oncology Value Framework[4] are "a major step forward" in helping health authorities to objectively evaluate different treatments and prioritize them.

Of course, an optimal health system should also be concerned about the patient experience.

When the Canadian Partnership Against Cancer (CPAC) refreshed its Canadian Strategy for Cancer Control for 2019–2029,[5] it identified five priority areas: prevention, diagnosis, quality of care, access, and patient support. This strategy seeks a broader definition of what an outcome should be.

"We believe that patient quality of life and satisfaction are outcomes we need to start measuring and responding to," says Cynthia Morton, CEO of CPAC.

Rami Rahal, CPAC's executive director for cancer control, takes this further: "This idea that disease-specific outcomes are somehow competing with other outcomes, like psychosocial and quality of life, is really a false assumption."

He adds that there is "very strong evidence" that addressing patient quality of life, anxiety, and psychosocial challenges, and ensuring that treatment approaches are aligned with patients' values and preferences, will lead to better health outcomes and improved survival.

Moving Toward a More Innovative Design and Funding Approach

There is also a need to make necessary changes to trial design and drug funding, says Giuseppe Curigliano, MD, PhD, head of the division of early drug development at the European Institute of Oncology, Italy, and a member of ESMO's Global Policy Committee.

"We will move from evidence-based medicine, based on prospective randomized trials with data collected by investigators, to real-life evidence in which you give a conditional approval and then, in real life, test if the drug is cost-effective," he says.

In Italy, physicians report patient characteristics and drug activity and toxicity to a registry, which allows the government to enter into risk-sharing strategies with drug companies. Consequently, expensive drugs that benefit patients and have low toxicity are fully reimbursed, but those that offer only a marginal benefit are not.

In Canada, the high cost of innovation means that jurisdictions are starting to work together on funding.

"Even though the provinces retain the individual authority to fund, they are making decisions collectively about treatments because, as new technology is introduced, it is clear that some of the small jurisdictions are simply not going to be able to fund it independent of a pan-Canadian strategy," Morton says.

Improving Care Means Considering Where and How You Give It

It is now recognized that the best outcomes are achieved in dedicated, specialized cancer units, with high-volume hospitals strongly associated with survival.[6,7]

While the concept is gaining traction in Europe, Cardoso says that it has been a long and difficult journey.

"When you start talking about reorganization of the health system and making sure that not every single person can treat rectal cancer, operate on breast cancer, or prescribe chemotherapy, then you have a lot of lobbies and interests that make this change difficult," she says.

Although the push for specialized units is most advanced for breast cancer, Cardoso believes that it is only a matter of time before the concept spreads to other forms of cancer.

Other countries, such as the United Kingdom and Canada, are focusing on incorporating cancer strategies into their national health systems.

Samuel says that in the United Kingdom, "all nations have or will have cancer strategies that set out the different priorities along the patient pathway and prioritize where we can make the biggest difference."

Morton agrees, saying that CPAC's aim is "to see which priorities span the country—and that we all collectively agree we need to work on in Canada, regardless of who has ultimate responsibility for the funding and delivery of the healthcare."

There are echoes of this in an initiative undertaken by ESMO to bring together 21 oncology societies across Asia to look at access to treatment, work with health ministries, and engage with industry.

"Once we have that, we'll be in a better position to gauge how best to move forward," Kanesvaran says.

But the picture is different in the United States, where there is perhaps a reluctance to consider universal healthcare solutions. In fact, when writing their recent report, Guadagnolo and colleagues were "specifically directed that one of the solutions that we put forth could not be to revamp the healthcare system." They nevertheless came up with a way to reorganize cancer, not from the center but from within: "Cancer control should be seen as a system of systems, with a focus on the concept of a 'complex adaptive system'...consisting of individual entities that act and interact with one another to advance their own 'interests,' modifying their behavior in response to what is happening in the rest of the system."[1]

This approach can already be seen in Europe.

Cardoso says that in Italy, "the government says you have the right to be treated anywhere you want, but we will only reimburse if the surgery takes place in a specialized center."

For breast cancer, that definition mandates at least 150 cases per year, "so what has happened very quickly, within 1 to 2 years, is that there are no more outside breast surgery centers who do fewer than 150 cases, because if they don't get paid, they won't do it," she says. The result supports the idea that data and incentives drive systems as complex as healthcare.

The goal for all healthcare systems is tackling cancer at every step along the life journey, from prevention, to diagnosis and treatment, to end-of-life care. There may be various paths to take to meet that goal, but we should at least be comforted that everyone seems to agree on the destination.

What do you think makes the best healthcare system for cancer? Let us know in the comments section.

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