Delivering High Value Cancer Care

3. Timely access to cancer care

Abstract

Timely cancer care is crucial for improving health outcomes and survival rates. However, delays can occur at multiple points along the cancer care pathway, from missed opportunities for timely cancer screening, symptom recognition and first contact with health services, to diagnosis and treatment – with negative consequences on treatment efficacy, people’s quality of life, and the health and economic costs of cancer. Many of these delays are avoidable and vary in length both across and within countries, by geography, gender, socio‑economic status and ethnicity. EU countries, Iceland and Norway are addressing these access challenges through communication, organisational and system-level interventions, as well as innovative solutions using digital tools and expanded professional roles. This chapter examines how health systems can ensure timely access to cancer care for all people who need it, regardless of where they live, their financial resources, or their social and cultural background.

In Brief

Delays in cancer care can occur at any stage of the care pathway, from a person’s first contact with the health system through diagnosis and treatment, leading to more complex therapies, poorer health outcomes, and higher costs for the health system. Such delays in accessing cancer services point to significant unmet needs.

Participation in cancer screening and contact with the health system

• Population-based breast cancer screening is implemented in all but three EU+21 countries, while three‑quarters run cervical and colorectal programmes. In 2023, breast cancer screening participation among women aged 50‑69 averaged 57% in the EU, while cervical cancer screening stood at 54% of the eligible population and colorectal cancer screening at 44%. Highly educated individuals are more likely to participate, while groups such as migrants and LGBTIQ+ people experience barriers. Personalised invitations and plain-language materials boost screening uptake, as do convenient options such as self-sampling for cervical screening, faecal immunochemical test (FIT) tests for colorectal cancer, mobile or flexible mammography options and involvement of primary healthcare.

• Around nine in ten cancer diagnoses originate outside of screening programmes. Even among screening-relevant cancers such as colorectal, robust screening programmes capture up to 40‑60% of cancer diagnoses. Timely help-seeking from health systems is key for early detection of such cancers but is challenged by ambiguous symptoms or masked by multimorbidity.

• Across the EU, 4% of people reported they have unmet needs for medical examination in 2022, mainly due to waiting times and high cost, though geographical barriers played an important role in some countries. Personal and health literacy related reasons (such as deciding to wait, fear, or time constraints) were reported by more than 4% of respondents in Denmark and Norway. To reduce geographic barriers, countries implement telemedicine solutions for primary healthcare and specialist visits, accounting for more than a quarter of physician consultations in Denmark, Estonia, Portugal and Sweden. Almost half of EU+2 countries do not have co‑payments for primary care visits, reducing delays in access to care particularly for low‑income and older populations, while others aim to keep co-payments low with small fees and annual caps.

Timely cancer diagnosis

• Early cancer diagnosis, critical for improving survival and treatment effectiveness, varies across EU+2 countries. An average of 56% of breast cancers in the EU were diagnosed at early stages (from 42% in Latvia to 66% in Norway), however this figure drops to 22% for colorectal cancer (from 16% in Latvia to 33% in Luxembourg). For cervical cancer, early diagnoses comprised 62% of diagnoses (from 37% in Latvia to 85% in Iceland). Cancer diagnoses made in emergency departments also indicate missed opportunities for earlier detection, with up to 37% of lung cancers in Croatia diagnosed via emergency presentation. For colorectal cancer, the proportion of emergency diagnoses was highest in Belgium, at 45% among people aged 15‑49 years and 29% among those in the screening-eligible age group.

• Despite their crucial role, only seven EU+2 countries offer cancer early‑diagnosis training for primary healthcare providers. Seven EU+2 countries also use decision support tools in primary healthcare for cancer detection, as pilots show impact: for example, in England such tools prompted referrals that would not have occurred in about 20% of cases. Countries are removing financial barriers to imaging, with more than two‑thirds of EU+2 countries not charging co-payments for diagnostic testing. Fast‑track diagnostic pathways and rapid diagnostic centres are increasingly implemented to cut time to diagnosis.

• Monitoring systems using actionable indicators can drive improvements in timely and equitable access to cancer diagnosis. Only three EU+2 countries (Denmark, the Netherlands and Norway) systematically track the cancer care pathway from first attendance in primary care to referral to a specialist and the start of treatment. 14 EU+2 countries monitor cancer care timeliness, and some, like Sweden, use near-real‑time dashboards. Yet, equity monitoring is rare, and countries use different indicators, which makes international comparisons challenging.

Timely cancer treatment

• Delays in initiating cancer treatment following diagnosis are strongly linked to increased mortality across multiple cancer types, with each four‑week postponement significantly raising the risk of death. In three EU+2 countries (Belgium, Denmark and Norway), more than 60% of people diagnosed with colorectal, breast or lung cancer started treatment within 30 days of tissue diagnosis.

• Financial hardship can discourage or delay cancer treatment, with 16% of Europeans with cancer across 25 countries reporting delaying some aspects of treatment, usually doctor visits or medicines. However, three‑quarters of EU+2 countries have implemented specific mechanisms to ensure low or no co-payments in cancer treatment.

• As cancer care often involves multiple providers, initiatives such as patient navigation and case management can facilitate care transitions. Standardised pathways have been developed in 17 EU+2 countries, establishing waiting time benchmarks between several care steps. Sweden stands out with 31 cancer-type‑specific pathways, introduced in 2015, based on Denmark’s cancer package approach established in 2007.

• Shortages of oncologists, radiotherapists and nurses remain a challenge across many EU+2 countries. In response, countries are implementing training reforms and workforce planning tools, while also testing new professional roles and establishing well-being initiatives to address staff burnout and increase retention. However, effective monitoring to inform strategic workforce planning remains difficult given cross-country differences in professional definitions, workload and scope of practice.

• Access to radiotherapy is uneven across Europe, while projections estimate a 25% increase in radiotherapy demand by 2050, which needs to be met with workforce and equipment availability. To keep up with the demand for radiation therapy by 2045, EU+2 countries would need to invest an estimated EUR 504 million in linear accelerators. As of 2025, 11 EU+2 countries can provide high-cost, high-precision particle‑beam therapy domestically.

• Delays in accessing cancer medicines after European Medicines Agency (EMA) approval result in missed opportunities for treatment, while variations across countries in reimbursement timelines lead to substantial health and economic losses. Some European countries, such as Austria and France, continue to have higher uptake of newer oncology medicines across cancer types, partly because the timelines between marketing authorisation and reimbursement are often shorter. Oncology clinical trials are concentrated in four large European countries (France, Germany, Italy and Spain), with smaller countries and those in Central Europe benefitting less.

1. EU+2 countries refer to EU27, Iceland and Norway.

3.1. Introduction

Timely cancer care depends on people’s ability to access health services they need. People with cancer have various touchpoints with the health system, from screening or initial referral for a symptom, to diagnostic services, to various treatment modalities and, ultimately, survivorship care. Barriers related to the approachability, acceptability, availability and organisation of services, as well as affordability and appropriateness (Levesque, Harris and Russell, 2013[1]), can lead to long waiting times and, in some cases, harmful delays in care.

Tumour growth rates can vary significantly depending on the cancer site and subtype. Because aggressive cancers can progress to advanced stages within weeks, early detection improves the likelihood of a successful response to treatment and contributes to better health outcomes and survival, while delays can lead to more complex and costly treatment. After diagnosis, even a four‑week delay in starting cancer treatment is associated with increased mortality across treatment modalities for seven cancer types (Hanna et al., 2020[2]).

Detecting cancer at an early stage also has implications for spending by health systems. A systematic review found that, compared with Stage I breast cancer, treatment costs increase by a third for Stage II and nearly double for Stage III (Sun et al., 2018[3]). A US-based study found similar significant cost increases across cancer types, with particularly steep increases for metastatic cancer (McGarvey et al., 2022[4]). In addition to direct treatment costs, timely care also improves people’s quality of life and experience of care, and decreases indirect societal costs such as productivity losses from premature mortality or long-term sick leave (see Chapter 5).

The duration of delays at each stage of cancer care depends on several factors, including tumour characteristics and person-level factors. While some delays are unavoidable, others arise from access barriers within the health system, pointing to significant unmet needs. Disparities in timely access result in inequities in cancer outcomes, including mortality and survival. This chapter examines delays in cancer care and policy actions to improve timely access to cancer care. It is organised around key components of the cancer care pathway, from first contact with healthcare services (Section 3.2) to receipt of timely diagnosis (Section 3.3) and treatment (Section 3.4) (Figure 3.1). Survivorship and support services are discussed in Chapter 5.

Figure 3.1. People with cancer have multiple contacts and varied needs during their care trajectory

Note: *Multidisciplinary tumour boards. Care pathways vary by cancer type and individual needs. Figure does not capture all touchpoints along the cancer care pathway.

Source: Adapted from OECD (2020[5]), Waiting Times for Health Services: Next in Line, https://doi.org/10.1787/242e3c8c-en.

3.2. Participation in cancer screening and early contact with the healthcare system is the first step to timely access to cancer care

3.2.1. Access to healthcare services remains uneven and needs strengthening

Population-based cancer screening programmes do not equally benefit all people across Europe

Population-based cancer screening is an effective intervention to detect abnormalities associated with cancer in asymptomatic individuals, thus catching cancer at an earlier stage, when treatment is less complex and less costly for the health system. All but three EU+2 countries have population-based screening for breast cancer, with Bulgaria, Lithuania and Romania instead relying on non-population-based screening. Three-quarters of EU+2 countries have established population-based screening programmes for cervical and colorectal cancers (OECD/European Commission, 2025[6]). In addition, the updated 2022 EU Council Recommendation2 proposes to examine evidence‑based feasibility to introduce gastric, lung and prostate cancer screening programmes, which by 2025 are being piloted or implemented in some countries (see Chapter 4).

Screening participation is associated with better outcomes. For example, the International Agency for Research on Cancer (IARC) estimates that women who attend breast cancer screening have a 40% lower risk of dying from breast cancer (Aapro M, 2021[7]). Similarly, a Swedish registry-based study found higher breast cancer mortality among women who did not attend breast cancer screening when first invited, largely because they were less likely to participate in subsequent screening rounds, leading to later diagnosis (Ma et al., 2025[8]).

Population-based screening for breast, cervical and colorectal cancers is a highly cost-effective public health intervention. The updated 2022 Council of the EU Recommendation endorses these programmes and sets targets to increase participation and reach vulnerable groups. A 2025 Dutch study of the three screening programmes found that all remain cost-effective in the Netherlands, providing substantial health benefits at relatively low costs to the health system. The analyses found that cervical (unvaccinated cohort) and colorectal cancer screenings are both cost-saving, with annual savings of EUR 23 million and EUR 72 million respectively, while breast cancer screening remains cost-effective at around EUR 4 000 per quality-adjusted life year gained. Women in the age cohort vaccinated against HPV were included in the Dutch cervical cancer screening programme for the first time in 2023, with initial data suggesting that the programme is less cost-effective in this group (Erasmus Medical Centre, 2025[9]).

Uptake of screening varies across OECD countries and population groups, with important implications for timely contact with healthcare services. Figure 3.2 shows participation rates among the target population for breast, cervical and colorectal cancer screening programmes.

Figure 3.2. Participation in breast, cervical and colorectal cancer screening programmes is uneven across EU countries

Note: EU averages are unweighted. Data represents administrative data from screening programmes in 2023, if not otherwise stated. 1. Survey data. 2. Data refers to 2020-2022. 3. Data refers to 2024. For cervical and colorectal cancer, the differences between countries in target age groups, screening frequency and screening methods lead to variations in the data coverage reported across countries.

Source: OECD Health Statistics 2025. Data for Canada are sourced from Statistics Canada (2025[10]) and data for Malta are sourced from Eurostat (2025[11]).

In EU+2 countries, breast cancer screening is typically offered every 2 years to women aged 50‑69 to detect abnormalities at an early stage. In 2023, an average of 57% of women in the target population in the EU participated, although uptake ranged from 83% in Denmark and Sweden to 15% in Greece (Figure 3.2). Overall, the average coverage across the EU has returned to approximately its 2019 level, following a decrease during the COVID‑19 pandemic. At country level, however, screening rates have increased compared with pre‑pandemic levels in Estonia and Lithuania, by 8.6 and 7.5 percentage points (p.p.) respectively, while Iceland, Italy and the Netherlands have seen declines of 5 p.p. or more compared with 2019.

Cervical cancer screening allows detection of cervical cell changes before they develop into cancer and is therefore a preventive intervention. The WHO global strategy for the elimination of cervical cancer recommends 70% coverage of cervical cancer screening at ages 35 and 45, alongside vaccination and early treatment targets (WHO, 2021[12]). Across countries, cervical cancer screening is often provided every three to five years to women aged 20‑69, with programmes often tailored by test type and age group. For example, in Spain, women aged 25‑34 are invited for a pap smear every three years and women aged 35‑65 are invited for an HPV test every five years. In Sweden, women aged 23‑49 are invited for HPV-based screening every five years, and women aged 50‑70 every seven years (OECD Health Statistics, 2025[13]). In 2023, an average of 54% of eligible women in the EU participated in cervical cancer screening, ranging from 78% in Sweden to 11% in Poland and 6% in Romania (Figure 3.2). Czechia, Ireland, Slovenia, Norway and Finland also reached coverage above 70%. Compared with 2019, several countries observed important increases in screening uptake, most notably Estonia (up 16.4 p.p.) and Latvia (up 15.5 p.p.). However, coverage dropped by 5 p.p. or more in Iceland, Ireland, Luxembourg and the Netherlands.

For colorectal cancer, country guidelines typically recommend biennial faecal occult blood tests for people in their 50s and 60s, although some countries use other methods, including colonoscopy. Differences in recommended screening intervals make cross-country comparisons challenging, but coverage generally remains lower than for breast and cervical cancer screening because programmes have been introduced more recently in many countries. In 2023, screening participation averaged 44% in the EU (Figure 3.2), below the desirable level of 65% set out in the European guidelines for quality assurance in colorectal cancer screening and diagnosis (European Commission, 2010[14]). The desirable level was reached only in Finland (74%), the Netherlands (67%) and Sweden (65%). The 45% level defined as acceptable in the European guidelines was reached in 11 countries, while screening rates were the lowest in Hungary (9%) and Portugal (17%). Compared with 2019, colorectal cancer screening rates increased the most in Latvia (from 15% to 26%) and Estonia (from 54% to 60%).

Twelve of the 26 EU+2 countries that responded to the OECD 2025 Policy Survey on High Value Cancer Care highlighted low screening participation as one of the main barriers to early cancer diagnosis, which also undermines the effectiveness of screening programmes. Czechia, despite overall high rates of screening for cervical cancer (Figure 3.2), reported misunderstandings about screening benefits, while low awareness of the programmes is considered a barrier in Bulgaria, Czechia, Greece, Ireland, Lithuania, Poland, Romania and Spain. Estonia, the Netherlands and Sweden reported concerns over particularly low uptake among groups with lower socio‑economic status and migrant backgrounds.

Data from the Survey on Healthy Ageing and Retirement in Europe (SHARE) highlights that educational inequalities in screening uptake persist across EU+2 countries (Figure 3.3). On average, people with high education levels had a 25‑p.p. higher probability of having had a mammography in the previous two years than those with low education, with an 8‑p.p. gap for colorectal cancer screening. For breast cancer screening, the largest gaps between people with high and low education were observed in Finland, Greece and Sweden (all above 35 p.p.), as well as in Israel (46 p.p.). Conversely, in Bulgaria and Romania differences by education are less than 10 p.p. while in Switzerland the difference is slightly negative. For colorectal cancer screening, the largest gap between people with high and low education (above 20 p.p.) was found in Denmark and Lithuania, as well as in Israel.

Figure 3.3. Uptake of cancer screening programmes is consistently lower among people with lower education

Note: Data refer to people aged 50‑74, weighted using the SHARE survey weights. A p.p. difference across population groups is shown. High education level refers to post-secondary or tertiary education, while low education refers to primary or lower secondary education. In Finland, rates for colorectal cancer screening reflect participation in opportunistic screening, as a population-based programme with coverage shown in Figure 3.2 was introduced in 2022.

Source: Survey of Health Ageing and Retirement in Europe (SHARE) Wave 9 (2022).

In all 15 EU countries with available data, women had higher participation rate in colorectal cancer screening than men, by an average of 6 p.p. in 2023. Estonia, Norway and Sweden reported larger gender differences at 10 or more p.p., followed by Denmark and Finland with differences of more than 9 p.p. Gender differences are also observed for other screening programmes as well, such as lung and gastric cancer screening, which are being piloted for both sexes in many European countries. Lower participation among men reflects a broader pattern of reduced use of preventive health services, influenced by social norms and attitudes that discourage help-seeking, as well as fear, embarrassment and lower risk perception (Teo et al., 2016[15]). Social support has also been identified as a key enabling factor for screening participation across European countries (Jolidon et al., 2024[16]). Addressing these issues calls for gender-sensitive interventions, strong provider recommendations, and tailored strategies like home‑based stool tests and community outreach.

Screening rates are also consistently lower among people who identify as lesbian, gay, bisexual, transgender, intersex and queer (LGBTIQ+), attributable to disparities in risk factors, healthcare access and preventive service utilisation (Heer et al., 2023[17]). Barriers include pain and embarrassment during procedures, limited awareness of screening options, and anticipation of discrimination in healthcare settings, highlighting the role of provider-patient relationships in equitable care delivery. According to the 2024 EU LGBTIQ survey among people aged 15 and above, 14% of respondents reported discrimination by healthcare or social services personnel due to their sexual orientation or gender identity, with national rates ranging from 21% in Cyprus and Hungary to 6% in Estonia (European Union Agency for Fundamental Rights, 2024[18]). Aligned with the literature, the survey also found lower mammography uptake rates in the previous two years among lesbian, gay or bisexual women who are also cisgender (14%), transgender men and women, and non-binary people (7‑9%), compared with 36% in the general population, based on the 2019 European Health Interview Survey. Cervical cancer screening rates were similarly lower across LGBTIQ+ groups. However, gay and bisexual men were more likely to participate in anal and colorectal cancer screening, with 12% undergoing colonoscopy in the past year versus 4% in the general population based on the 2019 European Health Interview Survey. Evidence from the United States identified similar patterns for prostate cancer screening, as gay and bisexual men were more likely to participate, while transgender individuals were less likely (Ma et al., 2021[19]).

Screening rates are also lower among migrants, who are often less likely to be diagnosed with early-stage cancer, partly due to perceived and experienced barriers to accessing healthcare services. Data from the European Health Interview Survey indicated that women born outside of the EU were 45% less likely to have had a mammogram in the last two years, 55% less likely to be up to date with cervical cancer screening, and 15% less likely to be up to date with colorectal cancer screening, while migrants from within the EU were less affected (Bozhar et al., 2022[20]). Country-specific studies similarly show lower likelihood of receiving recommended screenings among people with a migration background for colorectal screening in Norway (Bhargava et al., 2023[21]), cervical cancer screening in Germany (Brzoska, Aksakal and Yilmaz-Aslan, 2020[22]), and mammography in Austria (Wahidie, Yilmaz-Aslan and Brzoska, 2024[23]), although not all migrant groups were equally affected. Administrative data similarly indicated lower uptake of both breast and cervical cancer screening among women with foreign passports in Iceland (OECD/European Commission, 2025[24]) and among speakers of non-domestic languages in Finland (languages other than Finnish, Swedish and Sami) (OECD/European Commission, 2025[25]).

A scoping review from across the EU identified barriers and facilitators influencing cervical cancer screening among underserved populations, including ethnic minorities and migrants (Greenley et al., 2023[26]). Macro-level barriers include financial challenges such as lack of insurance coverage and concern about out-of-pocket costs; bureaucratic challenges related to service registration or inaccurate information included in registries that send invitations, and lack of trust in the health system. At the screening service level, cultural relevance and inclusivity, as well as translations were important. At the individual level, low awareness, stigma, fear, and competing life priorities were frequently cited as key barriers.

Delays in contact with healthcare following cancer symptom onset are a persistent issue

Most cancers are diagnosed outside of population-based screening programmes. This is due to several factors, including that screening is not conducted for many cancer types where epidemiological and cost-effectiveness evidence does not support population-based screening, that screening is limited to specific age ranges, and that some cancers are diagnosed between scheduled screening rounds (interval cancers). Estimates from 2022 indicate that people aged 70 and older, who are not included in most screening programmes, accounted for 56% of new colorectal cancer cases, 36% of new breast cancer cases and 18% of new cervical cancer cases in the EU (IARC, 2025[27]).

Although the exact proportion of cancer cases identified by different means of detection is rarely available, international estimates suggest that around nine in ten cancers are detected by means other than screening. For example, among all people diagnosed with cancer in Denmark between 2014-2017, 7.5% were diagnosed via population-based screening, 45.9% in primary care and 20% in secondary care (Danckert et al., 2021[28]). Data from the United States estimates that 14% of all cancers were detected through a screening test (NORC at the University of Chicago, 2022[29]). For colorectal cancer, where population-based screening programmes are available, an analysis across nine European countries (Belgium, Denmark, England, France, Italy, Ireland, the Netherlands, Slovenia and Spain) found that the proportion of screen-detected cancers remains below 30% in most countries (Cardoso et al., 2022[30]). The proportion was higher at 40‑60% in Slovenia, the Netherlands and the Basque Country in Spain, where colorectal cancer screening programmes have been fully rolled out. In Germany, around one in four colorectal cancer cases are diagnosed through population-based screening (Hornschuch, Schwarz and Haug, 2024[31]).

Outside of screening, recognition of cancer symptoms and prompt engagement with healthcare services is the first step in access to cancer care. Cancer symptoms vary widely depending on the type and location of the disease, which makes it challenging to ensure awareness among patients to identify them as serious enough to see a doctor. Delay is also dependent on symptom type – particularly for some cancers, such as brain and central nervous system, and haematological cancers, symptoms are broad and non-specific. Common warning signs across many cancer types include unexplained weight loss, persistent fatigue, pain, lumps or swelling, and skin changes such as jaundice or sores that fail to heal. Some cancers, however, present with more distinct and recognisable symptoms – for example breast cancer may cause a lump in the breast or changes to the nipple; while bladder cancer often leads to visible blood in the urine (Koo et al., 2018[32]). According to the OECD Patient-Reported Indicators Survey (PaRIS), among primary healthcare users aged 45+ living with cancer, more than three in four (76%) had other comorbid chronic diseases. Among these people, unspecific symptoms may be easily attributed to preexisting conditions.

Across cancer sites, non-recognition of symptom seriousness has been found to be the main individual-level factor for delays, with older age, lower socio‑economic status, and lower education levels contributing to longer delays (Macleod et al., 2009[33]). In women with new breast cancer symptoms, perception that the symptoms were not dangerous was the main factor associated with delayed care while adults with low health literacy were more likely to report avoiding doctor’s visits (Morris et al., 2013[34]). Emotional barriers such as fear of diagnosis or stigma further delay care‑seeking.

Long patient intervals, i.e. the time from symptom onset to first consultation, are common across countries. A United States-based survey among people with cancer noted that 21% waited more than three months before seeking care (Forbes et al., 2014[35]). People with prostate and rectal cancers were most likely to delay healthcare contact, with 44% and 37% respectively waiting more than three months before seeking care. People with breast cancer were least likely to delay, with only 8% reporting delays of more than three months, largely attributable to breast cancer symptoms being widely known and relatively non-ambiguous. Socio‑economic deprivation was associated with greater delays. Primary care data from the English National Audit of Cancer Diagnosis (Lyratsopoulus, 2015[36]) further showed that the longest median patient intervals (over 30 days) were observed for laryngeal and oropharyngeal cancers, followed by cervical, oesophageal and vulval cancers.

In most EU+2 countries, primary care is positioned as the preferred first contact point with the healthcare system (13 among 23 responding to the 2023 OECD Health System Characteristics Survey (OECD Health Statistics, 2025[13])) where referral is obligatory to access most types of specialist care, including further diagnostic services or co‑ordinated care pathways (see section “Countries address waiting times and diagnostic delays by streamlining capacity through fast-track pathways and rapid diagnostic centres”). In four countries (Belgium, France, Latvia and Sweden), individuals have financial incentives to obtain a referral, although direct access remains possible, while six countries (Austria, Czechia, Germany, Greece, Iceland and Luxembourg) do not require or incentivise primary care referrals. For some cancers, organ-specific specialists such as gynaecologists, dermatologists or dentists may also be an appropriate first contact point when symptoms appear. At a population level, having a central point of contact, usually primary healthcare, enhances trust and helps people interact more effectively with the healthcare system (see Chapter 5).

In 2022, across the EU, 4% of people reported unmet needs for a medical examination (including primary or specialist healthcare), with waiting times being the most commonly reported reason. More than 20% in Greece and more than 10% in Finland, Estonia and Latvia reported that their needs were not met due to waiting lists, cost of services or distance to services (Figure 3.4). These reasons were least often cited in Cyprus, Malta and Czechia, where fewer than 1% of people with a need for a medical examination reported them.

Figure 3.4. The most common reason for unmet medical needs in the EU is due to waiting times

Population reporting unmet needs for medical examination by main reason, and total among those at risk of poverty

Note: Data refer to the proportion of people aged 16 and over living in private households and who reported having medical needs. The coloured bars show proportion of people who report having unmet needs for a medical examination in primary care or specialist care, among all people with medical needs, by main reason. The diamond marker shows total reporting unmet needs due to these reasons, among people at risk of poverty, which is defined as those with an equivalised disposable income below 60% of the national median disposable income.

Source: Eurostat, EU-SILC 2024 (https://doi.org/10.2908/HLTH_SILC_08 and hlth_silc_08b).

Waiting times were most commonly declared as the main reason for unmet needs for medical examinations, with an average of 2% of people in the EU needing medical exams citing this reason for their unmet needs (Figure 3.4). Some countries had particularly high rates, such as Finland (12%), Estonia (10%), Latvia (7%) and Lithuania (5%). The 2023 Commonwealth Fund International Health Policy Survey of Adults found that waiting times for primary care is a concern in other countries as well. The proportion of people who had to wait more than a week for a primary care appointment was nearly one in three in Canada (32%) and close to one in five in France, Germany, Sweden, the United Kingdom, the United States and New Zealand. Although people describing severe symptoms may sometimes be fast-tracked for care, some individuals with acute symptoms instead reach the healthcare system through emergency services (see section “A high rate of emergency diagnoses for lung and colorectal cancers signals a critical gap in access to early detection services”), pointing to unmet needs and care being provided in a less appropriate setting. Anticipated long waits can also discourage initial help-seeking and cause distress while people wait for their appointment.

High cost was the second most frequently reported reason for unmet medical examination needs, especially in Greece, where 16% of the people with a need reported that it was unmet because of cost (Figure 3.4). Travel distance was less commonly declared as the primary reason for unmet need. However, people in rural or remote areas often have to travel long distances, have limited access to transport and face fewer available health facilities – with the highest proportion in Greece, where 2% of people with a need reported that it was unmet mainly because of travel distance. These factors delay care and may lead to reduced or less timely access across the cancer care continuum.

Figure 3.4 reveals stark disparities, as people at risk of poverty are more likely than the general population to report unmet need in all but two countries. The gaps were highest in Greece (10 p.p.), Romania (9 p.p.), Finland (9 p.p.), Latvia (8 p.p.) and Italy (6 p.p.). In addition to reasons highlighted in Figure 3.4, in some countries a substantial proportion of people reported unmet needs for a medical examination for reasons such as wanting to wait and see if the problem got better on its own, not having time, fear of doctor, hospital, examination or treatment, and not knowing any good doctor or specialist. Unmet needs for these reasons were highest in Denmark and Norway, where more than 4% of all survey respondents listed them as the main reason for their unmet need. These reasons are related to health literacy and help-seeking behaviour, as well as perceptions of the approachability and accessibility of health services.

3.2.2. Timely engagement with health services can be improved by addressing barriers at the individual, provider and health system levels

Low health literacy and cancer awareness, combined with cultural factors and the health system context, influence people’s decision to engage with health workers

Awareness of cancer, along with digital and health literacy, shapes healthcare‑seeking behaviour

The WHO defines health literacy as the ability to access, understand, appraise and use information and services in ways that promote and maintain good health and well-being. Health literacy is vital for cancer decision making, as participation in cancer screening programmes and healthcare seeking when experiencing cancer symptoms is influenced by awareness, attitudes, beliefs and ability to navigate relevant health information. Adequate health literacy increases participation in breast, cervical, and colorectal cancer screening (Baccolini et al., 2022[37]) and constitutes an important factor in recognition of symptom seriousness.

This represents an important avenue to increase health service contact, as approximately half of Europe’s population is estimated to have insufficient health literacy (M-POHL, 2021[38]; Baccolini et al., 2021[39]). Figure 3.5 highlights an education gap among primary healthcare users with chronic conditions, across all countries participating in the PaRIS survey. The average proportion reporting they understand health information across participating EU countries is close to two times higher among those with high, compared with low education level. Among people with low education level, self-reported understanding of health information was highest in the Netherlands, followed by non-EU countries Canada and Wales (United Kingdom), and lowest in Southern and Central Europe (Romania, Greece, Spain and Italy).

Figure 3.5. Among primary care users with chronic conditions, education gaps in health and digital literacy emerge across EU+2 countries

Note: Data refer to primary healthcare users with chronic conditions aged 45 and above. Health literacy is measured as the percentage of people reporting that health issues are not complex to understand and they do not experience difficulties in understanding the health information they read, while digital literacy is measured as the percentage of people reporting confidence in using information from the internet to make health decisions. *Data for Italy refer to people enrolled in outpatient settings for specialist visits in selected regions. **United States sample only includes people aged 65 years and older.

Source: OECD PaRIS 2024 Database.

Most people in the EU (58%) use the internet to help make decisions about their health, highlighting the importance of digital literacy (Eurostat, 2025[11]). However, across EU countries, fewer than one in five people aged 45 and over with chronic conditions report feeling confident using the internet to make health decisions (Figure 3.5), with confidence levels lower among people with low education in nearly all countries. Among people with low education, confidence was highest in Czechia, where around two in five people reported feeling confident, followed by Wales (United Kingdom). Across EU+2 countries participating in the PaRIS survey, people with high education were more likely to feel confident using the internet for health decisions in nearly all countries.

Decisions to seek formal care can be influenced by the widespread prevalence of misleading and inaccurate information about cancer symptoms and their implications. For example, Suarez-Lledo and Alvarez-Galvez (2021[40]) identified misinformation in 40% of social media posts about cancer. People with lower digital literacy are more vulnerable to misinformation and may lack the skills to critically evaluate the credibility and sources of the health information they encounter online (Arias López et al., 2023[41]).

Additionally, the approachability and acceptability of health services influence decisions about consulting a medical doctor. Beyond individual capacities, contextual factors such as system-level barriers and cultural attitudes play a role in care‑seeking behaviour and are particularly important for reaching individuals with low health literacy. Distrust of medical institutions and previous negative experiences can also reduce a person’s willingness or ability to seek care (Shukla, Schilt-Solberg and Gibson-Scipio, 2025[42]). Across OECD countries, 78% of patients aged 45 and over with a chronic condition reported trusting the last healthcare professional they consulted, ranging from 88% in Switzerland to 57% in Greece (OECD, 2025[43]).

At 45 years old, as a woman who didn't smoke or drink and had no family history of cancer, I didn't bother with mammograms or any other examination. I discovered it completely by accident.

Maria, 53 years old, breast cancer

EU+2 countries aim to improve cancer literacy and adapt the health system to patients’ needs, with simple, targeted messaging considered most effective

Among respondents to the OECD 2025 Survey on High Value Cancer Care, all but two EU+2 countries (Norway and Poland) reported they have initiatives to improve public health literacy regarding early cancer symptoms and screening benefits. To better reach people in their daily lives, 14 EU+2 countries reported initiatives in collaboration with schools, universities, or employers (e.g. occupational health partnerships or workplace‑based screening awareness programmes) aimed at improving health literacy on early cancer symptoms and encouraging participation in screening programmes.

Given lower than average screening uptake and engagement with health services in vulnerable populations, such as migrants, targeted interventions are crucial. Tailored, culturally sensitive approaches to develop information, resources and interventions are more effective than generic campaigns to reach diverse communities with information that is accessible and culturally relevant to them, both in terms of language and content (Whitehead et al., 2025[44]). To influence behaviour, Abdul Latip et al. (2023[45]) found that combining patient navigation, education, and cultural tailoring increased colorectal cancer screening uptake among ethnic minority groups. Because multiple factors can hinder screening, developing a one‑size‑fits-all solution that works across different cultures and countries is highly complex. To address growing population diversity, there is scope to strengthen interventions by addressing language barriers, cultural differences and discriminatory attitudes (see Table 3.1).

Table 3.1. Selected initiatives to improve cancer awareness and cancer-related health literacy from EU+2 and other OECD countries

Initiative type	Selected examples
Tailoring of communication to population groups	Ireland’s National Cancer Control Programme leads a broad range of initiatives, including annual paid social media campaigns and targeted regional educational sessions with high-risk groups. The National Screening Service has patient/public partnerships and includes the patient voice in the development of messages and resources. There are tailored resources for certain groups and links to these are shared widely on the National Screening Service website and on social media. NGO partnerships through the Irish Cancer Prevention Network, and community-based work by Regional Cancer Prevention Officers are dedicated to delivering cancer prevention and early diagnosis programmes to communities. The Netherlands shares information and videos about screening, and posts on social media in various languages spoken by migrants. France has online resources for disabled cancer patients, their families or caregivers (simplified and/or adapted format regarding screening, early diagnosis and cancer treatments).
Involvement of patient organisations and community	In Slovenia, the Institute of Public Health, regional healthcare centres, and NGOs jointly implement various community-based activities, including those tailored to specific populations such as the Roma community. Screening programmes have different features on their web sites and among their materials (for visually or hearing impaired, and for ethnic minorities). Malta leverages community events by embedding cancer awareness to reach low-literacy and underserved groups.
Engagement of schools and workplaces	In Ireland, the Marie Keating Foundation delivers a Schools Cancer Awareness Programme to around 10 000 secondary students annually with National Cancer Control Programme support, including education about cancer risk reduction and early signs and symptoms. Lithuania’s National Cancer Center organises school visits to address cancer prevention and early diagnosis. Slovenia implements broad initiatives involving schools, municipalities, and workplaces through its Network of Health Promoting Schools and mandatory Workplace Health Promotion Programmes. Australia provides funding to States and Territories to increase access to cervical screening services, which the state of Victoria uses to provide education on cervical screening and a popup clinic for cervical screening testing at workplaces.

Source: 2025 OECD Survey on High Value Cancer Care.

Health decisions should be based on reliable information, yet fragmented sources make it difficult to separate facts from misinformation. Clear, accessible, and trustworthy content, especially from official sources, is vital for individuals navigating screening processes and symptom interpretation, often via digital platforms. Several countries develop central resources that the population can refer to, making it clear and easy to distinguish official communication from unofficial. For example, Sweden’s 1 177.se provides inclusive, multilingual health information and tools on lifestyle and cancer risk, adapted for disabilities and LGBTIQ+ communities. Denmark also offers online resources outlining the benefits and risks of screening participation. In Germany, legislation in place since 2013 mandates that people invited to breast, cervical or colorectal cancer screening receive balanced, comprehensive information to support informed choices. To address misinformation concerns on non-official websites, the EU’s Digital Services Act (DSA) (European Commission, 2025[46]) seeks to create a safer online environment by holding platforms accountable for the content they host, including health information.

A review from OECD countries (Duffy et al., 2017[47]) emphasised the role of convenience in screening, with personalised invitations, GP endorsements and plain-language materials significantly increasing screening uptake, especially among underserved populations. To increase convenience, the Netherlands sends invitations, leaflets and test kits for colorectal cancer screening directly to eligible people. By contrast, in Hungary, people receive invitations only if their GP has joined the screening programme and must still order a test kit themselves (OECD, 2024[48]), contributing to a 6‑fold difference in screening uptake between the two countries. In Denmark, invitations to breast cancer screening include a pre‑booked appointment. In Slovenia, the DORA programme sends reminders for mammography appointments and in Malta invitations are accompanied by phone reminders the day before. Self-sampling and the engagement of various health professionals in screening likewise increase the approachability of services, as well as their geographical accessibility (see section “Making health services available close to people increases accessibility and participation in cancer screening programmes”).

Six EU+2 countries report early-phase activities that leverage data stored in patient records to detect possible undiagnosed cancer cases

To reach people who are not integrated into cancer care pathways at an earlier point, six EU+2 countries reported activities and pilots that use data stored in electronic health records to identify patients with possible undetected cancer, drawing on information collected by healthcare professionals during routine care, including laboratory and imaging tests. AI-supported data mining of electronic medical records is being implemented at regional or national levels in Czechia, Hungary and Sweden, as well as in Canada. In Germany, Luxembourg and the Netherlands, pilot activities are underway in select facilities, as is the case in Australia and Israel. Although these initiatives remain at the research and pilot phases, some milestones have been achieved. For example, in Germany, a new legislative permission enables statutory health insurance funds to use data-based evaluation of claims data to identify people with a possible cancer diagnosis and to recommend they seek medical advice. In Sweden, predictive machine‑learning models have been developed to identify metastatic colorectal cancer (Abedi et al., 2025[49]) and non-metastatic colorectal cancer (Nemlander et al., 2023[50]) using diagnostic data from primary care users.

Although these models show promising results, they have not yet been implemented nationally. In other OECD countries, such as Australia, work on AI use in electronic health records and pathology reports focusses on identifying cancer cases before they are reported to the cancer registry, with the aim of improving registry data quality and streamlining recruitment to clinical trials. While several such tools are in development, they require robust validation for effectiveness, safety and impact when implemented at the population level.

Making health services available close to people increases accessibility and participation in cancer screening programmes

Adapting screening delivery modes to the needs of individuals and populations increases uptake, alongside leveraging contacts with healthcare professionals

EU+2 countries are implementing a wide range of initiatives to improve accessibility and increase participation in screening programmes (Table 3.2). To enhance geographical access, 19 EU+2 countries deploy mobile screening units. These usually constitute mobile digital mammograph units (specially equipped buses) that travel across the country, offering high-quality mammography examinations for women closer to their place of residence. For example, Estonia has operated mobile mammography buses since 2009 (OECD/European Commission, 2025[6]), and Ireland has offered breast screening in wheelchair-accessible mobile units since the start of its screening programme. However, regions in Denmark are shifting to permanent screening sites distributed across regions. This approach is considered to increase accessibility by offering greater appointment flexibility and better access for people with disabilities who cannot use bus stairs, as well as improving working conditions for staff.

Table 3.2. Most EU+2 countries are taking action to increase uptake of screening programmes among the target population by adapting delivery modes

	Use of mobile screening units	Distribution of FIT self-sampling kits by mail or in communities	Use of self-sampling for HPV testing	Expanding the role of primary care	Expanding the role of pharmacists or other community health workers
Austria		Yes
Belgium1	Yes1	Yes	Yes1		Yes
Bulgaria2			2	2
Czechia		Yes	Yes	Yes
Denmark3	Yes3	Yes	Yes
Estonia	Yes	Yes	Yes	Yes	Yes
France	Yes	Yes	Yes		Yes
Germany	Yes			Yes
Greece	Yes	Yes	Yes		Yes
Hungary	Yes	Yes	Yes	Yes
Iceland	Yes	Yes
Ireland	Yes	Yes
Italy	Yes			Yes
Latvia	Yes			Yes
Lithuania		Yes
Luxembourg		Yes			Yes
Netherlands	Yes	Yes	Yes	Yes
Norway	Yes	Yes	Yes
Poland	Yes			Yes
Portugal	Yes	Yes	Yes
Romania	Yes	Yes		Yes
Slovak Republic		Yes		Yes
Slovenia4	Yes	Yes		Yes	Yes
Spain5	Yes	Yes5	Yes		Yes5
Sweden	Yes	Yes	Yes
Australia	Yes	Yes	Yes	Yes
Canada	Yes	Yes	Yes	Yes	Yes
Japan	Yes	Yes		Yes	Yes
Israel	Yes	Yes		Yes
Korea	Yes			Yes
Türkiye	Yes	Yes		Yes	Yes

Note: Country responses reflect adopted policies but may in some cases refer to broad pilot programmes.

1. In Belgium, mobile breast cancer screening units and the use of self-sampling for HPV testing (currently in a pilot phase) are available only in Flanders.

2. In Bulgaria, self-sampling for HPV testing is due to be introduced under the National Plan for Combating Cancer in the Republic of Bulgaria 2027, while the role of primary healthcare will expand in screening for colon and cervical cancer, following approval by the Ministry of Health in 2024.

3. In Denmark, mobile buses are being replaced with enhanced availability of permanent clinics, considered to better fit population needs, with some regions having already shifted fully to this model.

4. In Slovenia, self-sampling for HPV testing has been piloted and is under consideration for stepwise national implementation.

5. In Spain, home delivery of FITsampling kits is implemented in some autonomous communities (Andalucia, Cantabria, Valencian Community, Galicia, La Rioja, Navarra and the Basque Country), though generally an acceptance card is sent before the kit and the role of pharmacies is expanded in Ceuta, the Balearic Islands and Murcia, where self-sampling kits can be obtained.

Source: 2025 OECD Policy Survey on High-Value Cancer Care.

A review from OECD countries (Duffy et al., 2017[47]) found that offering more comfortable or convenient testing methods, such as FIT over colonoscopy or guaiac FOBT, and self-sampling for cervical cancer screening, improves participation. Activities to expand screening availability through self-sampling are present in 20 EU+2 countries for colorectal cancer screening and 12 EU+2 countries for cervical cancer screening. In Ireland, uptake of bowel screening (colon, rectal or colorectal) among first-time invitees increased when home test kits were sent directly along with a reminder letter, rather than requiring individuals to request a kit (Health Service Executive, 2025[51]). This approach was effective even among people living in lower socio‑economic areas. In Luxembourg, mailing FIT kits directly to eligible residents who have previously participated has improved uptake compared with an invitation-only system. Other countries, such as Norway, Finland and Cyprus, also send FIT self-sampling kits as part of their colorectal cancer screening programmes.

Recent research from EU countries shows that HPV self-collection tests are a powerful tool for reducing barriers to access to early diagnosis of cervical cancer. By allowing women to collect samples at home and return them by mail, these programmes address common obstacles like limited access to providers, travel barriers, time constraints, and discomfort with clinician-based screening. In Czechia, direct mailing of self-sampling kits significantly increased participation among women who had not attended traditional screenings by almost 8% (Ngo et al., 2024[52]). In the Netherlands, real-world data from the national screening programme showed that self-sampling is a reliable alternative to clinician-collected samples, with only a slight reduction in sensitivity, demonstrating the feasibility of large‑scale mail-in HPV self-sampling in a national population-based screening programme (Inturrisi et al., 2021[53]).

Countries are also exploring innovations in how screening is delivered, including expanding the role of primary healthcare providers (11 EU+2 countries) and pharmacists (seven EU+2 countries). For example, pharmacists in several countries are allowed to distribute self-sampling screening kits, most commonly for colorectal cancer screening. In France, Luxembourg and Belgium, pharmacists actively contribute to colorectal cancer screening by distributing free self-sampling kits. Some countries have additionally introduced new roles, such as Access Officers for each cancer screening programme in Ireland, who can be contacted directly by participants.

Eight EU+2 countries (Austria, Czechia, Estonia, Hungary, Latvia, Lithuania, Portugal, Romania) also aim to better leverage primary healthcare contacts to promote screening by offering financial incentives to healthcare providers. Payments for achieving performance indicators related to screening have been found to increase screening rates among eligible populations, with stronger effects when payments are made to individual providers rather than practices (Matthews et al., 2024[54]). In Estonia, an indicator on percentage of a physician’s patient list who have had a colorectal cancer screening test or received counselling on colorectal cancer screening is linked to annual supplementary funding to primary care practices amounting to 4% (Estonian Health Insurance Fund, 2025[55]). In Latvia, there are quality payments to general practitioners (GP) related to the stage of detection of cancer, as well as for colon, prostate, cervical, and breast cancer screening coverage. Korea takes a different approach through workplace‑based health screening programmes, where employers are legally required to conduct health screenings for workers, with penalties for non-compliance, in addition to the provision through the national cancer screening programme.

Telemedicine can improve people’s access to healthcare by reducing the time and travel burden associated with in-person visits

People who experience new, ambiguous symptoms that are not yet severe may be hesitant to seek care. To reduce time and travel burdens, including for those who are unsure how urgently they need to be seen and for those living in remote areas, innovative delivery models such as telemedicine can help to fill access gaps. In 2023, teleconsultations made up more than a quarter of all consultations with primary care doctors and specialists in Denmark, Estonia, Portugal and Sweden (OECD, 2025[56]). By contrast, they remained rare in Luxembourg, Germany, France and Finland with 0.3 or fewer teleconsultations per person.

Eliminating financial barriers to screening and healthcare visits is particularly important to reach vulnerable populations

Nearly all EU+2 countries reported in the 2025 OECD Policy Survey on High Value Cancer Care that screening tests are offered free of charge to the target population as a measure to increase access. Some charges may, however, still apply. For example, in Iceland, an arrival fee of ISK 500 (EUR 3.30) applies to any doctors’ visit, including those for breast or cervical cancer screening. In other OECD countries such as Japan, screening participation was previously found to increase when cost barriers are reduced (Tabuchi et al., 2013[57]), and national support is provided to municipalities for screening, while municipalities set out-of-pocket costs for individuals. However, an effective screening programme must similarly consider the ability of individuals to follow up on positive results. In a study from the United States, one in five patients said they would not have a breast cancer screening test if they knew they had to pay for follow-up on positive results (Ngo et al., 2023[58]). Ensuring the affordability of diagnostic tests is therefore crucial for the overall impact of screening programmes.

To encourage uptake by reducing the financial burden of screening, some countries also cover ancillary expenses, such as transportation or time off work. Romania’s colorectal cancer screening pilot (Manuc et al., 2023[59]) offered free transportation for vulnerable groups and for follow-up testing as part of the pilot, although in the absence of a population-based programme most people did not benefit. In Canada, screening is managed on a jurisdictional level; some jurisdictions cover transportation services, but such support is not universally available across all jurisdictions or to all screening participants. In other countries, transportation coverage often concerns follow-up testing.

In many EU+2 countries, co-payments for healthcare visits can create financial barriers for people with limited income, particularly when payment amounts vary widely across services or regions. For some, these costs can delay or prevent timely medical attention. Studies also indicate that vulnerable populations are disproportionately affected. People on lower incomes, older adults and individuals with chronic conditions are more likely to reduce their use of care when subject to co-payments due to the disproportionate burden on household budgets. Removing out-of-pocket costs for primary care is associated with significant increases in consultation rates and can shift healthcare use from secondary to primary care (Yee et al., 2024[60]; Kiil and Houlberg, 2014[61]), as reflected in co-payment arrangements at the point of care for primary care in EU+2 countries (Table 3.3).

Table 3.3. About half of EU+2 countries do not have co-payments at point of care for primary care

	Free at point of care for the whole population (public providers)	Free at point of care for a part of the population	Fixed co-payment	Percentage co-payment
EU+2	Bulgaria, Czechia, Denmark, Estonia, Greece, Hungary, Lithuania, the Netherlands, Poland, Portugal, the Slovak Republic, Slovenia, Spain	Austria, Germany, Ireland	Belgium, Finland, France, Iceland, Latvia, Norway, Sweden	Luxembourg
Other OECD Countries	Australia, Canada, Costa Rica, Israel, the United Kingdom			Japan, Korea, Switzerland

Note: Austrians pay a fixed annual e‑card fee, or alternatively fees of 10‑20% cost-sharing for some professional groups. In Germany, visits are free with social health insurance and most private health insurance schemes. In Ireland, approximately 40% of the population have access to free visits. Belgium, France, Iceland and Latvia apply fees of EUR 1‑6.5 per visit. Finland, Norway and Sweden apply fees of EUR 10‑26, but annual caps apply. Luxembourg applies 20% co-payments for GP visits, with exemptions for children, people with certain medical conditions and subject to an annual cap. Co-payments are 30% in Japan and Korea, while several exemptions apply, including for people on low incomes, and an annual cap. Switzerland has 10% co-payment after a general deductible, subject to an annual cap.

Source: Health System Characteristics survey 2023, Country Health Profile 2025: Slovenia.

3.3. Receiving an accurate and appropriate cancer diagnosis is a vital step in delivering timely care

3.3.1. Early cancer diagnosis is indicative of timely access to diagnostic services

Early diagnosis refers to the identification of people with cancer at an earlier stage of disease progression, often before symptoms become severe or the cancer has metastasised. Achieving early diagnosis requires both patient engagement with healthcare services and timely, effective responses from the health system. This process depends on the cancer type and usually involves a sequence of diagnostic tests, ranging from imaging to pathology, often requiring multiple steps before a definitive diagnosis is established, usually via tissue diagnosis (Figure 3.1).

It took 7 months to get my diagnosis, and the issue …is getting from GP to a hospital setting. Once you are in the system, I can honestly say I was so well looked after, but it is getting to the hospital stage that took the longest.

Pamela, diagnosed at 46 with pancreatic cancer

The proportion of cancers diagnosed at an early stage varies across countries and by cancer type

On average, more than half of breast cancers across EU countries are diagnosed at an early stage

The proportion of cancers identified at an early stage offers valuable insight into the effectiveness of screening programmes and clinical diagnosis of cancer across countries. For breast cancer, between 2018 and 2023, the share of cancer cases diagnoses at early stage (stage 0 and stage I) among women aged 50‑64 averaged 56% across 12 EU+2 countries with available data, varying from 42% in Latvia to 66% in Norway (Figure 3.6). The share of early diagnosis exceeded 50% in ten EU+2 countries (Belgium, Czechia, Iceland, Ireland, Luxembourg, the Netherlands, Portugal, Norway, Slovenia and Sweden), linked to more obvious symptomatology and longstanding population-based screening programmes in EU countries, as well as well-established diagnostic processes. Analyses indeed find a higher proportion of early-stage diagnoses among screening-age women compared to women outside the screening age (OECD, 2025[62]).

Figure 3.6. Participation in breast cancer screening contributes to the high share of breast cancers diagnosed at an early stage in EU countries

Note: Early stage refers to TNM stage 0 and stage I. Stage data refer to a three‑year average across years with data available, including 2021-2023 for Belgium, Slovenia, Czechia, Norway, the Netherlands, Sweden, Latvia and Estonia, 2020-2022 for Canada and Iceland, 2019-2021 for Portugal, 2018-2020 for Ireland, 2018-2019 for Luxembourg and 2023 for Colombia. Data coverage for Canada varies by cancer type and reference years for different provincial and territorial cancer registries. The reported rates exclude data for tumours where the stage of diagnosis is unknown or not reported. Canada and Iceland did not include Breast cancer in situ in Stage 0 tumours. Screening rates for EU+2 countries are based on the 2019 data from the European Health Interview Survey (EHIS) and refer to self-reported screening in the last two years among women aged 50‑69. For Canada, screening data refers to women aged 50‑74 who have had a test in the last three years, for 2017.

Source: OECD (2025[62]), “Assessing cancer care quality in OECD countries: New indicators for benchmarking performance”, https://doi.org/10.1787/b3f47ece-en; OECD Health Statistics 2025.

Over the five‑year period from 2018 to 2022, the proportion of breast cancers detected at an early stage has been largely stable in most reporting countries. Notable exceptions are Portugal, where this share rose by 9 p.p., and Iceland, which recorded a 6‑p.p. increase. These increases are consistent with evidence that Portugal’s organised breast cancer screening programme rebounded strongly after COVID‑19–related disruptions, restoring and expanding effective coverage by 2022 (OECD/European Commission, 2025[63]). Iceland’s increase can be linked to targeted measures to remove financial barriers and encourage first‑time attendance, which led to marked rises in mammography uptake just before and during this period (OECD, 2023[64]).

The share of colorectal cancer diagnosed at an early stage is lower, associated with lower participation in colorectal cancer screening programmes

OECD data shows that for colorectal cancer, among the screening age population (50‑64 years), the share of cancers diagnosed at an early stage (stage I) averaged 22% across EU countries, ranging from 16% in Latvia to 33% in Luxembourg (Figure 3.7). In EU+2 countries, the share of early diagnosis exceeded 25% in only four countries (Belgium, Luxembourg, the Netherlands and Slovenia). This lower proportion of early-diagnosed colorectal cancers is associated with the more recent introduction of population-based screening programmes for colorectal cancer, compared with breast and cervical cancers (OECD/European Commission, 2025[6]). It is also associated with relatively lower screening uptake, the appearance of symptoms at later stages of the disease and the non-specific nature of the symptoms. In addition, part of the reason why lower rates of early detection are reported for colon cancer compared to breast cancer is that colorectal pre‑cancers and polyps detected and treated during colonoscopy are not routinely entered into cancer registries. Thus, pre‑cancerous polyps removed via colonoscopy during colorectal screening are not captured and reported in the data, despite being identified at a very early stage.

Figure 3.7. A higher share of colorectal cancers is diagnosed at an early stage in countries with population-based programmes and higher participation in colorectal cancer screening

Note: Data refer to a three‑year average across years with data available, including 2021-2023 for Belgium, Slovenia, Czechia, Norway, the Netherlands, Latvia and Estonia, 2020-2023 for Iceland, 2020-2022 for Canada, 2019-2021 for Portugal, 2018-2020 for Ireland, 2023 for Colombia and 2019 for Luxembourg. Luxembourg is based on a very small number of colorectal cancers with available staging. Data coverage for Canada varies by cancer type and reference years for different provincial and territorial cancer registries. The reported rates exclude data for tumours where the stage of diagnosis is unknown or not reported. Screening rates are based on the 2019 data from the European Health Interview Survey (EHIS) and refer to self-reported screening in the last two years among people aged 50‑74. For Canada data refers to 2017.

Source: Health Statistics 2025; OECD (2025[62]), “Assessing cancer care quality in OECD countries: New indicators for benchmarking performance”, https://doi.org/10.1787/b3f47ece-en.

Between 2018 and 2022, the proportion of colorectal cancers detected at an early stage stayed broadly stable in most countries. The main exceptions were the Netherlands and Portugal, which each saw a three‑p.p. drop. In contrast, Latvia and Estonia reported notable gains in early-stage diagnosis over this period, with increases of 9 and 5 p.p., respectively, since 2018. These patterns are in line with evidence that colorectal cancer screening in the Netherlands and Portugal was disrupted and participation reduced during the COVID‑19 pandemic, leading to fewer screen‑detected early-stage cancers (Toes-Zoutendijk et al., 2023[65]; Morais et al., 2021[66]). By contrast, Latvia and Estonia progressively expanded and strengthened organised screening programmes over this period, increasing coverage and shifting diagnoses towards earlier stages (OECD/European Commission, 2025[67]; OECD/European Commission, 2025[68]).

Early-stage diagnosis of cervical cancer varies as much as two‑fold between countries

According to the OECD data, the share of early cervical cancer diagnosis (stage I) among females aged 15‑49 averaged 62% in EU countries, ranging from 37% in Latvia to 85% in Iceland (Figure 3.8). The share of early diagnosis exceeded 60% in nine EU+2 countries (Belgium, Czechia, Estonia, Iceland, Ireland, the Netherlands, Norway, Slovenia and Sweden). Seven of these nine countries had higher participation in cervical cancer screening, exceeding 60% in 2019. Differences may also be explained by historical variations in the organisation of and access to cervical cancer screening, including the starting age of screening, whether a medical consultation is required, the availability of self-sampling options, and the extent to which costs are covered for follow-up diagnostic testing.

Figure 3.8. Countries with a high share of cervical cancers diagnosed at an early stage tend to have high rates of cervical cancer screening

Note: Early stage refers to TNM stage I. Data refer to a three‑year average across years with data available, including 2021-2023 for Belgium, Slovenia, Czechia, Norway, the Netherlands, Sweden and Latvia, 2020-2022 for Canada and Estonia, 2019-2021 for Portugal, 2018-2022 for Iceland, 2018-2020 for Ireland and 2023 for Colombia. Data coverage for Canada varies by cancer type and reference years for different provincial and territorial cancer registries. The reference age group of 15‑49 for the stage of diagnosis data does not align exactly with the recommended screening age groups in most countries. The reported rates exclude data for tumours where the stage of diagnosis is unknown or not reported. Screening rates are based on the 2019 data from the European Health Interview Survey (EHIS) and refer to self-reported screening in the last three years among women aged 20‑69. For Canada, data refers to women aged 25‑69, for 2017.

Source: OECD Health Statistics 2025; OECD. (2025[62]), “Assessing cancer care quality in OECD countries: New indicators for benchmarking performance”, https://doi.org/10.1787/b3f47ece-en.

From 2018 to 2022, the proportion of cervical cancers detected at an early stage fell by at least 7 p.p. in five EU+2 countries (Iceland, Latvia, the Netherlands, Norway, Sweden). The sharpest declines were observed in Norway (down 12 p.p.) and in Sweden and Latvia (each down 11 p.p.). This broad drop in early diagnosis is likely linked to reduced participation in cervical cancer screening and delays in diagnostic work-up, due to disruptions to screening programmes and wider health services following the COVID‑19 pandemic (Smith et al., 2021[69]).

In the case of some cancers, a note of caution however concerns the risk of overdiagnosis, where early detection can lead to diagnosis of cancers that are unlikely or uncertain to impact patients’ health or risk of death from cancer. Very high rates of early-stage diagnosis may be driven in part by overdiagnosis of cancer through opportunistic cancer screening, such as for thyroid, prostate and lung cancers (see Chapter 4).

A high rate of emergency diagnoses for lung and colorectal cancers signals a critical gap in access to early detection services

People who do not reach the health system at an early cancer stage often present via emergency care, typically with more severe symptoms. The share of cancer diagnoses resulting from emergency presentation indicates gaps in timely diagnosis by capturing late‑stage cancer diagnoses identified when symptoms have become severe. This represents low-value care as more costly inputs are used for diagnosis and treatment, and it often results in poorer patient outcomes (Zhou et al., 2016[70]). Diagnosis following emergency presentation has been found to be associated with lower survival and higher mortality (McPhail et al., 2022[71]). Among a Danish cohort, one‑year mortality among people diagnosed with any invasive cancer following unplanned hospitalisation was more than three times higher than for people diagnosed in primary healthcare, and 37 times higher than among those diagnosed through screening programmes, who are usually asymptomatic (Danckert et al., 2021[28]).

For some cancers, an emergency presentation reflects the rapid progression of the disease and cannot be prevented. However, for some types such as lung cancer, emergency presentation often signals delayed care‑seeking or prolonged intervals between the onset of symptoms and diagnosis, suggesting issues in access to timely diagnostic services. Delays reflect differences in diagnostic capacity, care co‑ordination and access to timely referral pathways. Additionally, delayed presentation for lung cancer may also be exacerbated due to smokers being less likely to seek medical care for lung cancer symptoms (Friedemann Smith et al., 2016[72]; Kotecha et al., 2020[73]). A systematic review found that individuals under 60 years of age, as well as those with obesity, who smoke, or who lead a sedentary lifestyle, were more likely to forgo screening and less likely to visit a doctor (Unanue-Arza et al., 2021[74]).

Among EU countries with available data, the overall share of lung cancers diagnosed via emergency presentation ranged from 27% in Denmark to 37% in Croatia (Figure 3.9), though data for Belgium and Croatia may be slightly overestimated due to calculation methods. Country differences are affected by differences in clinician awareness and detection of lung cancer symptoms, or delays in access to diagnostic investigations, all of which underscore the importance of robust, timely, and equitable diagnostic pathways to prevent late‑stage diagnoses and reduce reliance on emergency care. On average, across countries, emergency diagnoses are slightly more common among men than women. Under the SOLACE project funded by EU4Health (European Commission, 2025[75]), 11 countries have begun to pilot risk-stratified lung cancer screening programmes using low-dose CT scanning (see Chapter 4). If effective, these pilots can be extended to population-level coverage among those at heightened risk (e.g. due to smoking status) and can reduce emergency presentations while increasing diagnoses of lung cancer at an earlier stage.

Figure 3.9. The proportion of lung cancers diagnosed via emergency presentation varies across EU countries, and is slightly higher among men than women

Note: Data refer to proportion of people aged 15+ years diagnosed with cancer who visited an emergency department with a principal diagnosis related to the cancer within 30 days of their confirmed diagnosis. Two exceptions are Croatia, where emergency department visits with a secondary diagnosis related to cancer are also included, and Belgium, where emergency department visits for any reason within 30 days of a cancer diagnosis are included. Data refer to a three‑year average across most recent years with data available, including 2021-2023 for Denmark and Latvia, 2020-2022 for Belgium, Canada and Croatia and 2018-2020 for Ireland. Canada’s data includes two provinces, Alberta and British Columbia.

Source: OECD Health Statistics 2025 ; OECD (2025[62]), “Assessing cancer care quality in OECD countries: New indicators for benchmarking performance”, https://doi.org/10.1787/b3f47ece-en.

Between 2018 and 2023, the share of lung cancers diagnosed via emergency presentation increased in almost all countries. The largest rises were seen in Denmark (+15 p.p.), Croatia (+13 p.p.) and Ireland (+11 p.p.). These increases are consistent with evidence that the COVID‑19 pandemic disrupted timely access to primary healthcare, imaging and specialist assessment for respiratory symptoms, leading to diagnostic delays and a higher likelihood that lung cancer was first identified during acute hospital attendance rather than through planned outpatient pathways (Pennisi et al., 2024[76]; Vella et al., 2023[77]).

For colorectal cancer, across all ages, between about 15‑40% of patients in the EU+2 countries are diagnosed via the emergency department. When analysed by age group, there is large variation in the share of cancers diagnosed through the emergency department. Among those aged 50‑69 (the screening-eligible population), the share diagnosed following emergency presentation ranges from 8% in Luxembourg to 29% in Belgium (Figure 3.10). In all EU countries with available data, the screening-eligible age group consistently had the lowest proportion of emergency colon cancer diagnoses. Ireland and Luxembourg report the largest age gradients, with the proportion of emergency diagnoses among the screening age population less than half that among those aged 15‑49. This pattern is potentially indicative of the impact of colorectal cancer screening in these countries.

Figure 3.10. The proportion of colon cancers diagnosed by emergency presentation is much lower in the screening eligible population aged 50‑69 in most countries

Note: Data refer to proportion of people aged 15+ years diagnosed with cancer who visited an emergency department with a principal diagnosis related to the cancer within 30 days of their confirmed diagnosis. Two exceptions are Croatia, where emergency department visits with a secondary diagnosis related to cancer are also included, and Belgium, where emergency department visits for any reason within 30 days of a cancer diagnosis are included. Data refer to most recent three‑year average across years with data available, including 2021-2023 for Denmark and Latvia, 2020-2022 for Belgium, Canada and Croatia, 2018-2020 for Ireland and 2019 for Luxembourg. The data for Canada data includes two provinces, Alberta and British Columbia.

Source: OECD Health Statistics 2025; OECD (2025[62]), “Assessing cancer care quality in OECD countries: New indicators for benchmarking performance”, https://doi.org/10.1787/b3f47ece-en.

Indeed, younger people with early-onset colon cancer tend to be diagnosed at a later stage and are more likely to present to the emergency department, due to more aggressive cancer, not being invited for screening, and atypical, unsuspected or unrecognised symptoms of colorectal cancer. More than two in five colon cancers among those aged 15‑49 years are diagnosed following an emergency presentation in Belgium and Ireland. Among older people (above 70 years), the share diagnosed following emergency presentation ranges from 16% in Luxembourg to 44% in Latvia.

Between 2018 and 2023, the share of colon cancers diagnosed via emergency presentation increased in most reporting countries. The largest rises were observed in Croatia (+12 p.p.), Ireland (+10 p.p.), Denmark (+9 p.p.) and Belgium (+7 p.p.). By contrast, Latvia recorded a marked decline of 12 pp. The increase in most countries is attributable to COVID‑19‑related disruptions in routine colorectal cancer screening and diagnostic services, leading to delays in diagnosis and more advanced disease at presentation (Pennisi et al., 2024[76]; Shinkwin et al., 2021[78]).

Overall, variations in the organisation, accessibility, and participation rates of colorectal screening programmes may help explain some of the observed cross-country differences. Croatia established national colorectal screening programmes in 2008, however participation rates remain low. Although Latvia formally has a colorectal cancer screening programme, no centralised invitations are issued; instead, free colorectal screening is offered to individuals in the target group through primary healthcare checkups, resulting in a more opportunistic invitation approach. Following changes to screening tests and introduction of a financial incentive for general practitioners, screening participation in Latvia has gradually increased between 2020-2023 (OECD/European Commission, 2025[68]).

3.3.2. Prioritising timely and equitable access to cancer diagnostic services

Delays in cancer diagnosis stem from multiple factors, including clinical assessment, test availability, and poor co‑ordination between care settings, often leading to loss of follow-up. A study of 158 primary care physicians in 23 European countries found that key challenges included non-specific symptoms, poor communication among providers, and low cancer risk perception among general practitioners (Hajdarevic et al., 2023[79]). Systemic barriers in the diagnostic process (e.g. poor continuity of care, inadequate follow-up, limited specialist collaboration and insufficient cancer-specific training) further contributed to delays. Countries address these challenges through interventions such as raising clinician awareness of cancer, establishing timely and equitable diagnostic pathways, reducing financial barriers to diagnostics, and capitalising on strong monitoring systems to identify and address bottlenecks in cancer diagnostics.

EU+2 countries boost primary healthcare capacity to detect and act on cancer symptoms through education and decision-aid tools, supporting referral to diagnostic services

The primary care interval is a key cancer care efficiency metric. It refers to the time between a patient’s first presentation in primary healthcare and their referral to secondary care (such as a specialist, diagnostic service, or hospital) for further cancer investigation. Longer primary care intervals delay cancer diagnosis and ultimately worsen health outcomes. Additionally, according to a 2018 pan-European survey performed by All.Can International among almost 4 000 people with cancer and carers, nearly one‑third of those whose cancer was detected outside a screening programme reported that it had initially been diagnosed as something else (All.Can, 2025[80]). Developing training and teaching materials on early cancer signs and up-to-date diagnostic pathways, as well as strengthening the use of electronic health records, can help shorten the time to a correct diagnosis (Harris et al., 2019[81]).

Targeted education campaigns for primary healthcare providers aim to improve early cancer recognition and appropriate referral by focussing on practical, accessible learning formats. These often include brief e‑modules, interactive referral checklists, and audit-and-feedback exercises. As of 2025, seven EU+2 countries offer dedicated training campaigns on cancer for primary care physicians, while seven EU+2 countries reported implementing decision support software to aid in early cancer detection (Figure 3.11).

Figure 3.11. Cancer-specific training for primary healthcare professionals and clinical decision support tools are implemented in less than a quarter of EU+2 countries

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.

In Ireland, the National Cancer Control Programme provides an Early Diagnosis of Cancer eLearning course for primary healthcare and allied healthcare professionals on recognising cancer symptoms and making timely referrals for eight common cancer types (National Cancer Control Programme, 2024[82]). Among other OECD countries, Cancer Australia offers a valuable example as it provides a wide range of resources to support healthcare professionals in cancer detection and management, including guidelines tailored specifically for general practitioners. Cancer Australia has also developed six online breast cancer courses that provide up-to-date, evidence‑based training for primary care professionals, equipping clinicians with practical knowledge for early detection, diagnosis and management (Australian Government/Cancer Australia, 2025[83]).

Clinical decision support tools can effectively help primary healthcare professionals recognise potential cancer signs and symptoms and direct referrals to specialist services or testing as relevant. Since 2020, Estonia implements a decision support tool for family physicians and nurses that is integrated into clinical software. It generates recommendations and reminders based on patient data such as diagnoses, medications, tests and treatments from the past five years (Estonian Health Insurance Fund, 2025[84]). Another notable example comes from the United Kingdom, where a Cancer Decision Support tool can help GPs decide whether further testing or a referral to a specialist is needed. Evidence from a pilot study indicated that around 20% of patients who were referred for further investigation would not have been referred if the software had not been in place (NHS England, 2021[85]). Following evaluation, the programme was expanded nationally. In Australia, a leading research cancer centre launched an online decision-support tool as part of the Colonoscopy Referral Education for Primary healthcare project, to support primary care practitioners in New South Wales with guideline‑appropriate assessment, triage, and referral for colonoscopy services (Cancer Institute NSW, 2025[86]).

According to the 2025 OECD Policy Survey on High-Value Cancer Care, 13 EU+2 countries (Belgium, Denmark, Estonia, France, Germany, Greece, Hungary, Italy, Latvia, Lithuania, Portugal, Spain and Sweden) reported using telemedicine in diagnosis as a measure to reduce delays, including by facilitating correct referrals. Estonia uses e‑consultations to connect primary healthcare physicians with specialists, allowing for referrals to take place virtually without an additional visit for the patient, speeding up the joint decision on next steps (Estonian Health Insurance Fund, 2025[84]). In Portugal, referrals from primary healthcare for first hospital specialty consultations in dermato-venereology should be made through the use of dermatological tele‑screening, combining clinical images with relevant clinical information, unless patients explicitly refuse (Office of the Assistant Secretary of State for Health, 2018[87]). This approach has substantially reduced waiting times. In 2016, the average waiting time for an in-person consultation was 225 days, compared with 27 days for a tele‑dermatology screening consultation, while maintaining similar levels of quality and safety. To encourage compliance, financial incentives and penalties are applied: hospitals receive a 10% payment increase for consultations referred via tele‑screening, but face penalties if less than 80% of referrals use this system. Similarly, primary healthcare facilities are assigned performance targets to ensure at least 80% of dermatology referrals are made through tele‑screening. In France, telemedicine is used by specialists for remote evaluation in skin cancer diagnosis in several regions, and tele‑pathology is applied within rare cancer networks to support centralised diagnostic expertise, with the National Cancer Institute (INCa) co‑ordinating the structuring and missions of these networks.

Reducing financial barriers to accessing diagnostic services should remain a critical priority across countries

Despite EU countries covering many essential services, diagnostic tests can represent a significant cause of financial strain within EU health systems. A study among Italian people with cancer found that diagnostic examinations represent the primary source of out-of-pocket (OOP)3 medical expenses among those with cancer, with an average yearly OOP cost for diagnostics of EUR 260 per patient (Lillini et al., 2023[88]). Several countries, including Greece, Hungary, Italy, Latvia, Portugal and Spain, reported in the 2025 OECD Policy Survey on High Value Cancer Care that financial barriers to accessing diagnostic services can be an obstacle, with a particularly negative impact on people with lower incomes and education levels.

According to the 2025 OECD Policy Survey on High Value Cancer Care, 22 EU+2 countries reported low or no co-payments for imaging services (e.g. CT or MRI) and 20 EU+2 countries reported the same for biomarker detection (such as liquid biopsies) (Table 3.4). In recent years, Portugal and Latvia have reported proactive steps to reduce financial barriers. In 2022, Portugal eliminated user charges for all cancer-related health services, including diagnostic services, which are now fully covered by the National Health System and provided free of charge (OECD/European Commission, 2025[6]). In Latvia, following the National Cancer Plan assessment in 2022, co-payments were removed for diagnostic examinations prescribed after cancer screening to ensure seamless diagnostic follow-up (OECD/European Commission, 2025[6]). This is also an ongoing policy in Estonia, where any follow-up examinations identified during screening are free of charge, removing the need for individuals to pay for diagnostic services after a positive result (Estonian Health Insurance Fund, 2025[89]).

Table 3.4. More than two thirds of countries in the EU ensure low out-of-pocket payments for diagnostic testing, expected to improve access

	Low or no co-payments for imaging services (e.g. CT or MRI)	Low or no co-payments for biomarker detection
EU+2	Austria, Belgium, Bulgaria, Czechia, Denmark, Estonia, Germany, Greece, Hungary, Iceland, Ireland, Italy, Latvia, Lithuania, Luxembourg, the Netherlands, Portugal, Romania, the Slovak Republic, Slovenia, Spain, Sweden	Austria, Bulgaria, Czechia, Denmark, Estonia, Germany, Greece, Hungary, Iceland, Ireland, Italy, Latvia, Lithuania, Luxembourg, the Netherlands, Portugal, Romania, the Slovak Republic, Slovenia, Spain
Other OECD Countries	Canada, Israel, Japan, Korea, Türkiye	Canada, Israel, Japan, Türkiye

Note: In the Netherlands, while visits to general practitioners are fully covered without copayment, this is not the case for other care such as diagnostics services. The compulsory deductible is EUR 385 in 2026, paid by the insured person; all remaining costs are covered by the health insurer.

Source: 2025 OECD Policy Survey on High Value Cancer Care.

Countries address waiting times and diagnostic delays by streamlining capacity through fast-track pathways and rapid diagnostic centres

In the 2025 OECD Policy Survey on High Value Cancer Care, 11 EU+2 countries (Czechia, Denmark, Estonia, Germany, Greece, Ireland, Lithuania, Portugal, Romania, Slovenia and Spain) identified long waiting times for specialist consultations, diagnostic tests and imaging as a key concern. At a physician appointment, a person may be referred for diagnostic testing, which for many cancers begins with imaging. Imaging relies on specialised equipment and countries differ in both equipment density and utilisation (Box 3.1).

Box 3.1. Imaging equipment availability and efficiency varies across countries

Imaging using diagnostic technologies is a crucial component of clinical decision making, including diagnosis, therapy and follow-up. Availability of mammographs, used almost exclusively for breast cancer, is highest in Greece at more than 70 per million population, whereas 13 EU+2 countries have fewer than 20 mammographs per million people (Figure 3.12). Among EU+2 countries, the combined availability of magnetic resonance imaging (MRI) and positron emission tomography (PET) scanners, crucial for cancer diagnostics, was highest in Greece at 40 per million population, followed by Italy and Finland with more than 37 per million. However, the highest number of exams was performed in Austria, France, Germany and Luxembourg, at more than 150 per 1 000 population, despite ranking lower on equipment availability. This underscores the importance of efficiency in equipment utilisation as lower equipment density does not result in lower examination rates in these countries. While optimal planning of availability should account for how equipment numbers affect waiting times and geographic access, excessive use can lead to inefficiencies from repeated examinations and may even be harmful. In 2025, 13 EU+2 countries reported targeted investment in diagnostic capacity to reduce waiting times. For instance, in Luxembourg, recent policy priorities have focussed on expanding advanced diagnostic technologies, including PET-CT scanners.

Figure 3.12. Diagnostic imaging equipment availability is uneven across EU+2 countries, yet countries with lower equipment density can have a higher number of exams per capita

Note: Data refer to 2023. Countries separated on the right of the figure include those where data on mammographs is not available. *Number of MRIs is underestimated in Denmark as only MRIs from the Capital region and Northen Denmark are included. **Luxembourg’s examinations include those performed for cross-border workers, who are not included in the denominator.

Source: OECD Health Statistics 2025.

In the EU, the Organisation of European Cancer Institutes (OECI) grants certification to cancer centres, representing a high-level quality label for oncology facilities (see Chapter 4 Section 2.3). To maintain this certification, OECI-accredited centres must provide data on waiting times for diagnostic tests, including CT and MRI scans, as well as on turnaround times for radiology reports. These assessments show substantial variation between centres. OECI data indicate higher median waiting times for MRI scans (14‑19 days) than for CT scans (9‑14 days). Some centres report scan-to-results reporting turnaround times of 1‑2 days, while others take several months; across nine EU countries, the median time from scan-to-reporting was three days.

Eighteen EU+2 countries have implemented fast-track diagnostic pathways to streamline triage

Individuals presenting in primary healthcare with non-specific symptoms often experience delays in receiving a cancer diagnosis due to the absence of clear referral criteria. Dedicated referral pathways offer these individuals structured, standardised referral access to specialists, ensuring timely investigations and results. Specialist services have rapid and direct access to a full range of diagnostic and support services. In most cases, national cancer waiting time targets exist alongside these pathways. According to the 2025 OECD Policy Survey on High Value Cancer Care, 18 EU+2 countries now have fast-track diagnostic pathways for suspected cancer and 13 EU+2 countries have introduced waiting time targets (Figure 3.13).

Figure 3.13. Countries are aiming to streamline access to diagnostic services by strengthening co‑ordination between providers and implementing waiting time targets

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.

Denmark’s cancer packages are standardised, time‑defined pathways that organise a pre‑planned sequence of investigations, multidisciplinary decisions, treatments and follow-up, including rehabilitation and palliative services (Sundhed.dk, 2025[90]) (see also Box 3.3). Introduced in response to the high prevalence of late‑stage diagnoses, these cancer packages provide a structured, three‑pronged fast-track referral system aimed at reducing diagnostic delays and improving cancer outcomes by strengthening co‑ordination between primary healthcare, hospitals, and specialist diagnostic centres (Vedsted and Olesen, 2015[91]). These referral pathways are categorised according to symptom types: 1) urgent referral for symptoms of a specific cancer, 2) urgent referral to diagnostic centres for non-specific symptoms, and 3) direct diagnostic access for GPs to fast-track investigations for vague symptoms. The pathways were found to expedite diagnosis for some patients with significantly lower diagnostic intervals (i.e. time elapsed from patient’s first presentation to healthcare until receipt of diagnosis), though patients not referred to a specific pathway had longer intervals (Jensen et al., 2015[92]). A recent retrospective observational study in Denmark shows improved cancer survival rates for high-grade soft-tissue sarcoma following the introduction of a specific cancer pathway (Thorn et al., 2024[93]).

Other recent evaluations of fast-track diagnostic pathways, such as the Swedish Cancer Patient Pathways and regional fast-track cancer pathways in Spain, demonstrate clear improvements in terms of both timeliness and patient experience, particularly for individuals presenting with non-specific yet concerning symptoms. In Spain, one study showed a reduction in the time interval between GP referral, specialist testing and cancer diagnosis (Martinez et al., 2021[94]), with good communication and co‑ordination between primary healthcare and specialised services identified as the key success factor. In Sweden, Cancer Patient Pathways also helped to reduce the time taken to diagnose patients with colorectal cancer (Fjällström et al., 2023[95]) and have been found to be an effective approach to detecting cancer (Borg et al., 2023[96]). In the Netherlands Cancer Institute, monitored throughput and access times were lower after implementation of fast-track diagnostics for 18 cancer types (van Harten et al., 2018[97]).

Malta, through its Directorate for Cancer Care Pathways (DCCP), operates a national fast-track referral system designed to accelerate the diagnostic pathway for patients with suspected cancer. Through this framework, GPs can issue fast-track referrals that route patients rapidly to specialist assessment and diagnostic services across multiple tumour types, including colorectal, lung, breast, prostate, haematological and skin cancers (Ministry of Health, 2025[98]).

Nine EU+2 countries have established rapid diagnostic centres to streamline diagnosis

In addition to pathways for people with site‑specific symptoms, several countries are developing Rapid Diagnostic Centres (RDCs), which also offer early diagnostic services for people with non-specific symptoms that may indicate cancer. Instead of being referred to multiple specialists, these people are offered a co‑ordinated, multidisciplinary assessment at a single centre, combining multiple steps in a diagnostic pathway. They often have access to imaging and laboratory tests, as well as specialist input, on the same day. Usually, RDCs are embedded in hospitals or clinics, where imaging, pathology and specialist staff are concentrated, allowing for a seamless integration into cancer-specific pathways after receipt of diagnosis.

Rapid diagnostic centres have been established in nine EU+2 countries (Belgium, Czechia, Denmark, France, Hungary, Ireland, the Netherlands, Poland and Sweden) (Figure 3.13). In France, 30 RDCs specialising in oncology have been accredited, covering various specialities. Ireland has rapid access clinics for breast, lung and prostate cancers, supported by performance monitoring and feedback mechanisms. Similarly, the Netherlands has an early diagnostics clinic as part of the Netherlands Cancer Institute Centre for Early Diagnostics in Amsterdam, specialising in referred people at increased risk of colorectal, prostate, breast and skin cancer (NKI Centre for Early Diagnosis, 2026[99]).

In the United Kingdom, the Suspected CANcer (SCAN) Pathway for people with non-specific symptoms was piloted in 2017 and adopted as standard care in 2020, having proven effective in identifying a relatively high proportion of cancers that are harder to diagnose (Smith et al., 2025[100]). Among 4 823 patients referred, 9% received a cancer diagnosis, most commonly lung, pancreatic and colorectal cancers. The median interval from referral to diagnosis was 37 days. Setting of waiting time targets can be a useful tool to define and communicate standards, with measurable success. The Faster Diagnosis Standard in the United Kingdom aims for 75% of patients to receive a diagnosis or rule‑out within 28 days of urgent referral. Between 2024 and 2025 and following targeted investments in the service, the target was met for 76% of patients, up from 72% the previous year, resulting in 80 000 more timely diagnoses (Open Access Government, 2025[101]).

Evidence suggests that RDCs in Wales can shorten the mean time taken to make a diagnosis, from 84 days in usual care to 6 days if a diagnosis is made at clinic (Sewell et al., 2020[102]). RDCs also reduce the number of unnecessary repeat consultations in primary healthcare and improve the experience of patients (Russel et al., 2025[103]). Another evaluation from Scotland similarly found that the country’s RDCs improved care experiences, reduced pressure on primary healthcare, and were cost-effective compared with standard primary care pathways, particularly for people presenting with vague or non-specific symptoms (Maguire et al., 2024[104]).

Interventions integrated in population-based screening programmes for structured follow-up increase retention for diagnostic testing

Primary healthcare can additionally play a role in ensuring adequate follow-up of abnormal cancer screening or diagnostic test results, which is essential to realise the full benefits of screening programmes. Evidence from the Netherlands indicates a loss to follow-up of around 4% after direct referral for colposcopy from a laboratory after an abnormal pap smear, where patients are contacted directly by the colposcopy service. However, loss to follow-up is higher when patients with an inconclusive result are referred for repeat testing, reaching up to almost 14% among women who initially self-sampled (Olthof et al., 2024[105]). In Denmark, about 10% of women with abnormal or inadequate primary cervical cancer screening results did not receive follow-up within 18 months (Fogh Jørgensen et al., 2024[106]).

Effective follow‑up requires clear protocols, robust information systems, and accountability mechanisms to ensure that no abnormal result is overlooked. Interventions such as electronic health record reminders, structured outreach to the patient and navigation support have been shown to improve timely completion of diagnostic work‑up, yet gaps remain, particularly where communication between primary and specialist care is fragmented. In cases where clear guidelines and protocols do not address when and how follow-up should take place, it tends to be uneven and heavily reliant on the patient. Embedding systematic follow‑up within cancer care pathways, supported by monitoring and quality indicators , is critical to reducing diagnostic delays and improving equity in cancer outcomes. A reminder system for cervical cancer screening follow-up, coupled with higher engagement by GPs over gynaecologists, was linked to better follow-up rates, as seen for example in comparisons between Denmark (with reminders) and Flanders (without reminders) (Fogh Jørgensen et al., 2024[106]).

Strong monitoring systems with robust indicators are needed to highlight inequalities and improve timeliness of cancer diagnostic processes

A mature cancer data ecosystem makes it possible to monitor diagnostic timeliness and to safeguard continuity and co‑ordination of care. It depends on key datasets, including cancer screening registries, cancer registries, administrative and reimbursement databases for healthcare activities, and mortality registries (see Chapter 2). Developing comprehensive cancer registries with high-quality, timely data, linking them to other health databases, and using unique patient identifiers is crucial for identifying bottlenecks at different stages of cancer care and shortcomings in the existing services.

Quality assurance and monitoring of cancer screening programmes are vital to ensure identification and development of strategies to reach underserved groups

Monitoring cancer screening outcomes is critical for evaluating programme effectiveness to understand gaps in coverage and develop targeted strategies to reach underserved populations. Studies linking risk factors, social inequalities and participation in prevention to screening are important to determine patterns related to non-participation in screening (Unanue-Arza et al., 2021[74]), with robust population-based data and cancer registries serving as a crucial basis.

Among 12 EU+2 countries surveyed in OECD work on patient safety, nine (Austria, Czechia, Latvia, Luxembourg, Germany, Iceland, Norway, Slovenia and Sweden) reported conducting a general or clinical audit of their national cancer screening programme(s) (Slawomirski et al., 2025[107]). However, only five track false negatives (Austria, France, Luxembourg, Norway and Slovenia), representing missed opportunities to identify delays and improve timeliness of care. Just five countries (Czechia, Germany, Norway, Slovenia and Sweden) report linking screening data with diagnostic services or cancer registries to monitor follow-up. Recall rates after a positive screen are reported in nine EU+2 countries, while referrals to diagnostic services are tracked in seven.

Commonly used indicators include participation rates (among people who receive an invitation) and coverage (among the population eligible for screening). Additionally, the rate of interval cancers arising between screening rounds is an important quality assurance indicator for screening programmes. Countries where this is calculated include Austria, Germany, Norway and Slovenia (Slawomirski et al., 2025[107]), as well as in Iceland and Ireland. In Iceland, 17% of women diagnosed with breast cancer in 2024 had received a normal mammography result in the preceding 24 months (Iceland Directorate of Health, 2025[108]), while for Ireland, the proportion was below 12% (Health Service Executive, 2025[109]).

Some countries link screening coverage indicators to quality monitoring or performance‑based funding for primary healthcare facilities. Additionally, in Israel, incorporating screening into the national quality indicators programme for primary care physicians (who receive reminders through the electronic health record during patient visits) was associated with increased rates of colorectal and breast cancer screening and reduced socio-economic disparities in screening rates (Weisband et al., 2021[110]).

Capturing the full cancer pathway in data allows identifying gaps in care continuity that may lead to bottlenecks in timeliness

Capturing the full cancer pathway in routinely collected data makes it possible to identify where continuity of care may be breaking down. Gaps or delays at any point in the pathway affect outcomes, people’s experience of care and system efficiency. A comprehensive view of the pathway allows health systems to pinpoint where patients wait the longest, where co‑ordination is weakest, and which phases of care require targeted improvement. Many countries monitor waiting times at multiple touchpoints along the pathway; however, the specific indicators, definitions and timepoints used differ substantially across systems, making cross-country comparison challenging.

In the 2025 OECD Policy Survey on High Value Cancer Care, 14 EU+2 countries reported monitoring timeliness indicators (Table 3.5). Specifically, the primary care interval is monitored in three EU+2 countries; nine collect data on the time between a suspected cancer referral and a diagnostic procedure; and eight measure time from suspicion of cancer to diagnosis. Time from diagnosis to treatment is the most commonly monitored indicator, used by all 14 countries who reported monitoring of timeliness.

Table 3.5. Time-related performance information collected by countries varies across the EU

Indicators	Primary care interval	Time from referral of suspected cancer to diagnostic procedure	Time from suspicion of cancer to diagnosis	Time from diagnosis to first treatment	None
EU+2 Countries	Denmark, the Netherlands and Norway	Denmark, France, Iceland, Ireland, Lithuania, the Netherlands, Norway, Poland and Sweden	Denmark, France, Ireland, Lithuania, the Netherlands, Norway, Poland and Sweden	Czechia, Denmark, France, Germany, Hungary, Iceland, Ireland, Lithuania, Luxembourg, the Netherlands, Norway, Poland, Slovenia, Sweden	Austria, Bulgaria, Estonia, Greece, Latvia, Romania, the Slovak Republic, Spain
Other OECD Countries	Colombia, Türkiye	Canada, Colombia, Türkiye	Colombia, Japan, Türkiye	Canada, Colombia, Japan, Korea	Switzerland

Note: Primary care interval refers to the time from first presentation with symptoms in primary care to date of referral to a specialist. Belgium, Italy, Lithuania, Luxembourg, Portugal, Slovenia, as well as Australia and Israel reported monitoring other aspects of timeliness.

Source: 2025 OECD Policy Survey on High Value Cancer Care.

Among EU+2 countries, only Denmark, the Netherlands and Norway monitor all the selected timeliness indicators from the point of initial presentation in primary healthcare. Beyond this, monitoring the full cancer pathway can involve tracking each touchpoint in detail and following the person through consecutive treatments and care outcomes. There is considerable variation across countries in how time‑related performance metrics are defined, particularly regarding the precise start and end points of the measured intervals. For instance, Portugal measures the time between the first primary healthcare referral and the first specialist appointment, while Italy measures the time between booking a consultation and the first treatment at a regional cancer network facility, with the aim of ensuring compliance with a maximum waiting time of 30 days. Slovenia monitors time intervals such as the turnaround time for pathology reports and the time between a multidisciplinary team decision and the initiation of treatment for the five most common cancers (breast, colorectal, melanoma, lung and prostate). Luxembourg measures the time from multidisciplinary team meeting to first treatment. By contrast, eight EU+2 countries reported that monitoring the timeliness of these critical aspects has not yet been fully implemented. In Spain, cancer timeliness indicators are not systematically recorded at the national level (although they may be used in some regions), but the National Cancer Plan includes timeliness indicators in its periodical evaluations.

Additional challenges concern the capacity to monitor timeliness by provider characteristics and by patient-level characteristics (e.g. sex, age, socio-economic status, ethnicity, migration background). Understanding timeliness across providers and patient subgroups is crucial, as missing or incomplete data can conceal performance variation and potential inequalities, limiting the ability to target improvements and ensure equitable care. According to the 2025 OECD Policy Survey on High Value Cancer Care, eight countries (i.e. Belgium, Czechia, Germany, Hungary, Luxembourg, Norway, Poland, Slovenia) reported monitoring timeliness of cancer care by both sex and age, while Iceland and Sweden reported monitoring by sex only. Only Norway reported having the capacity to monitor timeliness by ethnicity or migration background. Regarding provider-level characteristics, 12 countries monitor timeliness of cancer care by both hospital and region, while three countries monitor only by hospital and another three only by region.

Data on cancer care performance offers opportunities to meaningfully assess, compare, and improve cancer services delivery and outcomes. 12 EU+2 countries reported using data on the timeliness of cancer care for public reporting, primarily to support individuals make informed decisions about provider choice and to build trust (Figure 3.14). Timeliness data are also frequently used in feedback mechanisms to providers as part of ongoing quality improvement initiatives (nine EU+2 countries). For example, in Sweden, the Linköping Comprehensive Cancer Centre has developed a dashboard to monitor waiting times along cancer care pathways and drive improvements (see Box 3.2). In Slovenia, in addition to making timeliness of cancer care data available in public reports, findings are discussed with expert groups and other stakeholders to improve the overall accessibility and quality of care. In Lithuania, upgraded systems now enable monitoring of diagnostic and treatment pathways for cervical, colorectal and breast cancers, enhancing the ability to identify delays and address bottlenecks in care delivery (OECD/European Commission, 2025[6]). In Belgium, while timeliness data are generally used to inform the quality of cancer programmes, specific data on time delays (e.g. between diagnosis and treatment) are not publicly reported.

Figure 3.14. EU+2 countries are using information on timeliness of cancer care in various ways to reduce delays and improve access

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.

Box 3.2. Regular monitoring of cancer care processes supports data-driven improvements in Sweden and Slovenia

In Sweden, the Linköping University Comprehensive Cancer Centre employs near-real-time monitoring via dashboards to drive improvements in cancer care delivery

In June 2024, the Linköping University, in collaboration with Region Östergötland in Sweden, was accredited as a Comprehensive Cancer Centre by the Organisation of European Cancer Institutes. (see also Chapter 4). One of the centre’s key initiatives focusses on monitoring waiting times at various stages of the cancer care pathway. To support this effort, a dashboard has been developed to assist the teams responsible for each care pathway in monitoring their respective patient groups, providing a daily updated overview of the number of individuals at each stage of the care process, as well as the time spent in each stage. Key stages include the suspicion of cancer (start of the process), receipt of first referral; initial consultation within specialised care; first multidisciplinary team meeting; joint decision with the patient on the treatment plan and initiation of treatment (end of the process). This information has been essential for the continuous optimisation of care processes and has supported care teams in working towards the national target of completing 80% of cancer treatment pathways within the recommended timeframes.

Slovenia’s cervical cancer screening programme utilises digital records to monitor the programme and provide detailed feedback to screening service providers

Slovenia’s national cervical cancer screening programme ZORA combines cytology-based screening with HPV testing to detect and manage cervical cancer (Institute of Oncology Ljubljana, 2025[111]). It is centrally co‑ordinated by the ZORA office at the Institute of Oncology Ljubljana, which is responsible for developing guidelines, collecting data, and monitoring and evaluating all stages of the screening process. A major advancement has been the transition from paper-based to digital records, which has considerably improved the development of a data-driven approach to decision making across key actors. These data support quality assurance mechanisms such as annual performance reports submitted to the government, the National Cancer Control Plan, and the Health Insurance Institute. Screening service providers receive personalised performance reports with indicators allowing comparisons over five years and against national averages. ZORA’s performance is also discussed publicly in forums such as the annual ZORA Educational Day, contributing to transparency and continuous improvement.

3.4. Timeliness of appropriate treatment for cancer is an important determinant of survival

3.4.1. Timely treatment initiation varied across countries

The period between a cancer diagnosis and the start of treatment is a crucial stage in the cancer care continuum but is vulnerable to delays, interruptions in care and ultimately, poorer clinical outcomes. While the specific treatment modalities depend on tumour and patient characteristics, many people with cancer need more than one treatment modality, including radiotherapy, chemotherapy, or surgery (Figure 3.1). Barriers to timely diagnosis and diagnostic accuracy can limit the ability to match individuals to the most appropriate, evidence‑based therapies to which they are most likely to respond. Even after an accurate diagnosis of cancer is established, additional diagnostic testing is often needed to further characterise tumours and guide treatment selection. Many countries require or recommend the use of multidisciplinary teams (MDTs), also called multidisciplinary tumour boards, which can slightly increase the time to treatment initiation but support the selection and co‑ordination of appropriate treatment and have been shown to improve outcomes, including treatment planning, care experiences, and survival (OECD, 2024[48]) (see Chapter 4). Overcoming barriers to both timely and appropriate treatment is essential to reduce the use of low-value interventions, minimise adverse effects, and improve overall care experiences and outcomes for people living with cancer (see Chapter 4). The availability of a range of supportive services that address the broader needs of people with a history of cancer, including help with physical symptoms, emotional well-being and lifestyles, can also be limited by systemic, geographic and socio-economic factors (see Chapter 5).

Variation in time to treatment highlights gaps in access to cancer care and impacts cancer survival

Once cancer is confirmed through diagnosis (Section 3.3), initiation of treatment within a short timeframe improves clinical outcomes, including patient-reported outcome measures. Shorter time to cancer treatment initiation is associated with reduced mortality and is particularly critical for certain cancer types. Time from tissue diagnosis to treatment is an important indicator of care quality, with 30‑days often used as a benchmark (OECD, 2025[62]).

A meta‑analysis found that for every 4‑week delay in initiating cancer treatment, the risk of death increases by around 10% (Hanna et al., 2020[2]). Moreover, for each 4‑week delay in surgery, mortality risk increases significantly for bladder and colon cancers (by 6%), head and neck cancers (by 6%), and breast cancer (by 8%). Another meta‑analysis showed that each 4‑week delay in treatment for colorectal cancer was associated with a progressively higher risk of death, from a 12% increase after a 4‑week delay to a 39% increase after a 12‑week delay, underscoring the critical importance of timely care for improving survival (Ungvari et al., 2025[112]). Similar findings were found for cervical cancer, where each 4‑week delay was significantly associated with a 27% increase in mortality risk at 5‑year follow-up after radiotherapy (Shimels, Gashawbeza and Fenta, 2024[113]).

Among countries with available data (Figure 3.15), there are marked cross-country inequalities concerning treatment initiation within 30 days of tissue diagnosis. Treatment initiation within 30 days for female breast cancer was highest in Denmark (83%) and Norway (71%). Seven out of ten countries (Denmark, Norway, Belgium, Luxembourg, Ireland, Sweden and the Netherlands) met the 50% threshold for treatment initiation within 30 days of tissue diagnosis, suggesting more efficient care pathways in these countries. Four EU countries (Denmark, Norway, Ireland and Belgium) reported that at least 50% of people diagnosed with colorectal cancer began treatment within 30 days of diagnosis, with Denmark performing highest at 75%. For lung cancer, treatment initiation rates within 30 days ranged from 37% in Portugal to more than three in five in Denmark (74%), the Netherlands (69%), Norway (65%), and Belgium (61%). Similarly, the VENUSCANCER project (Allemani et al., 2025[114]) found substantial variation in time to treatment for breast, cervical and ovarian cancer treatment initiation across countries.

Figure 3.15. The share of female breast, colorectal and lung cancer cases where treatment was initiated within 30 days of tissue diagnosis was above 50% for all cancer types in three countries

Note: Data refer to a three‑year average across years with data available, including 2022-2024 in Denmark, 2021-2023 in Canada, Czechia, the Netherlands, Norway and Sweden, 2020-2022 in Belgium and Estonia, 2019-2021 in Portugal and 2018-2020 in Ireland. Data for Colombia and Slovenia refer to 2023 and Luxembourg’s data refer to 2017-2019 for breast cancer and 2019 for lung cancer. Data for Canada are based on two provinces: Alberta and Prince Edward Island.

Source: OECD Health Statistics 2025; OECD (2025[62]), “Assessing cancer care quality in OECD countries: New indicators for benchmarking performance”, https://doi.org/10.1787/b3f47ece-en.

Differences across cancer types may reflect variations in clinical decision making and care modalities, which can extend time to treatment initiation and complicate cross-cancer comparisons. Across countries, delays in starting treatment and in transitions between modalities are influenced by service availability and accessibility, as well as co‑ordination and continuity of care. Interpretation can additionally be influenced by the mix of years included in the data, including periods affected by the COVID‑19 pandemic. Between 2018 and 2023, the largest declines in the share of breast cancer cases treated within 30 days after diagnosis were observed in Estonia and the Netherlands (both –15 p.p.) and Belgium (–11 p.p.) (OECD, 2025[62]). For colorectal cancer, Estonia and the Netherlands also showed declines of more than 10 pp. By contrast, lung cancer exhibited mixed time trends, with increases in the share treated within 30 days in Estonia, Ireland and Norway, and slight to moderate decreases in Belgium, Portugal and Canada.

Observed declines in the proportion of breast and colorectal cancer cases treated within 30 days of diagnosis may reflect pandemic-related disruptions in service delivery, including delayed diagnostics, reduced surgical and oncological capacity, and increased strain on healthcare systems in some countries (Pennisi et al., 2024[76]; Tang et al., 2022[115]), while others may have adapted cancer pathways during the COVID‑19 period (Scanagatta et al., 2025[116]).

After I felt the lump, I was very lucky to go straight to the doctor, who performed all the tests, including a biopsy, on the same day…Within a week of receiving the diagnosis, I was already undergoing my first chemotherapy. The more problematic period is after treatment, during remission, when I am constantly dealing with health issues.

Nikol, 37 years, breast cancer

3.4.2. Cancer treatment timeliness is affected by care fragmentation and gaps in workforce and radiotherapy capacity, while access to innovative treatment varies

To improve timeliness through co‑ordination of cancer care, many EU countries have implemented treatment pathways and protocols with defined time benchmarks

Fragmentation and poor co‑ordination of care significantly contribute to delays in cancer treatment. A 2023 qualitative study conducted in-depth interviews with seven individuals who had been enrolled in a standardised cancer patient pathway in Norway between 2018 and 2020, before, during, and one‑year after completion of treatment (Solberg, Berg and Andreassen, 2023[117]). These participants described having to manage care involving multiple clinicians, with implications for continuity and collaboration at various levels of care delivery. Similarly, another qualitative study interviewed 40 individuals with a history of cancer across five countries (Greece, Cyprus, Spain, Italy and Serbia) (Hesso et al., 2022[118]). The findings revealed that cancer care pathways were frequently experienced as fragmented, with poor co‑ordination between providers and departments, often resulting in delays in diagnosis and treatment.

To improve co‑ordination, 17 EU+2 countries responding to the 2025 OECD Policy Survey on High Value Cancer Care have developed cancer care pathways and embedded clear time benchmarks that should be met. From these countries, Sweden stands out with its highly systematised 31 cancer patient pathways, implemented across 21 regional health authorities. These cover the most common cancer types, with evidence indicating the pathways have succeeded in ensuring more timely, equitable, and quality-assured access to cancer care (see Box 3.3). France piloted accelerated co‑ordinated cancer care pathways in seven hospitals for cancers with poor prognosis, reducing time to treatment, and streamlining communication with other providers to expedite access to supportive and palliative care.

Box 3.3. Most cancer cases in Sweden are managed within standardised care pathways

In Sweden, standardised cancer patient pathways (CPPs) were introduced in 2015, based on Denmark’s approach established in 2007 (Regionala Cancercentrum, 2025[119]). Developed by national cancer guideline working groups, their objectives include reducing waiting times, harmonising diagnostic approaches, improving care experiences and outcomes, and minimising regional disparities in timely access to care. Between 2015 and 2018, 31 CPPs were implemented. By 2023, 83% of people with a history of cancer were managed within one of these pathways (OECD/European Commission, 2025[120]).

Each CPP sets out the symptoms and signs that establish a well-founded suspicion of cancer, the principles for referral to specialised care, and any required pre‑diagnostic investigations. Some CPPs include a filter function, requiring confirmation of the suspicion by a specialist. Most CPPs also define a maximum lead time between the point of well-founded suspicion and the initiation of treatment. These limits, established in the National Clinical Cancer Care Guidelines, vary by diagnosis.

Two national CPP performance targets are defined: one is an inclusion target (at least 70% of people diagnosed with cancer should be investigated through the relevant CPP) and the other is a lead time target (at least 80% of people included in a CPP should complete investigation and start treatment within the diagnosis- and treatment-specific lead time). In 2024, almost 157 000 people were investigated for cancer through CPPs, and all regions met the 70% inclusion target (Regionala Cancercentrumen, 2025[121]). Across 27 CPPs, the inclusion target was achieved for 22 pathways. Despite improvements in lead times across all regions, with five regions meeting the lead-time target for at least half of patients, the 80% of people starting treatment within the lead time target is currently reached only for people diagnosed with acute leukaemia.

Regions also receive government funding conditional on reporting waiting times to a national database. Publicly available statistics include the number of cancer cases investigated and treated within CPPs and adherence to time limits. Care experience is measured using a questionnaire administered 6‑10 weeks after investigation, targeting both people diagnosed with cancer and those in whom cancer was ruled out. Since the implementation of CPPs, reported care experiences have generally been reported as positive in both groups (Regionala Cancercentrumen, 2025[121]). Although lead-time targets are not yet fully met, most people in a CPP remain satisfied with the duration of the diagnostic process, and results are broadly comparable across regions.

Among EU+2 countries, 14 countries have implemented patient navigation and case management initiatives to enhance access to and co‑ordination within cancer care services (Chapter 5). For instance, in Spain, many Autonomous Communities have established the role of healthcare liaison co‑ordinators or case managers, and in 2024, a national recommendation was issued to expand this role across the country. In addition, 17 EU countries have also adopted solutions to support scheduling and co‑ordination. For instance, Slovenia employs call centres for this purpose, while certain regions in Austria have established dedicated hotlines to support information provision and appointment management.

Across EU+2 countries, a range of policies address financial and geographical barriers to cancer care, aiming to reduce delays from the patient side

Individuals experiencing financial hardship are significantly more likely to delay, forgo, or discontinue recommended treatments, leading to poorer clinical outcomes, including reduced survival and increased recurrence risk. Medication non-adherence and missed appointments are common among those unable to meet care‑related costs (Reshma et al., 2024[122]). These challenges disproportionately affect socio-economically disadvantaged and marginalised populations, thereby exacerbating existing health disparities.

A survey among people with cancer across 25 EU countries found a high prevalence of financial hardship among participants, with 16% of respondents postponing or avoiding some care altogether (Vancoppenolle et al., 2025[123]). The highest proportions of people reporting postponed or forgone care were in Greece (47%), Bulgaria (38%), Belgium (23%), Germany (22%) and France (21%). The services most commonly delayed or avoided were doctor visits (6%) and buying medicines (7%), while treatments such as chemotherapy, radiotherapy and surgery were less frequently skipped. In Bulgaria, where out-of-pocket costs are high, 28% of respondents reported delaying or forgoing doctor visits, 18% did so for medicines and 3% for surgeries. Certain groups were at particular risk, including young adults (of whom up to 80% reported financial difficulties and 65% reported income loss), as well as divorced individuals, self-employed people, those with lower household incomes, and individuals with dependent children at the time of diagnosis.

To ensure cost does not present a barrier to treatment and to enable equal access, 22 EU+2 countries have implemented mechanisms to ensure low or no co-payments for cancer treatment. In Belgium, individuals with a Beneficiary of Increased Intervention status, primarily individuals on low-incomes and social allowance beneficiaries, receive higher reimbursements for medical care under the preferential reimbursement scheme. They could also be entitled to additional benefits, including a lower annual cap on OOP expenses. Once this cap is reached, all further medical costs in that year are fully reimbursed by compulsory health insurance. In Ireland, hospital-administered cancer treatments are free for patients treated in a public ward-type bed, which may however be subject to longer wait times. Outpatient treatments have capped co-payments, with reduced rates for those holding a medical card, which gives eligible residents free or reduced-cost access to public outpatient and inpatient services, GP visits and most prescribed medicines.

In addition to direct treatment costs, patients face additional barriers to accessing treatment such as travel distance to care facilities. The burden of travel extends beyond distance, encompassing time, financial costs and psychological stress, all of which can negatively affect care experiences and treatment outcomes. Nine EU+2 countries reimburse ancillary expenses such as transportation, childcare, or income loss. For example, Belgium offers partial reimbursement for transport through national and private insurance schemes, and in Ireland, the Irish Cancer Society provides volunteer driving services and transportation assistance funds. In France, people with cancer receive comprehensive support to maintain quality of life during and after treatment, including medical supplies after mastectomy, travel and accommodation support, home care services, financial aid for daily assistance, housing adaptations, remote assistance technologies, and psychological and social support (see also Chapter 5). These services are co‑ordinated by institutions such as the National Cancer Institute and the League Against Cancer.

Additional support includes child sickness benefits for parents of children with cancer in Germany and access to medical supplies in Ireland, such as post-mastectomy products, based on clinical need and eligibility. In Japan, all people enrolled in the public health insurance system are eligible for the high-cost medical expense benefit system, which caps monthly out-of-pocket medical costs based on age and income. This substantially reduces the financial burden experienced by people undergoing cancer treatment. The cap is lower for people on lower incomes and for most older people, and the health insurer bears the difference between the ceiling and the statutory co-payment that would otherwise apply.

Investing in cancer care capacity, including workforce and infrastructure, is key to meet the growing demand

Availability of a resilient and skilled oncology workforce must be a cornerstone of national cancer control plans

Accessibility to cancer care is frequently hindered by shortages and unequal distribution of specialised healthcare professionals. In 2022, EU countries faced a shortage of 1.2 million doctors, nurses and midwives, while over one-third of doctors and a quarter of nurses in the EU are aged over 55 and expected to retire in the coming years (OECD/European Commission, 2024[124]). Available projections estimate the workforce numbers will not meet the demand increase due to population ageing in coming decades (Bernini et al., 2024[125]). This has implications across medical fields, including cancer care.

Monitoring oncology workforce numbers is challenging, given differences in definitions, workload and responsibility of professionals. Among countries where application of a more comparable definition was feasible, the number of physicians classified as medical and clinical oncologists, and radiation oncologists averaged 7.6 per 1 000 estimated incident cancer cases, ranging from 11.6 in Czechia to 2.9 in Bulgaria, where data on radiation oncologists was not available (Figure 3.16).

Figure 3.16. The number of physicians classified as medical, clinical or radiation oncologists available per cancer case varies 4‑fold across countries, subject to measurement challenges

Note: Data refers to the nearest available year. Categories of physicians are based on national systems and reported data. Interpretation should account for limitations in data availability, disaggregation, or scope of definitions. Data exclude paediatric, haematological, and other oncologists which are not defined as separate categories in many countries. Data for Czechia refer to active physicians in any healthcare setting; data for Italy refer to active physicians; data for Slovenia includes medical oncologists and internal medicine specialists with special oncology training; data for Bulgaria refer to medical oncologists only (radiation oncology is a separate specialty); data for Malta and Denmark refer to clinical oncologists only; data for France refer to licensed physicians.

Source: Oncologist data from OECD 2024 survey, EU Country Cancer Profiles 2025, https://www.oecd.org/en/about/projects/eu-country-cancer-profiles-2025.html, Incidence data from European Cancer Information System (ECIS) https://ecis.jrc.ec.europa.eu/, accessed in July 2025.

Nursing shortages are similarly critical for timely cancer care. The European Cancer Nursing Index 2022, based on a survey of 436 cancer nurses across 29 countries, found an association between nursing shortages and bed closures and treatment delays (Catania et al., 2025[126]). Notably, preparing hazardous drugs in the workplace more than doubled the likelihood of treatment delays, while each additional patient per nurse significantly increased the odds of delays.

Cancer centres certified by the Organisation of European Cancer Institutes (OECI) monitor staffing levels of physicians, and nurses, as well as vacancies. Across centres submitting data, average capacity was around 32‑36 cancer cases per full-time equivalent physician employed. The proportion of cancer cases treated in OECI-certified centres differs by country (see Chapter 4), and standardised monitoring activities enable centres with OECI Cancer Centre certification to maintain high standards of care. Vacancies remain a significant concern: over half of centres reported open positions for medical oncologists and radiologists, while unfilled positions were most acute in oncology nursing.

The ageing of the healthcare workforce and difficult working conditions, exacerbated by the COVID‑19 pandemic, are contributing to staff retention problems and anticipated future shortages. These challenges are further compounded by increasing levels of burnout and turnover among healthcare professionals, as highlighted by the Mental Health of Nurses and Doctors survey conducted by the WHO Regional Office for Europe in collaboration with the European Commission (WHO Regional Office for Europe, 2025[127]) (Box 3.4).

Another survey by the European Cancer Organisation underscores the scale of the problem (European Cancer Organisation, 2024[128]). One in 12 cancer professionals plans to leave the field within the next five years, 19% experience high levels of burnout, 52% describe their workload as “endless,” 55% say administrative burdens make their job too difficult and 77% often work overtime. The situation is particularly severe in Central Europe, where professionals report higher burnout, lower workplace support and reduced job satisfaction compared with their Western counterparts. The crisis also reveals a persistent gender gap: although women account for around 70% of the health and care workforce, they remain underrepresented in senior oncology roles.

Box 3.4. Strengthening resilience in cancer care pathways requires targeted investment in interventions to prevent burnout among oncology professionals

Burnout among oncology healthcare professionals, largely driven by psychosocial risks such as high workloads and limited opportunities for professional development, poses a serious threat to both the quality of care and the long-term sustainability of the workforce. A meta‑analysis with a pooled sample of 4 705 oncologists reported average proportions of 32% for emotional exhaustion, 26% for depersonalisation, and 25% for low personal accomplishment, similar to 32%, 21%, and 26%, respectively, among 6 940 oncology nurses (HaGani, Yagil and Cohen, 2022[129]).

Further evidence from a survey of 83 nurses affiliated with the German Cancer Society revealed a high rate of burnout among German oncology nurses: 20% showed strong signs of disengagement, and 53% reported high levels of exhaustion. While age and disengagement were only mildly correlated, oncology nurses aged 50 and older were found to be three times more likely to experience disengagement than their younger counterparts (Helaß and Maatouk, 2024[130]).

Effectively addressing these interconnected challenges in oncology will require sustained attention, building on existing EU policies, while adapting solutions to national and subnational contexts. To support this effort, the European Society for Medical Oncology (ESMO) Resilience Task Force has issued 11 recommendations to improve professional well-being. These span from information and training, access to resources and advocacy, and targeting action at individual, institutional, and societal levels (Lim, 2024[131]). This initiative aligns with broader efforts such as the WHO European Region’s Bucharest Declaration (March 2023), adopted by 50 member states. The declaration calls for strong political commitment to protect, support, and invest in health and care workers across Europe and Central Asia, aiming to improve recruitment, retention, workforce performance, and planning.

Recruitment, retention, education and interprofessional collaboration are emerging as essential pillars of sustainable cancer workforce development. Insights can be drawn from a rapid review that identified existing planning tools for the health and care workforce based on different approaches, such as needs-based, workforce‑to-population ratio and utilisation-based (WHO, 2025[132]). Across EU+2 countries, efforts to strengthen the oncology workforce and related services are emerging through various mechanisms (Table 3.6), including workforce planning and training reforms, task reallocation, recognition of foreign qualifications and financial incentives. In addition, the EU-funded Joint Action on health workforce planning and forecasting (HEROES JA) is promoting progress in workforce planning through supporting the capacities of EU+2 countries in developing and putting to use specific planning and forecasting tools.

Table 3.6. A range of policies to improve recruitment and retention are being implemented across EU countries

Policy	Selected examples
Development or strengthening of workforce planning mechanisms and tools	The Netherlands: Used national forecasting tools to assess future needs, including for oncology nurses. Luxembourg, Malta and Slovenia: Invested in long-term planning and cross-sector collaboration to align education with healthcare needs.
Changes in training capacities	Czechia: Developed a specialised oncology nursing programme and trained GPs in cancer follow-up care. In the hospital setting, the role of cancer co‑ordinator has been developed to reduce the burden on healthcare staff. Denmark: Expanded postgraduate clinical training. France: Offers a national master’s programme for advanced practice nurses in oncology since 2018.
Development of new roles and changes in task allocation among healthcare professionals	Austria: Implemented the role of oncology nurse in some regions and that of community nurses in some municipalities. Belgium: Offered a specialised programme in oncology for nurses.
Recognition of qualifications of foreign-trained doctors and nurses already in the country	Iceland: Recruited Icelandic-trained doctors back to the health system and increased numbers of foreign-born doctors. Slovenia: Improving processes and language support for recognising foreign-trained healthcare professionals.
Provision of financial incentives	Belgium (Wallonia): Provided financial support for young doctors establishing practices in underserved areas (first 18 months). Greece: Offered financial benefits to physicians working in remote regions. Iceland and Malta: Financed specialised oncology training abroad due to limited domestic capacity.

Source: 2023 OECD Policy Survey on Cancer Care Performance and 2025 OECD Policy Survey on High Value Cancer Care.

Even if a diagnosis can be made quickly, another problem arises – the availability of treatment. There is a shortage of places in wards, there is a shortage of staff, sometimes even medicines or equipment... Patients have to "fight" for their place in the system, and this generates enormous stress and a sense of helplessness.

Renata Anielak, head of an association supporting cancer patients and their families

With a projected 25% increase in radiation therapy demand across EU+2 countries, addressing capacity gaps in the workforce remains critical

Expanding access to radiotherapy through strategic planning and investment ensures equal access in meeting increasing need for specialised therapies. Limited equipment availability constrains service capacity and leads to waiting lists, while outdated equipment increases the risk of failures and further treatment delays. Together, these factors contribute to higher mortality, poorer care experiences, and persistent health inequalities across and within European countries. A meta‑analysis found that each 4‑week delay in adjuvant radiotherapy was associated with higher mortality for breast (9%) and colon cancers (13%), while neoadjuvant radiotherapy delays increased mortality risk for breast (28%) and bladder cancers (24%) (Hanna et al., 2020[2]). Addressing these challenges through investment, modernisation and equitable geographic distribution of structures is crucial for Europe to achieve optimal outcomes and fair access to care (Lievens, Borras and Grau, 2020[133]).

The 2015 Lancet Oncology Commission on expanding global access to radiotherapy highlighted that radiotherapy can be effectively standardised and delivered irrespective of socio-economic, political and cultural contexts. While some progress has since been made, the new Lancet Oncology Commission on radiotherapy and theranostics (see Box 3.5), underscores that significant disparities in access persist (Abdel-Wahab et al., 2024[134]).

Box 3.5. Advancing theranostics, an emerging field in personalised cancer care, is a key priority for Europe

The emerging area of theranostics, an innovative field of personalised, precision medicine, combines diagnostic imaging and targeted therapy by administering a radioisotope bound to molecules that specifically attach to cancer cells, enabling highly precise location, followed by delivery of a similar molecule carrying a therapeutic isotope. This approach, particularly relevant for neuroendocrine tumours and prostate cancer, presents significant opportunities but also faces challenges in ensuring those that can benefit from it receive it in a timely manner. These include supply chain fragility for radioisotopes (often concentrated in a few countries), shortages of trained workforce, insufficient funding, and limited information on access and availability to inform decision making.

Three large‑scale projects are expected to position Europe at the forefront of the emerging field of theranostics: Thera4Care (Innovative Health Initiative, 2024[135]) aims to foster a collaborative European ecosystem for theranostics; ILLUMINATE (Innovative Health Initiative, 2024[136]) focusses on advancing new imaging techniques to enhance theranostic effectiveness, with a particular emphasis on prostate cancer that has spread to other organs; and ACCELERATE.EU (Innovative Health Initiative, 2024[137]), which aims to pioneer novel radiotheranostic pairs, targeting pancreatic, breast, and brain cancers. To improve equitable access to radiotherapy and theranostics globally, the new Lancet Oncology Commission recommends eight key actions focussing on enhanced co‑ordination, workforce alignment, infrastructure standards, radioisotope availability, data sharing, research priorities, innovative financing and intensified collaboration (Abdel-Wahab et al., 2024[134]).

A population-based study using GLOBOCAN 2022 cancer incidence estimates analysed current and projected demand for radiotherapy services following the 2013 CCORE model, which sets the optimal radiotherapy utilisation rate at 64% of cancer cases. The study estimates that between 2022 and 2050, the number of individuals needing radiotherapy in the EU will increase on average by 25%, reaching about 2.4 million people with cancer in 2050 (Zhu et al., 2024[138]). Correspondingly, the workforce demand for radiotherapy is projected to increase by a quarter, by almost 6 300 new professionals (almost 2 000 radiation oncologists, 1 100 medical physicists, and 3 200 radiation technicians), resulting in a need for close to 31 000 professionals in 2050. The projections show large variation across EU countries in the estimated growth of radiotherapy workforce demand, with demand growth of over 40% anticipated in Cyprus, Ireland, Luxembourg, Malta and the Slovak Republic.

However, relying solely on workforce expansion is unsustainable given demographic pressures, including ageing populations and shrinking working-age groups. Artificial intelligence (AI) and digital tools are positioned as essential to reconcile rising demand with limited workforce capacity and budgetary resources (Putz and Fietkau, 2025[139]). AI should be treated as a medical tool operating under clinical judgement, with radiation oncologists and medical physicists maintaining oversight of automated planning and delivery. Furthermore, professional training guided by scientific societies such as European Society for Radiotherapy and Oncology (ESTRO) and national radiation oncology associations helps to embed AI expertise in teams, while safeguarding professional roles and enabling safe, patient-centred innovation.

Projected increases in demand necessitate targeted investment in radiation equipment to ensure therapies remain available and are not subject to preventable delays

According to June 2025 data from the International Atomic Energy Agency Directory of Radiotherapy Centres (IAEA DIRAC), linear accelerators (LINACs) – the most common machines used for external beam radiotherapy (photon and electron/MV units), which deliver high-energy X-rays or electrons from outside the body to destroy cancer cells – account for almost 80% of the available radiotherapy equipment across the EU. In contrast, brachytherapy equipment, where radioactive sources are placed directly inside or next to the tumour, represents about 20%. Only 11 EU+2 countries report having particle‑beam (proton or light ion) capacity, an advanced technique that uses charged particles for highly precise dose delivery: seven in Germany, four in France, three in each of Italy, the Netherlands and Spain, two in Poland, and one in each of Austria, Belgium, Czechia, Denmark and Sweden. In countries where high-investment radiotherapy equipment such as particle‑beam systems is not available, patient referrals for treatment abroad may be needed, depending on tumour site, stage, and treatment goals (tumour control and/or toxicity reduction).

A recent study applied the Linear Accelerator Shortage Index (LSI) to estimate future shortages of equipment based on cancer incidence, number of LINACs, and current availability of radiotherapy centres (Moraes et al., 2025[140]). The LSI reflects the ratio of LINAC demand in 2045 to current availability and serves as a tool to prioritise the investment in LINACs within a country. Across EU countries, half recorded an LSI below 100 (Figure 3.17), indicating that no capacity shortage is anticipated to meet utilisation demand in 2045 at a projected 450 patients or less per LINAC (Moraes et al., 2025[140]). Eight countries (Germany, Greece, Latvia, Lithuania, Malta, Portugal, Spain and the Slovak Republic) show relatively low additional needs, with increase needs of 1‑30% of current capacity by 2045. However, six EU countries present LSI scores between 131 and 300, indicating substantial shortages to meet projected utilisation in 2045. Slovenia and Croatia each face an estimated shortfall of around 30%, Poland and Estonia around 40%, while Romania (57%) and Hungary (65%) showed the highest projected needs.

Overall, countries with higher LSI scores may need targeted infrastructure improvements to meet the growing demand for radiotherapy, requiring both financial investment in new linear accelerators and the replacement of outdated equipment. On average, EU countries would need to invest about EUR 504 million in LINACs to meet expected utilisation demand by 2045. This corresponds to an average investment of EUR 31 per capita (Figure 3.17). Substantial variability exists across EU+2 countries, ranging from EUR 47 per capita in Cyprus to EUR 15 per capita in Norway, reflecting differences in current capacity, equipment replacement needs, infrastructure development, and human resources. All countries with no anticipated capacity shortage to meet utilisation demand by 2045, except for Cyprus, Iceland and Luxembourg, have a per capita investment requirement for linear accelerators that is lower than the EU average.

Figure 3.17. Across EU countries, there is substantial variability in required investment to meet the demand for linear accelerators in 2045

Notes: The projected financial investment per capita required to meet radiotherapy needs in 2045 (including both new installations and replacement of obsolete LINACs) is shown in EUR following a conversion from US dollar at the rate of USD 1= EUR 1.0824 (2024 average) and based on 2024 population figures. Costs account for equipment, infrastructure, and human resources. Estimates assume a standard radiotherapy department design (8 h/day schedule, fixed staffing). A Linear Accelerator Shortage Index (LSI) below 100 indicates no estimated need for additional LINACs. Countries with an LSI between 101 and 130 have a modest need for additional LINACs, while those with an LSI above 131 have a high need.

Source: Adapted from Moraes et al. (2025[140]), “Global linear accelerator requirements and personalised country recommendations: a cross-sectional, population-based study”, -https://doi.org/10.1016/S1470-2045(24)00678-8.

Across the EU+2 countries, policies are being implemented to enhance the availability of radiation therapy, notably through different techniques (hypofractionation) and payment mechanisms that encourage better value and innovation in radiotherapy (see Chapter 4). According to data from the 2025 OECD Policy Survey on High Value Cancer Care, 16 EU+2 countries have adopted targeted investment approaches for radiation therapy. In France, the first European shared procurement initiative for radiotherapy equipment was launched in 2020, involving over 50 experts from French Comprehensive Cancer Centres and resulting in the joint purchase of 40 particle accelerators and related technologies. Ireland’s investment strategy is co‑ordinated through national governance structures, including the National Radiation Oncology Working Group and a Capacity Subgroup, which oversee timely access, strategic equipment replacement, and the expansion of public facilities based on demand. Targeted efforts also focus on developing centres of excellence for specialised treatments and facilitating international access to proton beam therapy until domestic capacity is established. Spain has made substantial investments through the INVEAT Plan, which is part of the country’s Recovery, Transformation and Resilience Plan, enabling the acquisition of 81 new linear accelerators to modernise and expand high-tech oncology infrastructure nationwide. This is embedded in a broader strategy to improve timely cancer treatment, including national targets for initiating radiotherapy within four weeks of diagnosis.

People living in larger and wealthier countries have better access to new cancer medicines and innovative clinical trials in oncology

Access to new cancer medicines varies substantially across countries and is not sufficiently supported by real-world evidence on patient outcomes

A key challenge to health system sustainability is the rising cost of new pharmaceuticals, including oncology medicines (see Chapter 4). This trend places strain on financial resources and exacerbates disparities in access to medicines across Europe, particularly for individuals in countries with smaller populations (Cancer Patients Europe, 2025[141]) and in those with lower purchasing power (Hofmarcher, Berchet and Dedet, 2024[142]).

Delays in accessing cancer medicines can result in health and economic losses. Differences in national public reimbursement timelines following regulatory approval by the EMA impact the availability of and timely access to new treatments across countries. According to a study commissioned by the European Federation of Pharmaceutical Industries and Associations measuring the wait time‑to‑access to new therapies (IQVIA, 2025[143]), the average time to availability of oncology products in the EU after market approval has increased by 33 days compared to 2023, from 553 days to 586 days. Delays between marketing authorisation and reimbursement still vary widely across countries, ranging from an average of 4 months in Germany to 34 months in Lithuania. Such delays can negatively affect timely access and health outcomes. For instance, an analysis focussing on two medicines (ipilimumab and abiraterone, both approved by the EMA in 2011) suggests that delays in reimbursement and market entry in the first year after approval across 26 European countries may have resulted in an estimated loss of around 21 600 life‑years (Uyl-de Groot et al., 2020[144]). At the same time, part of this interval is often used by countries for price negotiations and managed-entry agreements, which can improve affordability and broaden coverage.

However, differences in reimbursement status and time to reimbursement alone only partially account for the variation in the uptake of new cancer medicines. Broader use of medicines once they are on coverage lists often requires adaptation of clinical routines, staff training and supporting infrastructure and is impacted by early access pathways, health system and financing capacities. For these reasons, spending levels on cancer medicines represent a stronger predictor of uptake, with countries that devote more resources having consistently higher use of newer treatments (Manzano et al., 2025[145]).

A recent analysis carried out by the Swedish Institute of Health Economics shows wide variation in the uptake of newer cancer medicines in 2023 (Manzano et al., 2025[145]). Across 12 cancer types, Austria, Switzerland and France displayed the highest average overall consumption of newer cancer medicines per cancer case, with Austria achieving 88% of the theoretical maximum uptake, followed by Switzerland (76%) and France (73%). In contrast, uptake was substantially lower in Latvia (23%), Poland (27%), Estonia (35%) and the Slovak Republic (35%).

Looking at consumption of breast cancer medicines per cancer case in 2023, the highest-uptake country was Croatia (representing 100% for this cancer type), followed by Spain (92% of the uptake in Croatia), France (87%) and Austria (84%), while Estonia (40%), the Slovak Republic (39%) and Poland (38%) had the lowest uptake relative to the highest-uptake country (Figure 3.18 Panel A). For prostate cancer, France was the highest-uptake country, followed by Ireland (95% of the uptake in France) and Austria (87%), while Romania and Latvia (24%), and Poland (16%) had the lowest uptake (Figure 3.18 Panel B). Overall, the consumption of newer cancer medicines was more evenly distributed for breast cancer (with a 2.5‑fold variation across countries) than for prostate cancer (with a 6‑fold variation). The Swedish Institute of Health Economics shows some convergence over time in uptake level across countries for both breast and prostate cancers.

Figure 3.18. Cross-country variation in the consumption of new cancer medicines is more pronounced for prostate cancer than for breast cancer

Uptake of new cancer medicines, 2023

Notes: Data refer to volume of selected newer oncology medicines (standard weekly dose) per cancer case, relative to the highest-volume country (Croatia for breast cancer and France for prostate cancer). Data were not available for Cyprus, Greece, Luxembourg and Malta.

Source: Manzano et al. (2025[145]), Comparator Report on Cancer in Europe 2025 – Disease Burden, Costs and Access to Medicines and Molecular Diagnostics.

Not all new medicines have led to substantial improvements in health outcomes and survival, leading EU+2 countries to pursue various approaches to promote high-value pharmaceutical care (see Chapter 4). One of these approaches is to rely on health technology assessment in shaping reimbursement and pricing policies, and in informing clinical guidelines, to ensure that spending is aligned with value. At the same time, post-marketing reassessment of coverage and pricing decisions is another option for consideration. For this to happen, real-world evidence on treatment patterns and cancer survival is needed to evaluate how therapies perform in routine practice and to determine which deliver the greatest cost-benefit. Stronger data systems, supported by comprehensive cancer registries, would allow for better alignment of spending with clinical and patient-reported outcomes and help guide decision making, thereby promoting high-value pharmaceutical care and more equitable access.

Large cross-country differences in access to clinical trials emphasise the benefits of harmonising regulations and enabling cross-border clinical trial participation

The research capacity of EU+2 countries influences their attractiveness to industry sponsors for conducting clinical trials. This, in turn, affects the earliest-possible access to innovative treatments for people with cancer, who may be disadvantaged by limited access to clinical research that could benefit their treatment outcomes. The landscape of oncology clinical trials in Europe remains uneven. Larger countries in Western Europe benefit disproportionately from the cancer research ecosystem, while smaller countries, as well as parts of Central and Southern Europe remain underrepresented (EFPIA and Vaccines Europe, 2024[146]).

According to data from the European Atlas of Clinical Trials in Cancer and Haematology (EuroACT) (Cases et al., 2025[147]), France, Italy, Spain and Germany have the highest number of oncology clinical trials initiated since 2015 (Figure 3.19). Although trial activity is concentrated in large countries with broad patient pools, some smaller countries, notably Denmark, Belgium, Norway, the Netherlands and Austria host more trials relative to population size. This could be partially explained through a combination of robust research infrastructure, agile regulatory processes, strong government and industry support, and centralised recruitment systems for clinical trials (EFPIA and Vaccines Europe, 2024[146]; EURACTIV, 2025[148]). Austria, for example, has historically had a “fast-mover advantage” in approving clinical trials, which has benefited cancer patients via access to new therapies as well as contributed economically via job creation and increased productivity (OECD/European Commission, 2025[149]). Small countries such as Malta, Iceland, Luxembourg and Cyprus, as well as others in Central Europe, face challenges in attracting and initiating trials, with lower numbers of trials per capita compared to countries in Western and Northern Europe (e.g. Belgium, the Netherlands, Finland, Ireland).

Europe’s regulatory environment has administrative costs for initiation of clinical trials, contributing to a decline in its share of commercial clinical trials, from 25% in 2013 to 19% in 2023, with a geographic shift towards Asia (Castelo-Branco et al., 2025[150]). Oncology trial initiations in the European Economic Area (EEA) have declined by 22% since 2021 and are now below 2018 levels (EFPIA and Vaccines Europe, 2024[146]). Key barriers include regulatory fragmentation, lack of harmonised processes, limited research capacity, logistical and financial burdens for patients, insufficient training and education, and increasingly complex trial designs and eligibility criteria (Hofmarcher, Berchet and Dedet, 2024[142]; Castelo-Branco et al., 2025[150]).

However, the trial initiation rate across the EEA is expected to increase in coming years, particularly after the implementation of the EU Clinical Trials Regulation in 2022. This regulation represents a major shift toward harmonised clinical trial applications across 30 EEA countries via the Clinical Trials Information System (CTIS), enhancing transparency and minimising redundant documentation (European Medicines Agency, 2025[151]). Building on this regulatory foundation, the Accelerating Clinical Trials in the EU (ACT EU) initiative was launched to optimise the initiation, development, and conduct of clinical trials, with the goal of more effectively integrating clinical research into European health systems and supporting the development of high-quality, safe, and effective medicines (European Union, 2025[152]). While CTIS offers the potential to reduce geographic disparities in oncology trial access, structural barriers such as limited workforce capacity at trial sites and suboptimal funding models for trial implementation continue to restrict equitable clinical trial participation.

Figure 3.19. There is marked variation in availability of interventional cancer clinical trials across EU+2 countries, with strong concentration in four countries

Note: Data refer to interventional oncology trials in phases II-IV registered between 2015 and mid-2025. Data retrieved in July 2025. Methodology of the underlying data is described in Cases et al. (2025[147]). Most trials are multi-country, thus the number is not additive.

Source: EuroACT data from European Patient Advocacy Institute and WECAN Foundation.

Across the EU, Iceland and Norway, between 2015 and 2024, the cancer types most often targeted in trials were digestive cancers (Figure 3.20), followed by breast, lung and prostate cancers. While some more common cancers consistently attract research attention, others such as pancreatic cancer may be underrepresented. Rare cancers show the least research activity, with fewer than 50 trials initiated during this period.

Figure 3.20. Across EU+2 countries in the decade since 2015, interventional clinical trials most frequently targeted digestive, breast and lung cancers

Note: Data refer to interventional oncology trials in phases II-IV registered between 2015 and mid-2025 across EU+2 countries. Data retrieved in July 2025. Other cancer types include types with less than 100 trials in total, including neuro‑endocrine cancer, thyroid cancer, acute leukaemia, myelodysplastic syndromes, chronic myeloid leukaemia and less common combinations of cancer types addressed. Methodology of the underlying data is described in Cases et al. (2025[147]).

Source: EuroACT data from European Patient Advocacy Institute and WECAN Foundation.

Ongoing efforts aim to enhance clinical trial access across Europe. The EU-X-CT initiative aims to map and address barriers to cross-border trial participation while safeguarding safety, rights and data protection of participants (EFGCP and EFPIA, 2025[153]). Its recommendations highlight the regulatory gap from the absence of EU regulation on cross-border participation in clinical trials, despite opportunistic agreements among countries such as the Nordic Trial Alliance (Nordic Trial Alliance, 2025[154]). This regulatory gap, combined with fragmented national requirements, imposes logistical, legal, ethical, and financial barriers, often resulting in delayed or lost opportunities for participation.

Innovative trial designs such as decentralised clinical trials and pragmatic approaches are rapidly advancing across Europe. Initiatives like Trials@Home and the RADIAL project leverage digital technologies such as telemedicine, wearable devices, and electronic consent to increase accessibility, reduce participant burden, and improve recruitment and retention, particularly for individuals in remote or underserved regions. At the regulatory and infrastructure level, harmonisation efforts driven by the EU Clinical Trials Regulation and the Clinical Trials Information System are standardising trial oversight, reducing administrative complexity. Moreover, EU and national investments are supporting digital recruitment platforms, AI-powered patient matching, and e‑consent tools, which are proving effective in accelerating enrolment and increasing participant diversity (Lu et al., 2024[155]).

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Notes

← 1.  EU+2 countries refer to EU27, Iceland and Norway.

← 2.  Council Recommendation of 9 December 2022 on strengthening prevention through early detection: A new EU approach on cancer screening, replacing Council Recommendation 2003/878/EC – OJ C 473, 13 December 2022, p. 1 (2022/C 473/01).

← 3.  Direct payments made by individuals to healthcare providers at the time‑of-service use, without reimbursement.