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Review Supportive Care What Happens when the Cost of Cancer Care Becomes Unsustainable? Steven Simoens, 1 Wim van Harten, 2,3 Gilberto Lopes, 4 Arnold Vulto, 5 Klaus Meier 6 and Nils Wilking 7 1. KU Leuven, Leuven, Belgium; 2. University Twente, Enschede, The Netherlands; 3. Rijnstate Hospital, Arnhem, The Netherlands; 4. Sylvester Comprehensive Cancer Center, University of Miami, FL, US; 5. Erasmus University Medical Center, Rotterdam, The Netherlands; 6. HKK Soltau, Lower Saxony & Heidekreis-Klinikum GmbH, Saltau, Germany; 7. Karolinska Institutet, Solna, Sweden C ancer places a heavy burden on healthcare systems. The cost of cancer drugs is increasing, driven largely by the introduction of new, ever more innovative cancer treatments. This raises questions about value for money and the future sustainability of cancer care, and presents significant challenges for decision-makers in providing all patients with access to treatments and effective new cancer medicines. The aims of this article are to provide an understanding of how sustainability in cancer care is defined, what signs indicate that the limits of sustainability are being reached, and what potential impact this may have on patients with cancer within Europe. Each country is faced with making difficult decisions about the allocation of healthcare resources to cancer care, to best meet the health needs of their patients. Determining the value of individual cancer drugs can help to inform these decisions, because premium pricing for incremental innovation is no longer sustainable. When the cost of cancer care becomes unsustainable, countries may be forced to restrict health expenditure by limiting demand, cutting spending and reducing investment. This can lead to restricted access to treatment. New, innovative cancer treatments must provide greater value than current options, and measures are needed to contain and reduce expenditure and make best use of scarce resources, without impeding access to effective and safe treatments for all patients. Keywords Sustaining cancer care, cost-effectiveness, innovative treatments, value, outcomes Disclosure: Steven Simoens, Wim van Harten, Gilberto Lopes, Klaus Meier and Nils Wilking have nothing to disclose in relation to this article. Arnold Vulto has nothing to disclose in relation to this article and no financial interest in any pharmaceutical company. His institution receives financial compensation for consulting/lecturing activities from AbbVie, Amgen, Biogen, Boehringer Ingelheim EGA (Medicines for Europe), Mundipharma, Pfizer/Hospira, Roche and Novartis/ Sandoz/Hexal. Acknowledgements: Editorial assistance was provided by Fiona Bolland, PhD, of Spirit Medical Communications Ltd., funded by Sandoz International GmbH. Compliance with Ethics: This study involves a review of the literature and did not involve any studies with human or animal subjects performed by any of the authors. Authorship: All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship of this manuscript, take responsibility for the integrity of the work as a whole, and have given final approval to the version to be published. Open Access: This article is published under the Creative Commons Attribution Noncommercial License, which permits any non- commercial use, distribution, adaptation and reproduction provided the original author(s) and source are given appropriate credit. Received: 8 June 2017 Accepted: 14 August 2017 Citation: European Oncology & Haematology, 2017;13(2):108–13 Corresponding Author: Steven Simoens, KU Leuven Department of Pharmaceutical and Pharmacological Sciences, Herestraat 49 bus 521, 3000 Leuven, Belgium. E: Support: The publication of this article was supported by Sandoz International GmbH. The views and opinions expressed are those of the author and do not necessarily reflect those of Sandoz International GmbH. 108 The estimated incidence of cancer increased by almost one third across Europe between 1995 and 2012, and this growth is predicted to continue. 1,2 Compared with other diseases and disabilities, the lost years of life and productivity resulting from cancer represent a heavy drain on the global economy, especially in low- and middle-income countries, where the loss of income due to sickness or death is profound. In 2008, the total economic burden of cancer-related premature death and disability worldwide was US$895 billion (~€830 billion), with 85 million years of healthy life lost. 3 Notably, these figures do not include the direct costs of cancer drugs. In Europe, health expenditure on cancer increased from €35.7 billion in 1995 (population size: 462 million) to €83.2 billion (population size: 510 million) in 2014, and spending on cancer drugs increased from €7.6 billion in 2005 to €19.1 billion in 2014 (current prices). 4 As the incidence of cancer rises across the world, so does the amount of research and development into innovative medicines, signalling even higher costs in the future. As a result, the financial burden on society runs the risk of becoming unaffordable. 5 It has been suggested that all governments declare how much is affordable, taking into consideration the country’s economic situation, and make a decision on what drugs and treatments can be made available as a basic healthcare provision for all, and which cannot. 6 The economic burden of cancer care is a key component of the overall burden of healthcare, and on top of that, cancer drugs, in particular, have been associated with a dramatic increase in spending in recent years. 7 This is due in part to the growing number of high-cost, newly approved drugs and the increasing pressure placed on oncology facilities. Over 70 new oncology treatments have been developed over the past 5 years, and it is estimated that by 2020, over 100 new cancer drugs could be approved. 8 Administration of chemotherapy has shifted away from the lower cost setting of the physicians’ office, with a 30% increase in the number of infusions performed in higher cost outpatient settings between 2002 and 2014. 9 An increase in the volume of cancer treatment is a further contributory factor. For example, in prostate cancer, the newer hormonal therapies abiraterone and enzalutamide significantly TOU C H ME D ICA L ME D IA