The Lancet Oncology Commission Delivering aff ordable cancer care in high-income countries Richard Sullivan, Jeff rey Peppercorn, Karol Sikora, John Zalcberg, Neal J Meropol, Eitan Amir, David Khayat, Peter Boyle, Philippe Autier, Ian F Tannock, Tito Fojo, Jim Siderov, Steve Williamson, Silvia Camporesi, J Gordon McVie, Arnie D Purushotham, Peter Naredi, Alexander Eggermont, Murray F Brennan, Michael L Steinberg, Mark De Ridder, Susan A McCloskey, Dirk Verellen, Terence Roberts, Guy Storme, Rodney J Hicks, Peter J Ell, Bradford R Hirsch, David P Carbone, Kevin A Schulman, Paul Catchpole, David Taylor, Jan Geissler, Nancy G Brinker, David Meltzer, David Kerr, Matti Aapro The burden of cancer is growing, and the disease is becoming a major economic expenditure for all developed Lancet Oncol 2011; 12: 933–80 countries. In 2008, the worldwide cost of cancer due to premature death and disability (not including direct medical See Comment pages 923–32 costs) was estimated to be US$895 billion. This is not simply due to an increase in absolute numbers, but also the Kings Health Partners, King’s rate of increase of expenditure on cancer. What are the drivers and solutions to the so-called cancer-cost curve in College, Integrated Cancer developed countries? How are we going to aff ord to deliver high quality and equitable care? Here, expert opinion Centre, Guy’s Hospital Campus, London, UK from health-care professionals, policy makers, and cancer survivors has been gathered to address the barriers and (Prof R Sullivan MD); Duke solutions to delivering aff ordable cancer care. Although many of the drivers and themes are specifi c to a particular Cancer Institute, Duke fi eld—eg, the huge development costs for cancer medicines—there is strong concordance running through each University Medical Center, contribution. Several drivers of cost, such as over-use, rapid expansion, and shortening life cycles of cancer Durham, NC, USA (Prof J Peppercorn MD); technologies (such as medicines and imaging modalities), and the lack of suitable clinical research and integrated CancerPartnersUK, London, health economic studies, have converged with more defensive medical practice, a less informed regulatory system, a UK (Prof K Sikora FRCP); lack of evidence-based sociopolitical debate, and a declining degree of fairness for all patients with cancer. Urgent Peter MacCallum Cancer solutions range from re-engineering of the macroeconomic basis of cancer costs (eg, value-based approaches to Centre, University of Melbourne, Melbourne, bend the cost curve and allow cost-saving technologies), greater education of policy makers, and an informed and VIC, Australia transparent regulatory system. A radical shift in cancer policy is also required. Political toleration of unfairness in (Prof J Zalcberg FRACP); access to aff ordable cancer treatment is unacceptable. The cancer profession and industry should take responsibility University Hospitals Seidman and not accept a substandard evidence base and an ethos of very small benefi t at whatever cost; rather, we need Cancer Center, Case Comprehensive Cancer Center, delivery of fair prices and real value from new technologies. Case Western Reserve University, Cleveland, OH, USA Introduction have contributed their knowledge and viewpoints in this (Prof N J Meropol MD); Division The ability to deliver aff ordable cancer care is at a crossroads. Lancet Oncology Commission. In focusing on developed of Medical Oncology and Hematology, Princess Margaret A volatile mixture of demographics (ageing and expanding countries we have not forgotten that the global cancer Hospital and University of populations), rapid development of new technologies (such burden is radically shifting to low-income and middle- Toronto, Toronto, ON, Canada as medicines and surgery), and increasing health-care income countries, but the unique health and disease (E Amir MBChB, Prof I F Tannock MD); Hôpital expenditure is driving cancer-care costs upwards. Further- trajectory in the latter group (many experience the added Pitié-Salpêtrière, Paris, France more, as the overall cancer burden gathers pace, we are burden of signifi cant acute, infectious, and chronic (D Khayat MD); International seeing signifi cant economic losses due to premature disease) necessitates a separate policy approach and Prevention Research Institute, cancer-induced morbidity and mortality. The hard numbers discussion. There are also missing voices—namely the Lyon, France (Prof P Boyle PhD, P Autier PhD); Medical are stark. The worldwide cost of cancer due to premature regulatory authorities and health-technology assessment Oncology Branch, Center for death and disability (not including direct medical costs) has agencies—but none agreed to contribute. What this Cancer Research, National been estimated to be US$895 billion (in 2008 fi gures).1 It is silence says from a public policy perspective we leave the Cancer Institute, Bethesda, also clear from an analysis of survival and mortality data reader to judge. In the following chapters, a diverse and MD, USA (T Fojo MD); Cancer Services, Austin Health, that there is little direct relationship with the overall spend expert faculty grapple with key issues, from the Heidelberg, VIC, Australia on cancer in developed countries. The Economist perspectives of classical economics to fundamental (J Siderov MClinPharm); North Intelligence Unit estimates the costs associated with new principles of justice and equity. All major issues are dealt of England Cancer Network 2 and Northumbria Healthcare, cancer cases alone in 2009 to be at least $286 billion. with head on. Their conclusions and solutions have Northumberland, UK Medical costs make up more than half of the economic commonalities and surprises. (S Williamson MRPharmS); burden, and productivity losses account for nearly a quarter Centre for the Humanities and of the total. These fi gures refl ect today’s reality. By 2030, Part 1: Framing the challenge—the cost of Health, King’s College London, there will be an estimated 27 million new patients with cancer care London, UK (S Camporesi PhD); European Institute of 2 cancer per year worldwide. Patient numbers (due to the Why are we concerned with the cost of cancer care? Oncology, Milan, Italy ageing population) will increase, and treatment protocols Reducing the morbidity and mortality caused by cancer (Prof J G McVie MD); King’s will be more complex, and therefore more expensive. The is a global priority. Cancer aff ects an estimated 12 million College London and King’s challenge to developed countries is how to collectively new patients worldwide and leads to more than Health Partners Integrated Cancer Centre, London, UK 1 deliver reasonably priced cancer care to all citizens—ie, 7·5 million deaths annually. Many patients with cancer (Prof A D Purushotham MD); make cancer care aff ordable to individuals and society. would otherwise experience years to decades of good Department of Surgery, Umeå To inform and guide this essential public debate, leading health. Thus, devoting appropriate resources to the University, Umeå, Sweden members of the cancer community, from patient prevention and treatment of cancer, and to research (Prof P Naredi MD); Institut Gustave Roussy, Paris, France advocates to economists and health-care professionals, aimed at eradicating cancer in all forms, is essential. www.thelancet.com/oncology Vol 12 September/October 2011 933 The Lancet Oncology Commission (Prof A Eggermont MD); worth the cost to individuals or society. Novel, more Percent of GDP Memorial Sloan-Kettering eff ective, and less toxic interventions are needed, but the Cancer Center, New York, NY, USA 15·7 price of innovation contributes further to the costs of USA (Prof M F Brennan MD); France 11·0 3 Department of Radiation care. We are thus at a crossroads where our choices, or Oncology, David Geff en School Germany 10·4 refusal to make choices, have clear implications for our of Medicine, University of Canada 10·1 ability to provide care in the future. How can we provide California Los Angeles, Los Australia 8·9 care, improve options and outcomes for patients with Angeles, CA, USA UK 8·4 (Prof M L Steinberg MD, cancer, and do so within a socially responsible, cost- S A McCloskey MD, GDP=gross domestic product. eff ective, and sustainable framework? T Roberts MD); Radiotherapy Department, UZ Brussel, Vrije Table 1: Percent of GDP spent on health care in 20077 Universiteit Brussel, Brussels, How expensive is cancer care? Belgium (Prof M De Ridder MD, The economic impact of cancer care can be measured as Prof D Verellen PhD, 250 total spending, percent of national gross domestic Prof G Storme MD); Molecular product (GDP), or the cost to care for a single patient. Imaging and Targeted Therapeutics Laboratory, Concerns around escalating costs for cancer care include Peter MacCallum Cancer Centre, 137 all of the above, but estimating precise costs and East Melbourne, VIC, Australia 759 calculating total spending is challenging.4 (Prof R J Hicks FRACP); University 68 In the USA, it is estimated that total health-care spending College London Hospitals, Institute of Nuclear Medicine, in 2009 was US$2·5 trillion, accounting for 18% of the 102 Hospital care 5 London, UK (Prof P J Ell FmedSci); Medical doctor and GDP. By comparison, in Australia, total health-care Duke Clinical Research Institute 67 clinical services expenditures were $112·8 billion—roughly $5000 per and Department of Medicine, Other professional capita versus $11 000 per capita in the USA.6 Health-care Duke