Providing effective and efficient cancer care is as crucial as ensuring timely access to cancer care. High-quality cancer care must be evidence‑based, aligned with clinical guidelines, delivered in facilities subject to quality standards and monitored to ensure compliance. This promotes effective and appropriate treatment for various cancer types and stages, while minimising patient harm and waste. This chapter outlines the policies countries are undertaking to ensure quality and monitor the performance of their cancer care systems. It also examines strategies to provide more efficient cancer care, including targeted approaches to screening and diagnosis, shifting of care from the hospital setting, uptake of biosimilars, reduction of low-value treatments and deployment of new technologies and artificial intelligence to optimise diagnosis and treatment.
Delivering High Value Cancer Care
Abstract
Delivering evidence‑based and efficient cancer care is essential for both individual patients and health systems.
As a key marker of high-quality care, 5‑year survival rates have shown moderate to notable improvements for lung, colorectal, and breast cancer over the years, facilitated by earlier diagnosis and effective treatments.
Differences in cancer treatment practices and outcomes are seen across countries:
Partial mastectomy is less invasive and has similar survival outcomes to full mastectomy surgery, however EU+21 countries show a more than two‑fold difference in share of partial mastectomies out of all mastectomies (from 30% in Poland to 79% in Spain).
Age‑standardised 30‑day mortality rates following colorectal cancer surgery range from about 1.5% in Denmark and Norway to above 5% in Croatia and Czechia.
While cancer care accounts for between 4‑8% of healthcare spending in EU+2 countries, the direct real costs of cancer care in the EU more than doubled from EUR 54 to EUR 120 billion between 1995-2023.
To support high quality, evidence‑based care, 21 EU+2 countries report having either structural standards (such as equipment or personnel requirements) or minimum volume norms for cancer care, with many utilising both approaches.
However, gaps between standards and clinical practice demonstrate the importance of monitoring and enforcement mechanisms to ensure adherence.
Accreditation / certification is widely used to promote quality: 22 EU+2 countries report having such mechanisms for evaluating cancer centres by outside parties.
While 18 EU+2 countries report having other cancer care quality monitoring systems – often used to provide feedback to providers for improvement or for public reporting – only 12 report monitoring adherence to clinical guidelines for treatment of common cancers.
The OECD finds high compliance (76% – 89%) among the seven reporting EU+2 countries in the share of women with HER2+ breast cancer receiving evidence‑based treatment. Nonetheless, rates were still below the 90% target set by the European Society of Breast Cancer Specialists and half of OECD countries participating in the data collection were unable to report on this indicator.
Many countries have implemented risk-stratified cancer screening to improve the effectiveness and efficiency of cancer screening based on prevalence of factors such as family history (e.g. Czechia, Greece, Luxembourg, Slovenia), genetic mutations (e.g. Belgium, France, Germany, Slovenia, Spain), smoking (Estonia, Italy, the Netherlands, the Slovak Republic), or HPV vaccination (e.g. Hungary, Iceland, Sweden).
Opportunistic cancer screening contributes to potential overdiagnosis of thyroid and prostate cancer through detection of early-stage, low-risk tumours that are unlikely to affect life expectancy and quality of life, suggesting low-value care:
Prostate cancer overdiagnosis is a concern in 13 EU+2 countries while thyroid cancer overdiagnosis is considered problematic in eight EU+2 countries.
Among EU+2 countries, the share of early-stage prostate cancer diagnoses among men aged 75+ ranged from 53% in the Netherlands to 81% in Luxembourg, reflecting the lack of international consensus on and variation in prostate cancer screening practices.
The ratio of prostatectomies to prostate cancer cases in EU countries varies up to 70‑fold (from almost none in Finland to three out of four in Italy) highlighting an unwarranted level of diverging cancer care practices and potential over or under-treatment of prostate cancer.
This underlines the need for adoption of evidence‑based clinical guidelines to improve the quality of prostate cancer care for patients and to reduce harmful or low value care.
To reduce pressure on inpatient capacity, improve efficiency of care and enhance patient experience, EU+2 countries are shifting some cancer care away from the hospital setting. Strategies include changes in payment methods to incentivise or require use of day procedures instead of inpatient admissions and implementation of hospital-at-home models.
These approaches manifest in decreased hospital admissions, with colorectal cancer hospital discharges per diagnosed case decreasing 12% in the EU between 2012 and 2022 and lung cancer discharges falling by 24%.
Nordic countries (Denmark, Finland, Norway, Sweden) substantially shifted more than a quarter of mastectomies from the inpatient to the day procedure setting.
Belgium, Denmark, France, Greece, Hungary, Iceland, Ireland, Lithuania, Poland, Portugal, Slovenia and Sweden all report implementing hospital-at-home models for cancer care.
With more and higher cost of new cancer medicines, health technology assessments mechanisms, reassessment of coverage decisions after market entry, and treatment optimisation to identify the most effective dose are key policies to ensure high value cancer care.
Market entry of cancer biosimilars is associated with a 33% decrease in drug prices in the EU. While biosimilars uptake is relatively high, it ranges from 55% in Bulgaria to 96% in Denmark, where centralised tendering systems support a rapid shift towards biosimilars use.
Adjusting packaging sizes or vial sharing can reduce waste of infused cancer medicines, while better prescribing practices can help for oral medicines – however, regulatory, reimbursement or operational changes may be required, and safety must be ensured.
Clinician-led efforts like the Choosing Wisely initiatives can build alignment among physicians and support communication with patients towards reducing low-value care. There are 20 Choosing Wisely national-level recommendations to reduce low-value cancer care that have been adopted by between two to ten EU+2 and other OECD countries, highlighting international alignment in these areas and opportunities for other countries to promote these practices.
One of the most common recommendations – reported in Austria, Italy, Norway and Sweden along with six other OECD countries – is to avoid chemotherapy at advanced cancer stage if it is unlikely to benefit the patient. Four of seven EU+2 countries in the OECD data collection report that more than 5% of older patients with low-survival cancers received systemic treatment in the last 30 days of life.
Countries have embraced technological innovations via national and regional programmes, pilots and EU4Health initiatives to support gains in precision, efficiency and accuracy of cancer diagnosis and treatment.
These include minimally invasive liquid biopsies in monitoring cancer treatment response and relapse (5 EU+2 countries), AI-assisted imaging in cancer screening to improve the efficiency and accuracy of diagnosis (10 EU+2 countries) and robotic-assisted cancer surgery (16 EU+2 countries).
1. EU+2 countries refer to EU27, Iceland and Norway.
Chapter 2 showed the increasing number of people living with a cancer diagnosis is putting pressure on health systems to ensure delivery of high-quality cancer care in a sustainable manner.
Furthermore, delivery of effective, efficient, and evidence‑based cancer care is essential, as failing to do so has enormous consequences for individual patients and for the health system overall. For patients, ineffective care can potentially cause harm and missed opportunities for longer survival and gains in quality of life. The opportunity costs of ineffective low-value cancer care can result in delays in access to healthcare for other patients, wasteful healthcare expenditure and consumption of scarce healthcare resources including healthcare workers and diagnostic equipment.
Chapter 3 outlined the many investments needed to increase access to and reduce delays in cancer care – including in awareness and health literacy, screening and early detection initiatives, workforce, innovative medicines and radiotherapy. Similarly, Chapter 5 highlights the importance of supporting patients throughout the care journey via care co‑ordination processes and sufficient consultation times, as well as survivorship programmes including mental health, fertility preservation, and reintegration support. These all require substantial investments – resources that should not be lost to inefficient, low-quality care. This is particularly relevant in the current context of governments operating under a range of geopolitical, social, and economic budget pressures and increasingly tight health budget constraints.
A high-value care perspective takes into account the quality and outcomes of care relative to the resources which provide such care. As such, Section 4.2 examines the issue of high-quality efficient cancer care in the framework of two key goals – that is, how effective is the cancer care system (in terms of survival rates and quality variation) and at what financial cost (spending on care). Section 4.3 of the chapter explores how countries are designing their cancer care systems to promote high quality, evidenced-based care via system-level organisation and monitoring. The final section delves into the range of policies and practices undertaken by various stakeholders in the healthcare ecosystem to optimise both quality and efficiency across the realm from diagnosis to treatment – touching upon areas such as improving efficiency of diagnosis, shifting care from the inpatient setting, optimising use of cancer pharmaceuticals, and incorporating new technologies.
4.2.1. Survival estimates show moderate to notable improvements for lung, breast and colorectal cancer, but stagnation for cervical cancer
Survival rates are one of the most important markers of cancer care quality because they relate to a main goal of treatment – prolonging life. Higher survival rates point to early and effective cancer detection and treatment.
Among EU+2 countries with national data, overall five‑year cancer survival has improved over the last decades. For example, the Netherlands saw an increase in five‑year overall cancer survival from 53% for patients diagnosed with cancer in 1995‑2004 to 67% for the 2015‑2022 period, while in Estonia, five‑year survival increased from 54% (2007‑2011) to 58% (2017‑2021). Latvia and Slovenia also reported gains, with survival estimates slightly higher for women (60%) versus men (56%) in Slovenia, but rates improving faster among men over the most recent decade with available data (OECD/European Commission, 2025[1]).
Among the main cancer types, lung cancer survival estimates are typically quite low but have seen the biggest improvement in five‑year survival. All 17 EU+2 countries with trend data reported increases for this cancer type (See Figure 4.1).
Note: M stands for rates among Males; F for rates among Females. Data refer to colon cancer for Estonia, Hungary and the Netherlands instead of colorectal cancer as for the other countries. National level estimates are provided by countries based on different methodologies and thus estimates are not comparable across countries. For information on methodologies and data, see individual Country Cancer Profiles and sources below.
Source: For Norway, Sweden, Denmark and Iceland: Nordcan (2025[2]), Survival Trends, https://nordcan.iarc.fr/en/dataviz/survival?cancers=160&set_scale=0&years_available=1943_2023; For Slovenia: Zadnik, et al. (2021[3]), Survival of cancer patients, diagnosed in 1997-2016 in Slovenia, https://www.onko-i.si/fileadmin/onko/datoteke/rrs/kr/mon/Survival_of_Cancer_Patients_Diagnosed_in_1997-2016_in_Slovenia.pdf and Slovenian Cancer Registry, (2025[4]) Cancer in Slovenia 2022, https://www.onko-i.si/fileadmin/onko/datoteke/rrs/lp/LetnoPorocilo2022_online.pdf; OECD / European Commission (2025[5]), EU Country Cancer Profiles 2025, https://www.oecd.org/en/about/projects/eu-country-cancer-profiles-2025.html for all other countries.
Screening programmes, through their ability to detect earlier stage cancers that are more responsive to treatment (see Chapter 3), can improve survival trends. Breast cancer continues to feature among the highest survival rates, with estimates increasing moderately across all countries. As screening participation rates declined between 2014‑2022 in more than half of EU+2 countries with programme data (OECD/European Commission, 2025[1]), these gains may reflect improvements in treatment or other early detection approaches. Colorectal cancer survival has improved in nearly all 17 countries with data, coinciding with expanded screening programmes in the EU+2, but remains lower than for breast cancer. In contrast, cervical cancer survival trends are mixed. In eight of the 13 countries with available data, five‑year survival has stagnated or declined. However, Denmark, Ireland, the Netherlands, Norway and Sweden have seen modest improvements. For cervical cancer, stagnating survival rates are occurring alongside declines in screening participation in EU+2 countries (OECD/European Commission, 2025[1]). In addition, prostate cancer (not shown) also has very high survival rates, with improvements in most countries with available data – though some of the increase may reflect overdiagnosis (see Section 4.4.1).
For both lung and colorectal cancer for most countries, survival estimates are slightly higher for women, particularly for lung cancer. Research indicates that the survival gap in favour of women may be due to gender differences in cancer stage, histological type, and mutation patterns in lung cancer as well as hormonal differences and differences in risk factors and comorbidities between the genders (Li et al., 2025[6]; Tsokkou et al., 2025[7]; Kinoshita et al., 2017[8]).
4.2.2. Cancer care practices vary substantially between and within countries
Large variation in chemotherapy, radiotherapy and surgical practices and outcomes in cancer care are found across countries
Differences in survival estimates relate to differences in diagnosis and treatment. An International Cancer Benchmarking Partnership (ICBP) study examining variations in referral pathways for suspected cancer identified differences across ten countries, including lack of referral routes for non-specific symptoms, varying levels of primary care decision making autonomy and access to diagnostic testing, and reliance on emergency referrals (Lynch, Harrison and Emery, 2022[9]) (see Chapter 3). Another ICBP study revealed substantial variation in chemotherapy use across countries and cancer types. For example, the proportion of patients receiving chemotherapy ranged from 48% to 81% for ovarian cancer and from 4% to 51% for liver cancer (McPhail et al., 2024[10]). A parallel study assessing radiotherapy use found similarly wide international differences, ranging from 18% to 82% for oesophageal cancer and from 37% to 85% among stage II-III rectal cancer patients (McPhail et al., 2024[11]).
International differences in care practices are seen in breast cancer. Many patients with early stage breast cancer are eligible for breast conservation surgery (partial mastectomy) which has shown to have similar or better survival outcomes to full mastectomy while being less invasive, with shorter recovery periods and lower risk of complications (Chatterjee et al., 2015[12]; Christiansen et al., 2022[13]; de Boniface, Szulkin and Johansson, 2021[14]). In addition, OECD data from a pilot measuring patient-reported indicators generally shows higher levels of breast satisfaction following breast-conserving therapy compared to mastectomy and reconstruction (Kendir, Barrenho and Klazinga, 2022[15]), in line with studies showing more favourable patient-reported outcomes from breast conserving surgery (Panayi et al., 2024[16]).
In the EU on average in 2023, about two‑thirds (68%) of mastectomies were breast-conserving, with the rest being full mastectomies (Figure 4.2). Large differences are seen in rates of partial mastectomy in the EU+2. In Spain, about 80% of mastectomies are partial while this share stands at 50% or lower in Poland and Romania. Overall, the share of partial mastectomies in the EU has stayed relatively steady since 2013, although Norway, Finland and the Netherlands have seen increases of more than 20% while Poland has seen a decrease of almost 40%.
Percentage share of partial out of all mastectomies performed, 2013 and 2023 (or nearest)
Note: For the 2023 values, data from 2021 were used for the Netherlands, and 2022 data were used for Luxembourg, Australia and New Zealand. For the 2013 values, 2014 data were used for Switzerland.
Source: OECD Health Statistics.
Findings from the literature show higher rates of full mastectomy in countries with scarce radiotherapy coverage and high rates of late‑stage diagnosis (Pfob and Dubsky, 2023[17]). In addition, an evaluation of the national cancer database in the United States found that longer travel distance to a treatment facility and lower income is associated with higher rates of full mastectomy. It is important to note, however, that decisions on type of breast cancer surgery are dependent on social and cultural factors and that they must consider patients’ own preferences. For example, a small qualitative study found that the decision to undergo full double mastectomies in cases where it was not medically necessary was driven by patients and based on their family history, perceptions and concerns (Padamsee et al., 2023[18]). Hearing feedback from breast cancer survivors’ experiences with total or partial mastectomy can help provide valuable insight to providers and patients in the decision making process (Admoun and Mayrovitz, 2021[19]).
Mortality rates after colorectal cancer surgery differ substantially across countries and by planned versus emergency procedures
Mortality rates following colorectal cancer surgery also vary substantially across EU countries, as well as by age, gender and type of procedure (emergency or planned) (OECD, 2025[20]). As expected, 30‑day colorectal cancer mortality rates are highly correlated with age: wherein mortality rates among those ages 25‑44 are below 2%, rates among those ages 75‑84 were over 5%. After age‑adjusting the rates to the disease population, the 30‑day mortality figures for Norway (1.4%) and Denmark (1.5%) are on the low end, while those of Croatia and Czechia are above 5% (Figure 4.3). In addition, gender disparities are observed, with higher 30‑day mortality rates among men versus women in most countries. These findings align with previous studies that have consistently reported higher 30‑day mortality among men after colorectal cancer surgery, due to factors such as higher rates of co-morbidities and behavioural risk factors among men, alongside presentation at more advanced stage of disease.
30‑day mortality rate after colorectal cancer surgery, age‑standardised, most recent 3‑year average
Note: Standardised based on the disease population.
Source: OECD (2025[20]), “Assessing cancer care quality in OECD countries: New indicators for benchmarking performance”, https://doi.org/10.1787/b3f47ece-en.
In three of four EU+2 countries with available data (Denmark, Latvia, the Netherlands), 30‑day mortality rates for emergency colon surgery were at least three times higher than those for planned surgery. In the Netherlands, that difference stood at seven times (with 30‑day crude mortality of 11.1% for emergency colon cancer surgery versus 1.5% for planned surgery). This major difference shows the importance of colorectal cancer diagnosis via early detection mechanisms, rather than via emergency presentation (see Chapter 3). Early detection not only supports better survival through intervention at a less advanced cancer stage, but also allows appropriate time for surgical planning and patient preparation prior to the procedure.
Standardisation of surgical techniques and processes helps improve outcomes for colorectal surgery (Eto et al., 2018[21]). Furthermore, mortality rates are related to surgical and post-surgical care safety and effectiveness, as these affect the likelihood of surgical wound infections and the major mortality risk of anastomotic leak (de la Portilla et al., 2018[22]). A German study found that implementation of quality-based standards contributed to a 41%-reduction in 30‑day mortality following colon cancer surgery for patients treated in certified hospitals that met structural and procedural standards as compared to non-certified hospitals (Trautmann et al., 2018[23]). As Box 4.1 discusses, in general, there are opportunities for countries to increase the safety of cancer care across the care pathway.
Medical errors in cancer care refer to preventable incidents that occur during diagnosis, treatment, or follow-up, potentially harming patients or compromising outcomes. “Never events” such as administering the wrong treatment to the wrong patient or performing surgery on the wrong site are considered entirely avoidable. Other errors include preventable adverse drug reactions, treatment-related infections and equipment or therapy failures, whose occurrence can be significantly reduced using intuitive tools. Fostering a strong therapeutic relationship with patients and involving them as partners in their care, clear communication, and proper safeguards can make medical care less prone to error (Karp, Osburn and Gouda, 2024[24]). A recent commentary highlights the often‑overlooked issue of patient safety in cancer care, where many risks remaining unacknowledged and unaddressed. It emphasises the need for a cultural shift to recognise and address these hidden risks through fostering openness about safety concerns, providing oncologists with adequate resources, empowering patients to speak up, advancing patient safety research, and convening national stakeholders to develop systemic solutions (Jacobson and Brooks, 2024[25]).
Eight EU+2 countries responding to the 2025 OECD Policy Survey on High-Value Cancer Care report having policies or programmes to reduce medical errors in cancer care. The National Cancer Institute in France provides an organisational framework to support continuous improvement in the safety of injectable anticancer drugs in oncology-haematology day hospitals (National Cancer Institute, 2025[26]). In Ireland, the National Cancer Information System is a centralised electronic system designed to record and manage cancer-related patient information, supporting the safe delivery of systemic anticancer treatments as well as e‑prescribing and e‑administration of cancer drug treatment in publicly funded hospitals, operating in 22 sites nationwide (Health Service Executive, 2025[27]). In Slovenia, a dedicated 2024 law introduced new quality control processes for healthcare providers, guided by the principle of patient safety and involving proactive risk management to minimise harm and promote safe care delivery. Continuous learning from errors and sharing best practices also form key pillars of Slovenia’s approach to improving patient safety (PISRS, 2024[28]).
[For] the last 3 radiotherapy treatments…the doctor designed them wrong. The radiologist discovered it…and intervened to re-plan. The radiation therapy technicians that I had were very knowledgeable and excellent support for patients. But patients….with different technicians had several problems (e.g. early burns).
Maria, 53 years old, breast cancer
Studies from OECD countries find that individuals with lower socio-economic status are less likely to receive multidisciplinary care, curative treatment or targeted therapies
As shown by the data on colorectal cancer mortality, there are also within-country variations in treatment, not only based on age and sex, but by geography, socio-economic background, and ethnicity. In Italy there are regional differences in access to and reimbursement for molecular diagnostics (Rimassa, Khanc and Koerkamp, 2025[29]) as well as in the use of multi-disciplinary teams (MDTs), even though MDTs have been shown to improve outcomes in terms of treatment planning, patient satisfaction, and survival (OECD, 2024[30]). Other OECD countries provide examples on geographic variations in care as well. A report on lung cancer in England highlights significant variation in curative treatment between Trusts (which provide healthcare services under the National Health Service), with the share of non-small cell lung cancer patients with stage I – II cancer and good performance status receiving curative treatment ranging from 50% to 100%. In addition, the number of clinical trials available across the Trusts ranged from none to 45, and there were also substantial differences in the use of multimodality therapies and access to specialist palliative care (Beckett, Doffman and Toy, 2021[31]). A study of over 12 000 patients in the United States with bile duct cancer in the liver found that surgery (which offered the best outcomes), was more commonly performed in the Middle Atlantic region compared to the Mountain States (29% versus 18%) and that patients with lower income and African American males with Medicaid insurance were less likely to receive treatment (Uhlig, Sellers and Cha, 2019[32]).
Socio-economic disparities in cancer care are pronounced. One study found that patients in the most deprived income regions in Italy were less likely to receive curative treatment for liver cancer, and that moving from the most deprived to less deprived regions increased probability of receiving curative treatment by 10% (Cucchetti et al., 2021[33]). A Swedish study of over 83 000 patients with stage I‑III colorectal cancer found that patients with higher income were less likely to undergo emergency surgery and more likely to have MDT discussions, neoadjuvant, and adjuvant treatments (Osterman et al., 2024[34]). In Canada, those in the lowest income quintile were 18 percentage points (p.p.) less likely to receive curative surgery for lung cancer than those in the highest income quintile (Canadian Partnership Against Cancer, 2020[35]). A 2024 umbrella review of meta‑analyses (with studies mostly from North America and Europe) found that individuals with lower socio-economic status had less access to immunotherapies, targeted cancer therapies and precision treatments (Li et al., 2024[36]).
In addition to providing high quality diagnosis and treatment to all patients, cancer care systems must be sustainable, ensuring resources are available for other therapeutic areas and investments in overall public health. This requires assessment of spending on cancer care.
4.2.3. Spending on cancer care in the EU ranges from about 4% to 8% of health spending
It is challenging to know the true cost of cancer care as many countries do not provide data on cancer-specific health spending, and even when available, there is often a significant time lag. A 2025 report by the Swedish Institute for Health Economics estimated that 2023 cancer spending ranged from about 4% of health spending in the Nordic countries (Denmark, Finland, Iceland and Norway) to about 8% in France, Germany and the Central and Eastern European countries of Bulgaria, Lithuania, Poland and Romania (Manzano et al., 2025[37]), with an average of 6.9% in the EU (see Chapter 1).
After adjusting for inflation, it is estimated that the direct real costs of cancer in the EU more than doubled from EUR 54 billion in 1995 to EUR 120 billion in 2023 (Manzano et al., 2025[37]). Estimated health expenditures on cancer increased more quickly in the Central and Eastern European countries than in other countries between 1993 and 2023, leading to some convergence in cancer spending between countries. Growth in spending on cancer has outpaced growth in total health spending in some countries (Czechia, France, Germany, Poland, the Netherlands), but not in others (Estonia, Finland, Norway and Slovenia).
In addition to the direct costs of cancer care, the indirect burden of cancer on the workforce and the quality of life of cancer patients is substantial (see Chapter 5). These costs highlight the importance of country policies to improve provision of high-value cancer care, as described in this chapter, as well as policies to improve the overall well-being of patients and survivors.
To promote quality cancer care, countries set recommended or required quality standards for cancer care. These standards include structural requirements (such as quantity of equipment or number of oncologists that must be available) and process norms (such as a minimum volume of patients treated). Minimum volume norms can help promote better care as hospitals and surgeons with higher case volumes for complex cancer surgeries are associated with fewer complications for patients, lower post-operative mortality, and improved survival. Positive relationships between volume and quality of cancer care are found for breast cancer (Peltoniemi et al., 2011[38]; Vrijens et al., 2012[39]), paediatric cancers (Kowalczyk et al., 2014[40]), colorectal cancer (Huo et al., 2017[41]; Engdahl et al., 2023[42]), lung cancer (Baum et al., 2020[43]; Subramanian et al., 2022[44]), prostate cancer (Pohle et al., 2018[45]; Ploussard et al., 2022[46]) and pancreatic cancer (Krautz et al., 2018[47]; Huhta et al., 2022[48]; Thobie et al., 2023[49]). Nonetheless, in the process of concentrating cancer care at higher-volume centres, it is important to ensure that geographical access to or support for patients to reach cancer treatment facilities is available (Chapter 3).
Alongside defining standards of care, countries also implement mechanisms for oversight to ensure that standards are being met and care quality upheld. These include promoting accreditation or certification, a process by which an independent body evaluates a healthcare provider to assess whether it meets required standards of quality and safety, as well as quality monitoring processes to assess adherence to clinical guidelines. Nonetheless, adopting quality standards and maintaining accreditation or certification mechanisms requires sufficient workforce and infrastructure to meet the established requirements, which can be a challenge on both a national level and particularly in certain regions due to geographic disparities (Chapter 3).
The 2025 OECD Policy Survey on High-Value Cancer Care found a range of practices across EU+2 countries in terms of standards and oversight to assure high quality of cancer care (Table 4.1). This section of the chapter will review these topics in brief.
Note: Cells in dark teal refer to standards being used for each of breast, prostate, colorectal, lung and rare/paediatric cancers; aqua cells refer to standards being used for at least one of the above‑mentioned cancers, sky blue cells indicate that standards are not used for any cancers. Blank cells indicate no information available on that topic.
1. In Austria, structural standards are available for breast and rare/paediatric cancers, and minimum volume/process norms are available for pancreatic cancers. In Belgium, minimum volume/process norms are available for breast, pancreatic and head/neck cancers and cancers for adolescent and young adults. In Greece, structural standards are available for breast and rare/paediatric cancers. In Ireland, minimum volume/process norms are available for breast cancer. In Lithuania, structural standards are available for breast, prostate, colorectal and lung cancers. In the Netherlands, structural standards are available for rare/paediatric cancers, and minimum volume/process norms are available for prostate and rare/paediatric cancers. In Poland, structural standards and minimum volume/process norms are available for breast, prostate, colorectal, lung cancers and others such as ovarian, stomach, skin, and pancreatic cancers. In Portugal, minimum volume/process norms are available for breast cancer. In Slovenia, structural standards and minimum volume/process norms are available for rare/paediatric cancer. In Spain, structural standards are available for colorectal, lung, rare/paediatric cancers and minimum volume/process norms are available for colorectal, oesophageal-gastric and central nervous system cancers. In Sweden, minimum volume/process norms are available for rare/paediatric cancers. In Canada, structural standards and minimum volume/process norms are available for breast, colorectal and lung cancers. In Switzerland, structural standards and minimum volume/process norms are available for rare/paediatric cancers. In some countries, such as Greece, Italy, Slovenia, Spain and Sweden, standards are recommended but not required.
Source: 2025 OECD Policy Survey on High-Value Cancer Care; OECD/European Commission (2025[50]), EU Country Cancer Profile: Belgium 2025, https://www.oecd.org/en/publications/eu-country-cancer-profile-belgium-2025_744aaaba-en.html; OECI (2025[51]), Membership, https://www.oeci.eu/membership.aspx.
4.3.1. Most EU+2 countries set either structural and/or minimum volume norms for cancer care
Table 4.1 shows that 19 EU+2 countries report having structural standards while 17 EU+2 countries have minimum volume/process norms to promote high quality cancer care. In some countries, such as Greece, Italy, Slovenia, Spain and Sweden, standards are recommended but not required and may be set at the regional level (e.g. Sweden).
Most countries that set standards utilise both structural requirements and process/minimum volume norms, as seen in 15 EU+2 countries. However, Estonia, Greece, Lithuania and Romania set only structural standards, while Ireland and Portugal have opted for process/volume standards only. Several countries – Iceland, Latvia, Hungary and the Slovak Republic (where hospital reform to centralise provision of speciality care via minimum volume standards is underway (OECD/European Commission, 2025[52])) – do not currently have either structural or process standards for cancer care.
Examples of countries that have both structural and process norms are Czechia, Denmark and France. In Czechia, minimum staffing and equipment standards, as well as minimum volume norms, are set via accreditation requirements for comprehensive cancer care centres, while in Denmark, the Danish Health Authority regulates the institutions that are allowed to provide specialised treatment as well as minimum volume norms for different types of cancer. In France, requirements for cancer care providers are based on three pillars: 1) cross-disciplinary quality criteria applying to all cancer treatment modalities (radiotherapy, surgical oncology and systemic therapies); 2) technical and clinical infrastructure specific to each treatment modality; and 3) minimum activity thresholds (OECD/European Commission, 2025[53]).
4.3.2. Standards are often set for the most common cancer types
Countries often set structural standards for many cancer types, most commonly breast, colorectal and paediatric/rare cancers (between 16 to 17 EU+2 countries depending on cancer type) and lung and prostate cancers (14‑15 EU+2 countries). France and Poland also have standards for other cancers including ovarian, stomach and pancreatic while Czechia has structural standards for treating cervical cancer.
As part of structural standards, many of these countries also require or recommend the use of multidisciplinary teams (MDTs). In France, an MDT is mandatory to evaluate treatment plans for each cancer patient; for radiotherapy, for example, a team composed of a minimum of qualified radiotherapists, medical physicists, and medical electroradiology technicians is required. Similarly in Germany, for certification of oncological treatment centres by the German Cancer Society, multidisciplinary tumour boards meeting specific requirements must be available (Hermes-Moll et al., 2021[54]) while in Austria, Breast Health Centers must have mechanisms to ensure certain specified departments are available for participation in tumour boards.
Similar to structural standards, process/minimum volume norms are also commonly set for breast and rare/paediatric cancers (12‑13 EU+2 countries) and colorectal, prostate and lung cancer (9‑10 EU+2 countries). Austria, Belgium, France and Poland also set minimum volume norms for pancreatic cancer. Thresholds for minimum volume norms vary across countries by cancer type such as for breast, and in some cases, by type of service (e.g. surgery, radiotherapy and systemic therapy) as in France (Box 4.2). For example, for cancer originating in the chest cavity, the minimum volume requirement is 40 treatments per year in France and 75 in Germany (The Federal Joint Committee, 2025[55]). Volume norms can be established at the facility or the physician level, or both – in England, for example, hospitals must perform at least 10 surgeries for rectal cancer while individual surgeons should perform at least five per year (NICE, 2021[56]).
Minimum volume norms are not specifically used in some EU+2 countries such as Latvia and Lithuania (with relatively small population size), Greece (with population dispersed widely across archipelagos) as well as the Slovak Republic (implementation in progress) and in Hungary. In other smaller countries, instead of minimum volume norms, concentration of cancer care takes places via provision of care in one (Iceland) or three (Estonia) main facilities, or via sending specialised paediatric cancer cases abroad for specific treatments (Estonia, Luxembourg).
For breast cancer, the European Society of Breast Cancer Specialists requires accredited centres to have sufficient caseloads, which includes annually: a minimum of 150 new cases of breast cancer treated, each surgeon operating on at least 50 cases; each radiologist reading a minimum of 1 000 mammograms per year and diagnosing one cancer per week (Biganzoli et al., 2020[57]). Italy and Spain both follow this threshold for treatment volumes by breast centre and surgeon (AGENAS, 2021[58]; de León Carrillo and Frutos Arenas, 2021[59]). Similarly, Ireland sets the threshold for breast cancer at a minimum of 50 new patients operated per surgeon per year, as does Slovenia. In Belgium, the standard had been 50 operations per surgeon annually, but this was reduced in 2014 to 30 per year to increase access to care. Co‑ordinating breast clinics in Belgium must diagnose at least 125 new breast cancer cases a year and satellite breast clinics must diagnose at least 60 cases (KCE, 2023[60]). While France requires certified facilities to perform at least 70 breast cancer surgeries per year, Germany sets a higher threshold of 100 surgeries per hospital annually.
France has minimum volume norms not only for cancer surgeries, but also for radiation therapy and systemic treatment. With regards to minimum annual activity, France requires certified cancer facilities to meet the following thresholds:
For cancer surgery, the minimums are:
Breast cancer (70); head and neck and maxillofacial surgery (20); urological (30); thoracic (40); non-breast and ovarian gynecological (20); complete cytoreductive surgery for ovarian cancer (20).
Digestive cancers (30), with organ minimums: oesophagus and gastroesophageal junction (5), stomach cancer (5), liver cancer (5), pancreatic cancer (5), rectal cancer (5).
For radiotherapy: 600 patients for external beam radiotherapy; no threshold for brachytherapy.
For systemic cancer treatments: 100 patients treated per year, including at least 65 intravenous injections on an outpatient basis (Légifrance, 2022[61]).
4.3.3. While standards are important, countries must have mechanisms in place to monitor and ensure that they are met
While establishing quality standards and care guidelines is important to safeguard and promote the delivery of high-quality cancer care, mechanisms must be in place to monitor whether these are met. However, such monitoring is not always undertaken systematically. This can lead to gaps between structural and minimum volume standards and actual practice, as described in Box 4.3.
In Italy, since 2015, the National Outcomes Evaluation Programme (PNE) has set recommended minimum annual volume thresholds for specific surgical procedures, including cancer surgery. For prostate, breast, cervical and colon cancer, more than four in five procedures took place in hospitals that met these recommendations (Figure 4.4). In contrast, more than half of surgeries in 2022 for stomach, rectum and pancreatic cancer were performed in units below these volume thresholds.
For breast cancer specifically, 12% of surgeries took place in units performing fewer than 135 operations annually. Significant regional variations exist on this indicator: in Emilia-Romagna, Marche, Tuscany and Umbria, less than 5% of breast cancer surgeries occurred in low-volume units, while the figure exceeded 25% in Friuli-Venezia Giulia, Molise and the Autonomous Province of Bolzano. Even in high-capacity regions with centres of excellence such as Lombardy, a non-negligible share of breast cancer surgeries (13%) took place in low-volume units.
Share of surgical oncology procedures
Note: The “inappropriate” category refers to the proportion of surgical oncology procedures performed in facilities that failed to meet the cancer-specific minimum annual volume of patients for breast 135), lung (85), colon (50), prostate (30), cervical (20), rectum (25), stomach (20), ovarian (20) and pancreatic (30) cancers.
Source: OECD/European Commission (2025[62]), EU Country Cancer Profile: Italy 2025, https://doi.org/10.1787/1e742c63-en based on data from AGENAS (2023[63]), Fifth National Survey on the Status of Implementation of Regional Oncology, https://www.agenas.gov.it/images/2023/13_dic/5_indagine_Rapporto_ROR_12_12_2023.pdf.
Following observation of gaps between clinical standards and practice, Belgium and Germany introduced reforms to enforce evidence‑based clinical practice. In Belgium, following a 2023 report that found a 30% higher mortality rate among women treated in non-specialised centres, the government has ceased reimbursing facilities for breast cancer treatment (except for follow-up) administered outside of fully recognised clinics as of August 2024 (OECD/European Commission, 2025[50]).
Similarly, Germany’s programme for minimum volumes, in place since 2004, has faced challenges with implementation and adherence. A report found that 34% of hospitals in Germany (205 out of 605) failed to meet the minimum annual requirement of ten complex pancreatic surgeries in 2017, while 52% (198 out of 378 hospitals) did not meet the threshold of ten annual procedures set for oesophageal surgery (Hemschemeier, Bittkowski and Stollorz, 2017[64]). Since this period, Germany has strengthened sanctions on non-compliance to minimum volumes, although about 40% of cancer cases were still treated in general non-certified hospitals in 2024. Nonetheless, the hospital reform started in 2024 is leading to stronger concentration of cancer treatment in fewer specialised hospitals based on minimum volume requirements (OECD/European Commission, 2025[65]). Between 2024 and 2026, the number of providers fulfilling the minimum requirement and authorised to provide surgery in Germany was expected to decrease from 425 to 377 for breast cancer and 169 to 142 for lung cancer (AOK Federal Association, 2025[66]).
Cancer care quality is assessed via certification / accreditation and other monitoring mechanisms
One important approach to monitor alignment with expected structural and process standards and ensure quality of care is via certification / accreditation. In addition to providing oversight, implementing such processes can improve quality. A recent analysis from Germany found that access to accredited cancer centres significantly reduces breast, colon, and prostate cancer mortality risk and increases five‑year survival estimates by 2‑7 p.p. for five cancer types (Brand and Blankart, 2025[67]). The OECD survey on high-value cancer care shows that 22 EU+2 countries report using some mechanism for certification / accreditation of cancer care (Table 4.1).
Many countries in Europe place emphasis on international certification / accreditation, namely via the Organisation of European Cancer Institutes (OECI) (Box 4.4). Fourteen EU+2 countries use international certification or accreditation mechanisms only, while five EU+2 countries (Belgium, Czechia, France, the Netherlands and Spain) have both national and international accreditation or certification for cancer care. In Czechia’s national accreditation programme, outcome indicators including inpatient mortality, post-operative mortality, and survival rates are assessed alongside structural and process standards. Three EU+2 countries (Germany, Poland and Romania) currently have national mechanisms only. In an example from another OECD country (Canada), the process is primarily co‑ordinated through Accreditation Canada and provincial cancer agencies and is based on quality, safety and best practices in oncology care.
In the Netherlands, every rare form of lung cancer needs to be treated in an Expert centre. We are really a team. We have a research programme together. In my work as a patient advocate, they consult me, as well as I consult them.
Merel, 56 years old, lung cancer
OECI certification includes both qualitative and quantitative assessment of governance and organisational structure, patient centredness, multidisciplinary teams/care, research, education and training, as well as of the entire patient pathway from prevention, diagnosis and treatment. Comprehensive cancer centres (CCCs) must meet structural standards including an annual budget of EUR 50 million or more for cancer care, an annual budget of over EUR 8 million for cancer research, a total of 150 cancer care inpatient beds and beds in the ambulatory care setting, more than 50 full-time equivalent physicians dedicated to cancer, and minimum volume norms such as 2 500 newly treated patients. Since the certification highlights the importance of research, criteria include more than 125 peer-reviewed scientific publications, high impact scientific publications, and having phase I trials, among others. Certified OECI cancer centres need to meet criteria in similar areas as CCCs (except for in research), although requirements differ somewhat, and threshold levels are lower.
OECI certification also sets and assesses process and quality standards, including multi-disciplinary teams (frequency of meetings, team composition, the number or percentage of patients listed who were not discussed in the MDT) and quality of cancer care provided (e.g. re‑operation rates within 30 days by cancer type, 30‑day mortality after open and robotic surgery by cancer).
Use of electronic systems for cancer care can facilitate provision of evidence‑based care using real-time information shared across providers, improve patient engagement and care continuity and reduce medical errors. As such, OECI certification processes also assess use of information technology. Results indicate high uptake of IT in OECI certified centres: across the board almost all centres have electronic patient records, electronically available clinical guidelines, and electronic medication prescription and administration systems. The vast majority of centres also have the capability to process and exchange information electronically with external providers. Use of electronic patient portals shows slightly lower availability (ranging from 71% to 75% by country income tercile1), while anywhere between two‑thirds (Tercile 2) and 100% (Tercile 3) of centres have electronic patient referral systems.
Instead of the OECI programme, Germany relies on a national CCC programme initiated, monitored and designated by the Deutsche Krebshilfe (German Cancer Aid). At present there are 14 designated Comprehensive Cancer Centres (with a total of 26 Comprehensive Cancer sites). In order to apply to become a CCC, a centre must first be certified as an Oncology Centre by the German Cancer Society via assessment of treatment according to German national clinical guidelines for the respective cancer types. The Oncology Centre certification process includes yearly internal audits on technical and medical requirements. The evaluation and designation process as a CCC is then based on meeting criteria related to translational research, access to innovation and clinical trials, outreach and regional network structure and multidisciplinary care. In Germany’s Deutsche Krebshilfe programme, Comprehensive Cancer Centres also have well-developed information technology use. The centres generally utilise electronic tools for clinical guidelines, patient tracking systems, and medication prescription systems, as well as electronic patient medical records. Technology infrastructure to process and exchange patient information and biomedical images is well-developed and effectively utilised in processes such as MDTs or virtual tumour boards. Nonetheless, German privacy policies pose challenges to adequate sharing of patient information within and between CCCs.
Source: OECI (2021[68]), OECI data analysis, Deutsche Krebshilfe (Germany Cancer Aid).
1. The country income terciles divide EU+2 countries into three terciles based on GDP per capita for the purpose of OECI data analysis (see Figure 4.5).
OECI certification is of growing importance in the EU+2. Thirteen EU+2 countries have at least one CCC certified by the OECI, four other EU+2 countries (Denmark, Greece, Lithuania and Slovenia) have an OECI certified cancer centre, and three more (Iceland, Latvia and Poland) are in the process of OECI certification.
The OECI provided data about the number of newly treated cancer cases by country income tercile of EU+2 countries (Figure 4.5). About one in four new cases (26%) across all cancer sites are treated at OECI certified cancer centres in countries falling within the highest income tercile (Tercile 1). The figures are somewhat lower, at about one in ten (10%) in Tercile 2 and one in five (19%) in Tercile 3, the lowest income tercile. The shares for “all sites” together are higher than the shares treated for each of the common cancer types shown in the figure (except breast cancer for Terciles 2 and 3) as, in general, a greater proportion of less common cancers are treated in OECI-certified centres because these larger centres tend to specialise in more complex or rarer cancers.
Note: “All sites” includes both cancer sites shown in the figure as well as other cancer sites not shown. Terciles are based on 2023 GDP per capita in purchasing power standard terms. The first tercile includes the highest-income countries with Organisation of European Cancer Institutes (OECI) accredited cancer centres (Belgium, Denmark, Ireland, the Netherlands, Norway and Sweden); the middle tercile includes the middle‑income countries (Czechia, Finland, France, Italy, Lithuania, Slovenia and Spain); the third tercile includes the lowest income‑countries (Estonia, Greece, Hungary and Portugal). Data on cases treated are from 2019, 2021 – 2023 (depending on the centre), while incidence data is from 2022.
Source: Incidence data from European Cancer Information System (ECIS) https://ecis.jrc.ec.europa.eu/, accessed on July 2025; newly treated patients data from OECD analysis of OECI-provided data.
Alongside existing accreditation and certification mechanisms, the flagship EUNetCCC initiative aims to ensure that cancer patients have access to co‑ordinated, high-quality and comprehensive care across Europe via certified cancer centres (Box 4.5).
The EU Network of Comprehensive Cancer Centres (EUnetCCC), supported under the EU4Health programme, is developing a harmonised organisational and quality framework for cancer centres and the regional networks in which they operate. The initiative aims to ensure that cancer patients have access to co‑ordinated, high-quality and comprehensive care across Europe.
EUnetCCC is defining requirements in four main areas:
Governance, including clear leadership structures covering care, research and education, mechanisms for cross-institutional co‑ordination, patient involvement in decision making, and data-driven monitoring of performance.
Care organisation, including multidisciplinary tumour boards, defined patient pathways, risk management processes, access to specialised diagnostics and treatments, and collaboration with other hospitals to support equal access to services.
Research and innovation, including integration of research within care pathways, access to clinical trials and molecular tumour boards, capacity to support innovation uptake, and collaboration with academic and industrial partners.
Education and training, including structured programmes for health professionals and participation in European learning networks.
The approach combines centre‑level requirements with provisions for regional collaboration, reflecting the diversity of cancer care systems across Europe. Centres are expected to organise and document how necessary services are provided either directly or through formal partnerships with external institutions.
EUnetCCC is also developing a stepwise certification scheme, based on self-assessment and peer review, with regular monitoring and improvement cycles. The certification standards take into account existing national and international mechanisms, with work underway to explore mutual recognition where appropriate. Supporting tools, including an electronic platform, are being designed to facilitate data collection and comparability.
By creating a shared framework and terminology for organisation, quality management and co‑operation, EUnetCCC supports the improvement of cancer care across countries and regions, including in settings where access to highly specialised expertise is limited. The framework is currently under development and will be progressively tested and adapted as Member States engage in its implementation.
Source: French National Cancer Institute (INCa), co‑ordinator of EUNetCCC initiative
In addition to accreditation or certification systems, many countries have implemented other processes to monitor cancer care quality. A total of 18 EU+2 countries report having such mechanisms to monitor quality of cancer treatment providers. The two most common uses of quality monitoring processes, (each used by 14‑15 EU+2 countries), are for 1) provider feedback for quality improvement and 2) public reporting to promote transparency or patient choice (Figure 4.6).
Note: The figure shows the number of countries reporting use of cancer quality monitoring or audit mechanisms for each of the following purposes. 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 Netherlands has a clinician-led national system for monitoring cancer care quality, managed by the non-profit Dutch Institute for Clinical Auditing (DICA), which oversees 20+ audits across major cancer types such as colorectal, breast, lung, gynaecological, head and neck, prostate, and skin cancers. DICA’s validated registration system provides hospitals with direct insights into treatment outcomes, enabling continuous care improvements (DICA, 2024[69]). While Belgium undertakes quality monitoring for cancer care at the hospital level and has feedback systems to improve quality, publicly reporting of aggregated quality metrics takes place at the regional level. In Poland, there is public reporting on a list of indicators by cancer provider, while Italy undertakes monitoring of cancer care quality and outcomes at the regional level, publicly highlighting strengths and weaknesses for improvement.
Nordic countries including Denmark, Iceland and Sweden each have a comprehensive website available to monitor differences in quality of cancer care by cancer type, region and providers (Quality Registry). In Sweden, over 30 cancer-specific National Quality Registries facilitate monitoring via collection of individual-level data on diagnosis, treatment, and outcomes (RCC, 2025[70]). National care programmes are developed for each cancer type by the six Regional Cancer Centres and include a dedicated section on quality indicators and target levels based on national or international guidelines (RCC, 2025[71]). Performance compared to target levels is regularly assessed and forms the basis for reporting within the National Quality Registries. Slovenia is in the process of developing five clinical registries for monitoring the quality of cancer care, including the meeting of minimum volume norms. In other OECD countries, Canada provides another valuable example. Quality monitoring and audits support continuous improvement, transparency, and accreditation in cancer care. The Canadian Partnership Against Cancer also collects pan-Canadian indicator data to monitor system performance and identify priority areas for improvement.
Fewer countries report using quality monitoring mechanisms in cancer care to guide investment decisions such as staffing, training and equipment at the national level, or for licensing or performance‑based financing (4‑5 EU+2 countries). In Belgium, payment for breast cancer care, complex pancreatic and oesophageal surgical procedures are limited to providers meeting volume and/or structural standards (OECD/European Commission, 2025[50]). Furthermore, hospitals receive a financial incentive based on results obtained in relation to indicators (such as reporting data on clinical and pathological status of cancers, mortality, and increasingly, patient experiences). In Germany, hospitals must meet criteria in areas such as structural standards, minimum volume norms, training, co‑operation and research to receive add-on payments.
In Estonia, Hungary, Portugal and Romania, results from monitoring and auditing are not regularly reported or utilised beyond internal auditing purposes or as part of the licensing process.
Adherence to clinical guidelines is not monitored systematically in EU+2 countries
While two‑thirds of EU+2 countries have clinical guidelines for cancer in place (OECD, 2024[30]), it is critical that these guidelines are systematically updated, accessed and implemented in practice in order to promote high-quality cancer care. For example, in breast cancer, a systematic review of observational studies across EU countries found that adherence to treatment guidelines was associated with significantly improved survival outcomes, with 138 more survivors and 336 more women free of recurrence per 1 000 patients at five‑year follow-up among those receiving guideline‑adherent care (Ricci-Cabello et al., 2020[72]).
However, evidence from across EU+2 countries indicates that adherence to clinical guidelines in routine practice remains inconsistent, which can have important consequences for patient outcomes. A population-based study in France using European Society of Breast Cancer Specialists (EUSOMA) indicators reported good compliance for most treatment indicators, yet lower adherence for staging procedures such as sentinel lymph node biopsy and imaging, with marked geographic and institutional variation (Cowppli-Bony et al., 2019[73]). A broader review also highlighted that adherence to breast cancer guidelines across Europe was suboptimal in many settings, with median adherence to treatment processes ranging from 58% for overall treatment to 76% for systemic therapy, impacted by physician perceptions, lack of awareness, and intentional deviations (Niño de Guzmán et al., 2020[74]).
In lung cancer, studies from Finland have documented under-treatment among elderly patients, even when performance status would have allowed for guideline‑based care (Lindqvist et al., 2022[75]), (Paakkola et al., 2023[76]). For prostate cancer, nearly half of men aged 70 and older in a multicentre French cohort received treatments that did not comply with international guidelines, with guideline‑discordant treatment linked to reduced survival (González Serrano et al., 2021[77]). In ovarian cancer, only 30% of patients received fully guideline‑adherent care in a French multicentre study, and deviations were associated with a two‑fold increase in mortality risk (Jochum et al., 2021[78]). In radiotherapy, a key study among European countries found that the share of radiotherapy courses performed versus the optimal utilisation ranged from 55% to 90% across countries (Borras et al., 2015[79]). These findings reinforce the importance of systematic monitoring to reduce unwarranted variation from clinical guidelines.
The OECD’s data collection included an indicator on the use of targeted therapy for HER2+ breast cancer – a well-established care guideline to increase survival rates for this aggressive cancer. It found that adherence to this guideline was relatively high among the EU+2 countries reporting data, ranging from 76% in Portugal to 89% in Sweden (Figure 4.7). Across all countries, rates were still below the 90% target set by the European Society of Breast Cancer Specialists. Some of this gap, in Ireland for example, may be due to receipt of HER2+ treatment in community settings that are then not recorded in hospital medical records. Only half of OECD countries participating in the data collection reported on this indicator, suggesting room for improvement on data and monitoring for guideline‑concordant care in many countries. Compared to the OECD data collection, results from the Venus study for patients diagnosed in 2015‑2018 find slightly lower rates for use of targeted therapies in HER2+ breast cancer in Belgium, Ireland, the Netherlands and Portugal, but higher rates for Luxembourg (Allemani et al., 2025[80]).
Proportion of female patients with HER2+ breast cancer under age 70 receiving targeted HER2+ treatment, latest 3‑year average
Note: Reference years are from 2021-2023 (Netherlands, Norway, Sweden, Portugal), 2018-2020 (Ireland), 2020-2022 (Canada, Belgium), Luxembourg (2017-2019) and Colombia (2023). Data for Canada includes Alberta and Prince Edward Island provinces.
Source: OECD (2025[20]), “Assessing cancer care quality in OECD countries: New indicators for benchmarking performance”, https://doi.org/10.1787/b3f47ece-en.
It can be challenging to monitor adherence to clinical guidelines given new developments in cancer treatment and frequently changing recommendations that require effective real-time health data systems to allow oversight. Indeed, only 12 EU+2 countries monitor adherence to clinical guidelines for treatment of cancers such as breast, prostate, colorectal and lung cancer. One example of monitoring is in Germany, whose published quality reports by cancer centre includes a list of indicators based on adherence to clinical guidelines. For breast cancer, for example, indicators cover areas such as appropriate use of sentinel lymph node biopsy, endocrine therapy in metastatic settings, and radiotherapy after breast-conserving surgery along with use of targeted therapy in treatment of HER2+ cancer (German Guideline Program in Oncology, 2021[81]). In Denmark, use of clinical guidelines is monitored for various cancers including haematological, bladder, head and neck, brain, renal and pancreatic cancers; if treatment does not follow clinical guidelines, information on and reasons for such needs to be recorded in the patient record.
Often, cancer care protocols call for use of MDTs, which are common in cancer care in almost all EU+2 countries (OECD, 2024[30]). However, the implementation and organisation of MDTs vary significantly across countries. For example, in Estonia, practice by MDTs is inconsistent due to a lack of specific guidelines, leading to disparities in how cases are managed and treated. In Latvia, MDT conferences, known as “consilia”, are generally established in major hospitals; however, they lack standardised protocols. There are no regional or national MDTs, whether convening in person or virtually (OECI, 2023[82]).
Only 14 EU+2 countries reported evaluating the use of multidisciplinary teams for cancer care. Belgium, Ireland and the Netherlands measure the number or share of patients treated by MDTs for various cancer types (OECD, 2025[20]). In France, Regional Health Agencies (ARS) audit a sample of licensed cancer care providers to examine adherence of MDT recommendations to clinical guidelines and to check alignment between treatment given and MDT recommendations.
Across the cancer care spectrum, from diagnosis, to hospitalisation and cancer pharmaceuticals, there are initiatives to increase the value of cancer care by improving outcomes and efficiency. This section examines the current situation, trends, programmes and policies with regards to these efforts, which are summarised in Figure 4.8.
Note: EOL: End of life. 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.
4.4.1. To increase effectiveness, countries are adapting existing screening programmes and piloting new ones, while addressing overdiagnosis
EU+2 countries are adopting targeted screening initiatives to make existing screening programmes more effective
Population-based screening programmes have shown high evidence of cost-effectiveness, allowing earlier detection and better outcomes (Chapter 3). Beyond age‑based criteria, some countries are implementing risk-stratified screening of specific populations with higher prevalence of cancer risk factors, such as smoking history, family history, chronic infection, high breast tissue density, or carriers of genetic mutations (Figure 4.9). These initiatives involve inviting cohorts of eligible patients or adapting screening type or frequency based on risk factor profile. Targeted cancer screening based on risk-stratification is important for cost-effective and efficient allocation of healthcare resources, maximising benefits while minimising harms to patients. Targeting screening through risk-stratification increases the likelihood of detecting cancer in those at highest risk of developing cancer compared to screening the age‑eligible population, yielding an increased rate of early diagnosis relative to the resources allocated. Additionally, targeting screening may reduce the screening burden and potential harms to those at lower risk of developing cancer in the population, offering a more person-centred approach to prevention (Fitzgerald et al., 2022[83]).
Note: 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.
A majority of EU+2 countries report targeting existing screening programmes at patients with a family history of cancer, or genetic mutations (such as BRCA genes or Lynch syndrome) which predispose to certain cancer types. In Greece, screening for breast cancer takes place starting at younger ages in cases of strong family history, while in Czechia, individuals with a family history of cancer are not included in the general screening programme but are monitored under a different screening protocol. In Belgium, follow-up cancer screening for genetically at-risk individuals takes place according to guidelines from ERN GENTURIS (the European Reference Network for patients with one of the rare genetic tumour risk syndromes). There are special screening protocols for those at high risk of colon cancer in the Slovak Republic, and in Germany, a consortium of clinics manages patients with familial colorectal cancer. In Iceland, BRCA gene carriers are screened more frequently for breast, cervical cancer and melanoma. To help identify those at higher cancer risk, genetic testing for people with familial cancer history is publicly financed under certain conditions in countries such as Austria, Germany, Greece and Italy. In an example from other OECD countries, some genetic testing (such as for BRCA genes) at the population level is fully (Israel) or partially (Australia) covered.
Additionally, 13 EU+2 countries (Belgium, Czechia, Estonia, France, Germany, Greece, Hungary, Italy, Lithuania, the Netherlands, Poland, Romania, the Slovak Republic) reported risk-stratifying cancer screening by lifestyle factors – mainly lung cancer screening pilots based on smoking history. Nine EU+2 countries (Belgium, Czechia, Greece, Hungary, Iceland, Italy, Lithuania, Spain and Sweden) reported adapting their cervical cancer screening programme based on HPV vaccination status, to ensure unvaccinated women at highest risk for cervical cancer are screened more often, and vaccinated women at lower risk are screened less. As of 2025, few countries have introduced liver cancer screening based on risk from chronic hepatitis B or C infection in the population. However, a number of countries are piloting screening for Helicobacter pylori, a leading risk factor for stomach cancer, to reduce cancer mortality. In addition to the above initiatives, Estonia is piloting an Artificial Intelligence guided approach to risk-based stratification of women for breast cancer screening (see Section 4.4.5).
Adapting breast cancer screening modalities and frequency according to breast tissue density is an evolving area and there have been recent calls in some EU countries to integrate breast density measurement into cancer screening (NIH National Cancer Institute, 2024[84]). This is because higher breast density can affect the accuracy of mammography, and is itself an independent risk factor for breast cancer; however, the evidence regarding the benefits versus risks is uncertain (Tse et al., 2024[85]). This approach to screening women at higher risk based on higher breast density with MRI or ultrasound imaging or at a younger age, is currently reported by seven EU+2 countries (Austria, Estonia, Hungary, Iceland, Italy, Lithuania, Luxembourg).
New data from lung, prostate and stomach cancer screening pilots are providing insights on feasibility and cost-effectiveness of expanding to population screening programmes
In addition to recommendations related to the three main cancer screening programmes, the Council of the EU Recommendation (2022) on cancer screening invites countries to take a stepwise approach to consider screening programmes for lung, prostate and stomach cancer (European Parliament, 2022[86]), as per the following:
Lung: Explore feasibility and effectiveness of screening programmes via low-dose CT, starting with heavy smokers and ex-smokers;
Prostate: Explore feasibility and effectiveness of organised programmes with prostate‑specific antigen (PSA) testing in combination with follow-up MRI scanning;
Stomach: Consider screen-and-treat strategies for Helicobacter pylori (H. pylori) in areas with high stomach cancer incidence and mortality, as well as identification and surveillance of patients with precancerous stomach lesions.
This guidance aligns with and builds on existing knowledge on cost-effectiveness in a range of OECD countries. For example, lung cancer screening using low-dose CT scanning was found to be cost-effective in 87% of reviewed trials and modelling studies (Grover et al., 2022[87]), especially when targeted at smokers aged 55‑75 years with at least 20 years of smoking history. Similarly, with the cost-effectiveness threshold for a screening intervention commonly set at EUR 30 000 per life year or quality-adjusted life year (QALY) gained, screening studies in Australia (Behar Harpaz et al., 2023[88]), Belgium (Desimpel F, 2024[89]), the United Kingdom (Field et al., 2016[90]), the Netherlands (Al Khayat et al., 2022[91]), Spain (Gómez-Carballo, Fernández-Soberón and Rejas-Gutiérrez, 2022[92]), and Switzerland (Tomonaga et al., 2024[93]) have fallen within this threshold. Among non-smokers, lung cancer screening was not found to be cost-effective in the United States, while it was in Japan due to higher incidence of lung cancer among non-smokers in Asia (Kowada, 2022[94]). For stomach cancer screening, the cost-effectiveness of test-and-treat strategies for H. pylori infection is determined by stomach cancer incidence, H. pylori prevalence, age at screening, and the costs of testing and treatment of stomach cancer (Lansdorp-Vogelaar and Sharp, 2013[95]). These factors should be accounted for when assessing the cost-effectiveness of implementing stomach cancer screening in EU countries.
In line with the Council Recommendation, progress has been made on implementing pilot screening studies for lung, stomach and prostate cancer in EU+2 countries (Table 4.2). For lung cancer, 11 countries are involved in pilots in the EU SOLACE project on screening feasibility and cost-effectiveness (European Commission, 2023[96]), while France, Portugal and Sweden have undertaken lung cancer screening pilots since 2023. Looking at all OECD countries, Croatia (in 2020) and Australia (in 2025) have taken the next step by implementing nationwide lung cancer screening programmes, with Germany planning to start national roll-out in 2026 and England expecting national roll-out to be completed by 2029. Similarly, Canada has implemented population-based lung cancer screening in two provinces (Ontario and British Columbia), with partial implementation or planned introduction in eight other jurisdictions.
Note: Programmes are shown in green shading; pilots in purple shading.
For stomach cancer, screening programmes have been implemented in higher incidence countries of Japan and Korea. The EU-funded TOGAS initiative (11 piloting EU countries) is examining a test-and-treat screening approach for H. pylori infections in young adults, while other stomach cancer pilots are underway via the EU-funded EUROHELICAN (2 piloting EU countries) and in Portugal.
For prostate cancer, the EU-funded PRAISE‑U initiative is assessing feasibility and sustainability of initial PSA testing followed by risk-stratified MRI in men aged 50‑69 in Ireland, Lithuania, Poland, and Spain. Meanwhile Czechia implemented a population-based PSA screening programme in 2024 for men aged 50‑69, while nationwide opportunistic prostate cancer screening has been in place in Lithuania (men aged 50‑69 or those aged 45 and over with a family history) since 2006 (Gondos et al., 2015[115]).
Risk-stratified screening strategies in combination with screening algorithms and standardised diagnostic approaches can improve the effectiveness of cancer care
In addition to considering clinical and cost-effectiveness, new proposals for implementing risk-stratified screening programmes for prostate and lung cancer are also aiming to reduce overdiagnosis from overly broad opportunistic screening approaches. Overdiagnosis of cancer refers to detection and diagnosis of cancers that would otherwise have remained asymptomatic and not impacted an individual’s health in their lifetime had they remained undetected. The relative proportion of overdiagnosis depends on both the cancer type and the screening technology and strategy applied to the population.
In The Economics of Diagnostic Safety, the OECD outlined the considerable economic costs of overdiagnosis of cancer from screening and diagnostic testing (Slawomirski et al., 2025[116]). The risk of overdiagnosis from cancer screening ranges from 60% for prostate cancer screening using PSA testing to 4‑19% for lung cancer screening, contributing to substantial direct healthcare costs (through unnecessary tests, treatments and follow-up care). Overdiagnosis also generates significant indirect costs, including lost productivity, later complications from surgery and chemotherapy, and psychological distress.
The risk of overdiagnosis can be mitigated by clinical decision making and by patient-informed discussion. Not all positive screening tests result in a diagnosis of cancer, and not all overdiagnosis results in overtreatment. The availability and application of evidence‑based shared decision making, screening algorithms informed by best practice guidelines, and adherence to rigorous cancer diagnostic standards ultimately determine the effectiveness of these screenings at reducing cancer mortality in health systems.
Application of algorithms based on combined demographic and biomedical patient data to determine who best to screen for cancer, and how to better interpret the risk of a clinically significant cancer based on the results of a screening test can mitigate the risk of cancer overdiagnosis (Crosby et al., 2022[117]). An example is polygenic risk scoring of individuals with detected anomalies suggestive of cancer, to profile patients into stratified risk categories and further improve cancer screening efficiency. This technological approach could be used to stratify screening test results into high versus low risk of cancer for the patient, such as for prostate cancer in the Finnish arm of the European Randomised Study of Screening for Prostate Cancer, in order to reduce the risk of overdiagnosis (Pashayan et al., 2015[118]).
The OECD Survey on High-Value Cancer Care revealed that overdiagnosis of prostate cancer is a real concern in 13 EU+2 countries (Austria, Czechia, Denmark, Estonia, France, Hungary, Iceland, Ireland, Italy, Lithuania, Norway, Slovenia and Sweden). Overdiagnosis of thyroid cancer is of concern in eight EU+2 countries (Belgium, France, Germany, Hungary, Ireland, Italy, Norway and Slovenia), and has been a major area of change in cancer screening policy in Korea (Sik, Jung and Gilbert, 2025[119]; Yi, 2016[120]) (Box 4.6). Overdiagnosis of breast cancer, given the high numbers participating in screening programmes, was reported as a problem by five EU+2 countries (Belgium, Denmark, France, the Netherlands and Norway). In contrast, only Norway reported overdiagnosis of melanoma as a concern (see Figure 4.10).
Note: 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.
Highly variable opportunistic screening practices and lack of uniform policies on diagnostic approaches contribute to overdiagnosis of prostate cancer
The risk of overdiagnosis of prostate cancer is particularly large, estimated at 42% to 57% for cases identified by screening, as well as for cases diagnosed clinically (Heijnsdijk et al., 2009[121]). Overdiagnosis of prostate cancer in older patients, where the disease is less likely to impact health or mortality, carries the risk of overtreatment and generating low-value care (Directorate-General for Health and Food Safety, 2025[122]). The economic costs due to overdiagnosis were estimated to account for 40% of total healthcare costs of prostate screening (EUR 24 million to screen 100 000 men) in a modelling scenario in the Netherlands (Heijnsdijk et al., 2009[121]). Much of this overdiagnosis is driven by opportunistic screening using PSA testing alone, resulting in 20‑fold variation in prostate cancer incidence internationally (Vaccarella et al., 2024[123]).
Based on the 2025 OECD data collection, the share of early-stage (stage I and II) prostate cancer diagnoses among men aged 75 years and older ranged from 53% in the Netherlands to 81% in Luxembourg (see Figure 4.11). This is among the largest variability by stage at diagnosis among breast, colorectal, cervical and prostate cancers (OECD, 2025[20]), and likely reflects large international variation in prostate cancer screening practices, and the lack of evidence‑based consensus on who and when to screen (IARC, 2024[124]; OECD, 2024[30]). Indeed, Luxembourg reported among the highest number of diagnostic exams performed per 1 000 persons in the EU, after Austria (see Chapter 3, box 3.1). Among countries included in Figure 4.11, only Czechia has a structured national prostate cancer screening programme, implemented in 2024. A lack of standardised screening policy results in opportunistic prostate cancer screening practice, which drives overdiagnosis and potential overtreatment of prostate cancer in EU countries.
Stage of prostate cancer diagnosis, among men age 75+
Note: Most recent 3‑year average for each country (ranging from 2018 to 2023). Early-stage combines TNM stage I and II.
Source: OECD (2025[20]), “Assessing cancer care quality in OECD countries: New indicators for benchmarking performance”, https://doi.org/10.1787/b3f47ece-en.
Updated screening strategies and pilot studies can inform screening policy on who and how to screen for prostate cancer
Screening strategies aimed at those more likely to benefit from early cancer diagnosis, and using more accurate and precise technology, can help reduce overdiagnosis of prostate cancer. In line with the Council Recommendation (Council of the European Union, 2022[125]), the stepwise design of the PRAISE‑U screening pilots in Ireland, Lithuania, Poland and Spain wherein initial PSA testing is followed-up with MRI aims to reduce the risk of overdiagnosis based on elevated PSA results alone using more accurate imaging technology.
Similarly, screening beyond age 70 is less likely to confer survival benefit and more likely to cause harm and incur costs from low value care and from detection of less aggressive prostate cancers in older patients. The Canadian Urological Association recommends careful consideration of when and who to screen for prostate cancer based on patient age and life expectancy, and shared decision making about proceeding to further diagnostic investigation of suspected prostate cancer (Mason et al., 2022[126]). Among national clinician led-initiatives such as Choosing Wisely (described further in Section 4.4.4), three EU+2 countries (Austria, the Netherlands, Spain) have recommendations to avoid routine PSA testing.
Adoption of evidence‑based clinical guidelines for prostate cancer management are needed to harmonise practice and reduce potential overtreatment and associated costs
A major concern about cancer overdiagnosis is that it leads to potential overtreatment. Once a cancer diagnosis is made, there is pressure on clinicians as well as patient expectations to provide curative or life‑extending care. Radical prostatectomy is the main surgical procedure for active treatment of prostate cancer; however it may not be the most cost-effective, or patient-centred approach for all patients with prostate cancer (Noble et al., 2020[127]). As a major surgery, prostatectomy can result in considerable long-term consequences for patient quality of life, including impotence and urinary incontinence. Alternative treatment approaches such as chemoradiotherapy and active surveillance of prostate cancer have been shown to yield similar overall survival (Hamdy et al., 2023[128]), and offer a less aggressive treatment option for patients.
OECD data shows large variation in prostatectomy rates in EU+2 countries (Figure 4.12), while there is little country variation in the high rates of 5‑year survival for prostate cancer. Furthermore, there is little correlation between the incidence of prostate cancer and the number of prostatectomy surgeries performed. Indeed, the ratio of prostatectomies to prostate cancer cases varies more than 70‑fold from almost none (0.01) in Finland to three out of four cases (0.76) in Italy. Northern European countries (Finland, Denmark, Norway, Ireland) reported the lowest ratios, while Central and Southern European countries (Italy, Austria, Germany, Spain) reported the highest. Some of the observed variation may be attributed to availability and infrastructure of radiotherapy treatments (see Chapter 3) or patient preferences between treatment modalities and/or active surveillance; however, the lack of consensus on optimal treatment for high-risk prostate cancer may be driving unwarranted surgical treatment in some countries and leading to under-treatment in others.
Note: Prostate cancer incidence refers to estimated 2022 age‑standardised incidence for EU countries and to 2017 age‑standardised incidence for Norway and other OECD countries. Prostatectomy rate refers to the number of prostatectomy procedures per 100 000 in 2022, except for NLD and LUX which are from 2021.
Source: Incidence data from European Cancer Information System (ECIS), https://ecis.jrc.ec.europa.eu/, accessed in July 2025 for EU countries; Incidence data from IARC (2025[129]), https://gco.iarc.fr/overtime/en for Norway and other OECD countries; Prostatectomy data from OECD Health Statistics (2025[130]), https://www.oecd.org/en/data/datasets/oecd-health-statistics.html.
Countries that promote “watchful waiting” or offer alternative treatment options such as active surveillance – reserving surgery for cases of clear need – may avoid overtreatment of prostate cancer and thus reduce expenditures for patients and the healthcare system. For prostate cancer, shared decision making (see Chapter 5) on screening and treatment choices (considering patient age, preferences and expectations, and the likelihood of aggressive or indolent cancer) is particularly important for ensuring people‑centred care and reducing costs to patients and healthcare systems from lower quality care.
Clinical guidelines for prostate cancer aim to reduce the risk of overdiagnosis and overtreatment by providing specific indications on how and when to treat prostate cancer, and in which patients. The European Association of Urology provides evidence‑based guidelines for treatment options for prostate cancer to guide decision making, however it acknowledges lack of consensus regarding the optimal treatment of men with high-risk prostate cancer (European Association of Urology, 2025[131]). Ireland recently published national clinical guidelines for active surveillance of men diagnosed with prostate cancer, to reduce the risk of overtreatment (Health Service Executive Ireland, 2025[132]). Two other EU+2 countries (the Netherlands, Portugal) have clinician-led recommendations to discuss active surveillance in patients with low-risk prostate cancer (see Section 4.4.4). Among the countries surveyed in 2025, 11 EU+2 countries (Czechia, Denmark, France, Germany, Hungary, Luxembourg, the Netherlands, Norway, Poland, Slovenia and Sweden) and one other OECD country (Canada) monitor adherence to clinical guidelines (Section 4.3.3) for treatment of prostate cancer.
While survival outcomes may be similar, the long-term post-prostatectomy complications borne by patients and the costs of additional surgeries to healthcare systems differ greatly. As such, adoption of evidence‑based guidelines and developing consensus on best practices can help to harmonise care and reduce the variation in rates of surgical treatment for prostate cancer across health systems.
Thyroid imaging is a major driver of cancer overdiagnosis internationally, and national guidelines advise against screening
Overdiagnosis of thyroid cancer is a global problem, due to increased detection of small indolent tumours unlikely to be of clinical significance for patients in their lifetime. Despite a recent decrease in thyroid cancer incidence from 2015 onwards in Austria, France, Ireland, Italy, Canada, Israel, Korea, and the United States, more than half of cases diagnosed are estimated to represent overdiagnosis (Li et al., 2024[133]). In EU countries from 2013 to 2017, the proportion of thyroid cancers representing overdiagnosis ranged from 26% in Estonia to 89% in Cyprus, despite changes in screening policies and clinical guidelines. In France, overdiagnosis was reported to account for 29‑57% of thyroid cancer diagnoses from 2011-2015, with estimated economic costs of EUR 60‑160 million (Li et al., 2023[134]).
Regional variation in rates of overdiagnosis, such as in France, underscores the importance of implementing national clinical guidelines to standardise investigation, diagnosis and management of thyroid cancer and to reduce the volume of low quality care (Li et al., 2021[135]). The high burden from overdiagnosis and overtreatment of thyroid cancer in Italy (Dal Maso et al., 2018[136]) spurred national stakeholders working with the International Agency for Research on Cancer (IARC) to report new guidelines to limit the risk of thyroid cancer overdiagnosis, emphasising the psychological and physical harms of aggressive treatments to patients and the costs to the healthcare system (IARC, 2025[137]). To address overdiagnosis in Canada (Topstad and Dickinson, 2017[138]), the clinician-led Choosing Wisely initiative recommends limiting routine use of thyroid ultrasound (Choosing Wisely Canada[139]). Similarly, countries can learn from the experience and evidence‑based policies of Korea in thyroid cancer when implementing cancer screening policy, diagnostic imaging and treatment guidelines (Box 4.6).
Technological advances in the availability of medical imaging and testing biomarkers for cancer can risk driving demand for early cancer diagnosis and treatment. Careful evaluation of cancer screening and diagnostic technology by health policymakers is needed to ensure only evidence‑based and cost-effective methods are implemented for early diagnosis in health systems (Fitzgerald et al., 2022[83]), and that these are made equally available to those at highest risk. Otherwise, the extra volumes generated by unregulated testing and incidental and overdiagnosis may exceed the capacity of health systems to provide urgent and routine cancer care.
Overdiagnosis driven by opportunistic screening
In Korea, a 15‑fold increase in thyroid cancer diagnoses occurred from 1993 to 2011, due to thyroid ultrasound screening being added as a fee‑for-service reimbursed by the government and offered in tandem with breast cancer screening (Kim, 2024[140]). This epidemic of overdiagnosis of papillary thyroid cancer resulted in significant economic burden and harm to patients, without substantial changes in thyroid cancer mortality (Sik, Jung and Gilbert, 2025[119]).
Policy changes to reduce harms
Intervention by the Coalition for Prevention of Overdiagnosis of Thyroid Cancer led to a reduction in overdiagnosis and updated evidence‑based national guidelines for diagnosis and treatment being implemented in 2015 (Yi, 2016[120]). The updated Korean national thyroid association guidelines do not recommend routine screening for thyroid cancer and cancer guidelines advise against biopsy and surgical treatment for small tumours, instead recommending active surveillance (Yi et al., 2015[141]).
National guidelines for lung cancer screening are needed to limit the burden and costs of screening to low risk patients
For lung cancer, the issue of overdiagnosis can arise when screening is offered to non-smokers (Gao et al., 2022[142]). This can result in increased detection of early-stage adenocarcinoma tumours, associated with a low risk of cancer mortality (Welch et al., 2025[143]). As a result, non-risk stratified lung cancer screening is less likely to improve overall cancer survival, while causing harm to patients from the anxiety, medical interventions and healthcare costs associated with diagnosis and treatment. In Korea for example, private opportunistic screening for lung cancer in non-smokers is considered a policy challenge due to overdiagnosis. The Council Recommendation (Council of the European Union, 2022[125]) advises exploring the feasibility and effectiveness of risk-stratified lung cancer screening limited to high risk individuals with a history of smoking, to minimise costs to health systems and harms to low risk individuals.
Additionally, five EU+2 countries reported overdiagnosis as an issue for breast cancer, stemming from breast cancer screening (Belgium, Denmark, France Netherlands, Norway) (see Figure 4.10). While overdiagnosis is a known inherent risk of breast cancer screening and diagnosis, particularly among older women (Ding et al., 2022[144]), the proportion of breast cancers which represent overdiagnosis is less than for prostate or lung cancer, and this inherent risk is generally tolerated given the proven benefits of screening.
Nine EU+2 countries have policies to address the issue of overdiagnosis in cancer and 12 have policies to optimise imaging use
Among countries participating in the 2025 OECD Survey on High-Value Cancer Care, nine EU+2 countries (Belgium, Czechia, Denmark, Estonia, Germany, Norway, Poland, Slovenia and Sweden) reported policies to reduce cancer overdiagnosis. These namely include implementation of organised as opposed to opportunistic cancer screening, and updated screening guidelines and treatment protocols to reduce overtreatment. A further 12 EU+2 countries reported efforts to optimise the use of imaging (in either screening or treatment), aiming to reduce overuse via cancer-specific clinical guidelines (Ireland, Poland, Slovenia), or as part of the National Cancer Plan (Czechia). These should enable better management of cancers that are detected incidentally or of uncertain clinical consequence. Other examples cited included working under the European Cancer Imaging Initiative (European Commission, 2023[145]), which aims to improve the accuracy and efficiency of imaging for cancer screening (Belgium), and rationalising imaging for certain cancer types to avoid unnecessary use (Denmark).
Once a cancer is appropriately diagnosed, the emphasis shifts to ensuring the quality and efficiency of the cancer treatment delivered.
4.4.2. Countries are shifting cancer care away from the inpatient setting
Over the years, provision of healthcare has shifted away from inpatient and towards ambulatory and day procedures, which offer potential savings in infrastructure and staff and can reduce pressure on inpatient capacity. Compared to inpatient, same‑day discharges also benefit the patients in terms of scheduling, ease of access, lower risk for hospital acquired complications, and better patient experience (Kreutzberg et al., 2024[146]; Wu, Lim and Koh, 2021[147]). Studies indeed find lower procedure costs of day compared to inpatient surgeries, with better or similar morbidity, mortality and cost outcomes in the follow-up period (Madsen et al., 2022[148]; Brüngger et al., 2021[149]; Friedlander et al., 2021[150]). A cancer-specific study using the American College of Surgeons’ registry data found mortality and morbidity outcomes for prostatectomies and mastectomies performed in the day setting were similar or better than those in the inpatient setting, indicating effective patient selection for day surgeries (younger, fewer co-morbidities, lower risk status) (Madsen et al., 2022[148]).
The shift to day surgeries is seen across a number of EU+2 countries, supported by policy measures such as defined lists of permitted day surgery procedures, changes in payment mechanisms to require or incentivise use of day surgeries (such as in Austria, Bulgaria, Estonia and France), policy targets on share of day surgeries, and national strategies promoting the expansion of day surgery units (Kreutzberg et al., 2024[146]; Milstein and Schreyögg, 2024[151]; Dubas-Jakóbczyk et al., 2020[152]). Poland and Lithuania as well have undertaken or updated reforms in recent years to require or incentivise day procedures (Ministry of Health, 2025[153]; Lithuania Parliament, 2025[154]).
For cancer, the shift towards day treatment has included use of specialised infusion centres, ambulatory surgery centres and treatment at home, supported both by developments in cancer therapies allowing their administration outside of hospitals as well as the COVID‑19 pandemic (Sabbagh Dit Hawasli, Barton and Nabhani-Gebara, 2021[155]; McDevitt et al., 2024[156]; Wu, Lim and Koh, 2021[147]). Indeed, as shown in Figure 4.8, this shift is of high priority, with 17 EU+2 countries responding to the 2025 OECD Policy Survey reporting policies shifting cancer care away from the inpatient setting.
In Greece, the Oncology Hospital of Athens Agios Savvas has established a day centre with a capacity of 45 beds and provides chemotherapy, radiotherapy and day surgeries for cancer patients, freeing up capacity for other operations at the main hospital and offering a more efficient and patient-centred experience (Agios Savvas Oncology Hospital, 2021[157]). In Bulgaria, the emphasis has been on the provision of chemotherapy and radiotherapy outside of hospitals, while Ireland has adopted a model of care (with implementation not yet complete) for systemic anti-cancer therapy that focusses on delivering services as close to the patient as possible, including via high-quality ambulatory centres and at home (National Cancer Control Programme, 2024[158]). In Slovenia, a stepwise shift away from higher intensity settings after the main treatment is completed is being implemented, whereby primary care and specialists at the local level conduct the follow-up and monitoring of patients, guided by survivorship plans detailing ongoing care needs of patients (Cancer Association of the Slovenian Medical Association; Institute of Oncology Ljubljana, 2024[159]). Outside the EU, Canada developed ambulatory chemotherapy services standards in 2011.
The trend towards day cancer surgeries is seen in some EU+2 countries, with Nordic countries leading the way
Certain procedures that were previously always done in the inpatient setting, such as mastectomies, are now occasionally taking place via same‑day discharges. While most EU countries still do few mastectomies in the day setting, there has been an increase over time. Nordic countries have substantially shifted mastectomies to the day setting, with a quarter to half of procedures done on a day basis in Denmark, Finland, Norway and Sweden (Figure 4.13). These results align with other studies showing that the Nordic countries have rapidly shifted surgeries such as tonsillectomies, hernia, and cataract surgery to the day setting (Kreutzberg et al., 2024[146]). Among non-EU+2 countries, Korea, Costa Rica and the United Kingdom also had a third or more mastectomies in 2023 performed in the day setting, while Canada reached 60%. A major increase in the share of day mastectomies compared to a decade prior is seen in nearly all countries shown in (Figure 4.13).
Share of mastectomy day procedures out of all mastectomies, 2013 and 2023
Note: Only countries with at least 5% of mastectomies performed as day procedures in 2013 or in 2023 are included in the figure. *Data refers to 2024 for Finland, Iceland, Norway and Portugal.
Source: OECD Health Statistics (2025[130]), https://www.oecd.org/en/data/datasets/oecd-health-statistics.html.
Home hospitalisation is becoming more common to replace or shorten hospital stays, although many countries have not yet fully adapted this approach
A number of countries have introduced hospital-at-home‑programmes designed to either fully replace inpatient hospital stays for some patients or enable earlier discharge by providing enhanced monitoring and care in the patient’s home (OECD, 2025[160]). While such programmes began in the 1970s, these initiatives have gained renewed momentum particularly during the COVID‑19 pandemic, as they promote safe, home‑based care while alleviating hospital capacity pressures and managing rising healthcare needs (Mittaine‐Marzac et al., 2021[161]; Nogués et al., 2021[162]). In hospital-at-home programmes, patients usually receive home visits by doctors and nurses, services such as intravenous therapy, imaging, treatment, monitoring, and chemotherapy, and have a 24‑7‑hotline for assistance as well as digital support tools. Programmes are generally hospital-led and while some are aimed at or limited to non-cancer conditions such as cardiovascular, respiratory or infections, many instead use criteria regarding age, clinical stability, self-management or other safety aspects. Costs per hospital-at-home stays are around 20‑30% lower than for inpatient admissions while patients value receiving care in their familiar surroundings (OECD, 2025[160]). A systematic review of oncology hospital-at-home programmes found high patient satisfaction with and preference for home treatment, with cost savings found in the majority of studies (Cool et al., 2018[163]).
In the 2025 OECD Policy Survey on High-Value Cancer Care, Belgium, Denmark, France, Greece, Hungary, Iceland, Ireland, Lithuania, Poland, Portugal, Slovenia and Sweden all report hospital-at-home‑models for cancer care. While a couple of countries note that this is limited to palliative cancer care (e.g. Portugal and Slovenia), in other countries the services go well beyond (Box 4.7). In Spain, recommended guidelines for home administration of oncologic treatments, developed via a national expert consensus process, were published in 2024 with the aim of supporting roll-out and implementation of such services (Villegas et al., 2024[164]).
Belgium
In Belgium, parenteral administration of cancer treatments can be delivered at home under strict conditions and hospital supervision. The possibility of home hospitalisation is discussed with the patient and once approved, a detailed care plan is developed in collaboration with hospital and home care teams. Quality and safety are ensured through close co‑ordination between healthcare providers. The hospital is responsible for the preparation, transport, and delivery of medications, and the collection of hazardous medical waste. The initiative is designed to be cost-neutral, including for patients, with an evaluation of the processes and costs planned (INAMI, 2024[165]).
France
Home hospitalisation for systemic cancer drug treatments is part of France’s 2021‑2026 national roadmap (ONCO AURA, 2025[166]). The model relies on close co‑ordination between hospitals, community health professionals, and families, supported by information-sharing systems. There are both facility-integrated and stand-alone models, under which injectable cancer drugs, including immunotherapies and targeted therapies can be administered at home if preparation, monitoring, and safety requirements are met. In 2023, nearly 210 000 days of home‑based care had been provided in France for cancer chemotherapy by 193 providers, with an average length of stay of 3.9 days. However, there is substantial variation in use of home hospitalisation for systemic therapy by region. In Normandy, where rates of utilisation for home‑based chemotherapy are particularly low, the Regional Health Agency launched a three‑year experimental programme in February 2025 whereby selected hospitals authorised for cancer treatment will receive fixed payments for referring patients to home hospitalisation and these services will receive fees for treatment administration (ARS Normandie, 2025[167]).
Greece
Greece’s “Oikothen” (“from home”) care programme, launched in June 2023 by one of the leading cancer hospitals in Athens, delivers cancer treatments directly to patients’ homes. By December 2024, 156 patients had benefited from the programme, improving patient well-being and relieving pressure on hospital resources. It has expanded to four additional hospitals, with plans underway to extend coverage to all major cities (Bouloutza, 2024[168]).
Poland
The National Institute of Oncology in Warsaw offers portable chemotherapy infusers as an alternative to inpatient care – deploying up to 10 000 devices annually. These infusers allow for the prolonged administration of chemotherapy at home and are primarily used in postoperative and palliative treatments for colon, stomach and pancreatic cancers. Patients receive training on how to use the infuser safely at home and have access to telephone support from their treatment centre (Wyrwicz, 2023[169]).
Given the efforts described above, the number of hospital discharges relative to cancer cases has decreased over the past decade, falling in virtually all countries with available data (Figure 4.14). On the EU level, annual colorectal cancer hospital discharges per new case decreased 12% between 2012 and 2022, from 2.3 discharges per case to 2.0. Notably, there remains large variation by country in where patients are treated – central European countries tend to treat more colorectal cancer cases in hospitals, while western European countries tend to utilise hospitals less.
There is a similar, but larger, reduction in hospital discharges for lung cancer over time, decreasing by 24% from 2.2 to 1.7 discharges per new cancer case in the EU on average. This is also supported by changes in treatment modalities, which now includes an emphasis on molecular diagnostics to guide care (see Section 4.4.5) and a rapid increase in new medicines entering the market (NICE, 2025[170]). In breast cancer as well, use of systemic therapies (i.e. pharmaceutical treatment) as the first course of treatment is supporting a shift in treatment modalities away from more hospital-centred surgeries (Boersma, Mjaaland and van Duijnhoven, 2023[171]).
Hospital discharges per new cancer case, 2012 and 2022 (or nearest)
Note: Colorectal discharges also include those for anal cancer. 2022 or nearest refers to estimated number of cancer cases; 2012 or nearest refers to observed incidence. For the 2012 incidence and discharge values, data from 2013 were used for Latvia and Sweden, and from 2010 for Portugal and the Slovak Republic. For the 2022 values, data from 2021 were used for Croatia and Poland for incidence and discharges while in the Slovak Republic, 2021 data was used for discharges only.
Source: Hospital discharge data from OECD Health Statistics (2025[130]), https://www.oecd.org/en/data/datasets/oecd-health-statistics.html; incidence data from European Cancer Information System (ECIS) https://ecis.jrc.ec.europa.eu/, accessed on 25 November 2025.
Even with the shift away from hospital care, hospital spending on cancer care has increased over the past years
The shift of some care away from hospitals is occurring alongside decreases in hospital length of stay for cancer cases; nonetheless hospital spending on cancer care is still increasing.
Among the common cancer types, average length of stay for inpatient hospital cancer care in 2023 in the EU ranged from about 4.5 days (skin cancer) to 9.4 days (colorectal cancer). Across these cancer types, there has been a decrease in average length of stay in the EU between 2013 and 2023, ranging from an 11% reduction for skin cancer to a 25% decrease for prostate cancer. These reductions reflect advances (not limited to cancer care) in surgical techniques, improved pharmacological treatments, enhanced surgery recovery protocols, telehealth-supported discharge planning (Hirani et al., 2025[172]) and home hospitalisation programmes. Some countries or cancer centres also prioritise prehabilitation (interventions such as exercise, nutrition or psychosocial interventions to improve the health and well-being of cancer patients prior to surgery), potentially shortening length of stay (Lambert et al., 2020[173]; Voorn et al., 2023[174]). However, there is some concern that the evidence base for prehabilitation is not well established and that lower socio-economic groups may have less access (Stewart et al., 2025[175]).
Between 2015 and 2023 (or latest year), annual hospital spending on cancer care in real terms grew by an average of 3.7% in EU countries (Figure 4.15). Spending on hospital care for cancer tended to grow faster in Central European countries compared to Western European countries. In Poland, Romania, Bulgaria, Portugal and Latvia, average annual hospital spending on cancer care grew between 6% and 11% during the 2015-2023 period, while in France, Belgium and Norway, annual increases were much more moderate, at around 1% or less on average. In Estonia, Finland and the Netherlands, the growth in annual hospital spending on cancer care in real terms was negative.
Annual growth in hospital spending on cancer care (real terms), 2015-2023 (or latest years).
Note: Hospital spending on cancer care was estimated using cancer discharges as a share of total hospital discharges in 2015 and in 2023 (or latest years) multiplied by total inpatient expenditures in real terms of the national currency unit for each country.
Source: OECD Health Statistics (2025[130]), https://www.oecd.org/en/data/datasets/oecd-health-statistics.html.
Spending increases can be driven by increasing prices of hospital care including due to new technologies and increasing complexity of cases treated. They can also be driven by growing cancer incidence due to ageing populations as well as for certain cancer types on an age‑standardised basis, such as breast and lung cancer among women (see Chapter 2). Regardless, the increase highlights the importance of continuing to find safe and effective opportunities to shift cancer care out of the hospital given the higher costs of care in this setting.
Even with efforts to provide care in less intensive settings, the emergency care route is frequently used by cancer patients
Cancer can often lead to challenging emergency situations for patients, as they encounter a sudden worsening of their condition or serious side effects from treatment. Indeed, data from PaRIS (see Chapter 5 Box 5.1 and (OECD, 2025[176])) shows that more than a third of adults with a cancer diagnosis (35%) attending primary care clinics had an emergency care visit during the past year (ranging from 21% in the Netherlands to 49% in Portugal) (Figure 4.16). This is a statistically significant higher rate than among other primary healthcare patients (27%). In addition, on average, patients with a cancer diagnosis and low education were about 20% more likely to report an emergency room discharge in the previous year than those with higher education, with this social gradient found in 14 out of the 18 OECD countries participating in PaRIS. The fact that primary care patients with a cancer diagnosis in the past five years, who mainly represent stable, post-acute patients – and particularly those with lower education – have more emergency visits, highlights the higher risk of “sudden worsening” among this population and the need for tailored care practices for those with a history of cancer.
Primary care patients reporting emergency department visit in previous 12 months
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.
4.4.3. Due to high costs of cancer drugs, countries are looking to optimise spending on cancer pharmaceuticals
Countries are undertaking various approaches to reduce spending on cancer pharmaceuticals. These efforts are driven by increased spending stemming from many new cancer medications coming to market and high prices (Hofmarcher, Berchet and Dedet, 2024[177]). Data from the OECD 2025 Country Cancer Profiles show that cancer medicines accounted for about 20‑30% of pharmaceutical spending in Italy, Norway and Portugal, while (Manzano et al., 2025[37]) shows that in Sweden, that figure increased from 12% in 2018 to 17% in 2022.
Post-marketing reassessment of coverage and pricing decisions, as well as treatment optimisation are increasingly important to limit low-value pharmaceutical spending
Since 1995, all cancer medicines in Europe have been approved through a centralised process, granting marketing authorisation (i.e. regulatory approval) across all EU Member States, Iceland and Norway. Subsequent decisions on coverage and pricing are made at the national level, often informed by Health Technology Assessments (HTA) that determine the clinical and economic value of the medicine. HTA processes are key in shaping reimbursement and pricing policies, as well as for informing clinical guidelines to ensure that use of and spending on cancer medicines is aligned with value. Concerningly, a study of 131 oncology drugs approved by the European Medicines Agency (EMA) between 1995 and 2020 that evaluated their added clinical benefit using ratings from health technology assessment bodies found that 41% of ratings indicated negative or non-quantifiable added benefit (Brinkhuis et al., 2024[178]).
Follow-up of medicines after marketing authorisation and changes in coverage status or pricing is also important given that many cancer medications are approved based on surrogate endpoints or via accelerated approval processes that ensure quicker access for patients in need. In Sweden, a study examined cancer drug indications that were reimbursed even though they initially lacked evidence of improvements in overall survival and quality of life. After an average follow-up of 6.6 years, only seven of 22 indications showed conclusive evidence of benefits in either overall survival or quality of life (Strand et al., 2023[179]). Similarly, a 2024 study found that more than half of 46 indications of cancer medicines approved by the Food and Drug Administration (FDA) in the United States between 2013‑2017 showed no clinical benefit in terms of survival or quality of life within five years of approval (Liu, Kesselheim and Cliff, 2024[180]). Among those with no clinical benefit, only ten drugs were withdrawn from the market.
Some countries have established formal processes for using post-market evidence to support or adjust coverage and reimbursement decisions for very costly medicines, such as Chimeric antigen receptor (CAR)-T cell therapies that have transformed care for some blood cancers but at the cost of hundreds of thousands of euros per treatment (Litvinova et al., 2024[181]). These therapies have successfully entered the European market over the past years, often through time‑limited or outcome‑based reassessment mechanisms as in France, Germany, Italy and Spain (Jørgensen, Hanna and Kefalas, 2020[182]; Remap Consulting, 2022[183]). In England, after temporary funding allowed for reimbursement of certain CAR-T cell therapies during a process of evidence development, regular coverage was granted for some indications based on data collected. Belgium has implemented automated collection of clinical data on use of CAR-T in multiple myeloma to inform reimbursement decisions and serve other research objectives (RWE4Decisions, 2025[184]), while in Canada, the CanREValue Collaboration recently developed a framework for generation and use of real-world evidence to inform cancer drug coverage reassessment (Chan et al., 2025[185]).
One important example of reassessment of cancer pharmaceuticals came in June 2025, when the Dutch Health Care Institute removed coverage for the expensive PARP-inhibitors for many cancer indications, based on new international evidence regarding their ineffectiveness at extending life span or quality of life. This decision is anticipated to reduce by half the number of patients in the Netherlands using PARP-inhibitors, with 2022 spending on this drug amounting to about EUR 33 million in 2022 (NL Times, 2025[186]; National Health Care Institute, 2025[187]). As challenging as it is to implement in practice, reassessment of coverage and pricing decisions based on emerging evidence is key to ensuring efficient use of funding in cancer care.
In addition to reassessments on reimbursement, cancer treatment optimisation also holds potential to improve patient well-being and reduce costs. This is because even though a cancer drug is on the market, it does not necessarily mean that the treatment course is optimised – i.e. that it achieves meaningful therapeutic benefit while minimising risks from adverse events and negative impact on patient quality of life (Tannock et al., 2025[188]). Indeed, in practice, dosing regimens used in trials for clinical approval by the EMA and other regulatory agencies are often based on the maximum tolerated dose established in early phase trials, resulting in higher, more frequent, or more prolonged dosing than may be necessary to achieve the desired clinical benefit. These regimens not only increase side effects and reduce quality of life, but they also lead to unnecessary spending on drugs and on treating avoidable side effects.
Highlighting the opportunities for treatment optimisation, a recent review of the cancer medicines approved by the EMA and FDA between 2020 and 2023 found that 65% (or 20 medicines) were potential candidates for either dose reduction or an adjusted dosage regimen to improve patient safety or convenience (Hoog et al., 2024[189]). An older, but well-publicised example of dose optimisation came via a trial of abiraterone (an expensive prostate cancer drug), which found that one‑quarter of the standard dose was effective if the medicine was taken with a low-fat breakfast instead of on an empty stomach (Szmulewitz et al., 2017[190]). Various articles in the Lancet over the years have called for seeking the “minimum” rather than “maximum” effective dose for cancer treatments and customising trial design to focus on modelling of optimal dose (The Lancet Oncology, 2018[191]; Tannock et al., 2025[188]). Other recommendations include incorporating post-marketing evidence via post-licensing registries and randomised clinical trials to support new lower-intensity regimens that provide similar outcomes. The optimisation process could be considered a continuum, with an emphasis on dosage optimisation before products come to market, and a focus on duration and sequencing of the medicine after market approval.
Along these lines, the European Medicines Agency’s Cancer Medicines Forum fosters collaborative efforts to help advance research into optimising cancer treatments (EMA, 2025[192]). Similarly, the FDA has also recently released new guidance on dose optimisation in oncology, underscoring the importance of early, data-driven dosing strategies, and is undertaking Project Optimus to improve dose optimisation in the cancer drug development process (FDA, 2024[193]).
Use of biosimilars is higher in cancer than in other disease areas, but varies greatly among countries
Biosimilars are medicines that are highly similar to already approved biologics (medicines that come from living organisms), without clinically meaningful differences. A key approach by countries to reduce cancer drug spending is to encourage take‑up of generic or biosimilar medicines where these options are available, as prices may be up to 80% lower for generics (Hofmarcher, Berchet and Dedet, 2024[177]) and 20% to 50% or more lower for biosimilars depending on the product and market (IQVIA, 2025[194]). With 152 new cancer medicines approved by the EMA between 2004‑2022, and a marked annual increase in annual approvals over the last decade, there are increasing opportunities for products to come off patent protection and face competition from generics or biosimilars.
The top three selling cancer medicines in 2015 in Europe (bevacizumab, rituximab and trastuzumab) each have biosimilar competitors approved (Hofmarcher, Berchet and Dedet, 2024[177]). An analysis of biosimilars consumption from IQVIA suggests fairly rapid uptake of biosimilars in the cancer space since the first biosimilars became available in the EU in 2017 (rituximab and trastuzumab) (Figure 4.17), and higher uptake than in other therapeutic areas. While in 2017, oncology biosimilars represented less than 5% of the market, by 2023 this figure stood at around 80% (IQVIA, 2025[194]). Uptake varies from 55% in Bulgaria to 96% in Denmark.
Treatment days consumed, for referenced products and biosimilars in cancer
Note: Referenced products refer to the original cancer biologic medicine: Mabthera (rituximab), Herceptin (trastuzumab), Avastin (bevacizumab). Biosimilars include 20 different products for these three referenced products. Treatment days is an estimate of the number of days patients are treated based on the volume of product sold and typical dosing patterns.
Source: IQVIA The Impact of Biosimilar Competition in Europe 2024 (published January 2025) KPI data (page 29).
Similarly, a 2025 OECD analysis showed that biosimilar uptake both in terms of volume and spending has increased faster in oncology compared to other disease areas (TNF inhibitors and insulin), across the seven OECD countries assessed (Australia, Belgium, Denmark, France, Germany, Italy, Korea) (Barrenho et al., 2025[195]). This may be aided by the greater use of oncology biosimilars in the hospital setting compared to other therapeutic areas that are distributed in the retail arena.
In the EU on average, list price reductions for oncology biologics following biosimilar market entry averaged 33%; however, they were almost negligible in Austria (1%) compared to very substantial (66%) in Poland (IQVIA, 2025[194]). The introduction of cancer biosimilars in Europe has been accompanied by an overall increase in treatment volumes, as measured by treatment days, with the largest gains observed in countries where list prices declined most significantly (Figure 4.18). For example, Bulgaria, France and Portugal all saw price decreases of 40% or more for cancer biologics with biosimilars on the market, and these three countries have seen increases of 70% or more in treatment days per capita with these biologics (IQVIA, 2025[194]).
Note: Changes for price and treatment days are calculated by comparing the value in 2023 to the year prior to biosimilar market entry for cancer products with biosimilars (i.e. Mabthera (rituximab), Herceptin (trastuzumab), Avastin (bevacizumab)). Analysis excludes Norway, which was an outlier given that it had a price increase in 2023 relative to the year before biosimilar entry. Prices refer to list prices (the manufacturer’s published price for a drug before negotiated discounts or rebates); since list prices do not reflect negotiated discounts, actual price decreases are likely higher than the figures shown.
Source: OECD Secretariat analysis of IQVIA, The Impact of Biosimilar Competition in Europe 2024 (published January 2025), KPI data (page 30).
Countries have undertaken various policies to increase biosimilar consumption, including mandating or allowing substitution – that is using/dispensing one medicine instead of an equivalent prescribed medicine. Several countries pointed to procurement policies as a key driver of biosimilar uptake, where centralised tendering systems allow rapid shifts to biosimilars (for example, in Denmark) (Barrenho et al., 2025[195]). Pricing policies, such as in Belgium and Italy, require biosimilars to be priced at a certain discount (e.g. 20%) to the reference product, which creates direct financial incentives for their use by healthcare providers. However, originator companies can negotiate discounts directly with hospitals in some countries, such as in Belgium, which can limit biosimilar use and lead to differences in biosimilar uptake across institutions in the same country.
Medication reviews may be particularly needed for patients with a history of cancer
PaRIS data on patients aged 45+ with a cancer diagnosis seen in primary healthcare shows that 92% take medications regularly, which is fairly similar to the share among non-cancer patients. However, patients with a history of cancer take more medications, with almost a quarter (23%) of cancer patients taking 5‑9, statistically significantly more than the 20% figure among non-cancer patients. An additional 4% of patients with a history of cancer take 10+ medications (compared to 3% among non-cancer patients).
This highlights the importance of regular reviews of medications to avoid an excess number of prescriptions and ensure rationale medicine use. About three‑quarters of PaRIS patients in the EU11 with a history of cancer had a health professional review their medication with them in the last 12 months (Figure 4.19). However, substantial cross-country differences are revealed. Only about four in ten cancer patients in Iceland and Slovenia had a medication review, while the figure was more than eight in ten in Belgium and Czechia. With rates of medication reviews similar among cancer and non-cancer patients in the same country, the likelihood of medication reviews appears to be based on country policies and practices in primary healthcare rather than related to cancer specifically.
Primary healthcare patients with a cancer diagnosis who had a medication review with a health professional in the last 12 months
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.
There are opportunities to reduce waste of infusion and oral cancer medication
The large number of medicines required by patients with cancer points to opportunities to examine medication waste, which refers to expired, unused, or contaminated medicines that are no longer needed or safe to use. Reducing medication waste not only minimises safety and environmental risks (arising from toxic cancer medicines) but also helps decrease unnecessary healthcare spending.
For injectable drugs, weight‑ or body size‑based dosing can lead to medication waste as available vial sizes do not align with the amount needed by the patient, with the remaining often discarded due to limited shelf-life (Chapman, Paris and Lopert, 2020[196]). One way to reduce this waste is to use vial sharing, that is, using one medication vial to prepare doses for multiple patients. A survey of 74 oncology pharmacist respondents from 20 countries found that 53% used vial sharing for commonly used cancer drugs. This practice was associated with reduced drug waste (reported by 61% of respondents), alleviation of medication shortages (noted by nearly half), and cost savings in 74% of cases (Gilbar, Chambers and Musicco, 2022[197]). In Slovenia, robotic systems for medication preparation have been implemented in central pharmacies of hospitals to reduce waste while in Estonia, the Health Insurance Fund reimburses hospitals for medicines in a way that incentivises minimising waste, encouraging practices including vial sharing. In Australia as well, vial sharing is supported by large hospital manufacturing units and pharmaceutical compounding companies.
Another way to reduce infusion medication waste is to engage in safe dose rounding. The Haematology/Oncology Pharmacy Association recommends allowing for rounding doses of monoclonal antibodies and other biologic agents to the nearest vial size, within 10% of the prescribed dose (Fahrenbruch et al., 2018[198]). In the National Health Service (NHS) in England, dose rounding, via the advanced bulk preparation of standardised doses for patients based on national dose banding tables, as well as vial sharing, is used (Gilbar, Chambers and Musicco, 2022[197]).
Other sources of waste in oral cancer medicines arise due to changes in treatment plans, patient non-adherence, or adverse effects. In such cases, prescribing or dispensing of lower quantities based on need, particularly for patients at the end of life or starting new therapies, can reduce waste. Furthermore, in June 2025, a group of EU clinicians, pharmacists and researchers published a call for legalisation on re‑dispensing unused oral anticancer drugs under strict quality controls, emphasising the need for re‑evaluation of existing legislation to enable evidence‑based, sustainable healthcare practices (Smale et al., 2025[199]). Table 4.3 summarises key challenges and corresponding strategies for reducing medication waste in cancer care, highlighting implementation barriers and supporting measures.
Source: OECD Secretariat based on Bach et al. (2016[200]), “Overspending driven by oversized single dose vials of cancer drugs”, https://doi.org/10.1136/bmj.i788; Fahrenbruch, R. et al. (2018[198]), “Dose Rounding of Biologic and Cytotoxic Anticancer Agents: A Position Statement of the Hematology/Oncology Pharmacy Association”, https://doi.org/10.1200/JOP.2017.025411; Gilbar, Chambers and Musicco (2022[197]), “Preventing drug vial wastage and reducing expenditure associated with injectable cancer drugs: International oncology pharmacy survey”, Journal of Oncology Pharmacy Practice, doi: https://doi.org/10.1177/10781552211024723; Smale et al. (2023[201]), “Feasibility of an Individualized Dispensing Program for Patients Prescribed Oral Anticancer Drugs to Prevent Waste”, https://doi.org/10.1200/OP.22.00553; Smale et al. (2021[202]), “Waste-minimising measures to achieve sustainable supply and use of medication”, https://doi.org/10.1016/j.scp.2021.100400; Staskon. et al. (2019[203]), “Estimated Cost and Savings in a Patient Management Program for Oral Oncology Medications: Impact of a Split-Fill Component”, https://doi.org/10.1200/JOP.19.00069; Looney et al. (2024[204]), “Financial impact of integrated specialty pharmacy efforts to avoid oral anticancer medication waste”, https://doi.org/10.18553/jmcp.2024.30.5.465.
4.4.4. Choosing Wisely initiatives aim to reduce low-value cancer care while improving patient-centredness
The Choosing Wisely campaign, active in over 30 countries globally including over ten EU+2 countries, aims to reduce unnecessary medical interventions through clinician – patient dialogue to encourage alignment with national clinician-led care recommendations. An analysis of Choosing Wisely recommendations in cancer care across EU+2 and other OECD countries shows that certain recommendations are more common across countries. Although they differ somewhat in their specific wording, Table 4.4. shows that there are 20 overarching recommendations that can be found in at least two or more countries’ Choosing Wisely initiatives.
The two most common recommendations across countries, each found in ten OECD countries, is to avoid chemotherapy in advanced cancer if it is unlikely to benefit patients (including in four EU+2 countries) and to be cautious in undertaking routine PSA testing in order to reduce prostate cancer overdiagnosis (including in three EU+2 countries). Eight OECD countries (among them four EU+2 countries) advise avoiding use of extended radiation fractionation in palliative treatments. Seven OECD countries have the following recommendations: avoiding cancer screening in individuals unlikely to benefit due to limited life expectancy (two EU+2 countries), avoiding routing scans after cancer treatment in asymptomatic patients (two EU+2 countries), and ensuring early access to palliative care (five EU+2 countries). Noting areas where there is particularly high alignment across countries in these policies can help prioritise awareness, communication and monitoring of these recommendations at the country level where they already exist, and diffuse good practices to other countries.
Choosing Wisely recommendations related to low-value cancer care that are common across OECD countries
Note: Exact recommendations differ in wording by country and in some cases refer to the specific cancer type shown in parentheses. Colombia’s recommendations are in the consultation process and have not yet been finalised. In the Netherlands, the recommendations are not within the Choosing Wisely initiative but are found in guidelines for providers.
Source: DianaHealth (2025[205]), Dissemination of Initiatives to Analyse Appropriateness in Healthcare, https://dianasalud.com/index.php (accessed on 20 June 2025); Choosing Wisely Canada (2024[206]), Oncology, https://choosingwiselycanada.org/recommendation/oncology/ (accessed on 20 June 2025); Choosing Wisely (2022[207]), Recommendations, https://www.choosingwisely.org.au/recommendations (accessed on 20 June 2025); Choose Wisely (2020[208]), One list of Choosing Wisely recommendations on on tests, treatments, and procedures health professionals should question, https://www.hqsc.govt.nz/assets/Resource-library/Choosing-Wisely/Publications-resources/Combined-list-of-AU-and-NZ-recommendations-March-2020.pdf (accessed on 20 June 2025); Academy of Medical Royal Colleges (2020[209]), Choosing Wisely recommendations archive, https://www.aomrc.org.uk/projects-and-programmes/choosing-wisely/choosing-wisely-recommendations-archive/ (accessed on 20 June 2025); Vælg Klogt (Choose Wisely) (2024[210]), Recommendations, https://vaelgklogt.dk/anbefalinger (accessed on 20 June 2025); The American Society of Breast Surgeons (2023[211]), Choosing Wisely® Campaign, https://www.breastsurgeons.org/resources/choosing_wisely (accessed on 20 June 2025); Choosing Wisely Japan (2017[212]), FAQ, https://choosingwisely.jp/service/ (accessed on 30 June 2025); Institute for Quality in Medicine (2017[213]), Choose Wisely, https://www.ima.org.il/MedicineQuality/ChoosingWisely.aspx (accessed on 30 June 2025); Die Deutsche Gesellschaft für Innere Medizin (The German Society for Internal Medicine) (2024[214]), Overview of “Decide Wisely” recommendations, https://www.klug-entscheiden.com/empfehlungen/uebersicht (accessed on 30 June 2025); Gemeinsam gut entscheiden – Choosing Wisely Austria (2019[215]), Recommendations by area, https://gemeinsam-gut-entscheiden.at/bereich/empfehlungen/ (accessed on 30 June 2025); Smarter medicine – Choosing Wisely Switzerland (2024[216]), Medical Oncology, https://www.smartermedicine.ch/de/top-5-listen/medizinische-onkologie (accessed on 30 June 2025); Medicina Interna Lugo (Internal Medicine Lugo) (2019[217]), “Choosing Wisely” recommendations from SEMI and the Family Medicine Societies, https://medicinainterna-lugo.es/recomendaciones-choosing-wisely-de-la-semi-y-las-sociedades-de-medicina-de-familia/ (accessed on 30 June 2025); Kim, Lee and Kim (2020[218]), “Choosing Wisely: The Korean Perspective and Launch of the ‘Right Decision in Cancer Care’ Initiative”, https://doi.org/10.4143/crt.2020.221; Gjør kloke valg (Make wise choices) (2024[219]), Norwegian Oncological Society, https://legeforeningen.no/kloke-valg/anbefalinger/legeforeningens-anbefalinger/norsk-onkologisk-forening/ (accessed on 30 June 2025); Choosing Wisely Portugal (2024[220]), Recommendations for Healthcare Professionals, https://ordemdosmedicos.pt/amp-divulgacao-cientifica/choosing-wisely-portugal/recomendacoes (accessed on 30 June 2025); NHG (2024[221]), Prostate Cancer, https://richtlijnen.nhg.org/standaarden/prostaatkanker#volledige-tekst-richtlijnen-diagnostiek; Federatie Medisch Specialisten; (2014[222]), Prostate Carcinoma – Expected Outcomes with Active Monitoring, https://richtlijnendatabase.nl/richtlijn/prostaatcarcinoom/gelokaliseerd_prostaatcarcinoom/actief_volgen.html; Federatie Medisch Specialisten (n.d.[223]), Breast Cancer – Radiotherapy, https://richtlijnendatabase.nl/richtlijn/borstkanker/behandeling_invasief_carcinoom/primair_chirurgische_behandeling/radiotherapie.html; Sweden & Colombia: national experts.
In order to promote implementation, healthcare provider awareness of and education on these recommendations, as well as effective patient communications skills among healthcare professionals, are key. This highlights the importance of continued professional learning in cancer care (Box 4.8).
Continuing medical education (CME) helps ensure that professionals are up to date with evidence in the field, new technologies and developments and good practices across the cancer care pathway. The Accreditation Council of Oncology in Europe (ACOE) is the main body providing accreditation to providers of continuing medical education in oncology in the EU. Accreditation ensures high quality, independent and unbiased education as well as monitoring of training attendance by physicians.
A 2025 survey conducted by ACOE and the European Union of Medical Specialists (UEMS)1 in collaboration with the OECD found that among nine of the ten countries responding, national CME requirements in terms of credit hours were consistent for physicians regardless of specialty. In Luxembourg, no official CME programme exists. In the Netherlands, oncologists must have all their education credits relate to oncology. In Romania, two‑thirds of credits must be from the physician speciality, while in Slovenia, 50 of the 75 credits must be from the physician specialty and five credits must be in ethics and communication. Physicians in Ireland must develop a Continuing Professional Development Plan related to their specialty that includes practice review, work based learning and accredited learning programmes. Seven of the nine countries with CME (Austria, Bulgaria, Ireland, the Netherlands, Romania, the Slovak Republic and Slovenia) reported that it is mandatory, required for relicensing or recertification, or results in investigations or sanctions such as fines or loss of license if not undertaken. In Spain, CME is voluntary but can be required by hospitals for admissions or treatment privileges and can come with financial incentives. In Portugal, CME is not required but encouraged and supported.
Furthermore, an ACOE data analysis for this report found that in 2024, there were 188 event applications for oncology CME events accepted by the organisation, a small increase from 167 events in 2019. Starting during the COVID‑19 pandemic, there was a substantial shift in events to distance learning, with 69 distance learning events held in 2024 as compared to only 20 in 2019. Distance‑learning events may facilitate knowledge transfer across geographies, providing access to EU-wide learning for participants in countries that may have been less likely to attend events in person.
In addition to CME for physicians, some countries have Continuing Professional Development (CPD) for other healthcare providers working in the oncology space. For example, in Ireland, Romania and the Slovak Republic, nurses, radiation therapists and pharmacists have requirements for continuing education while Switzerland requires it for radiation therapists and pharmacists (but not nurses). Given the interdisciplinary nature of cancer care and importance of ensuring quality along the cancer care pathway, ACOE has expanded its accreditation efforts to include distance learning opportunities for non-physician healthcare providers. This initiative is designed to complement existing systems by addressing accreditation gaps, particularly in areas or professions where formal CPD accreditation processes are currently lacking.
CME is an important aspect of certified cancer centres. OECI data shows that OECI certified centres in Tercile 2 held a median of 14 educational sessions annually, while 18 were held in Tercile 1 and 21 in Tercile 3.2 More of the courses in Tercile 1 and 2 had an international audience, which may be because those centres are in larger countries and treat a slightly higher number of patients on average. Similarly, in a sample of eight of the 14 CCCs in the German Deutsche Krebshilfe evaluation and designation programme, an average of 18 educational courses were offered in CCCs in 2022.
1. UEMS is the representative organisation of medical specialists from across Europe and beyond, working to promote the highest standards of training, practice and continuing education. Through its European Accreditation Council for Continuing Medical Education (EACCME®), the UEMS accredits high-quality CME/CPD activities across all medical specialties in Europe and internationally.
2. The country income terciles divide EU+2 countries into three terciles based on GDP per capita for the purpose of OECI data analysis (see Figure 4.5 or more details).
Reducing aggressive cancer treatments at the end of life is a priority among EU+2 countries
In line with the Choosing Wisely recommendations, the 2025 OECD Policy Survey on High-Value Care reveals that reducing aggressive treatments near the end-of-life (EOL) is of high priority in 13 EU+2 countries. While aggressive chemotherapy, radiotherapy, surgery, or intensive care admission during the final weeks of life may aim to prolong life or relieve symptoms, it often results in limited therapeutic benefit. Instead, it can lead to increased physical and emotional burden, reduce patients’ quality of life, lower family satisfaction with care, and contribute to higher medical costs (Ma et al., 2024[224]).
Aggressive EOL cancer care can have significant financial strains globally. A US study found that aggressive interventions significantly raised healthcare spending during the final month of life in cancer patients, whereas early initiation of palliative care was associated with cost reductions of USD 3 000 and advanced directives with reductions of USD 4 000‑5 000 (Davis et al., 2023[225]). In France, aggressive EOL care significantly increased costs during the last 30 days of life for lung cancer patients – EUR 9 480 compared to EUR 6 378 for those who did not receive aggressive care (Bylicki et al., 2021[226]).
The OECD data collection measured the use of systemic anti-cancer therapies in the last 30 days of life. Among patients aged 70+ with low-survival cancers (pancreatic, lung, or stomach cancer), use of aggressive therapies ranged from about 1 patient per 100 in Latvia to 17 in Belgium (Figure 4.20). In all EU+2 countries reporting, men aged 70+ with low-survival cancers were more likely than women to receive aggressive treatment at the end of life. It is important to note that part of the reason for variation in end-of-life care practices is due to personalised ethical and clinical considerations as well as patient-informed choice. Nonetheless, although this issue is of high priority in OECD countries, numerous countries were unable to provide data for this indicator via the pilot. Even among those submitting, there were notable methodological differences, suggesting that many countries have challenges in effectively monitoring cancer care quality at the end-of-life.
In other countries, studies found that 10% of cancer patients received chemotherapy in the last month of life in 2017 (Germany) (van Baal et al., 2020[227]) and 17% received anticancer treatment in the last two weeks of life in 2019 (Ljubljana, Slovenia) (Golob et al., 2024[228]). Notable rates of aggressive EOL cancer care have also been reported in France (Bylicki et al., 2021[226]) and Sweden (Szilcz et al., 2022[229]).
The OECD’s data collection and studies from France, Germany, and Slovenia show that younger cancer patients are more likely to receive aggressive end-of-life (EOL) care. Haematological malignancies were linked to more intensive EOL care, possibly due to their more unpredictable prognosis, a higher chance of curative success (Martins-Branco et al., 2020[230]; Mehlis et al., 2020[231]) and less frequent and later initiation of palliative care (Gebel et al., 2024[232]). Enrolment in palliative care reduced the likelihood of aggressive interventions in studies from Denmark, Slovenia, the Netherlands, Finland, and Italy (Gerhardt et al., 2024[233]; Vestergaard et al., 2023[234]; Golob et al., 2024[228]; Boddaert et al., 2022[235]; Miinalainen et al., 2022[236]; Chiaruttini et al., 2024[237]). Evidence supports the early integration of palliative care, showing it can help align treatment with patient values, reduce unnecessary or burdensome interventions, and improve quality of life and end-of-life outcomes (See Chapter 5).
Share of cancer patients age 70+ receiving systemic anti-cancer therapies in the last 30 days of life, latest 3‑year average
Note: The share is out of patients with low-survival cancers (pancreatic, lung or stomach cancer) who died during the course of the year. Most recent three‑year average: for Israel, Norway, the Netherlands, Latvia, Belgium and Portugal (2021-2023); Croatia, Czechia and Canada (2020-2022); and Colombia (2023). Data for Canada refers to the provinces of Alberta and Prince Edward Island. There are methodological differences in the definition of treatment in last 30 days of life across countries.
Source: OECD (2025[20]), “Assessing cancer care quality in OECD countries: New indicators for benchmarking performance”, https://doi.org/10.1787/b3f47ece-en.
4.4.5. New technologies and digital infrastructure are being deployed or piloted to improve cancer care efficiency and quality – from diagnosis to treatment
AI promises improvements in accuracy and feasibility of cancer screening and diagnosis
The majority of EU+2 countries surveyed in the 2025 Policy Survey on High-Value Cancer Care, reported implementation of AI-assisted imaging/radiology for cancer screening (see Figure 4.21), either as national or regional programmes (Denmark, Germany and the Netherlands), as national or regional pilots (Belgium, Hungary, Luxembourg, Norway, Slovenia, Spain, Sweden), or in selected private facilities (Austria, Czechia, Iceland, Lithuania, Luxembourg, Romania; not shown in figure). In terms of treatment, the majority of countries reported that they have not implemented AI-facilitated decision making in cancer treatment as of 2025. However, two EU+2 countries (Belgium and Hungary) reported use on a pilot basis and others (Czechia, France, Ireland, Romania, Sweden; not shown in figure) in select private healthcare facilities.
Note: Programmes and pilots refer to those at the national and / or regional level. Liquid biopsies refer to their use for cancer treatment effectiveness or relapse. Additional countries report use of these technologies in select private facilities (not 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.
AI-assisted imagery is primarily reported for breast cancer mammography. In addition, interviews with 20 OECD countries found that eight used AI for cancer diagnosis – for breast (Norway), as well as lung (Portugal and Lithuania) and skin (Germany and Portugal). Use was mainly limited to AI-assisted imaging in Czechia, Estonia, Germany, Greece, Lithuania, the Netherlands and Portugal, often localised to applications or pilots in certain care settings.
In Germany, a study demonstrated improved breast cancer detection rates in screening eligible women aged 50‑69 years by using AI-assisted double reading of mammography (Eisemann et al., 2025[238]), without increasing recall rates, with the benefits including cost savings from reduced workload for radiologists in reviewing results (University of Lübeck, 2025[239]). In Norway, a randomised controlled trial is underway to investigate whether artificial intelligence in combination with radiologists is as good as or better at detecting breast cancer than the current standard procedure where two radiologists evaluate the images (Norwegian Institute of Public Health, 2025[240]). The Belgian Precision pilot is demonstrating the usability of a new data platform for the purposes of the European Cancer Imagining Initiative (a flagship of Europe’s Beating Cancer Plan), which aims to create a platform of over 60 million images that can be used for developing, testing, and benchmarking AI-driven tools to advance personalised cancer care (EUCAIM Consortium, 2025[241]).
As part of the EU-funded BRIGHT project, Estonia is piloting a personalised, genetic risk-based breast cancer screening model for women aged under 50 (Antigenes, 2024[242]). This AI-supported approach generates polygenic risk scores (PRS) derived from genetic and health data to stratify individuals by their predicted susceptibility to breast cancer. Women identified as high-risk are invited to undergo more frequent and targeted screening to detect cancer earlier, while those at lower risk follow a less frequent schedule to reduce over-screening and optimise the use of healthcare resources. In other diagnostic applications, Israel is using AI in pathology via its Imagine AI system to identify cancer-related mutations from biopsy samples within two days. AI systems for pathology are used in prostate, breast and gastrointestinal cancers.
Liquid biopsies promise a minimally invasive means of detecting and monitoring cancer, but must be balanced with minimising harms to patients
In the 2025 OECD Survey on High-Value Cancer Care, five EU+2 countries reported use of liquid biopsies to monitor cancer treatment effectiveness or relapse in either regional or national programmes or pilots (see Figure 4.21). An additional six EU+2 countries report use in select private facilities.
There are a few purposes for using liquid biopsies, which detect circulating tumour cells (CTCs) in the blood (Smit and Pantel, 2024[243]). One is for patients with a known cancer, for surveillance of recurrence (Lawrence et al., 2023[244]), without the need for costly and uncomfortably new tissue biopsies or radiological imaging. Liquid biopsies through simple blood samples could reduce travel requirements for patients, waiting times, and costs from more expensive and invasive cancer tests during cancer treatment and follow-up. The EU-funded Joint Action on Personalised Cancer Medicine launched in November 2025 includes a transnational pilot that is examining whether implementation of personalised liquid biopsy-based risk-stratified surveillance can help achieve earlier recurrence detection in cancer survivors.
There is an additional possibility of using CTC detection to distinguish aggressive from indolent tumours at an early stage, and therefore potentially avoiding the harms from overdiagnosis and overtreatment of certain prostate and lung cancers; however as of 2025, this remains an area for further research and innovation. Finally, another use of liquid biopsies is as a minimally invasive method of detecting early-stage cancers without the need for more invasive tissue biopsy. The feasibility and accuracy of using this innovation is undergoing clinical research studies to determine if it can be applied to screening for lung and colorectal cancers (Lawrence et al., 2023[244]). However recent results suggest that the CTC sensitivity may not be sufficient for detection of early-stage tumours, thus limiting effectiveness (Shaukat et al., 2025[245]).
The field of molecular diagnostics is rapidly developing to help classify tumour types and guide optimal treatment for patients
Biomarker testing forms the foundation of precision medicine, enabling a shift from generalised treatment approaches to individualised strategies (Bayle et al., 2023[246]). While equitable access to cost-effective biomarker testing across Europe is important for the timely delivery of precision oncology and improved cancer outcomes, access remains highly variable. Basic single‑gene testing is widely available in Europe, but due to its much higher costs, access to advanced methods such as large next-generation sequencing (NGS) panels and complete genomic profiles is often limited to clinical trials or research settings. The main challenges to implementing multigene testing include inadequate reimbursement for tests and treatment, prescribing limitations, and limited opportunities for clinical trial enrolment (Bayle et al., 2023[246]).
Two of the main cancer types where NGS is more widely used are lung and colorectal. Figure 4.22 illustrates that small NGS panels (<50 genes) in routine practice across European countries are somewhat more available for lung than colorectal cancer, and that there is significant variation across countries. Among EU+2 countries, NGS panels were reported as always available for lung cancer (and usually/occasionally for colorectal cancer) in Denmark and Luxembourg, while experts in countries such as Austria, Belgium, Czechia, Finland, Iceland, Malta and the Netherlands reported that panels were usually (but not always) available for both cancer types. In contrast, in countries such as Bulgaria, Estonia, and Romania, NGS was limited to research settings (Bayle et al., 2023[246]; Manzano et al., 2025[37]).
To reduce unequal access to personalised cancer care, an initiative within the EU-funded Can.Heal project is using NGS technology to allow efficient genetic profiling of tumour cells, allowing cancer centres across countries to collaborate and apply similar diagnostic and therapeutic approaches to patients with comparable cancer profiles.
Note: Availability refers to the presence of the test but does not imply formal reimbursement, as costs may be covered by the general hospital budget or a pharmaceutical company rather than through third-party payer reimbursement.
Source: OECD Secretariat using Bayle et al. (2023[246]), ESMO study on the availability and accessibility of biomolecular technologies in oncology in Europe https://doi.org/10.1016/j.annonc.2023.06.011; Manzano, A. et al., (2025[37]), Comparator Report on Cancer in Europe 2025 – Disease Burden, Costs and Access to Medicines and Molecular Diagnostics, https://ihe.se/en/rapport/comparator-report-on-cancer-in-europe-2025-disease-burden-costs-and-access-to-medicines-and-molecular-diagnostics-2/. For Malta and Slovenia: information provided by Ministry of Health.
One major challenge was that clinical protocols were rigid and not always adapted to the patient’s sex, current blood chemistry, or overall health status. This sometimes led to treatments being prescribed based on “average” scenarios rather than personalized needs. There were delays in adjusting therapies or performing certain investigations because protocols did not provide flexibility for tailored decisions.
Maria, 52 years old, endometrial cancer
Given the many biomarkers that could be tested for and the rapid developments in the space, the European Society for Medical Oncology in 2018 began publishing a Scale for Clinical Actionability of molecular Targets (ESCAT). ESCAT categorises molecular targets into six tiers based on clinical evidence and relevance for patient care – ranging from those ready for routine use to those with no evidence of actionability. ESCAT provides a standardised framework to prioritise genomic alterations that could benefit from targeted cancer therapies, aiming to guide clinical decision making. Between 2021 and 2024, ESCAT scores were progressively integrated into the European Society for Medical Oncology’s clinical practice guidelines for various cancers such as metastatic and early breast cancer, metastatic colorectal cancer, metastatic non-small cell lung cancer as well as thyroid, stomach and pancreatic cancers.
Beyond clinical decision making, ESCAT tiers can also support reimbursement decisions. Notably, in 2023, Italy approved the reimbursement of targeted therapies for genomic alterations classified as ESCAT Tier I, based on NGS profiling (ESMO, 2025[247]). While Germany does not have a national policy formally linking ESCAT to reimbursement, a recent study showed that off-label molecular therapy reimbursement in metastatic breast cancer was significantly more likely when supported by strong ESCAT evidence (Tier I and II) (Pixberg et al., 2024[248]).
Many countries are deploying robotic-assisted laparoscopy in cancer treatment
Robotic-assisted laparoscopic surgery is a technological innovation used to improve the precision of and reduce complications from cancer surgery such as prostatectomy. This surgical innovation requires considerable short-term capital investment and surgical training, but can provide long-term sustainable benefits in terms of surgical outcomes and patient complications, which include reductions in blood loss, post-operative pain and length of hospital stay (John Hopkins Medicine, 2025[249]). For prostate cancer, robotic-assisted laparoscopic prostatectomy offers faster recovery, better urinary continence and potency outcomes compared to conventional laparoscopic surgery (Rifai Fauzi and Alemina Ramadhani Ginting, 2024[250]). A systematic review concluded that robotic-assisted surgery is potentially cost-effective in 28 of 33 economic evaluations, mainly for prostate and kidney cancer (Sadri et al., 2023[251]). Norway is conducting a formal economic evaluation of robotic-assisted prostatectomy to inform how access to robotic-assisted surgery should be prioritised (Gaustad JV, 2024[252]).
Robotic or robot-assisted surgery is available on some basis in 19 EU+2 countries participating in the 2025 OECD Survey on High-Value Cancer Care. In 13 EU+2 countries (Austria, Czechia, Denmark, France, Germany, Greece, Iceland, Ireland, Luxembourg, the Netherlands, Portugal, Slovenia and Sweden) robot-assisted surgery is already available through regional or national programmes, while three other EU+2 countries (Hungary, the Slovak Republic and Spain) currently offer it only on a pilot basis at the population level. In Belgium, Lithuania and Romania, it is available in select private facilities.
EU European Regional Development Funding has enabled rollout of the da Vinci surgical system for robotic-assisted cancer surgery in Poland (EUR 2.7 million) and in Spain (EUR 1.8 million) (European Commission, 2020[253]; European Commission, 2017[254]). The use of the technology is being expanded to urological, gynaecological and colorectal cancer surgeries and in recent years, France has been using it in cervical, colorectal and liver cancer surgeries in select cancer care facilities (Gustave Roussy, 2025[255]).
For both surgery and radiotherapy, however, there are challenges in understanding the value of and supporting innovations in technology and processes (Borras, Corral and Aggarwal, 2022[256]). Indeed, new approaches are being developed to promote high-value radiotherapy and optimise treatment (Box 4.9).
A framework to support clinical and reimbursement decisions for radiotherapy is being developed
Health Technology Assessment approaches, as used with pharmaceuticals, are not yet well-developed in evaluating radiotherapy investments and reimbursement, as benefits such as lower toxicity and better quality of life may only be evident months or years following treatment. Furthermore, factors such as training, operator skills and quality processes make it difficult to isolate the causal impact of radiotherapy innovations (Borras, Corral and Aggarwal, 2022[256]).
Most European health systems reimburse radiotherapy primarily through budget-based, fee‑for-service, or fraction-based models. This creates considerable variability in reimbursement across countries and often incentivises volume over value. To address these challenges, the EU-funded Joint Action Innovative Partnership for Action Against Cancer brought together 24 EU Member States and recommended that reimbursement policies shift toward using episodes of care as the fundamental payment unit using a two‑tiered approach: 1) episode‑based reimbursement for standard of care and 2) additional funding mechanisms to support the adoption and evaluation of emerging innovative treatments with uncertain value (Borras, Corral and Aggarwal, 2022[256]). This approach was used with stereotactic body radiotherapy (SBRT) in Belgium, which was initially not reimbursed due to clinical and economic uncertainties (Lievens et al., 2024[257]).
The Value‑Based Radiation Oncology initiative by the European Society for Radiotherapy and Oncology is establishing a rigorous evaluation framework to assess the value of radiotherapy innovations. It will support investment decisions, clinical implementation, and reimbursement of new radiotherapy technologies and techniques (ESTRO, 2025[258]).
Radiotherapy hypofractionation can be as effective and safe as conventional radiotherapy
Radiotherapy hypofractionation is a treatment innovation in which the total prescribed dose of radiation is divided into fewer fractions, typically administered once daily or less frequently, with each session delivering a higher dose compared to conventional radiotherapy. This results in shorter overall treatment time – often completed in days or weeks rather than several weeks or months. By reducing the number of treatment sessions, hypofractionation can enhance patient convenience, improve access to radiotherapy services, and potentially lower treatment costs. Hypofractionation gained prominence during the COVID‑19 pandemic as its fewer treatment visits benefitted both patients and healthcare systems (Thomson et al., 2020[259]). However, hypofractionation is associated with increased complexity in treatment planning and delivery. Reassuringly, a recent systematic review on hypofractionation concluded that for individuals with breast, prostate, or rectal cancer, hypofractionation likely results in little to no difference in overall survival compared to conventional radiotherapy (Landsteiner, Sowerby and Ullman, 2023[260]).
Digital health infrastructure allows for more efficient, higher quality cancer care at the patient level alongside benefits to quality monitoring at the system level
Cancer diagnosis and treatment often requires numerous investigations and tests from multiple providers, with need for sharing and transfer of results between specialists and healthcare settings. Individual health record identifiers and electronic data linkage are thus critical to improve the safety and efficiency of information flow by reducing medico‑administrative error and delays, to ensure that the right care is provided to the right patient in a timely manner. Stronger health data infrastructure can support clinical practice in real time, such as in Estonia, where evidence‑based support is available to Estonian doctors in decision making and tracking a patient’s health information, including diagnoses, medications, analyses and procedures (OECD/European Commission, 2025[261]).
In addition to the patient-level benefits, data linkage, primarily via cancer registries, provides a key mechanism for monitoring the quality and efficiency of cancer care systems. However, there is a wide range in the quality and completeness of the data recorded. While almost all registries have epidemiological data, some are not linked to screening information and most do not have patient-reported indicators (see Chapter 2). Experience from the OECD cancer data collection shows that even when registries are supposed to be populated with certain information, in many cases this may be missing for a share of patients (e.g. treatment data). The EU4Health-funded Joint Action CancerWatch, launched in 2025, will support Member States to improve the timeliness, quality and completeness of cancer burden data collected by cancer registries. The Joint Action will also help assess registries’ capability of collecting information such as staging and treatment and define common quality and comparability criteria. This will contribute to ensuring more accurate, comparable and timely data for assessing cancer control.
A total of 25 EU+2 countries responding to the OECD Policy Survey on High-Value Cancer Care report using cancer registries to monitor incidence, survival, stage and other epidemiological trends (Figure 4.23). Many can also report on inequalities, although this is often limited to geographic or gender inequalities, with socio-economic data available in only about a third of EU+2 countries (Chapter 2). Eleven EU+2 countries report using cancer registries for research to improve timeliness of care and ten report utilising them to improve treatment or clinical guidelines (although countries such as Denmark, Iceland and Sweden are not shown in the figure but have quality registries for such purposes). Only three EU+2 (Belgium, Ireland, the Netherlands) countries report using cancer registries to guide coverage or reimbursement decisions for pharmaceuticals. However, as shown in Section 4.4.3 above, this type of real-world evidence on patient outcomes is critical for supporting better coverage and pricing decisions.
Note: For improving patient pathways, timeliness of care and/or treatment or clinical guidelines, Denmark, Iceland and Sweden are not shown in the above graph because they don’t use cancer registries for this purpose; however, they may use quality registries to do so. 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.
Ultimately, cancer registries have a significant role in oversight of cancer care in countries. As shown in Chapter 2, they are instrumental for monitoring developments in cancer incidence, and when data registration is thorough, they provide important insight into timeliness of cancer care (as seen in Chapter 3). Cancer registries and quality registries can also provide input on the quality of cancer care and adherence to clinical guidelines, as well as providing survival estimates – all key aspects explored in this chapter. Finally, all these topics are of great importance, but must be put in the context of what matters most to patients – their overall well-being and quality of life – which is explored in Chapter 5.
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