With rapid advancements in oncology, even the wealthiest countries around the globe find it increasingly challenging to provide – and sustain – access to new medicines. Challenges include managing the uncertainty surrounding the extent of benefit of new treatments; complexities in determining the price and place in therapy of certain products; and the need to reconcile affordable, equitable access with spending efficiency and fiscal sustainability. Differences in timing of market entry and heterogeneity of coverage processes and policies contribute to inequity in access across the OECD and EU. Future policies and practices to promote sustainable access to oncology medicines will likely focus on improving affordability for patients and value-for-money for payers. An important element will be strengthening the evidence base, drawing on both clinical trial and “real world” evidence, and enhancing international collaboration and information sharing to improve countries’ collective capacity to address clinical and economic uncertainties.