Based on the OECD PaRIS Data, this chapter examines the impact of living with cancer on people’s health and well-being across EU countries and shows how improving people‑centredness can support better health outcomes for those living with cancer. The chapter also provides guidance on how to improve people‑centred care for patients living with cancer, looking at key dimensions including participation in decision making, self-management, and care co‑ordination. The chapter lastly emphasises the importance of integrated policies combining medical, social and economic support for better quality of life and social well-being. The findings aim to inform policymakers on how to reduce inequalities and promote more co‑ordinated, people‑centred care pathways for the growing number of people living with cancer.
Delivering High Value Cancer Care
Abstract
Cancer reduces health, social and economic well-being
According to the OECD PaRIS Survey, which focusses on primary care patients aged 45 years and older, patients with a cancer diagnosis had significantly lower physical health than other patients – mainly driven by a higher level of fatigue and pain, as well as poorer well-being and social functioning.
On average, people with a cancer diagnosis are a third less likely to report their health as good, very good or excellent, compared to other primary healthcare patients.
There is a 3‑fold variation in people living with cancer reporting good health across countries, ranging from 20% in Portugal and Italy to 60% Iceland and Belgium.
The health gap between those with and without cancer is the largest in Greece, Portugal, Slovenia and Spain.
Similar to patients without cancer, there is a large social gradient in patient-reported outcomes among those living with cancer, in favour of higher educated groups.
On average in the EU11 countries included in PaRIS, among people living with cancer, those with a low level of education are almost 30% less likely to report good to excellent health.
Primary care patients with cancer and lower levels of education face a double health burden: 1) the health disadvantages associated with limited education and 2) the additional challenges imposed by the disease, which together accumulate and compound.
Country-level variations are striking. In the Netherlands and Iceland, there is no gap between education groups, whereas Greece, Luxembourg, Portugal and Slovenia show disparities of more than 16 percentage points (p.p.) on general health.
The impact of cancer on employment outcomes is large.
According to the SHARE survey, employment rates among those having a cancer diagnosis are 26% lower compared to those without such a diagnosis, and with a large social gradient in disfavour of people with low education.
On average, a cancer diagnosis reduces the likelihood of employment by 14%.
The largest gaps in employment rates between individuals with a cancer diagnosis and those without are observed in Bulgaria, Czechia, Cyprus, Hungary and Ireland, calling for labour market policies and workplace reintegration support.
Strengthening people‑centred care is key to improving quality of life and health outcomes of people living with cancer
People living with cancer who report more people‑centred care tend to report better physical and mental health, as well as higher overall well-being. Similar patterns of better reported health are observed among those who report being confident in self-managing their care and those reporting higher level of care co‑ordination.
However, less than a third of patients living with cancer in the EU11 report a high level of people‑centred care, ranging from 42% in Belgium to 16% in Greece. Sufficient consultation time, effective communication with one’s doctor, and the possibility to talk about health issues are all associated with a more positive people‑centred score.
There is large potential to improve people‑centredness through more effective use of medical records. Almost one‑third of people living with cancer need to repeat information already available in their health records during consultation, signalling weak integration of care and insufficient data systems. This is a key concern in Italy and Greece, where at least half of people living with cancer need to repeat information already available in their health records.
To further improve people‑centred care, there is scope to invest in co-production of health, including patient involvement in decision making and supporting patients in self-management (particularly in Greece, Iceland and Romania which are lower performers). In addition, care co‑ordination processes, including setting up a care plan, would allow cancer patients to experience care that is seamless and well-integrated (particularly in Iceland, the Netherlands and Spain).
More can be done to meet broader health, social and economic needs of people living with cancer
Cancer care plans and medication reviews, tailored to an individual’s needs and preferences, translate complex medical decisions into clear, actionable roadmaps to guide patients and their care teams through cancer treatment. To maximise their effectiveness, these tools should be supported by robust care co‑ordination and patient navigation protocols (such as in France, Denmark and Estonia), out-of-hours support (such as in Germany and Ireland), and the use of digital solutions (such as in Greece and Sweden).
Important actions are needed to expand the cancer care pathway beyond curative medical treatment to encompass broader social and health needs. These range from integrating palliative care as early as possible and developing community-based palliative care (as done in Belgium, Italy, Norway, Poland, Slovenia). A variety of supportive services have also gained prominence, such as fertility preservation programmes (as done in Germany, the Netherlands or Poland), sexual health support (as done in Austria or Denmark), and lifestyle guidance and psychological support (as done in France, Ireland and Latvia). Survivorship programmes are also slowly emerging to address comprehensively the broader health and social needs of cancer survivors (as developed in the Netherlands and the Slovak Republic).
Financial and employment protection matters to the health and quality of life of cancer patients and their caregivers. Expanding legislation on the “Right to be Forgotten” beyond the nine EU+2 countries where it currently exists is key to prevent discrimination and improve life opportunities. Given the growing burden of early onset cancer, return-to-work support is increasingly critical to safeguard employment and avoid financial toxicity (such as is done in Germany, the Netherlands and Sweden).
Advancements in early cancer detection and treatment have significantly improved survival rates, but they have also brought greater visibility to the challenges patients face in life after diagnosis and treatment. A cancer diagnosis brings with it a wide range of needs and challenges, underscoring the importance of supporting well-being and quality of life for patients living with cancer. These challenges often span multiple dimensions of life, including physical, psychological, social, financial, and spiritual well-being. Ensuring effective access to supportive cancer and survivorship services requires a fundamental shift in perspective – from focussing solely on treating the disease to addressing the comprehensive needs and expectations of the person (Bower, 2014[1]).
Beyond supportive care and survivorship services, people‑centred care is also crucial to enhance quality of life and well-being, as it puts the needs, preferences, values and goals of people at the heart of decision making and care delivery. Unlike traditional models, which focus primarily on diseases, people‑centred care emphasises comprehensive, respectful and co‑ordinated care that supports individuals throughout their health journey – not only during periods of illness, but also during prevention, survivorship and end-of-life care. It goes beyond “patient-centred” care by recognising individuals as active partners in managing their own health, and by addressing the social, emotional and cultural factors that affect health outcomes.
People‑centred care improves health outcomes and patient experiences by focussing on individual preferences, strong patient engagement and effective care co‑ordination (OECD, 2025[2]). This approach is particularly beneficial for managing complex conditions such as cancer – which involves multiple specialists, diagnostic procedures, treatments (surgery, chemotherapy and radiotherapy), follow-ups, supportive care and palliative care. A people‑centred system helps to manage the complexity and reduce the fragmentation in cancer care, fostering communication between patients and providers, thus leading to greater trust, well-being and improved health outcomes.
Based on the OECD PaRIS data (see Box 5.1), this chapter starts by analysing the health, social and economic outcomes of people living with cancer. It shows how strengthening people‑centred care for people living with cancer can lead to improved health outcomes and well-being. It then evaluates how people‑centred primary healthcare systems are performing for people living with cancer and compares key dimensions of people‑centred care across EU countries, including participation in decision making, self-management, and care co‑ordination. Finally, it explores opportunities to make health systems more people‑centred through co‑ordinated clinical care processes, supportive services and financial and workplace programmes.
The Patient Reported Indicator Surveys (PaRIS)
PaRIS captures patient reported outcomes and experience measures (PROMs and PREMs respectively), which matter most to people living with chronic conditions, such as their mental and physical health, social functioning, and psychological well-being, together with their experiences of care co‑ordination and people‑centredness. The survey is the first of its kind to provide harmonised performance indicators for 19 countries on people aged 45 years and older living with chronic conditions and managed in primary healthcare (PHC).
PaRIS includes PHC patients living with cancer, and those who have been diagnosed with or treated for cancer in the five years prior to the survey. This focus provides insight into the treatment and post-acute or survivorship phase of cancer care, where people‑centred approaches shift from supporting quality of life during treatment to ensuring effective care co‑ordination and managing recurrence risk, side effects, and long-term consequences of treatment. The analysis is limited to those patients who have access to PHC. PaRIS echoes the voices of around 107 000 patients in more than 1 800 primary care practices in 19 countries (Australia, Belgium, Canada, Czechia, France, Greece, Iceland, Italy, Luxembourg, the Netherlands, Norway, Portugal, Romania, Saudi Arabia, Slovenia, Spain, Switzerland, Wales (United Kingdom) and the United States), representing nearly 104 million primary care patients.
Sample of patients living with cancer
Overall, 7% of patients in the PaRIS sample reported living with cancer. Cancer patients in PaRIS tend to be older, with a notably higher proportion aged 65 to 74 (33%) and 75+ (27%) compared to the overall PaRIS population. When examining the prevalence of chronic conditions, cancer patients appear to be broadly similar to non-cancer patients, although the prevalence of some conditions is slightly higher among those with cancer. They exhibit a higher prevalence of arthritis (33% versus 32% overall), cardiovascular disease (24% versus 20%), diabetes (19% versus 17%), and hypertension (49% versus 44%). Education levels are also comparable, with 40% of people with cancer having a higher education compared to 41% among the rest of the population. Men make up a slightly larger share of cancer patients (47%) than in the general group (44%).
Percentage of primary healthcare patients aged 45 and older that have or have had cancer in the last five years
Note: *Data for Italy refer to patients enrolled in outpatient settings for specialist visits in selected regions. **United States sample only includes people aged 65 years or older.
Source: OECD PaRIS 2024 Database.
5.2.1. Cancer patients have worse health outcomes and are less likely to report good social functioning than other patients
Cancer patients frequently experience poorer physical and mental health than individuals with other medical conditions due to the multifaceted aspects of the disease, its treatment and long-term impact. Treatments such as chemotherapy, radiation, and surgery, can cause side effects including chronic fatigue, pain, nausea, or loss of appetite, all of which reduce mobility, independence and overall functioning. These symptoms often persist long after treatment ends, leading to lasting impairments. Long-term effects of cancer treatment can significantly impact quality of life; for example, men treated for prostate cancer may experience persistent sexual dysfunction or urinary incontinence following prostatectomy. These late effects are often under recognised but can endure for years and require ongoing management (Lustberg et al., 2023[3]). Mentally, the diagnosis of cancer is also often associated with high levels of psychological distress, including anxiety, depression, and fear of recurrence. The uncertainty surrounding prognosis, frequent hospital visits, body image changes, persistent symptoms, and the disruption to daily life and work further exacerbate emotional strain. Together, these physical and psychological burdens place cancer patients at a higher risk of poor physical and mental health and quality of life compared to those with other chronic conditions.
Empirical studies consistently reported that cancer patients or survivors frequently experience persistent fatigue, reduced physical capacity, and impairments in daily functioning. Based on the Survey of Health, Ageing and Retirement in Europe (SHARE), older adults with a history of cancer reported higher rates of physical limitations – such as mobility issues or difficulties with activities like climbing stairs or carrying groceries – than individuals without cancer (Bültmann, U., Hinzmann, D., & Hasselhorn, H. M., 2023[4]; Veiga, D., Peralta, M., Carvalho, L., Encantado, J., Teixeira, P. J., & Marques, A., 2025[5]). In a similar vein, cancer survivors in SHARE survey waves tend to show higher levels of depressive symptoms and lower subjective well-being than non-cancer peers, especially if they experience functional limitations or lack social support (Vasconcelos, Peralta and Marques, 2025[6]; Veiga, D., Peralta, M., Carvalho, L., Encantado, J., Teixeira, P. J., & Marques, A., 2025[5]). Cancer, especially when occurring alongside conditions like cardiovascular disease or diabetes, was associated with elevated EURO-D depression scores,1 highlighting the impact of co-morbidities on mental health (Feng et al., 2023[7]).
The PaRIS data support earlier findings reported in the literature. Compared to other patients, those with a cancer diagnosis had a significantly lower average self-rated physical health T-score (43 compared to 46 on the PROMIS Physical Scale) (Figure 5.2). The difference in scores is primarily driven by a higher proportion of cancer patients reporting moderate to high levels of fatigue (16%) and pain (20%), compared to 11% and 15%, respectively, among other primary care patients. PHC patients living with cancer in Romania and Portugal have the lowest self-rated physical health (with a score of 40 or less) and the largest gap compared to patients without cancer, alongside Spain (3 points or more). By contrast, Iceland, Luxembourg, the Netherlands and Slovenia have the smallest gap in self-rated physical health between PHC patients with and without cancer (at 2.2 points or less).
Physical health T-score
Note: PROMIS® Scale v1.2 – Global Health component for physical health is a T-score metric with a range of 21‑68, and a good-fair cutoff of 42 (physical health), higher values represent better physical health. *Data for Italy refer to patients enrolled in outpatient settings for specialist visits in selected regions. **United States sample only includes people aged 65 years or older. All within country differences of the PROMIS physical scale between people with and without cancer are statistically significant (p<0.05).
Source: OECD PaRIS 2024 Database.
Smaller gaps are observed for the self-rated mental health indicator. Compared to other patients, those with a cancer diagnosis in the past five years had lower average self-rated mental health (45 compared to 46 on the PROMIS Mental Scale) (data not shown). Nevertheless, the gap between the two patient groups was not significant at 5% error in any of the participating countries.
Much larger differences appear between PHC patients with and without cancer for the likelihood to report good, very good or excellent health. On average in the EU11, only 44% of PHC patients with a cancer diagnosis in the last five years rated their health as good, very good or excellent, compared to 66% of other primary healthcare patients (Figure 5.3). In Romania, Portugal and Italy, less than three in ten PHC patients living with cancer report a good health status compared to six in ten PHC patients with cancer in Belgium, Iceland and Luxembourg. The gap between PHC patients with and without cancer is the largest in Greece (30 p.p.) and Portugal (27 p.p.), and the lowest in Iceland (6 p.p.) and Norway (14 p.p.).
Note: Answer to the question: “In general, would you say your health is …”, “good, very good or excellent” versus “fair or poor”. *Data for Italy refer to patients enrolled in outpatient settings for specialist visits in selected regions. **United States sample only includes people aged 65 years or older. All within country differences between people with and without cancer are statistically significant (p<0.05).
Source: OECD PaRIS 2024 Database.
Looking at other patient reported outcome measures (PROMs), the PaRIS results show that PHC patients with cancer are less likely than other primary healthcare patients to report favourably in terms of social functioning and well-being (Figure 5.4). On average in the EU11, the well-being score of cancer patients is 4 points lower than those without cancer (57 versus 61 on a 0‑100 scale). In addition, only 80% of primary care patients with cancer are positive on average about their social functioning compared to 85% of other primary care patients.
For social functioning, the cross-country variation ranges from 60%‑90%. Southern Europe, including Spain, Portugal and Italy have the lowest share of PHC patients with cancer reporting positive outcomes for their social functioning (around 70% or less), while France, Slovenia, Greece and Belgium have the highest, with almost 90% of cancer patients reporting favourably in terms of social functioning and well-being.2
Cancer affected my wellbeing because of several surgeries, chemotherapy and endocrine treatment, that caused a lot of physical problems such as nausea, vomit, fatigue and pain…I still continue having pain and fatigue.
Conchi, 68 years old, breast cancer
Note: WHO‑5 well-being index. Response to five questions measuring well-being. Raw scale 0‑25 converted to 0‑100 scale, higher scores represent higher well-being. PROMIS® Scale v1.2 – Global Health. Answer to the question: “In general, please rate how well you carry out your usual social activities and roles”, “good, very good or excellent” versus “fair or poor”. * Data for Italy refer to patients enrolled in outpatient settings for specialist visits in selected regions. **United States sample only includes people aged 65 years or older.
Source: OECD PaRIS 2024 Database.
SHARE is a longitudinal survey providing internationally comparable data on individuals aged 50+, encompassing domains such as health, employment, income, family, and well-being. The sample of this analysis includes all SHARE respondents aged 50 and above who self-reported a diagnosis of cancer (excluding minor skin cancers) between 2004 and 2022, at any point prior to or during their participation in the survey. Rather than focussing exclusively on recent diagnoses, this population captures a broad spectrum of cancer survivors at various stages of post-diagnosis, including long-term survivors.
The CASP‑12 scale is used as a proxy to assess quality of life in older adults, encompassing four domains: control, autonomy, self-realisation, and pleasure. CASP‑12 scores range from 12 to 48, with higher scores indicating better quality of life. Results revealed substantial variation in CASP‑12 scores among people living with cancer across European countries (Figure 5.5). The highest scores were observed in Denmark (40), the Netherlands and Luxembourg (39), pointing to relatively favourable survivorship experiences. In contrast, the lowest averages were recorded in Greece (30), the Slovak Republic (31) and Bulgaria (32), underscoring poorer outcomes in Southern and Central European countries. Countries such as Poland, Malta, France, Belgium, are closer to the EU27 average, with scores around 35. Overall, the results suggest a marked geographical gradient, with Northern and Western European countries generally providing environments more conducive to well-being after a cancer diagnosis, while survivors in Southern and Central Europe experience systematically lower quality of life. These findings are consistent with earlier SHARE‑based analyses that documented persistent East-West inequalities in older adults’ well-being (Bazilainsky et al., 2023[8]), and they reinforce the need for comprehensive survivorship policies that address not only medical care but also social and economic determinants of quality of life.
CASP‑12 score among people living with cancer
Note: CASP‑12 scale measures quality of life among older adults, with higher scores indicating better quality of life. The analytic sample includes 15 849 respondents. To ensure a longitudinal perspective, individuals were required to have participated in at least two survey waves. An exception was made for those who already reported a cancer diagnosis at their baseline interview, who were also included even if they contributed only one wave. This approach preserves representativeness of cancer survivors while allowing for within-person change to be observed.
Source: SHARE Survey, Wave 1 (2004) to Wave 9 (2021/22).
Across all surveyed countries and waves, people living with cancer reported significantly lower quality of life compared to their peers without cancer, which persisted after adjusting for age, sex, comorbidities, education, and marital status. The gap in quality of life between people living with cancer and those without varied widely across Europe: cancer survivors reported the largest quality of life losses in Greece, Hungary, the Slovak Republic and Spain, where scores were well below those of their peers, while differences were smallest in Denmark, Finland, the Netherlands and Sweden.
The SHARE analysis also shows that barriers to specialist care are a key driver of reduced well-being. Individuals who reported being unable to access a specialist because care was unavailable scored systematically worse on CASP‑12, regardless of whether they had cancer. This illustrates how unmet medical needs undermine quality of life (see Chapter 3). Crucially, the analysis also reveals that cancer survivors bear an extra burden in contexts where specialist care is lacking. In countries such as Latvia and Croatia, the cancer – no cancer gap in quality of life nearly doubled when respondents reported that a specialist was unavailable.
Education-related inequalities compound challenges for cancer patients. Across Europe, survivors with lower educational attainment consistently reported poorer quality of life than their more educated peers. This gradient was visible even after accounting for comorbidities and other socio-demographic factors. Taken together, these results reinforce the case for integrated survivorship policies that combine medical follow-up with health literacy initiatives, targeted support for disadvantaged groups, and social protection.
Note: Estimates are derived from regression models of standardised CASP‑12 scores. All models included as regressors: cancer status (β1), barriers to specialist care (β2), and their interaction (β3), along with covariates for age, sex, education (ISCED groups), marital status, and comorbidity count. Country and wave fixed effects were included in pooled OLS regressions, while individual fixed-effects models additionally controlled for time‑invariant characteristics of respondents by excluding person-level fixed effects, together with wave (and country, for the pooled model).
5.2.2. PHC patients with cancer and lower education are almost 30% less likely to report good to excellent health compared to those with higher levels of education
PaRIS data show that among PHC patients who live with cancer, there is a strong social gradient in patient-reported outcomes. There are significant differences between education levels in well-being, general health and social functioning (data not shown) in favour of higher educated groups (Figure 5.6).
This finding has already been demonstrated in the general population (OECD, 2023[9]). However, the social gradient between PHC patients with and without a cancer diagnosis does not differ. In other words, receiving a cancer diagnosis does not diminish the education-related health gap. As a result, PHC patients with cancer and lower levels of education face a double health burden: the health disadvantages associated with limited education and the additional challenges imposed by the disease, which together accumulate and can compound over time.
On average in the EU11 countries, among PHC patients living with cancer, those with a low level of education are almost 30% less likely to report good to excellent health status. Country-level variations are particularly striking for general health. In the Netherlands and Iceland, there is virtually no gap between education groups, whereas countries such as Greece, Slovenia, Luxembourg and Portugal show disparities of more than 16 p.p. On average there is a tenfold variation in the size of the gap between countries.
While differences in well-being by education groups between countries are somewhat less pronounced, notable disparities still exist. On average in the EU11 countries, the gap in the well-being score between education groups remains at seven points, with well-being score being 11% lower among those with a lower level of education compared to those with a higher-level education. Cross-country variation in the educational gap is also evident. It ranges from a gap of two points in the Netherlands to ten points in Spain and Romania.
General health and well-being among PHC patients living with cancer
Note: WHO‑5 well-being index. Response to five questions measuring well-being. Raw scale 0‑25 converted to 0‑100 scale, higher scores represent higher well-being. PROMIS® Scale v1.2 – Global Health. Answer to the question: “In general, would you say your health is …”, “good, very good or excellent” versus “fair or poor”. *Data for Italy refer to patients enrolled in outpatient settings for specialist visits in selected regions. **United States sample only includes people aged 65 years or older.
Source: OECD PaRIS 2024 Database.
In addition, among PHC patients living with cancer, those with higher education show more favourable scores on physical and mental health. There are statistically significant gaps of four points on average among the sample of patients for self-rated physical and mental health T-scores (Figure 5.7). For physical health, the largest educational gaps are found in Iceland and Romania, while for the mental health score, the largest social gradient is found in Czechia, the Netherlands and Romania. Among other OECD countries, the United States displays the largest social gradient for both self-rated physical (6 points) and mental health (10 points) T-scores.
Note: PROMIS® Scale v1.2 – Global Health component for physical and mental health is a T-score metric with a range of 21‑68, and a good-fair cutoff of 42 (physical health) and 40 (mental health), higher values represent better physical and mental health respectively. *Data for Italy refer to patients enrolled in outpatient settings for specialist visits in selected regions. **United States sample only includes people aged 65 years or older.
Source: OECD PaRIS 2024 Database.
5.2.3. Cancer diagnosis reduces the likelihood of employment by 14%
A handful of studies consistently shows that cancer has a substantial and multi-faceted impact on employment and productivity, both at the individual and societal levels. A systematic review analysing the impact of lung cancer on the employment status of cancer survivors shows that lung cancer survivors are two to three times more likely to be unemployed compared to individuals without a cancer diagnosis (Vayr et al., 2019[10]). Among breast cancer survivors, employment outcomes are particularly concerning: around 30% of those who were employed at the time of diagnosis were no longer working four years later, with chemotherapy increasing this risk of unemployment by 40% (Jagsi et al., 2014[11]). The long-term impact on lost earnings and unemployment is particularly of concern where cancer is diagnosed at a younger age (Bentley et al., 2022[12]).
In terms of work capacity and productivity, many patients living with cancer report significant challenges. A national survey in the United States found that 70% of employed cancer patients experienced work disruptions during treatment, including missed days (32%), wage losses (18%), and reduced work quality (10%) (Kansal et al., 2024[13]). People living with colorectal and breast cancer exhibit higher rates of long-term disability and more frequent absenteeism (Zheng et al., 2015[14]). For example, one study based on the 2008-2012 Medical Expenditure Panel Survey in the United States found that colorectal and breast cancer survivors had 14% and 5% (respectively) higher disability rates compared to those without cancer (Zheng et al., 2015[14]). Overall, at the macro level, the indirect cost of cancer on productivity and workforce participation is large, as it is estimated that OECD countries lose the equivalent of 3.1 million full-time workers due to cancer (1.1 million in the EU) (OECD, 2024[15]). This translates into a lost workforce output of EUR PPP 180 per capita per year, or EUR PPP 163 billion per year.
Figure 5.8 demonstrates average employment rates across the 27 EU countries in the SHARE sample. The results indicate that the proportion of individuals employed or self-employed among those having a cancer diagnosis is 26% lower compared to those without such a diagnosis (49% vs. 66%). The estimated effect is aligned with a synthetic study by de Boer et al. (2020[16]), who estimated the loss of work being 27% immediately after a cancer diagnosis. The employment rate is consistently lower among respondents with a history of cancer, regardless of gender, educational attainment, or country of birth. However, among respondents with a cancer diagnosis, the employment rate is 39% lower among those with a low level of education compared to those with higher education levels. Disparities are less pronounced when considering country of birth: the employment gap between native‑born and foreign-born respondents with a cancer diagnosis is 3 p.p. (50% vs. 47%, respectively).
Percentage of employment and self-employment, EU average over 2004-2022
Note: Austria, Belgium, Bulgaria, Croatia, Cyprus, Czechia, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, the Netherlands, Poland, Portugal, Romania, the Slovak Republic, Slovenia, Spain and Sweden are included. SHARE is among people aged 50 and above.
Source: Survey of Health, Ageing and Retirement in Europe (SHARE), Wave 1 (2004) to Wave 9 (2021/22).
Controlling for individual and country-specific effects, regression analysis largely confirms the negative and significant association between a cancer diagnosis and employment prospects. Having a cancer diagnosis is consistently associated with a statistically significant reduction in the likelihood of being employed, with coefficients ranging from ‑0.161 to ‑0.142 from Ordinary Least Squares models and from ‑0.065 to ‑0.068 from fixed effects models (Table 5.1), meaning that having a cancer diagnosis reduces the likelihood of employment by between 14%‑16%, compared to not having a cancer diagnosis This negative association remains robust even after adjusting for demographic characteristics, chronic conditions, and fixed effects for country and year.
Note: Level of significance: NS: non-significant, *p<0.10, **p<0.05, ***p<0.01. Standard errors are clustered at the individual level. The number of observations is 112 692 in all models. The constant term is included in all OLS models. Probit estimation of the likelihood to be employed or self-employed yield similar results (data not shown). Age2 refers to the square of the age variable, which allows the model to capture non-linear effects of age.
Source: Survey of Health, Ageing and Retirement in Europe (SHARE), Wave 1 (2004) to Wave 9 (2021/22).
At the country level, the employment gap between individuals living with a cancer diagnosis and those without tends to be smallest in countries with the highest proportion of people employed/self-employed, including the Nordic countries and Lithuania (Figure 5.9). The most substantial employment gaps are observed in Hungary (‑46 p.p.), Czechia (‑38), Cyprus (‑29), Ireland (‑28) and Bulgaria (‑28). It highlights significant cross-country disparities in the employment impact of cancer, suggesting that national-level factors – such as labour market policies, social protection systems, and workplace reintegration support – play a key role in shaping labour market outcomes for people living with cancer. In Denmark, for example, a population-based study finds that employment outcomes between cancer survivors and the general population become negligible after five years during the observation period of 2000 to 2015, except for those who experienced lung, colorectal, upper gastrointestinal and blood cancers (Brink et al., 2024[17]).
Country-specific fixed-effects regression results (data not shown) further support these findings. Among countries performing above the EU average, the negative effect of a cancer diagnosis on employment is statistically significant in Estonia and France; as well as in Cyprus, Italy, Czechia and Hungary among underperforming countries, indicating a negative impact of cancer on employment outcomes all things being equal (holding all other characteristics constant). These findings suggest both structural and policy-related differences across countries that may influence the ability of individuals with cancer to remain in or return to employment.
Note: Latvia, Romania and the Slovak Republic are not presented as the share of people with a cancer diagnosis is too small in the sample (with less than 1.5% of observations in each country) but are included for the EU average. SHARE is among people aged 50 and above.
Source: Survey of Health, Ageing and Retirement in Europe (SHARE), Wave 1 (2004) to Wave 9 (2021/22).
The increasing incidence of early-onset cancer (see Chapter 2) is expected to have significant long-term economic consequences, particularly due to lost productivity and reduced workforce participation and working hours among younger patients. Greater attention must be given to return-to-work support for people living with cancer (see Section 5.5). Moreover, the impact extends beyond patients themselves, affecting family members and caregivers – many of whom face job disruptions, stress-related absenteeism, and financial hardship due to their caregiving responsibilities.
People‑centred care puts the needs, preferences, values and goals of individuals and communities at the heart of decision making and care delivery, emphasising respectful and co‑ordinated care that supports individuals throughout their health journey. People‑centredness is particularly critical for people living with cancer, who often navigate complex care pathways involving multiple providers and settings – such as primary healthcare, oncology, palliative care, and support services. For these patients, people‑centred care can help ensure better co‑ordination and continuity across the full spectrum of care, improve communication with providers, and empower them to actively participate in decisions about their treatment and support, ultimately leading to better health outcomes. In PaRIS, people‑centredness is measured by the concept of person-centred care using the P3CEQ scale (Lloyd et al., 2018[18]), which includes eight items ranging from discussion on what is important and involvement in decision making, to having confidence to self-manage care (see Box 5.3).
PaRIS measures people‑centredness using the P3CEQ scale, which refers to the concept of person-centredness. The scale combines the following eight items that are equally weighted from 0 to 3 (the higher the score, the higher the person-centredness). The final scale ranges from 0 to 24:
Discuss what is important, derived from the question “Do you discuss with the healthcare professionals involved in your care what is most important for you in managing your own health and well-being?”
Involved in decisions, derived from the question “Are you involved as much as you want to be in decisions about your care?”
Considered as a whole person, derived from the question “Are you considered as a ‘whole person’ rather than just a disease/condition in relation to your care?”
Need to repeat information, derived from the question “Were there times when you had to repeat information that should have been in your care records?”. The positive item is when the patient indicates that there is no need to repeat information.
Care organisation, derived from the question “Is your healthcare organised in a way that works for you?”
Support to self-manage, derived from the question “Do you receive enough support from healthcare professionals to help you manage your own health and well-being?”
Information to self-manage, derive from the question “To what extent do you receive useful information at the time you need it to help you manage your own health and well-being?”
Confidence to self-manage, derived from the question “How confident are you that you can manage your own health and well-being?”
Cross-country variations in person-centred care might also reflects differences in patient expectations regarding the degree of person-centred care, which varies by age, gender, and individual preferences.
Source: Lloyd et al. (2018[18]), “Validation of the person-centred coordinated care experience questionnaire (P3CEQ)”, https://doi.org/10.1093/intqhc/mzy212; OECD (2025[2]), Does Healthcare Deliver?: Results from the Patient-Reported Indicator Surveys (PaRIS), https://doi.org/10.1787/c8af05a5-en.
5.3.1. PHC patients living with cancer who experience more person-centred care report better physical and mental health, and have higher well-being
PaRIS data show that in all countries, PHC patients living with cancer who report higher levels of person-centred care (corresponding to a person-centred score of 19 or more out of 24) feel healthier and report better physical health score than those who report lower person-centred care (score below 17). On average, the difference between cancer patients reporting higher and lower levels of person-centred care stands at about four points for both the PROMIS physical scale and the mental health scores (Figure 5.10).
An interesting finding is that cancer patients who report high levels of person-centredness show even better mental health than patients with other chronic conditions treated in primary healthcare. In terms of physical health, high person-centredness places cancer patients on par with patients with other chronic conditions, whereas cancer patients reporting low person-centredness have significantly worse health outcomes (Figure 5.10).
When comparing cancer patients with high versus low levels of person-centred care, the largest absolute differences in physical scores are seen in France, Spain and Romania, as well as the United States. Conversely, countries like Belgium, Greece and Iceland displayed relatively small gaps in physical scores between cancer patients with high and low levels of person-centred care. The largest differences in mental health between cancer patients with high versus low person-centred care are seen in Romania, Italy and Norway, as well as in Australia and the United States. On the other hand, Iceland and Slovenia showed the smallest gaps. Overall, increasing person-centred care is of particular importance in Romania, Portugal, Italy and Spain – which are countries that present the lowest physical and mental health scores among cancer patients reporting low levels of person-centredness. A key policy direction to mitigate the indirect health impact of cancer is to enhance people‑centred primary healthcare.
PROMIS Physical and Mental health score by levels of P3CEQ Person Centredness
Note: PROMIS® Scale v1.2 – Global Health component for physical and mental health is a T-score metric with a range of 21‑68, and a good-fair cutoff of 42 (physical health) and 40 (mental health), higher values represent better physical and mental health respectively. The figure compares physical and mental health score of people with low-medium person-centredness care (score below 17 points out of 24) and the group with high person-centredness care (score above or equal to 19 points out of 24). The “no Cancer” group comprises only people with chronic conditions (other than cancer). *Data for Italy refer to patients enrolled in outpatient settings for specialist visits in selected regions. ** United States sample: only includes people of 65 years and older.
Source: OECD PaRIS 2024 Database.
Looking at the well-being index provides similar results (data not shown). On average in the EU11, those living with cancer and with high levels of person-centred care report a higher well-being score (64) than their counterparts with low levels of person-centred care (53). Overall, the highest gap in well-being among cancer patients having high and low levels of person-centred care was found in France, Portugal and Italy.
While direct evidence from trials demonstrating that P3CEQ scores lead to improved clinical outcomes such as reduced hospitalisations or mortality is still emerging, there are consistent correlations with higher quality of care and improved self-management (Rijken et al., 2022[19]). Higher person‑centred care experience translates into better health engagement and satisfaction, which are intermediate predictors of longer-term health and social benefits (Kuipers, Cramm and Nieboer, 2019[20]).
5.3.2. PHC patients living with cancer who are confident in self-managing care have better physical and mental health
Confidence to self-manage, which measures how confident patients living with cancer are in managing their own health and well-being, is a key component of person-centred care. According to PaRIS data, in all countries, PHC patients living with cancer who are more comfortable self-managing their health have higher physical and mental health outcomes (Figure 5.11). On average, the difference in health outcomes between cancer patients reporting confidence and no confidence in self-management is of five points on both the PROMIS physical and mental health scores. The health gap between respondents being confident and those not being confident is the largest in the Netherlands, France and the United States for physical health, and in Iceland, Norway, Wales (United Kingdom) and Australia for mental health. For both health outcomes, Romania, Portugal, Spain and France present the lowest physical and mental health scores among those not being confident in self-managing their health, highlighting the scope for improvement in these countries. Similar results are found looking at the well-being index (data not shown).
These results align with several studies showing that self-management support is associated with improved physical and mental health outcomes for cancer patients, but the reverse relationship also holds true (patients with poorer health outcomes often feel less capable of managing their own health). A 2024 systematic review examining 32 self-management programmes for cancer patients, shows that two‑thirds led to improvement in quality of life, associated most often with combined individual and group delivery on topics such as lifestyle advice and support, training for psychological strategies or information about the condition and its management (Rimmer et al., 2023[21]). A more recent randomised controlled trial has shown that colon cancer survivors who followed a structured exercise regimen saw survival rates rise to 90%, compared to 83% in controls, alongside reduced fatigue and pain (Courneya et al., 2025[22]). A 2023 scoping review also showed that self-management exercise programmes among breast cancer survivors improved physical function, decreased fatigue, and enhanced emotional well‑being (Bo et al., 2023[23]).
Lastly, similar results are found using the indicator on experienced co‑ordination, another key component of person-centredness. Cancer patients who reported a seamless and continuous journey through different healthcare practices and settings experience higher levels of physical, mental, and overall well-being (data not shown). These findings are consistent with observational studies which show that survivors who receive co‑ordinated care – characterised by clear information exchange, emotional support, and continuity – report better physical, social, and functional outcomes (Monterosso et al., 2019[24]; Bell et al., 2020[25]). Recent systematic reviews also corroborate these findings, demonstrating that co‑ordination yields the largest quality of life gains in people living with cancer and with social disadvantage (Chen M, Wu VS, Falk D, Cheatham C, Cullen J, Hoehn R., 2024[26]).
PROMIS Physical and Mental health scores by having confidence in self-managing care
Note: PROMIS® Scale v1.2 – Global Health component for physical and mental health is a T-score metric with a range of 21‑68, and a good-fair cutoff of 42 (physical health) and 40 (mental health), higher values represent better physical and mental health respectively. Confidence to self-manage: Response to question: “How confident are you that you can manage your own health and well-being?”, response options range from not confident at all (0) to very confident (3). *Data for Italy refer to patients enrolled in outpatient settings for specialist visits in selected regions. * United States sample: only includes people of 65 years and older.
Source: OECD PaRIS 2024 Database.
5.4.1. PHC patients living with cancer reported similar experiences of person-centredness compared to patients with other chronic conditions
Using the P3CEQ scale, PaRIS results show that primary healthcare patients with cancer and other chronic conditions do not differ significantly in their experience of person-centred care, with the score averaging 17 (out of a maximum 24) for both populations. In addition, in all countries, patients living with cancer scored on average above the cutoff value indicating positive experience (>=12). This means that on average, in each country, over 50% of patient living with cancer responded positively to the 8 questions. Among the EU11 countries, P3CEQ score was highest in Belgium and Romania, and lowest in Portugal, Iceland and Greece (Figure 5.12).
P3CEQ Person centredness score
Note: P3CEQ Person-centredness score (1‑24) where a higher score means more person-centredness. P3CEQ scores are only calculated for people with chronic conditions, hence, the “No cancer” group has at least one other chronic condition (other than cancer).
Source: OECD PaRIS 2024 Database.
5.4.2. A third of PHC patients with cancer report high levels of people centredness in the EU11
Figure 5.13 presents the percentage of people reporting high person-centredness (score at or above 19). Among EU11 countries, about four in ten PHC patients living with cancer in Belgium consider their primary healthcare highly person-centred. In contrast, only 1.6 out of ten PHC patients living with cancer reported this in Greece. Overall, there is a 2.5‑fold variation across countries in the percentage of PHC patients living with cancer reporting high person-centred care. As mentioned in Box 5.3, some of the observed variation likely reflects differences in patient expectations regarding the degree of person-centred care, highlighting the importance of tailoring cancer care to individual needs and preferences.
Percentage of patients reporting high person-centredness (score of 19 or over)
Note: P3CEQ Person-centredness score (1‑24) where a higher score means more person centredness. P3CEQ scores are only calculated for people with chronic conditions, hence, the “No cancer” group has at least one other chronic condition (other than cancer). *Data for Italy refer to patients enrolled in outpatient settings for specialist visits in selected regions. * United States sample: only includes people of 65 years and older.
Source: OECD PaRIS 2024 Database.
According to PaRIS analyses, sufficient consultation time, effective communication with one’s healthcare professional, and use of digital tools contribute to person-centred care experiences in general. Spending enough time during consultations and the provision of easy-to‑understand instructions are particularly important for more person-centred care, as well as the use of digital tools (OECD, 2025[2]). These results are also confirmed among PHC patients living with cancer. There is a positive correlation between the proportion of people reporting a high level of person-centred care and those receiving easy-to‑understand explanations, and the time spent with health professionals (Figure 5.14), as well as the possibility to talk about health issues (data not shown).
Note: High-level of person-centredness refers to score of 19 or more based on P3CEQ Person-centredness score (1‑24). P3CEQ scores are only calculated for people with chronic conditions, hence, the “No cancer” group has at least one chronic condition (other than cancer).
Source: OECD PaRIS 2024 Database.
5.4.3. Person-centredness could be improved through more effective use of medical health records
According to PaRIS, almost one‑third of PHC patients living with cancer needed to repeat information that should have been in their health records (Figure 5.15). Having to repeatedly provide health information that should be documented in a patient’s care record signals weak integration of care, insufficient data systems, and limited capacity to support smooth care transitions. The highest percentages were observed in Italy and Greece, where more than half of people living with cancer reported that they needed to repeat health information that should have been available in their health records. By contrast, this applied to only one in six people living with cancer in Belgium, Slovenia and Czechia.
Percentage of cancer patients who needed to repeat information that should have been available in their health records
Note: *Data for Italy refer to patients enrolled in outpatient settings for specialist visits in selected regions. * United States sample: only includes people of 65 years and older.
Source: OECD PaRIS 2024 Database.
5.4.4. A range of additional attributes can help strengthen the co-production and co‑ordination of care
Two key dimensions of person-centredness are co-production of health and co‑ordination of care. These dimensions reflect different but interrelated aspects of person-centredness:
Co-production of health refers to the extent to which patients are involved in shaping their care and managing their health. It includes experiences such as being involved in decision making, feeling confident in managing one’s own health and being supported with the right information and resources to manage care (see Table 5.2).
Co‑ordination of care relates to the organisation and continuity of care across different providers and settings, so that patients experience care that is seamless, consistent, and well-integrated. It includes receiving co‑ordinated services, being treated in practices well-prepared to co‑ordinate care, and having an overall care plan.
Table 5.2 presents a set of indicators that summarise these two dimensions based on PaRIS. While not exhaustive, these indicators provide a meaningful overview of each concept and provide guidance to policymakers on how to improve person-centred care in primary healthcare settings for people living with cancer3.
Note: P3CEQ Co‑ordination score (0 to 15), based on response to five questions measuring care co‑ordination (care joined up, single named contact, overall care plan, support to self-manage, information to self-manage). Cells are shaded darker green for values above the 95% confidence interval of the EU11 average, and lighter green for values below it. *Data for Italy refer to patients enrolled in outpatient settings for specialist visits in selected regions. ** United States sample: only includes people of 65 years and older.
Source: OECD PaRIS 2024 Database.
EU countries like Belgium, Czechia and Spain consistently perform well across most indicators of co-production, alongside Australia, Canada and Switzerland. On the other hand, Greece, Iceland and Romania show weaker results, in addition to other OECD countries like Wales (United Kingdom) and the United States. On average in the EU11, most patients with cancer report being involved in decision making (92%), and over 95% of patients report involvement in Australia, Belgium, Canada, Czechia, Iceland and Luxembourg.
Just under three out of five (58%) PHC patients living with cancer in the EU11 report being confident in managing their own health and a higher proportion (67%) say they receive enough support to manage their own health. Confidence in managing one’s own health varies widely, with rates ranging from 85% in France and 76% in the Netherlands to just 24% in Italy and 33% in Iceland, pointing to wide disparities in how empowered patients feel to manage their own health. These results suggest that even health systems with high patient engagement may lack the organisational capacity to deliver fully integrated, supportive care.
On the co‑ordination of care side, Italy and Romania consistently perform well across most indicators, while the Netherlands and Spain (as well as Canada and Wales (United Kingdom)) show weaker results. The contrast between Romania’s comparatively weaker position in co-production and stronger position in co‑ordination can reflect a historical paternalistic approach of primary healthcare doctors with more recent improvements in care pathways guidelines. Nevertheless, in 2023 Romania implemented a pioneering law establishing the right to personalised medicine, with important elements regarding co-production of health (Geanta et al., 2024[27]). The effects of this reform will most likely be seen in the coming years.
The average score of co‑ordination of care reported by PHC patients living with cancer was just above half of the total possible score (8.7 out of 15), ranging from 10.6 in Romania and 10.4 in Switzerland to 6.7 in Iceland and 5.7 in Wales. On average across the 11 EU countries, 40% of PHC patients living with cancer receive primary care in practices that report being well-prepared to co‑ordinate care. Only Iceland (56%), Italy (50%), Slovenia (46%) and Portugal (44%) report better results than the EU11 average. In addition, half of PHC patients living with cancer report having a care plan (50%). This proportion varies more than 6‑fold across countries, from a low of 12% in the Netherlands to a high of 79% in Italy. As highlighted in the following section of this Chapter, establishing a care plan is a key policy option to enhance care co‑ordination and to guide both patients and care teams throughout treatment.
5.5.1. People‑centred cancer care: Shaping clinical care processes and organisation around patients’ needs
A range of policies can make care more people centred. Cancer care plans and medication reviews address a person’s needs and preferences. These tools translate complex medical decisions into clear, shared roadmaps that guide patients and their care teams through treatment and beyond, and can be supported by effective care co‑ordination, patient navigation or case management, out-of-hours support, and digital tools (Figure 5.16).
Note: Countries reporting “Yes” to the question “Has your country introduced policies to promote people-centred cancer care?” are included. EU+2 countries are represented in dark green, while other OECD countries are represented in light green.
Source: 2025 OECD Policy Survey on High Value Cancer Care.
Cancer care plans and medication reviews help to put patient needs at the centre
Providing personalised cancer care plans is a widely adopted approach across EU+2 countries to foster people-centred cancer care. According to the 2025 OECD Policy Survey on High-Value Cancer Care, a personalised care plan was reported in 15 EU+2 countries. These are typically structured as a comprehensive document to guide patients and their healthcare teams through active treatment and are updated regularly to reflect patient preferences. Key components range from details of diagnosis and staging, test results, planned treatment with dosage, timing and scheduling, identification of responsible providers at each stage of care, and anticipated side effects and their management via supportive services (Prabhu Das et al., 2018[28]). Such plans support care co‑ordination, enhance teamwork among professionals, and empower patients to actively participate in treatment decisions. Integration into electronic health records further facilitates their use and relevance.
Adoption of personalised cancer care plans grew substantially throughout the 2000s and 2010s, with early implementation in European countries such as France. Ensuring that all patients can access such care plans can be done with a regulatory framework mandating the systematic use of care plans, as in France, or with a guideline framework, as in Denmark. In France for example, healthcare establishments authorised to treat cancer must systematically provide patients with a written Programme Personnalisé de Soins (PPS). This is mandatory for all newly diagnosed cancer patients since 2009 as part of the national Plan Cancer. Developed by the multidisciplinary oncology team in consultation with the patient, the PPS sets out the diagnosis, the sequence and objectives of planned treatments, anticipated side effects, supportive care options, and the healthcare professionals involved. It is provided in writing at the time of diagnosis and updated as needed throughout the treatment journey. The PPS serves as both a clinical co‑ordination tool and a communication document, ensuring that patients, their families, and all members of the care team share the same information and treatment objectives.
My first oncologist included my husband and me in all discussions and treatment decisions…A hospital curator met my children, husband and me for information, talks and advice; we drafted together a survivorship care plan, she connected me to psychological services and health education classes and listened to my worries and suicidal thoughts...
Margareta, diagnosed with Non-Hodgkin’s lymphoma at age 49 years
Other countries, such as Denmark, but also the United Kingdom and South Korea, promote care plans as part of a national guideline framework. These guideline frameworks include the standardisation of treatment. In Denmark’s Cancer Plan V for example, the written treatment plan is described as a core people-centred tool given to every individual diagnosed with cancer. It is developed in collaboration between the patient and the multidisciplinary cancer team and is intended to be individualised and accessible. The written treatment plan outlines the diagnostic and therapeutic steps to follow, describing the overall path of cancer care. It is to be reviewed and updated throughout the care pathway to reflect changes in the patient’s condition, preferences, or treatment options.
In the United Kingdom, the guideline framework also states that each patient diagnosed with cancer should receive a tailored care package that addresses physical, emotional, social, and practical needs, following a broad needs assessment. One valuable lesson for EU countries is the importance of ensuring that structured primary care cancer reviews are carried out by local general practitioners or nurses, giving patients a dedicated opportunity to discuss their concerns and receive guidance on available community services. Additionally, the care plan should include end-of-treatment summaries that outline completed treatments, possible side effects, recurrence warning signs, and follow-up contact points. In 2022, the NHS England estimated that 80% of cancer multidisciplinary teams offered such care plans (NHS England, 2025[29]).
Expanding the role of hospital pharmacists is another way to place patients’ values and preferences at the centre of cancer care (see also Chapter 4). Despite medication reviews being a core clinical responsibility of pharmacists, the 2025 OECD Policy Survey on High-Value Cancer Care reports that such reviews are implemented in oncology in only four EU+2 countries. Involving oncology pharmacists can bring clear benefits: a recent systematic review of 20 randomised controlled trials across multiple countries found that pharmacist-led interventions improved cancer treatment adherence nearly five‑fold and reduced medication related problems by about half compared with standard care (Fentie et al., 2024[30]). Slovenia has been gradually introducing clinical pharmacists into hospital settings in recent years, progressing incrementally due to limited human resource capacities. In France, since 2023, hospital pharmacists can now adapt and renew prescriptions for hospitalised patients, including those undergoing cancer treatment. In Germany, the state of Lower Saxony has made it mandatory for hospitals to have ward pharmacists. These medication experts advise and support doctors and nursing staff, thereby ensuring greater patient safety, including in oncology wards.
This is also the case in other OECD countries, such as Australia, where hospital pharmacists play an active role in oncology care by participating in prescribing decisions, monitoring toxicities, and adjusting anti-cancer drug dosages. The Australian Government is considering expanding their scope of practice in order to improve medication safety and relieve pressure from doctors and nurses in hospitals (Australian Government, 2022[31]). England is also implementing the most ambitious expansion of pharmaceutical prescribing authority in Europe, with plans for all new British pharmacy graduates to automatically qualify as independent prescribers from 2026. This means that many more independent prescribing pharmacists will be able to initiate, adjust, and manage medications for cancer patients.
The delivery of a personalised care plan requires effective care organisation to meet patients’ needs, preferences and expectations
The delivery of a personalised care plan requires putting in place systems that ensure co‑ordination and continuity, such as communication protocols between specialists, patient navigation or case management programmes, out-of-hours support, and digital tools.
Co‑ordination and communication protocols between specialists, reported by 17 EU+2 countries, often take the form of systematic multidisciplinary team reviews for cancer patients. Their effectiveness stems from the involvement of a wide range of professionals with complementary expertise, tailored to the type and stage of cancer.
Many EU countries mandate systematic multidisciplinary reviews, such as Czechia, Denmark and Germany. In Czechia, all newly diagnosed patients and those requiring treatment changes are required to undergo a multidisciplinary team review. About 60‑80% of newly diagnosed cancer patients currently undergo multidisciplinary team consultation. Comprehensive Cancer Centres have higher rates, with for example, over 80% of stage I-III breast cancer patients in such centres receiving multidisciplinary assessment compared to only 45‑55% in regional centres. The Ministry of Health is addressing this gap through standardisation initiatives, planned support for regional oncology groups, and development of a unified communication platform (Zdravotnický deník, 2024[32]). In Malta, the Cancer Nurse Navigator is part of the multidisciplinary team to co‑ordinate care and support patients and families across the entire cancer pathway, from suspicion and diagnosis through treatment, and into survivorship or palliative care.
Examples from other OECD countries offer valuable lessons for EU countries. In Switzerland, patients receiving treatment at Geneva University Hospitals receive care and support from the Interprofessional Specialised Oncology Team (IMAD, 2024[33]). The team includes oncology and palliative care nurses, community health assistants, home help staff, a co‑ordinator, and a team leader. They work in collaboration with dietitians, occupational therapists, social workers, and a liaison nurse, ensuring that care is closely co‑ordinated with Geneva University Hospital oncologists. Available seven days a week, with multiple visits per day if needed, this service ensures continuity of care and a rapid response to changing needs. Access is based on a medical prescription, with costs covered 90% by basic health insurance.
In Japan, the mandatory multidisciplinary team approach integrates diverse healthcare professionals across hospitals, long-term care homes and home care providers. Designated Cancer Care hospitals are required to establish multidisciplinary meetings involving multiple healthcare professionals for discharge planning processes, and they systematically integrate palliative care specialists, GPs, visiting nurses, and community providers to support transitions. Multidisciplinary meetings are required to annually bring together hospital teams with regional medical facilities and home care providers to align treatment approaches and better understand regional capacities (Ministry of Health, Labour and Welfare, 2024[34]).
Multidisciplinary teams also have scope to measure PREMS and PROMS in oncology, for example on treatment side effects, quality of life, and well-being. In Malta for example, PREMs indicators are in development, structured around five patient-centred domains: respectful person-centred care, managing physical health and symptoms, emotional and spiritual well-being, navigating and co‑ordinating care, and communication and responsiveness. As mentioned in Box 5.4, while there is growing interest in measuring PROMs for cancer patients, these efforts are often limited to the local or regional level, or to research initiatives, and are not integrated into patients’ electronic health record. Even though patient-reported initiatives at the national level are still limited in scope, there is increasing recognition that PROMs are critical tools for assessing the value of new cancer medicines (Box 5.5).
While there is some interest in measuring PROMs for cancer patients, they are often limited to the local or regional level, or research initiatives:
Belgium: In Flanders, the Patient-Reported Outcomes in Oncology initiative includes patients diagnosed with a primary invasive cancer of the lung or rectum, with individual hospitals responsible for data collection from their patients. The Belgian Cancer Registry will be responsible for merging of the hospital-specific datasets and linkage with other available healthcare information.
Canada: The Provincial and Territorial cancer care programmes/agencies carry out PROMs data collection.
Denmark: PROMs for cancer patients are collected in the Danish Healthcare system.
Luxembourg: National data collection is carried out among patients with breast cancer.
The Netherlands: PROMs are collected in 9 DICA registries, including for cancer patients (head and neck, colon, uterine body, ovarian, cervical, and vulvar cancer, breast cancer, melanoma, oesophagus and stomach cancer), and patients receiving palliative care.
In Norway, PROMs are collected through the national quality registries. Patients receive questionnaires at multiple points throughout the disease trajectory, allowing quality of life to be measured both during and after cancer treatment.
Sweden: A majority of National Quality Registries have developed and are collecting PROMs data in Sweden. A national service/platform has been developed with digital PROMs. As of 2024, the platform includes about 30 different PROMs, including in the area of cancer.
Slovenia: The Oncology Institute in Ljubljana, the major institution for cancer care in Slovenia, has recently introduced PROMs instruments in some areas.
National efforts such as in Denmark, the Netherlands and Sweden focus on PROMs use for clinical purposes (individual care improvement) rather than for system-wide use. This also limits international data collection as the tools chosen and target patient groups remain very context-specific. At EU level, the EUonQoL (Quality of Life in Oncology) initiative is a European project to develop and pilot a European Oncology Quality of Life Toolkit (EUonQoL-Kit) – a patient-centred, unified tool for use by cancer patients, survivors, and patients in palliative care across Europe.
Source: OECD Policy Survey on the Systematic PROMs data collection and use for quality improvement and assurance.
Cancer clinical trials usually assess a medicine’s effect on overall survival or surrogate endpoints such as progression-free survival or overall response rate. In recent years, patients, clinicians, and regulators have shown increasing interest in understanding how new drugs affect quality of life. PROMs in clinical trials offer direct insight into how patients feel and function during treatment, highlighting the real-world impact of therapies. Both the U.S. Food and Drug Administration (FDA) and the European Medicines Agency (EMA) now increasingly use PROMs to evaluate tolerability and treatment impact in the drug approval process (Bellino and La Salvia, 2024[35]), while health technology assessment agencies consider it in coverage and reimbursement decisions. Across EU+2 countries, EuroACT shows that between 2015 and 2024, the use of PROMs as either a primary or secondary outcome measure in cancer clinical trials almost doubled, increasing from about one in four clinical trials in 2015 (25%) to four in ten (41%) in 2024 (Figure 5.17) (Cases et al., 2025[36]; 2025[37]). In later phase trials, which serve to provide the pivotal data used for marketing approval and coverage decisions, PROMs play an increasingly important role: while only 25% of Phase II trials between 2015-2024 had PROMs as an outcome measure, that figure grew to 47% among Phase III trials.
Share of oncology clinical trials using PROMs as a primary and/or secondary outcome measure, by year
Note: Data represent the number of interventional clinical trials in oncology initiated since 2015 across EU27+2 countries. Data retrieved in July 2025.
Source: EuroACT data from European Patient Advocacy Institute and WECAN Foundation.
As expected, countries with a large number of oncology clinical trials (France, Spain and Italy) (see Chapter 3) had the largest number of trials with PROMs as primary or secondary outcomes. Trials for breast and prostate cancers, which have among the highest survival rates, were more likely to measure PROMs (with respectively 43% and 41% of clinical trials for these cancers incorporating PROMs as primary or secondary outcomes), compared to 30% for lung and pancreatic cancers clinical trials. Requiring PROMs in drug development ensures new cancer therapies address patient needs and deliver value, and collecting real-world evidence on both PROMs and clinical data is necessary to reassess pricing and coverage decisions to secure sustainable care (Chapter 4).
Patient navigation or case management programmes were also reported in 14 EU+2 countries. Navigation programmes may be delivered by health professionals (e.g. nurses, social workers), voluntary workers (e.g. peer supporters), or digital systems. Navigators help address barriers to timely and appropriate care based on patient needs and care goals. A recent systematic review found that navigation programmes shorten delays between screening, diagnosis and treatment (see Chapter 3). Other benefits included reduced hospital readmissions during both active treatment and survivorship (Chan et al., 2023[38]). As for case management programmes, they involve co‑ordinated assessment, planning and care delivery to address the comprehensive needs of patients and their families. While evidence of its impact on quality of life, patient satisfaction, and survivorship is mixed and inconclusive, case management is found to enhance symptom control, cognitive function, and treatment adherence (Wang et al., 2022[39]). In Estonia, the Estonian Cancer Center, established in 2024, is mandated to oversee the implementation of the national cancer plan, which includes the development of services to improve navigation in cancer care pathways (Ministry of Health, 2024[40]).
Out-of-hours care arrangements, reported by only 8 EU+2 countries, represent another key organisational innovation to further meet people’s needs. These arrangements usually cover specific groups of cancer patients and can provide 24/7 telephone access to nurses who can assess symptoms, provide guidance on treatment side effects, and determine when patients need immediate medical attention. They help to reduce emergency visits and hospitalisations. For instance, in Germany, only cancer patients with complex needs are legally allowed to access Specialised Outpatient Palliative Care, where multiprofessional teams comprising doctors, nurses, and co‑ordination staff deliver 24/7 care to manage symptoms outside standard hours. In Ireland, The Cancer Society provides a night nursing service, which offers up to 10 nights of free, end-of-life nursing care in the patient’s home for palliative care cancer patients. Access is by referral from a specialist palliative care nurse, public health nurse, or GP. In 2024, the organisation provided over 6 000 nights of nursing care to cancer patients across Ireland (Irish Cancer Society, 2025[41]). In Canada, Ontario’s CARE path After Hours Programme allows patients from the 72 cancer care sites who receive chemotherapy or radiation treatment to speak with oncology nurses during evenings, weekends and holidays (Cancer Care Ontario, 2025[42]). The first evaluation of the provincial programme showed that only about 24% of the callers were referred to the emergency department, and that an estimated annualised 5 211 emergency department visits were avoided, resulting in cost-savings of CAN 3.8 million (Martelli et al, 2023[43]).
Finally, digital tools are increasingly essential to support care planning and communication, as well as to empower patients in self-management. A large body of evidence shows that these tools are effective in enhancing patient empowerment, self-efficacy, and core self-management skills such as decision making and goal setting (Tuominen et al., 2024[44]; Lim, 2023[45]). The interactive features of digital platforms also help connect patients with health professionals and peers. While the benefits are greatest among younger, more educated patients with higher digital literacy, overall patient feedback is positive (Tuominen et al., 2024[44]; Lim, 2023[45]). Digital tools were reported by 17 EU+2 countries. Digital communication tools, secure data-sharing platforms and symptom trackers are empowering cancer patients to engage as active partners in their care. For instance, in Sweden, the six regional cancer centres developed the “My Care Plan”, a digital tool aligned with the National Cancer Strategy, to store and share treatment summaries, follow-up schedules, and standardised clinical information, and to provide secure patient-provider communication. In the EU, the ongoing European Cancer Patient Digital Centre project aims to develop a novel approach to present cancer information in a standardised way for citizens and patients, and develop personalised access to and sharing of personal cancer-related data in a uniform and interoperable way across all EU countries (ECPDC et al., 2022-2023[46]). Real-time symptom monitoring represents another growing application of digital tools in cancer care, with projects implemented across and within several countries. The Advanced Symptom Management System project, which is implemented across multiple European countries, aims to enable real-time remote symptom monitoring for patients undergoing chemotherapy (Box 5.6). In addition, the EU-funded Joint Action eCAN showed that telerehabilitation and telepsychology appear to be an appropriate support for cancer care, according to the results of pilot projects conducted with breast, head and neck, and advanced cancer patients. The results show an improvement in patient-reported outcomes such as quality of life, pain and distress when telehealth interventions are used. The follow up Joint Action eCAN plus, launched in June 2025, is now working towards the implementation of telemedicine tools in different cancer care settings to enhance the digital collaboration between cancer centres.
The Advanced Symptom Management System (ASyMS) is a real-time, mobile phone‑based remote monitoring and management platform. It is designed to help patients undergoing chemotherapy report their symptoms daily, triggering alerts to clinicians when intervention is needed. The overarching objective is to reduce symptom burden, enhance quality of life and improve the timeliness and appropriateness of clinical responses. The ASyMS platform is being tested in multiple European countries via the eSMART study, which is being conducted in five European countries (Austria, Greece, Ireland, Norway and the United Kingdom). Over 1 000 cancer patients have been enrolled in the trial. Initial evaluations yielded positive perceived results (McCann et al., 2024[47]), with beneficial effects on cancer care experiences, psychological well-being and quality of life.
5.5.2. People‑centred cancer care pathways should encompass palliative care and supportive services such as mental health care, lifestyle guidance and fertility preservation
Palliative care access is recommended as early as possible for patients diagnosed with cancer
Palliative care aims to improve the overall quality of life of people and their families by addressing the physical, psychosocial, and spiritual consequences of the disease. Evidence shows that for people living with cancer, palliative care reduces pain and distress, improves emotional well-being, strengthens communication, decreases unnecessary hospitalisations, and helps patients receive care aligned with their preferences (Petrillo et al., 2024[48]). According to the WHO Palliative Care Atlas of Europe, cancer is the leading condition for which palliative care is needed by a significant margin, ahead of cerebrovascular diseases (European Association for Palliative Care, 2025[49]).
Access to palliative care for cancer patients is a policy concern, primarily due to a lack of available providers
The 2025 OECD Policy Survey on High Value Cancer Care indicates that access to palliative care is often a policy concern due to a shortage of providers in seven EU+2 countries (Figure 5.18). Problems with timely referrals to palliative care for cancer patients are also a common policy concern in four EU+2 countries, followed by cost-sharing and the financial burden on cancer patients.
Note: Only countries reporting “Usually” and “Sometimes” to the question “To what extent is access to palliative care for cancer patients a challenge or a policy concern in your country with regards to…?” are shown. EU+2 countries are represented in dark green, while other OECD countries are represented in light green.
Source: 2025 OECD Policy Survey on High Value Cancer Care.
The most recent Atlas on Global Access to Palliative Care and Pain Relief confirms large inequalities in the availability of palliative care services across EU+2 countries. On average, there are 1.2 specialised palliative care services per 100 000 inhabitants across EU+2 countries (Garralda et al., 2025[50]), with large variability across countries. For example, Austria and Lithuania report 3.7 and 2.5 services per 100 000 inhabitants, respectively, while Estonia and Greece report a significantly lower 0.2 and 0.04 services per 100 000 inhabitants respectively (Garralda et al., 2025[50]). In addition, according to the Atlas, paediatric palliative care services are not available in Cyprus, Estonia and Iceland.
Another major barrier to accessing palliative care services also relates to misconceptions among both clinicians and the public that palliative care is only appropriate at the end of life, which often leads to late referrals. This is compounded by cultural barriers and emotional factors that impede discussing death and dying.
Disparities in the supply of palliative care services translate into disparities in access to pain management medication (such as morphine, codeine, fentanyl, hydromorphone, buprenorphine, and oxycodone). This is demonstrated by the positive correlation between the availability of palliative care services and annual opioid consumption (Figure 5.19). Austria, the Netherlands, Belgium, Portugal, Norway and Sweden are countries having higher supply of specialised palliative care services and higher reported annual opioid consumption, while Greece, Slovenia, Bulgaria, Romania and Estonia have the lowest supply of palliative care and lowest annual opioid consumption. Barriers to the availability of pain management medication in community settings tend to reduce providers’ ability to deliver quick and convenient patient-centred palliative care to cancer patients. This increases the risk of avoidable and costly hospital admissions for pain management, which represents poor care quality for patients and their families.
Notes: Defined Daily Doses for Statistical Purposes (S-DDD) per million inhabitants per day, based on the average consumption of narcotic drugs (excluding methadone) during the years 2020‑2022.
Source: EAPC Atlas of Palliative Care in the European Region 2025.
Integrating palliative care into the cancer care pathway from an early stage is essential for improving quality of life
In cancer, early integration of palliative care alongside curative or life‑prolonging treatments is recommended to support patient and caregiver well-being from the time of diagnosis (Jordan, Aapro and Kaasa, 2018[51]). Among high-income countries in 2017, an estimated 60% of adults requiring palliative care due to cancer were not in the terminal phase of illness but rather were still living with the disease (Worldwide Hospice Palliative Care Alliance/WHO, 2020[52]). This figure highlights the importance of integrating palliative care from the time of diagnosis. As indicated by evidence from Ireland, late palliative care referrals (defined as ≤ 3 months before death) were associated with increased hospitalisations during the final month of life (O’Sullivan, Conroy and Power, 2025[53]) (See also Chapter 4 on aggressive treatments at the end of life). All EU+2 countries have developed palliative care structures and policies, with some countries more advanced than others (Table 5.3).
Note: PC refers to palliative care. The maturity levels, ranked from highest to lowest, are: “Advanced”, “Established”, “Progressing”, and “Emerging”, in line with the original data source.
Source: EAPC Atlas of Palliative Care in the European Region 2025.
While Central European countries have made strides, these countries still have gaps in certain areas of their palliative care policies. For example, Bulgaria, Croatia, Cyprus, Greece, Latvia, Lithuania, Malta, Poland and the Slovak Republic rank lowest in advanced care‑planning related policies, which are key for early integration. By contrast, Italy and Norway have among the most advanced palliative care structure and policies in Europe (Table 5.3), although many barriers and gaps remain. Italy has recognised the right to palliative care through law since 2010, with delivery through hospitals, hospices, and community home care. As of 2021, nearly all regions had established palliative care networks and nearly all local health authorities have at least one multidisciplinary team offering palliative care in the community. However, in practice, only a minority of Italian regions were considered to deliver adequate levels of palliative care to cancer patients, with better served regions located in the North and the Centre of Italy. In response, the 2023 National Oncological Plan aims to ensure comprehensive coverage by the end of 2025. In a similar vein, in Norway, while basic palliative care is provided by all healthcare services – including in community settings, specialist care is delivered only by dedicated hospital and nursing home teams which can limit early initiation of palliative cancer care (OECD/European Commission, 2025[54]). There have been positive developments in some regions, such as the Orkdal region which introduced an outpatient clinic to provide both cancer and palliative care in the region through collaboration between specialist services (hospital oncology and palliative teams) and primary care services (see Box 5.7). Malta has also introduced a palliative care navigator to encourage greater integration of cancer and palliative care. The palliative care navigator supports care co‑ordination with hospice, facilitates home transfers and provides mobile support.
In addition, the Designated Centres of Integrated Oncology and Palliative Care initiative, launched by the European Society for Medical Oncology (ESMO), accredits cancer centres that provide high-quality palliative care fully integrated into oncology services. The programme promotes best practices in symptom management, communication, and end-of-life care, encouraging a comprehensive approach to patient needs. As of 2025, there are more than 250 centres accredited in 56 countries (ESMO, 2025[55]).
The Orkdal model is an outpatient clinic based in a rural hospital (Orkdal Hospital) whose mission is to deliver both oncology and palliative care, integrating symptom relief, supportive care, and patient needs alongside cancer treatment. It serves a region comprising many municipalities, so that patients can access these services closer to home, reducing travel burden and improving continuity.
The model uses a multidisciplinary team: oncologists and oncology nurses with palliative care training, working together with physiotherapists, occupational therapists, social workers, dietitians, and chaplains as well as community‐based health services (home care, GPs, nursing homes). There are standardised care pathways for different disease stages: referral to the integrated clinic, during active treatment/follow‐up, and end‐of‐life care. The standardised care pathway includes criteria and checklists, symptom/functional assessment tools, templates for documentation, and mechanisms for communication and co‑ordination across hospital, community and primary care including an electronic patient record. In response to the shortage of oncologists formally trained in palliative medicine, the clinic employed oncology residents with mandatory palliative care training and specialised cancer nurses with additional palliative care expertise. To strengthen competence, weekly team education was established, and staff systematically trained colleagues across hospital wards and community care settings.
Source: Brenne et al. (2020[56]), “Fully Integrated Oncology and Palliative Care Services at a Local Hospital in Mid-Norway: Development and Operation of an Innovative Care Delivery Model”, https://doi.org/10.1007/s40122-020-00163-7.
Across other OECD countries, Japan also provides a good practice example as the country places strong emphasis on early integration of palliative care and care co‑ordination. Designated Cancer Care Hospitals in Japan are required to establish regional information systems that map available palliative care services, including specialised hospital and home‑based teams. Mandatory training is required for all doctors involved in cancer care, with targets for completion rates. Training is also extended to nurses, pharmacists and other professionals through multidisciplinary programmes. Palliative care teams also take part in discharge planning and collaborate with primary care and rehabilitation services to ensure that palliative care needs are met during care transitions (Ministry of Health, Labour and Welfare, 2024[34]).
As many patients express a preference to die at home, several countries have strengthened community-based palliative care models. Home‑based palliative care often results in better outcomes, including fewer unplanned hospital visits and lower psychological distress for patients and families (OECD, 2023[57]). In Poland, over half of palliative care patients receive such care at home. The National Health Fund finances home hospice care, offering at least two weekly nurse visits, two monthly physician visits, and free rental of medical equipment, with adjustments based on patient need. A 2024 policy reform extended financial coverage from only life‑saving procedures to any medically required service for cancer patients in palliative care (OECD/European Commission, 2025[58]). In Slovenia, palliative care can be offered at the patient’s home, organised by an extended family medicine practice team (including family doctor, community nurse, and an out-of-hours and emergency service). There are also some specialised mobile palliative teams that have been developed in some Slovenian regions, to support primary care palliative teams (Homar and Pogocar, 2023[59]). Belgium also offers free of charge palliative home care supported by general practitioners, nurses and (partially) physiotherapists. In addition, cancer patients and their families can claim a lump sum to offset costs such as medication and medical equipment. In 2020, about 23% of cancer patients died at home, two‑thirds in hospital, and 7% in residential care (For a healthy Belgium, 2024[60]).
Providing palliative care at home requires strong support systems. Advanced care planning and the involvement of primary care providers, particularly general practitioners and community nurses, plays an important role (Driller et al., 2022[61]). Educational tools, such as video education, can also help patients and their families increase their knowledge and preparedness for at-home palliative care (Cruz-Oliver, 2020[62]). Supporting informal caregivers is also critical to develop home‑based palliative care. In home settings, most personal and domestic care falls on another family member when people become very dependant. Leave entitlements for those caring for someone who is dependent or terminally ill are therefore an important enabler (see Section 5.5).
Integrating fertility preservation options, mental health care and survivorship plans to create comprehensive people‑centred cancer care pathways
Comprehensive cancer care pathways include not only palliative care but also mental health support along with lifestyle guidance, fertility preservation services, sexual health support, and cancer survivorship plans (Figure 5.20).
Note: Only countries reporting “Usually” to the question “To what extent do cancer patients who need it receive the following support services?” are shown. EU+2 countries are represented in dark green, while other OECD countries are represented in light green.
Source: 2025 OECD Policy Survey on High Value Cancer Care.
Reproductive preservation options are a core component of a people‑centred cancer care pathway
Fertility impairment is often a life‑altering late effect of treatment, affecting body image, sexuality, relationships, and overall well-being. A study in Canada on female adolescents and young adults found that cancer survivors had a 30% higher risk of receiving an infertility diagnosis compared to women without cancer (Velez et al., 2021[63]). As for men, between 15‑30% of male cancer patients may become sterile after treatment for cancer, making fertility preservation a growing priority (Yumura et al., 2023[64]).
According to the OECD Policy Survey on High Value Cancer Care, 17 EU+2 countries reported that fertility preservation options were integrated into the cancer care pathway and usually accessible to patients. Fertility preservation options can include different treatment for sperm, embryo, oocyte or ovarian tissue cryopreservation, as well as temporary ovarian suppression during chemotherapy. In France, Germany, the Netherlands, Nordic countries, Poland or Slovenia, the statutory health insurance covers the cost of fertility preservation for medical reasons. In addition, offering oncofertility counselling in young patients to discuss fertility and pregnancy-related issues in parallel with oncological follow-up is also essential..
In addition, recent EU policy initiatives (including the Europe’s Beating Cancer Plan), highlight that sexual health support are an important but often underdeveloped service in EU countries (Rossi A, 2025[65]). More systematic assessment and management of sexual health within the oncology pathway is necessary and could follow international initiatives. For example, the European Organisation for Research and Treatment of Cancer (EORTC) validated a Sexual Health Questionnaire that offers practical tools and guidance to enable routine assessment, and ESMO provides guidance on assessment and treatment pathways. In Denmark, the Danish colorectal cancer survivorship guideline explicitly recommends assessment for sexual dysfunction after treatment and offers concrete interventions for post-treatment sexual problems. In Austria, the Comprehensive Cancer Centre Vienna runs a platform called “Sexual Health in Cancer Patients” to assess and address sexual health issues among cancer patients.
Mental health care is increasingly acknowledged as an essential pillar of the cancer care pathway
As shown with PaRIS data, cancer diagnosis and treatment often trigger significant emotional and psychological distress, with anxiety and depression commonly reported. In response to the growing recognition of these needs, a range of evidence‑based psychotherapies for patients living with cancer has been developed, including cognitive behavioural therapy (Wangjie et al., 2024[66]), mindfulness-based interventions (Lee et al., 2022[67]), and acceptance and commitment therapy (Jiang et al., 2023[68]). Group formats can be as effective as one‑on-one therapies and are more cost-effective for cancer patients (Nicklas et al, 2022[69]). They tend to foster mutual understanding, reduce social isolation and create space for emotional expression.
In 2025, 16 EU+2 countries reported having integrated psychological support in the cancer care pathway to ensure it is usually accessible to patients. Common elements across countries include early assessment of psychological needs, multidisciplinary collaboration between oncology teams and mental health professionals, and involvement of Non-Governmental Organisations (NGOs). In Ireland, the Adult Psycho-Oncology Model of Care (published in 2020) and the Psycho-Oncology Model of Care for Children, Adolescents and Young Adults (published in 2023) aim to enhance psychological well-being through early diagnosis and intervention. Community cancer support centres have been established to provide ongoing psychosocial support in local communities. In 2021, over EUR 500 000 in grants was awarded to 24 cancer support centres and national organisations to improve and expand survivorship programmes. For example, the Cancer Thriving and Surviving Programme, a six‑week initiative, helps individuals transition from active treatment to living well with cancer through self-management and well-being modules. The LACES Workshop for post-treatment cancer patients offers information to improve quality of life and access to community support, while the CLIMB® Programme supports children aged 6‑12 whose parents have cancer to help them cope. In Slovenia, psycho‑oncological support is offered at the Institute of Oncology Ljubljana, and delivered by a multidisciplinary team, including a psychiatrist, clinical psychologist, and specialised nursing staff. It can be offered both in inpatient and outpatient settings, providing individual counselling, psychotherapy, crisis support and – when needed – psychiatric treatment. This service forms an integral part of cancer care, aiming at identifying psychological distress early and supporting patients’ emotional well-being, treatment adherence and long-term rehabilitation.
In France and Italy, mental healthcare is part of the supportive service package. A 2022 study by the French National League Against Cancer found that 69% of cancer patients referred to a psychologist or psychiatrist during their care used the service (Ligue nationale contre le cancer, 2022[70]). In Italy, despite laws and guidelines, access remains limited. A study of about 3 000 people with cancer showed that only 20% reported receiving psychological support and just 16% said that a therapist was present throughout their cancer treatment (Corriere della sera, 2024[71]). In Canada and Australia, national cancer agencies describe psychosocial care as part of standard cancer care, from diagnosis through survivorship and palliative care.
Countries can collaborate with NGOs to provide further mental health support. For example, recently, Latvia introduced additional strategies to manage the emotional and mental health impact of cancer. Since 2018, state budget is allocated to the Oncological Patient Support Association “Tree of Life” to provide psychosocial rehabilitation for individuals with cancer and their relatives, and to the Society for Children’s Palliative Care for psychosocial rehabilitation for children in palliative care and their family members. To increase access and facilitate cancer patients’ return to social and economic life, a psycho‑emotional support day centre was also established in 2019. A hotline for psychological support is available 24 hours a day. In addition, digital tools support psychosocial well-being by facilitating access to information, therapies and peer support. For example, the OACCUS (Outdoor Against Cancer Connects Us) project has developed virtual platforms with 280 resources for young people living with cancer and a trained network of 500 Ambassadors in 15 EU countries (European Commission, 2024[72]) (Box 5.8).
Launched in 2022 and completed in 2024, the OACCUS project aimed to promote healthy, active lifestyles and facilitate social connection among young people living with or surviving cancer. Funded under the EU4Health programme (EUR 3 million) and co‑ordinated by Umeå University in Sweden, the project brought together 14 partners from six EU member states (Germany, Greece, Italy, Portugal, Spain and Sweden).
OACCUS developed the OACCUS Network Toolbox, a multilingual, interactive platform offering more than 280 evidence‑based resources, including articles, podcasts, videos, infographics, training exercises, a cookbook, interactive databases and games. These resources focus on four pillars:
Outdoor physical activity and sports
Balanced nutrition
Mental and physical well-being (psychoeducation)
Sustainable, healthy lifestyles within nature
Between January and March 2024, OACCUS trained over 500 ambassadors – young cancer survivors, their families, friends and professionals – across 15 EU countries.
Source: https://oac-connect.eu/.
There is a need to more systematically embed self-management programmes supporting heathier lifestyles directly within personalised cancer care plans
Few countries reported self-management programmes to lead a healthier lifestyle as usually accessible to patient in order to improve people‑centred care. According to the OECD Policy Survey on High Value Cancer Care, self-management programmes to lead a healthier lifestyle was reported in five EU+2 countries. Such efforts support long-term behaviour change such as smoking cessation, alcohol reduction, improved nutrition, and greater physical activity. These modifications are associated with significantly better cancer outcomes when adopted after diagnosis (Rabbani et al, 2025[73]).
Lifestyle guidance is most often delivered by health professionals but approaches to integration vary in depth and structure. Across countries, a common challenge lies in ensuring that lifestyle support is not limited to information provision alone. Evidence shows that long-term behaviour change requires structured and sustained interventions beyond written or oral advice (Cannioto et al., 2023[74]). In some countries, lifestyle guidance is embedded directly within personalised cancer care plans or survivorship plans (with referral and/or public coverage), while others rely more on broader public health initiatives. NGOs frequently play a complementary role, particularly in awareness campaigns and patient support.
For example, in France, the cancer care pathway, which includes survivorship (see next section), integrates lifestyle guidance as well as financial support for dietician consultations. In contrast, in Central European countries, prevention programmes are not routinely embedded in cancer care pathways (Cedzynska-Peregoy et al., 2022[75]), but prevention programmes are widespread for the general population. For instance, Poland puts more focus on broader population-level preventive programmes. A platform called “I am planning a long life” was launched to educate on healthy lifestyles and screening. Several social campaigns dedicated to lung cancer, colorectal cancer, malignant skin cancer, breast cancer, cervical cancer and prostate cancer were disseminated through television, radio and the internet. In addition, since 2020 the National Health Fund co‑ordinates a free‑of-charge “8 weeks to health” online training programme to encourage healthy lifestyles and regular physical activity (Planujedlugiezycie, 2025[76]). In Czechia, similarly, smoking cessation programmes are not specifically embedded in cancer care, but they are widely available. There are more than 40 centres for the treatment of tobacco addiction, which operate on an outpatient basis at hospitals. These centres are complemented by about 200 specialised outpatient physicians and several dozen pharmacies providing expert advice on smoking cessation (Národní zdravotnický informační portál, 2023[77]).
Cancer survivorship care plans are emerging as a comprehensive strategy to address people’s needs and preferences
Survivorship care plans (SCPs) are post-treatment documents designed to guide patients after active treatment has ended to support long-term health, monitoring and quality of life. While they typically include medical surveillance schedules, SCPs address broader needs such as psychological support, fertility, lifestyle promotion, and rehabilitation. By clarifying what follow-up is needed, by whom, and when, SCPs aim to ease the transition from active treatment to long-term survivorship care. Evidence suggests SCPs can improve survivors’ awareness of their treatment history and follow-up needs, facilitate communication with healthcare providers, and support shared decision making (Joshi et al, 2021[78]; Hill et al, 2020[79]).
Cancer survivorship care plans were reported in only seven EU+2 countries. However, in most EU countries, professional organisations or public bodies provide evidence‑based recommendations and guidelines for cancer survivorship care plans. They typically have the following features:
Treatment summary outlining diagnosis, therapies received, and key clinical findings.
Follow-up schedule including surveillance tests, frequency, and responsible providers.
Supportive care such as referrals for rehabilitation, psychosocial support, nutrition, and physical activity.
Patient-friendly format to encourage understanding and self-management, increasingly integrated in secure digital portals.
Shared-care principles linking oncology, primary care, and other providers to ensure continuity.
In France, a survivorship care plan is integrated in the care plan. Since 2020, cancer patients can receive prescribed assessments and consultations as part of their post-cancer treatment care. This includes an assessment for adapted physical activity, potentially leading to a personalised physical activity plan; nutritional and/or psychological assessments; and consultations for nutrition and/or psychology. The programme is slowly being deployed through targeted health professionals and centres identified by the regional health agencies. As part of the National Cancer Strategy 2021‑2030, the National Institute of Cancer is also tasked with proposing a set of measures that will improve the transition from active treatment to survivorship. In Germany, the National Cancer Plan recognises survivorship as a key pillar of cancer control, with the aim of improving quality of life and long-term outcomes for cancer survivors. The German Cancer Aid has invested EUR 8 million to support research into the prevention and management of late effects of cancer treatment. The German Cancer Research Center (DKFZ) is also co‑ordinating innovative projects such as IMPULS-A, a randomised controlled trial that provides older cancer survivors with structured need assessments, personalised care navigation and connections to regional support networks.
There are also some initiatives that focus on specific cancer populations, rather than systematic delivery for all cancer patients. For instance, in the Slovak Republic, the National Cancer Institute has established a dedicated testicular cancer survivorship programme focussed on long-term annual follow-up of germ cell tumour survivors. This programme aims to monitor and manage late toxicities of treatment and therefore improve quality of life. In the Netherlands, the BETER consortium is a survivorship programme for Hodgkin and non-Hodgkin lymphoma survivors organised within the Netherlands Cancer Institute (NKI). Patients attend dedicated survivorship clinics where follow-up care is tailored to their risk profile, and long-term outcomes are tracked through a national registry. Slovenia has also piloted two comprehensive cancer-survivorship programmes developed by the Institute of Oncology Ljubljana. The first pilot, carried out between 2019 and 2022 among women with breast cancer, demonstrated clear benefits, including higher quality of life, fewer treatment-related problems and shorter sick leave – and has therefore been integrated at national level (Institute of Oncology Ljubljana, 2025[80]). A second pilot programme for colorectal cancer patients has been under implementation since 2022, testing a similar co‑ordinated, multidisciplinary rehabilitation pathway aimed at addressing physical, psychological, social and functional needs throughout the cancer journey (Institute of Oncology Ljubljana, 2025[81]). Malta has introduced the National Oncology Survivorship Services to help cancer survivors reintegrate after active treatment. Initially, the service was piloted for colorectal and urological cancer patients, with the goal to extend to other cancer types. It includes a survivorship co‑ordinator, alongside a survivorship pathway developed in co‑ordination with multi-disciplinary teams across different cancer sites (Innovative Partnership for Action Against Cancer, 2021[82]).
At the EU level, the Pan-European Network for Care of Survivors after Childhood and Adolescent Cancer has launched a comprehensive initiative to improve survivorship care delivery through the Horizon 2020-funded PanCareFollowUp project. This project involves 14 partners across ten European countries, including survivor representatives, and aims to develop and evaluate two complementary interventions: a person-centred, guideline‑based survivorship care model and an innovative eHealth lifestyle coaching platform. The project involves prospective evaluation of 800 survivors in Belgium, Czechia, Italy and Sweden for the survivorship care intervention assessment. Upon completion, the project will produce freely available Replication Manuals containing tools and implementation guidance (van Kalsbeek et al., 2022[83]).
5.5.3. Financial and employment protection matter to the health and quality of life of patients and their caregivers
Employment protection policies support individuals both during and after cancer treatment
Support during cancer treatment: extended paid leaves and work accommodations
Cancer-related financial toxicity is a major cancer policy challenge in EU and other OECD countries, affecting both health outcomes and economic security. A recent study of over 2 500 people across Europe showed that 56% of cancer patients lost income following diagnosis, and 86% faced additional treatment-related costs. This dual burden led 16% of people to delay or avoid necessary care, risking poorer health outcomes and potentially higher long-term healthcare costs (see also Chapter 3). People most vulnerable to financial toxicity are those self-employed, on lower incomes, and with children (Vancoppenolle et al., 2025[84]). Financial toxicity has also been demonstrated recently in the Netherlands, Germany, Finland, Spain. A meta‑analysis on cross-country differences in financial hardship suggested stronger social protection and income replacement as key policies to reduce financial hardship during cancer treatment (Pauge et al, 2021[85]).
Keeping a job during cancer treatment protects from financial hardship. But during treatment, many cancer patients are temporarily unable to work, so they become at risk of workplace discrimination. In recognition of this, cancer is often covered under disability or anti-discrimination legislation, which protects individuals from unfair treatment based on a cancer diagnosis or history. Countries can monitor dismissals to protect the disabled workers. For example, Austria and Germany require prior approval from public bodies before dismissing a registered disabled worker. At the EU level, the European Equal Treatment Directive (2000/78/EC) prohibits workplace discrimination on the basis of disability – including cancer. In addition, the Occupational Safety and Health framework Directive (Directive 89/391/EEC), requires employers to prevent occupational risks through risk assessment and to take special protective measures for particularly sensitive risk groups, including workers with disabilities or long-term health conditions such as cancer, by identifying necessary workplace adaptations and reasonable accommodations to ensure their safety and continued participation in work.
To help patients remain in the workforce, most EU and non-EU OECD countries offer extended paid sick leave for long-term illnesses, which includes cancer, according to a 2018 Policy Survey (World Policy Analysis Center, 2018[86]). They are generally of 12 months or more with wage replacement rates of at least 80%. Thirty-six OECD countries, including 22 EU countries, provide extended paid leave entitlements, with only Korea and the United States lacking such provisions. Among these countries, 23 OECD countries, including 18 EU countries, offer a paid leave of 12 months or more (the Netherlands and Luxembourg offering among the longest leave of up to around 2 years, and France up to 3 years for severe illnesses). In addition, in Slovenia, there is no upper limit on the duration of paid sick leave; however, when a patient’s condition is deemed permanent, the personal physician must refer them for a disability assessment, which may lead to eligibility for a disability benefit.
Adequate wage replacement is also critical to avoid falling into poverty especially for people on low incomes. Nineteen OECD countries, including 14 EU countries, provide wage replacement rates of at least 80%, and 10 countries provide wage replacement rates between 60% and 80%. Only the Slovak Republic provides a wage replacement rate below 60%. In Germany, cancer patients can receive paid sick leave for over a year, with 70% of their gross income covered; it may not exceed 90% of their net wages (§ 47 Absatz 1 SGB V). In EU countries, employers typically have to fund the first two to six weeks of the leave.
In addition, to help patients remain in employment during treatment, many EU and other OECD countries allow part-time sick leave (e.g. Belgium, Denmark, Finland, France, Ireland, Norway, Slovenia, Sweden, as well as Canada, Chile, Israel, and New Zealand). Employer obligations to provide reasonable workplace accommodations – together with occupational health specialists – are also common across these countries, including measures such as reduced working hours, modified duties, telework, and paid time‑off for medical appointments.
Support for return to work after leaves: Encouraging gradual return to work
There are nationwide reintegration frameworks to promote return to work after illness-related leaves, but only a handful of countries have cancer-specific projects to support return to work, such as Belgium, Germany, Italy, the Netherlands and Spain. Instead, cancer patients typically rely on general measures supporting people with disabilities or chronic illnesses (European Commission: European Health and Digital Executive Agency, ECORYS, 2024[87]).
Denmark, France, Germany, the Netherlands, Norway, Spain and Sweden (as well as Australia and Canada among other OECD countries), implemented nationwide reintegration frameworks to promote return to work after leaves. They aim to support early intervention, sometimes within weeks of leave commencement. Cancer survivors frequently require a gradual return, rather than the “0% or 100%” work binary. They need gradual, part-time reintegration. Frameworks usually involve multiple people and organisations (healthcare providers, social insurance, employers and sometimes local authorities) who work towards a gradual return-to-work plan tailored to worker health status and job demands.
Countries can implement a legal right for gradual return, work adjustments and career prospect. Spain introduced an explicit “right to return” law that allows reduced working hours or remote work following treatment. France and the Netherlands mandate workplace adjustments, such as lighter duties or part-time work.
In Sweden, Germany and the Netherlands, the nationwide reintegration frameworks are well-developed. Sweden put more focus on early medical co‑ordination and structured multidisciplinary collaboration, while Germany and the Netherlands emphasise the employer’s obligation to arrange a process backed by medical and rehabilitation services:
Sweden’s return-to-work system aims to provide early, co‑ordinated, and medically supervised rehabilitation plans designed by rehabilitation co‑ordinators if needed. They co‑ordinate with healthcare providers, employers, and the Swedish Social Insurance Agency (Försäkringskassan) (Svärd et al., 2023[88]).
In Germany, the return-to-work programme targets employees absent for more than six weeks within a 12‑month period. Employers are mandated to offer an individualised reintegration plan, in collaboration with occupational health professionals and the employee. The process emphasises workplace accommodation and a graduated return (Gesund.bund de, 2020[89]).
In the Netherlands, similarly, employers must maintain “reintegration dossiers”, conduct regular progress meetings, and provide at least 70% of previous salary for up to two years. This “dossier” must include an action plan, periodic progress reports, and correspondence with the health service, and is required for Employee Insurance Agency assessments.
I was very lucky because I received my salary during all my treatment: 18 months out of work but receiving 100% of my salary. The problems I faced concerns returning to work…The returning to work must be gradual depending on the patient situation - once you finish your treatments, you are not ill neither healthy.
Conchi, 68 years old, breast cancer
The Right to be Forgotten is enacted in only nine EU countries, but could be expanded across EU and other OECD countries
While cancer survival is increasing over time (See Chapter 4), cancer survivors routinely encounter discrimination when accessing financial services, including loans, mortgages, and insurance products. They can face higher premiums or refusal of services based on medical history (Lawler et al., 2024[90]; Meunier, Scocca and Tulkens, 2025[91]). A 2021 survey in Ireland showed that cancer survivors faced three times the difficulty of the general population in accessing appropriate insurance products, with one‑quarter unable to obtain quotes for financial services solely due to their previous cancer diagnosis (Irish Cancer Society/Core Research, 2022[92]). In France, a quasi‑experimental study shows that difficulties in accessing loan-related insurance were reported by 65% of breast and childhood cancer survivors, compared to only 15% of individuals without a history of cancer (Bougas et al., 2025[93]).
In response, nine EU countries (France in 2016, Belgium in 2020, the Netherlands in 2021, Portugal and Romania in 2022, Spain, Italy and Cyprus in 2023, and Slovenia in 2024) have enacted the “Right to be Forgotten” legislation which establishes that individual’s past history with cancer is no longer taken into account when applying for loans or associated insurance products, provided that the individual has finalised their active treatment and has not relapsed (Lawler et al., 2024[90]; Meunier, Scocca and Tulkens, 2025[91]; Grazia and Meunier, 2022[94]). In addition, Ireland, Malta and Poland are countries moving toward the introduction of the Right to be Forgotten, as well as Luxembourg, which will move from a convention to a law.4 Luxembourg has a non-binding Convention with the Association des Compagnies D’assurance et de Réassurances (Ministère de la Santé, 2019[95]). In Ireland, the government has announced an upcoming law that will prevent insurers and lenders from requiring disclosure of a past cancer diagnosis after a remission period of seven years for adults above age 18. Malta is at the proposal stage, with a draft bill under discussion that would introduce similar protections and set a 10‑year remission limit. Meanwhile, Poland has not yet introduced a specific law, although debate is ongoing, and policymakers have expressed interest in aligning with EU policies. As of 2025, current protections for cancer survivors in Poland remain limited to general anti-discrimination and data protection rules.
The length of mandatory waiting periods varies across countries, ranging from five years in France, Belgium and Spain, to seven years in Romania and Slovenia, and up to ten years in the Netherlands, Portugal, Italy and Cyprus. These timelines apply to adults who have remained free from relapse or recurrence, with additional conditions in some countries – such as a financial threshold in the Netherlands, where it applies only to mortgages not exceeding EUR 278 004 per person. Special provisions can also exist for younger people. Romania reduces the waiting period to five years for diagnoses occurring before age 18, while Belgium, Cyprus, the Netherlands, Portuga, and Slovenia apply similar reductions for diagnoses before age 21. Belgium, France, the Netherlands and Slovenia have also introduced reference grids to provide shorter timelines for cancers with better prognoses.
In addition, several other EU countries have adopted voluntary-based alternatives, but most often these only apply for certain insurance companies, or certain cancers. Czechia, Denmark, Greece and Ireland for example have implemented self-regulatory codes of conduct within their financial and insurance sectors.
Binding legal measures around the Right to be Forgotten are key to adequately protect cancer survivors against financial discrimination. In France, the introduction of the Right to be Forgotten law has reduced the likelihood of experiencing difficulties in obtaining a loan, from 65% in 2010 to 35% in 2022 (Bougas et al., 2025[93]). This calls for the expansion of a binding legal framework in all EU and other OECD countries in the coming years, considering each country’s specific financial, employment and legal framework. In the EU, the Consumer Credit Directive, entered into force in 2023 with transposition required by November 2026, requires countries to ensure that consumer credit is not based on personal health data up to 15 years following the end of treatment. Currently, these protections remain concentrated in the EU. Aside from Chile, no other OECD countries provide equivalent legal Right to be Forgotten through national legislation. Chile recently adopted such a law, while in Costa Rica, a 2024 draft law proposed implementation of the Right to be Forgotten, without success yet.
I wanted to take out a mortgage to build a house on my own, about ten years after my diagnosis. Since I receive disability benefits, the bank asked me why, and I answered truthfully. Despite my high and sufficient income and collateral, the bank required a co-signer.
Nikol, 37 years, breast cancer
Support for working-age informal carers is key to maintaining their employment and well-being when caregiving is burdensome
For people of working age, caregiving responsibilities can significantly influence both labour force participation and working hours. Evidence suggests that providing 20 or more hours of care per week is associated with a reduction in labour market participation and working hours, with much more pronounced effects observed among those providing over 40 hours of care weekly (European Commission, Directorate-General for Employment, Social Affairs and Inclusion, 2021[96]).
Flexible work arrangements, such as telework, flexible scheduling, or reduced working hours, can help carers, particularly those providing low-intensity care, to better reconcile work and caregiving responsibilities. At the EU level, the 2019 Work-Life Balance Directive underlines the right for carers to request flexible working conditions, including flexible hours, reduced working time, and flexibility in the place of work. However, such measures may not sufficiently support those providing moderate to high levels of care.
For more intensive caregiving needs, care leave schemes may be more appropriate. These schemes are particularly relevant in situations requiring substantial but time‑limited support, such as caring for a terminally ill relative with cancer or providing informal post-hospital and rehabilitation care. The design of compensation levels of care leaves involves a trade‑off: if too high, they may discourage return to work, especially when care needs become prolonged; if too low, they may increase the risk of financial strain for caregivers.
About 16 EU countries grant entitlements to either paid or unpaid leave to care for a dependent person, regardless of the cause of the dependency. Thus, these entitlements are applicable only when a cancer patient becomes dependent. They are typically defined based on the caregiver’s relationship to the dependent person and the assessed level of care needs (Rocard and Llena-Nozal, 2022[97]).
The duration of leave varies from five days in Spain5 to three months (renewable once) in France, and with no set limit in Denmark. In four countries, Estonia, the Netherlands, Norway and Spain, paid care leave for non-terminally ill recipients is restricted to less than one month. In Germany, the caregiver allowance provides compensation for loss of earnings in the event of a short-term absence from work, allowing up to ten working days per calendar year per person in need of care to organise appropriate support.
Eligibility criteria often include family or co-residency ties: in all EU countries with paid leave, except for the Nordic countries, Belgium, Germany and Ireland, the care recipient must be a family member and/or live in the same household. In all Nordic countries except Norway, municipalities set eligibility criteria and directly employ informal carers. Nordic countries and Poland tend to offer the most generous financial wage compensation. In five EU countries (Belgium, Denmark, France, Luxembourg and Sweden), paid care leave is specifically targeted at those caring for a terminally ill relative. Other eligibility criteria can include the age of the carer, the carer or household income, and the informal caregiving intensity.
Belgium stands out with one of the most comprehensive paid leave systems among EU countries, with three different types of care leave: one related to terminal illness of up to 2 months, one related to long-term care of up to 1 year, and one in the form of time credit of up to 5 years related to palliative care. This time credit involves either completely suspending work or reducing working hours, and employees do not need a specific reason, thus providing extensive flexibility for the employees to manage their work-life balance.
Unpaid care leave has been developed in seven EU countries. Conditions of unpaid leave vary to a lesser extent than for paid leave. Unpaid leave entitlements tend to be longer than paid ones. The care recipient has to be a member of the family and/or be a co-resident. Eligibility criteria may be strict, and can depend on employers’ approval, and the sector in which workers are employed (whether public or private). Duration varies between three months in the Netherlands to about six months to two years in Hungary and Spain, with the exception of Belgium (ten days in the private sector, two months in the public sector). In Austria and the Netherlands unpaid leave is targeted only to those caring for terminally ill relatives.
In addition to paid and unpaid leaves, expanding access to respite services is essential to prevent caregiver burnout. While most EU countries offer in-kind respite care (such as in-home respite or short-term residential respite to allow the caregiver to take a break), uptake remains limited due to low financial compensation, limited availability, and organisational barriers (Rocard and Llena-Nozal, 2022[97]). Providing counselling and psychological support also plays a key role in safeguarding the well-being of informal caregivers.
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← 1. The EURO-D is a standardised depression screening scale developed to assess and compare levels of depression across European population. It gives a score from 0 to 12, where higher scores mean more depression.
← 2. Given that country rankings are similar when examining PHC patients without cancer, cross-country differences may also reflect cultural factors that influence how respondents answer questions.
← 3. The assessment of co-ordination and coproduction reflects a general assessment from primary healthcare patients living with cancer, not necessarily specific to cancer care system.
← 4. Luxembourg has introduced a convention “Droit à L’oubli” in 2019. Further information is available at https://www.aca.lu/wp-content/uploads/2022/06/CONVENTION-DROIT-A-LOUBLI-.pdf.
← 5. In Spain, workers are entitled to paid leave to care for a family member with cancer, though the type and duration of support vary. A five‑day paid leave is available in cases of hospitalisation, serious health condition or surgery of a close relative up to the second degree. In addition, parents of children under 18 diagnosed with cancer may request a reduction of at least 50% of their working hours with corresponding financial compensation; this benefit can be extended and remains available until the child turns 23, or up to 26 years of age in cases of severe disability.