Vast cancer care inequalities along patient pathways are highlighted in a new report from the Swedish Institute for Health Economics (IHE). Recent IHE research also shows divergence not only across the European Union, but within each country.
EURACTIV discussed the report in depth with Dr. Thomas Hofmarcher, Research Director at the IHE. Hofmarcher explained how the findings demonstrate that a minority of EU member states are reaching aims defined in Europe’s Beating Cancer Plan (EBCP), or other relevant benchmarks.
He said overcoming the disease depends largely on where the patient lives, while the overall number of cancer cases is projected to rise considerably in the coming decades.
“If you compare the countries against each other, the biggest inequalities were found both for the HPV vaccination rates and for the colorectal cancer screening,” said Hofmarcher, one of the report’s authors.
The report, commissioned by the EFPIA Oncology Platform, examines the processes of cancer care provision, focusing on five case studies in line with the pillars of EBCP: Prevention: Human Papillomavirus (HPV) Vaccination; Early Detection: colorectal cancer screening; Diagnosis and Treatment: biomarker testing, cancer medicines, and evidence-based care; Survivorship: access to financial products (“the right to be forgotten”).
Vast inequalities
Two member states, Bulgaria and Estonia, still don’t include boys in their HPV vaccination programme, and vaccination rates for girls range from 9% in Bulgaria to 94% in Portugal, the report shows. Additionally, Bulgaria and Romania have no screening programme for colorectal cancer. In countries with a programme, the screening rates range from 4% to 5% in Cyprus, Bulgaria, and Romania to 76% in Denmark.
Noticeable disparities are also reported in diagnosing practices, with access to next-generation sequencing (NGS) testing being low across the EU. Denmark and the Netherlands are the only countries where more than half of biopsies are analysed with NGS. Eastern European countries have the least access; no biopsy samples are analysed with these methods in Czechia and Slovakia.
There is also a substantial variation in outcomes. For colon cancer, the five-year survival rates range from 50% in the worst-performing countries (Croatia, Slovakia, Romania, Bulgaria, Poland) to 70% in the top performers (Germany, Finland, Sweden, Belgium, Cyprus).
It is estimated that more than 20 million cancer survivors are living in Europe, but they face discrimination in accessing financial products (eg life insurance or bank loans). According to the report, only eight Member States (France, Belgium, Cyprus, Italy, the Netherlands, Portugal, Romania and Spain) have adopted legislation on the ‘right to be forgotten’.
Access to medicine
The report shows that only around one out of two patients with advanced non-small cell lung cancer in Finland, Poland or Romania receive cancer medicines according to European guidelines, although the drugs are reimbursed. In Belgium and Portugal, it is nearly eight out of ten. No countries provide adequate access to immunotherapies and targeted therapies, relying more on less effective chemotherapy.
“It’s obvious that the introduction of immunotherapy made a big difference in increasing the survival rate for patients with melanoma or lung cancer, for example. So, there’s value in these high-priced medicines, if they’re effective, as immunotherapies are,” remarked Dr. Hofmarcher.
Inequalities within countries
The report also found notable inequalities within country borders when accessing cancer care, stemming mainly from the geographic distance to university hospitals and comprehensive cancer centres, but also the availability of supporting infrastructure and medical professionals.
“As specialised cancer care services are naturally located in bigger cities, where you can gather the experience, and also have a large enough volume of cases to build up and maintain the expertise, people living in rural areas or islands will always have more difficulties accessing early diagnosis and adequate treatment,” Hofmarcher said.
Differences based on socioeconomic status and health literacy level, including general awareness and knowledge, perception of risks associated with a disease, and the means to acquire information, also play a significant role.
“People need to understand why vaccination is needed, why screening is important, and why they need to visit a physician even if they feel healthy because that could detect cancer before they get symptoms,” he added.
Roots of inequalities
The report shows significant budget differences, with the lowest-spending country, Romania (€70 per capita), spending one-quarter of the highest-spending country, Luxembourg (€294).
For Dr Hofmarcher, the root of the disparities, recorded both in the report and in a study conducted by the IHE on access to novel cancer medicines in four countries in Central and Eastern Europe (Czechia, Slovakia, Hungary, and Poland), is mainly lack of resources, combined at times with low political will.
“If the politicians don’t make a decision, nothing will change, of course. Although politicians might have good intentions, but then they lack the necessary funds”, he says.
He argues that huge differences are still observed even between countries with similar budgets, wealth and economic strength, as seen in the study on access to new cancer medicines in the “Visegrad Four”.
“We analysed the big sample of new medicines approved between 2011 and 2020 and then looked whether they were available in 2022 and realised that in Czechia 64% was available, but in Slovakia, 19%”, explained Hofmarcher – also a principal author of the ‘access to novel cancer medicines’ paper.
“Why does Czechia spend more on cancer medicines than Slovakia, then? It must be political prioritisation,“ he commented.
Prioritising value
The critical role of efficient use of healthcare budgets in providing high-quality care to address inequalities in patient outcomes is underlined in the report, which provides short- and long-term recommendations in sync with EBCP goals.
“It’s important to realise that the battle against cancer can only be won if we choose a comprehensive approach,” Dr Hofmarcher told EURACTIV, adding that “it’s good if politicians prioritise HPV vaccination. But that will only affect some parts of cancer care.”
Another aspect he mentions is the need for data through National Cancer Registries. “If you cannot measure the effects, the outcomes, you’re steering the ship blindly.”
In both papers, a prioritisation of reimbursement is suggested, especially for medicines with high clinical benefit and next-generation sequencing. When asked by Euractiv how would prioritising procedures and therapies of higher costs help countries with limited healthcare budgets, Dr Hofmarcher explained that “when you prioritise, it also means that you can deprioritise something else.”
“Maybe it’s not necessary to strive for access to 100% of medicines but focus efforts and limited budgets on the 50% that provide a substantial clinical benefit to patients. Maybe fast-track them in reimbursement decision-making,” he suggested.
According to Hofmarcher, “You have to look at the value”. As he explained, upfront testing with NGS technology, which includes using biomarkers, is needed to be able to select the right medicine for the right patient, and “testing has gotten a lot cheaper over time”.
Additionally, he suggests using a tool that the European Society of Medical Oncology (ESMO) developed. It is a value framework, an easy scale, that scores every new medicine or indication between one and five, with five being the best. “Focus on the fives and fours and deprioritise the ones, twos and threes,” he said, proposing even a two-track system, having different procedures for different medicine, following societal needs.
[By Vasiliki Angouridi, Edited by Brian Maguire | Euractiv’s Advocacy Lab]
