➜Mary Gospodarowicz: Just do it➜ The patients who are paying a price for Europe’s

debt crisis➜A career dedicated to themost stigmatised group of all➜Why your patients

may be not be sticking to their prescriptions, and how you can help them do better

Mary Gospodarowicz

Education & knowledge through people & facts

Number 49, July-August 2012

CancerW

orld

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AUGUST2012

CANCER WORLD ■ JULY/AUGUST 2012 ■ 3

Editorial

A re we winning the war againstcancer? This is the provoca-tive title of theWorldOncology

Forum (WOF), which will take place inLugano, Switzerland on October 25–27,to mark the 30th year of the EuropeanSchool of Oncology. Rather than hosting aparty or a more conventional symposium,ESO feels this is the rightmoment to tacklesome of the big questions the cancer com-munity needs to address. Researchers,directors of cancer institutes, policymakers,chairpersons of professional and researchorganisations, and representatives of phar-maceutical companies, patients organisa-tions, and international organisations suchas the WHO – 80 experts in total – willgather together for two days of intense dis-cussion. A special feature of WOF will bethe participation of 20 scientific journalistswho will play the role of devil’s advocate,challenging the logic and the evidence forthe propositions put forward.Our understanding of the biology of

cancer has improved tremendously inrecent years, opening many avenues fornew treatments that could work better.But how much of the progress that weseem to have achieved with targeted ther-apies and so-called personalised medicineis really being translated into better out-

➜ Franco Cavalli ■ GUEST EDITOR

comes, and how much is hype? What canwe do about the rapidly rising numberof cancer cases and deaths in low- andmiddle-income countries, where optionsfor prevention, early diagnosis and treat-ment are so limited? Many of these coun-tries spend only around $50–100 per personon health every year, while the cost of thelatest targeted therapies in rich countriesaverages $150,000 per patient per year.Can we develop sustainable treatmentoptions? These are some of the questionswe will be debating at WOF.Will we find answers? This is a very

complex topic, whichmay be themain rea-son why last September’s UN Summit onnon-communicable diseases, which recog-nised the huge and increasing burden ofcancer worldwide, failed to come up withprecise commitments and deadlines.WOFwill carry this discussion further, helping tosharpen the focus and the boundaries of thisextremely important debate. We are proudto have the cooperation of The Lancet. Itseditor-in-chief, Richard Horton, will leadthe final session, where he will ask the con-ference to weigh up the arguments heardover the two days and answer the ques-tion: “Are we winning the war against can-cer?” I’m sure I’m not the only one who iseagerly awaiting the verdict.

Winning or losing?ESO asks the experts

Franco Cavalli is the Chairman of the World Oncology Forum and ESO Scientific Committee

ImpactFactor

Certainly not; more potentially activedrugs are available, including othertaxanes and alternative platinum com-pounds that are probably not com-pletely cross-resistant to cisplatin,which is most commonly used in thefirst-line setting. Even anthracyclinesor mitomycin may show benefit infurther treatment lines. To date,single-agent irinotecan, given in abiweekly (150 mg/m²) or three-weekly(250–350 mg/m²) schedule has thebest evidence to improve survivaland symptom control in post-progres-sion advanced-stage gastric cancer.A smaller randomised German studyof the Arbeitsgemeinschaft Inter-nistische Onkologie (AIO) showed aconsistent benefit for second-linetreatment with irinotecan thatresulted in a reduction of the hazardratio for death to 0.48 (95%CI 0.25–0.92, P=0.012) in the irinotecan armcompared with best supportive carealone.7 Beyond chemotherapy, medic-inal pain management, nutritionalsupport, psycho-social support andmany other interventions do not yethave proven benefit for patients withadvanced gastric cancer.3

A consistent benefit of ‘salvage

chemotherapy’ has been observed inmost of the prospectively defined sub-groups of the Korean study.4 Never-theless, in the era of personalisedmedicine and increasing disease strat-ification, the benefit of specificmedicinal interventions must be chal-lenged in future studies that mayassess whether this benefit might bethe same for different ethnic sub-groups,8 for different histological phe-notypes,9 and for different gastriccancer genotypes.10

In summary, irinotecan or doce-taxel significantly prolonged overallsurvival compared to best supportivecare in the studied patients. Second-line chemotherapy can now be con-sidered as a proven treatment optionfor pretreated advanced-stage gastriccancer and this option should be inte-grated into a comprehensive palliativecare strategy.

References

1. R Siegel, D Naishadham and A Jemal. (2012)

Cancer statistics. CA Cancer J Clin 62:10–29

2. F Kamangar, GM Dores and WF Anderson. (2006)

Patterns of cancer incidence, mortality, and

prevalence across five continents: defining priorities

to reduce cancer disparities in different geographic

regions of the world. JCO 24:2137–50

3. AD Wagner et al. (2006) Chemotherapy in

advanced gastric cancer: a systematic review and

meta-analysis based on aggregate data. JCO

24:2903–09

4. JH Kang et al. (2012) Salvage chemotherapy for

pretreated gastric cancer: a randomized phase III trial

comparing chemotherapy plus best supportive care

with best supportive care alone. JCO 30:1513–18

5. W Koizumi et al. (2008) S.-1 plus cisplatin versus

S.-1 alone for first-line treatment of advanced gastric

cancer (SPIRITS trial): a phase III trial. Lancet

Oncol 3:215–221

6. JS Temel et al. (2010) Early palliative care for

patients with metastatic non-small-cell lung cancer.

NEJM 363:733–742

7. PC Thuss-Patience et al. (2011) Survival

advantage for irinotecan versus best supportive care

as second-line chemotherapy in gastric cancer – a

randomised phase III study of the

Arbeitsgemeinschaft Internistische Onkologie (AIO).

Eur J Cancer 47:2306–14

8. VE Strong et al. (2010) Comparison of gastric

cancer survival following R0 resection in the United

States and Korea using an internationally validated

nomogram. Ann Surg 251:640–646

9. M Messager. (2011) FREGAT working group –

FRENCH. The impact of perioperative

chemotherapy on survival in patients with gastric

signet ring cell adenocarcinoma: a multicenter

comparative study. Ann Surg 254:684–693

10. IB Tan et al. (2011) Intrinsic subtypes of gastric

cancer, based on gene expression pattern, predict

survival and respond differently to chemotherapy.

Gastroenterology 141:476–485

Author affiliations

Klinikum Braunschweig, Department of

Haematology and Oncology, Braunschweig, Germany

Competing interests

Florian Lordick declares associations with the

following companies: Pfizer, Sanofi-Aventis

44 ■ CANCER WORLD ■ JULY/AUGUST 2012

Manufacturer sponsorship bias

in economic analyses matters

➜ David Kerr and Ahmed Elzawawy

A qualitative study indicates that there is a positive selection bias towardsfavourable economic analysis of targeted therapies when these are fundedby themanufacturer.At a time of increasing budgetary constraints and pub-lic scrutiny of the relationship between industry and the professions,weneeda more mixed economy of funding for this field.

In terms of the history of medi-cine and health care, the 19thcentury may be regarded as the

century of Public Health, clean water,sewerage and understanding the basisof infection; the 20th century mightbe regarded as the century of know-ledge, when systematic clinical andlaboratory research yielded extraordi-nary insights into the mechanism ofdisease; we predict that the 21st cen-tury will be driven by value. Consid-ering the spiralling costs of healthcareand an often confused approach tohow we define value in a societal

This article was first published online in Nature Reviews Clinical Oncology on 1 May 2012, and is republished with

permission. © 2012 Nature Publishing Group. doi:10.1038/nrclinonc.2012.75

sense, and given the global financialcrisis and the likelihood that for manynations the health budget will flat-line, it is obvious that we need moredata on the relative cost-effectivenessof innovative diagnostic or therapeu-tic agents if we are to make transpar-ent and defensible judgements ontheir relative worth. This situation isset against a backdrop of increasingsuspicion from policy and lawmakersand some patient groups that the rela-tionship between practising cliniciansand purveyors of these new technolo-gies is not at sufficient arm’s length.1

In 2007, Djulbegovic et al.,2 publisheda fascinating historical case study ofthe first conflicts of interest policy atthe National Academy of Sciences. Afundamental debate in this case waswhether one can simply declare afinancial interest or whether one mustalso admit that this financial interestis a potential source of bias.

Now, a new study has beenpublished by Valachis et al.3 thataddresses this question in a differentway. One of the characteristic pointsof the study is that the authors tried toinvestigate the role of manufactur-ers’ influence in various manifesta-tions, such as the presence of anyauthor affiliated with the manufac-turer of the drug being assessed, orthe presence of direct funding fromthe manufacturer for the health-eco-nomic study – as shown in previousstudies – the role of funding and itsbias in economic evaluation of drugsin oncology,4 and medical research ingeneral.5 Of the 81 eligible studiesthat they identified, the authorsfound that economic analyses thatwere funded by pharmaceutical com-panies were more likely to reportfavourable qualitative cost estimatesthan those without an expressedfunding association with these com-panies (28 out of 34 studies [82%]

versus 21 of out of 47 studies [45%];P=0.003). This phenomenon wasseen to a similar degree for thosestudies that reported any financialrelationship with the manufacturers,for example, author affiliation orauthor funding. Valachis et al.3 dis-cuss the weaknesses inherent in theirstudy with candour: the linkagebetween the eligible studies and theirfinancial aspects depended solely onpublished details, as Valachis et al.3

made no effort to contact authorsdirectly to further verify these data;there may have been a publicationbias towards positive reports thatmight have skewed results; certainstudy criteria were poorly repre-sented, so the database was rathersmall (for example, affiliation withmanufacturers); and finally, theiranalysis was based onqualitative data. Nev-ertheless, Valachis etal.3 do seem to havedemonstrated a con-sistent sponsorshipbias towards themanufacturer of costly,targeted drugs withrespect to economicanalyses. It is con-cluded that the bestway of dealing withperceptions of sponsorship bias is notincreased rhetoric, but ratherincreased public funding for eco-nomic evaluation of medicines,thereby creating a true mixed econ-omy for research funding in this field.

Does this sponsorship bias mat-ter? If we are to adopt Michael Porter’sdefinition of value,6 then, yes it does.

“Value in any field must bedefined around the customer, not thesupplier. Value must also be measuredby outputs, not inputs. Hence it ispatient health results that matter, notthe volume of services delivered. But

all outcomes are achieved at somecost. Therefore, the proper objectiveis ... patient health outcomes rela-tive to the total cost (inputs). Effi-ciency, as well as other objectivessuch as safety, is subsumed in theconcept of value.”

Adoption of any new therapeuticagent in the current climate is likelyto involve trade offs, comparing thevalue gained from the introductionof the targeted therapy relative toexisting gold standards in cancertreatment, or, even more widely,comparing its value with that gainedfrom hip replacements or cataractoperations. The latter comparisonmight seem absurd, but within afinite health budget in which there isno ring-fencing of cancer funding,this could become an issue. So an

economic evaluationof the new drug willhave an often criticalrole in whether thedrug is made availableto cancer patients bygovernments or pay-ers.7 If there are sig-nificant doubts aboutthe veracity of thedata, hanging overthe analysis like thesword of Damocles,

then this starts to undermine thevalidity of the data and even reducethe chances of a targeted therapypassing over whatever health-economic hurdles have been erectedin its way.

So, is there a way to square thiscircle? In the same way that we nowhave mandatory listing of clinical tri-als8 to offset publication bias, onemight establish a register of pharma-coeconomic studies; approachesmight be made to journal editorialboards to lower their threshold forpublishing negative studies; and

ImpactFactor

CANCER WORLD ■ JULY/AUGUST 2012 ■ 45

“The way to deal

with perceptions

of sponsorship

bias is not

increased rhetoric,

but increased

public funding”

ImpactFactor

payers could establish independentlyfunded analytical units to give anentirely unbiased view of the eco-nomic case for acceptance or not ofthe agent under investigation. If theworkings of these analytical units wereutterly transparent and open to publicreview, then this would furtherenhance their credibility and rele-vance to citizens. Do we think thatthere is some methodical misrepre-sentation of results? Of course not;however, the paper by Valachis et al.3

is a timely warning of the subtle biasesthat can creep in unnoticed, and isperhaps doubly important given the

wider economic challenges faced byall healthcare systems and, therefore,the increasing scrutiny that will beapplied to all such economic analyses.

References

1. EG Campbell et al. (2007) A national survey

of physician–industry relationships. NEJM

356:1742–50

2. B Djulbegovic, C Angelotta, KE Knox et al. (2007)

The sound and the fury: financial conflicts of

interest in oncology. JCO 25:3567–69

3. A Valachis, NP Polyzos, A, Nearchou et al. (2012)

Financial relationships in economic analyses of

targeted therapies in oncology. JCO 30:1316–20

4. S Jang, YK Chae, T Haddad et al. (2010) Conflict

of interest in economic analyses of aromatase

inhibitors in breast cancer: a systematic review.

Breast Cancer Res Treat 121:273–279

5. M Barbieri, MF Drummond. (2010) Conflict of

interest in industry-sponsored economic evaluations:

real or imagined? Curr Oncol Rep 3:410–413

6. ME Porter. (2007) Defining and introducing value

in health care. In: MB McClellan, JM McGinnis,

EG Nabel et al (eds). Evidence-based medicine and

the changing nature of health care: 2007 Institute of

Medicine (IOM) annual meeting summary, 1st edn.

National Academies Press, Washington DC, chapter 14,

pp 161–171

7. R Sullivan et al. (2011) Delivering affordable

cancer care in high-income countries. Lancet Oncol

12:933–980

8. US National Library of Medicine. (2012)

http://www.clinicaltrials.gov

Author affiliations

David Kerr, Nuffield Department of Clinical and

Laboratory Sciences, University of Oxford, UK; Ahmed

Elzawawy, Suez Canal University, Port Said, Egypt

46 ■ CANCER WORLD ■ JULY/AUGUST 2012

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oncologist or organ specialist,

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The new, redesigned CancerWorld

website invites you to contribute

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CANCER WORLD ■ JULY/AUGUST 2012 ■ 57

few scrub nurses.The inevitable result

is long waiting lists.Spiliotis says he just told a

patient diagnosed with col-orectal cancer to come back in

45 days.Waiting times for

radiotherapy are evenlonger, he says. In the four

main cancer hospitals and nineother public hospitals with radio-

therapy equipment, the waiting list isthree to four months. “It is very dif-ficult to propose neoadjuvantchemoradiation forpatients with rectal can-cer with waiting timeslike that. So the patienthas to get this treatmentfrom private practice.”

Supplies of essentialcancer medicines, includingTaxotere, Temodal,Avastin, Herceptinand Mabthera, are drying up, says KathiApostolidis, a breast cancer andpatients rights advocate. She describesdriving around the hospitals andpharmacies of Athens for a friend, insearch of supplies of Zometa (zoledronic

acid for controlling bonemetastases). Pharmaceuti-cal companies are insistingon advance payment fromhospitals and public healthinsurance, she says, whilepharmacies are refusing

to deliver medicines topatients on credit.She believes patients

are being held hostage

in the battles between theMinistry of Health, pharmaceu-

tical companies and pharmacists.There are worries too that

financial concerns are leadingpatients to delay visits to a doctor.

“We have a problem that 15–20%of patients do not consult a physi-cian. We compared results from2007 to 2009, and it seems that weare seeing cancer patients at a moreadvanced stage than three years ago,though we do not have statistically sig-nificant data on this as yet.” If true, thiswould mean that not only are fewerstaff having to care for more patients,using fewer resources, but a higherproportion of patients are presenting

with cancers that are more com-plex, more expensive to treat

and more likely to be fatal.While Greece is

undoubtedly at the sharpend of Europe’s debt

crisis, it is by nomeans alone. With

austerity the pre-vailing watch-

word, public spending is being reinedin everywhere. Although countriessuch as Spain, Italy, Portugal and Ire-land are in the frontline, countries suchas France, Belgium, UK and theNetherlands are not far behind. EvenGermany, the strongest economy inEurope, has plans to cut public sectordebt by €80 bn by 2014.

As healthcare accounts for a highproportion of public spending,and cancer accounts for asizeable chunk of healthcarespending – with its need forcomplex multidisciplinaryapproaches to care, heavyuse of expensive imagingtechniques, and reliance

on some very expensive drugs – cancerservices are under pressure as neverbefore.

For patients, many of whom at thebest of times feel they have to fight forquick access to the best treatments, themost urgent question is to what extentthe financial pressures on Europe’s can-cer services are affecting frontline care.

In an effort to answer that question,Cancer World asked its European read-ers for feedback on how the Europeandebt crisis is impacting on cancercare in their own countries. Ninetyresponses from 20 European memberstates suggest that there is a strongperception that the debt crisis is havinga direct impact on patient care wellbeyond the countries facing the tough-est cuts (see box overleaf). Drawing oncomments appended to the survey andon interviews with some of the respon-dents reveals a patchy picture acrossEurope, but patterns are emerging.

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ACCESS TO DRUGSAccess to certain cancer drugs ischanging across Europe. Fatima Car-doso, director of the Breast CancerUnit at the Champalimaud CancerCentre in Lisbon, reports that somedrug companies have started to with-hold supplies from hospitals that havebeen slow paying their bills. The gov-ernment has been trying to intervene incases where the hospitals have no alter-natives, but Cardoso expects this prob-lem to get worse.

Some doctors have been reduced tolying to patients because they don’twant to admit there is no money topay for the drugs they need, she says.Cardoso cites the case of a patient

whose bone metastases, which causeextreme pain and increase the risk offracture, were being left untreated.“She had been told there are notenough data to support the use of bis-phosphonates, because people are notfrank enough to say: you should receivethis drug but we have no money togive it to you.”

As with Greece, public cancer hos-pitals and oncology departments inPortugal are finding themselves flooded

with people who have had to give upprivate medical insurance. But eventhose who retain their private insur-ance can no longer afford the drugsthey need, says Cardoso. “Even after somany years on the market, the price oftrastuzumab is so shamefully high thatmost private health insurance barelycovers the cost of one year of treat-ment, leaving nothing over to pay forthe chemotherapy and all the otherthings patients need. For adjuvant ther-apy people sometimes do desperatethings such as selling their houses toget the money for one year of treat-ment. But if you have to go on and on

for as many years as possible,what can you do?”

In Italy, Anna Costato,who is being treated foradvanced breast cancer,but is also a GIST patientadvocate as a parent of achild with paediatric GIST,reports that access to newdrugs takes longer and candepend heavily on where

you live. This is because regionalhealth authorities have the final sayon what will be reimbursed, so a new

medicine may be restricted even afterapproval by the European MedicinesAgency and the national Italian agencyAIFA.

Patients with rare cancers are hitparticularly hard by measures that reg-ulate the prescribing of drugs for off-label use. Costato believes that themeasures, introduced in 2007, are nowbeing wrongly used to restrict access toexpensive drugs. She gives the exam-ples of sorafenib (Nexavar), dasatinib(Sprycel), and nilotinib (Tasigna),

58 ■ CANCER WORLD ■ JULY/AUGUST 2012

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“People are not frank enough to say: you need

this drug but we have no money to give it to you”

WHAT THE SURVEY FOUND

A survey of Cancer World readers, asking about how public spending cuts are impacting on

frontline cancer care, attracted 90 responses from 20 of the 27 Europeanmember states.

Overall only 10% of respondents reported no impact on the quality of care cancer patients

receive, with the vast majority reporting “some impact” (around 40%) or “quite an impact”

(around 35%), and a little under 15% reporting “a huge impact”.

Asmight be expected, access to anti-cancer therapies (regardless of speed of access) showed

the least impact, with almost 35% reporting no impact, a slightly higher proportion report-

ing “some impact” and only 25% reporting “quite an impact” or “a huge impact”. Access to

other types of care, such as supportive care and rehabilitation, appears to be taking more

of a hit, with only 20% reporting “no impact” andmore than 40% reporting “quite an impact”

or a “huge impact”.

Patients in many countries are also having to wait longer to get access to the services they

need. The impact seems to be greatest for specific cancer therapies, such as surgery or radio-

therapy, with almost 40% reporting a “huge impact” or “quite an impact” and only 20% report-

ing “no impact”. Butmany patients are also facing longer waiting times for seeing a specialist

and getting the necessary diagnostic tests (around 25%and30% respectively

reporting the top two impact categories).

Interpretation of these findings are subject to all the usual warnings about

self-selection of respondents and the subjective nature of the responses.

LEVELS AND QUALITY OF STAFFINGStaff shortages and/or the de-skilling ofcertain roles due to budget cuts wasanother theme mentioned by manyrespondents.

In Portugal, waiting times for radio-therapy at public hospitals have beenthe focus of highly critical press cov-erage, because there are too few staff tooperate facilities to full capacity.Patients are being badly let down saysCardoso. “I recently had a patient whohad intensive bone metastases in herspine, particularly the cervical spine.She had been waiting for more thanthree months for radiotherapy. Inthe meantime, she developed lep-tomeningocarcinomatosis [affectingthe tissue that covers the brain] andshe is dying, at 37 years old.” Cardosobelieves that while poor prioritisation ofpatients and poor organisation may bepartly to blame, lack of personnel isalso an important cause.

Costato in Italy talks of a steadydecrease in the number of nurses,alongside a decrease in the number ofhospital beds and length of hospitalstays. What concerns her is that thecare patients get on leaving hospital islargely given by low-paid untrainedworkers, which is impacting on thequality of care. Staff hiring is effectivelyfrozen in hospitals, she says, whichmakes itself felt in longer waiting timesfor CT and MRI scans and for consul-tations with oncologists. MassimoConio, a gastroenterologist in Sanremo,Italy, reports similar increases in wait-ing times for surgical procedures.Other survey respondents talk aboutstaff shortages impacting on access tosupportive therapies, “reducing thepossibility of supporting the quality oflife of children and families.”

Ingrid Kössler, a breast cancerpatient advocate involved in Sweden’sNational Cancer Control Strategy,reports similar concerns over the

increasing use of less trained nurse-assistants in place of nurses. Staffing isso tight, she says, that hospitals havecome to rely on student nurses to coverabsences during summer holidays. Thisyear the student nurses are refusing towork unless they are paid a full salary;it is not clear how that will be resolved.

A scandal centred in Gothenburgover 60 patients with melanoma whowere wrongly told they did not havecancer has put a spotlight on the strainspersonalised medicine is putting onpathology departments. Pathologistspoint out that they are being asked toperform many more tests for manytypes of patient than was the case a fewyears ago, and at current staffing levelsthey are finding it hard to cope. WhileSweden is not one of the countrieshardest hit by the debt crisis, saysKössler, the ageing population meansthat while cancer and other age-relatedchronic diseases are putting a greaterburden on the health budget, there arenow only two people working – andpaying taxes – for each retired person,compared with a five-to-one ratio afew decades ago. A stagnant economyis not helping.

Comments from Ireland talk abouta reduction in the number of “alliedprofessionals” involved in the deliveryof cancer care, including psychologicalsupport. A lower staff-to-patient ratiomeans less time spent with patients.

In the UK, survey respondents talkabout reductions in follow-up visits andcutbacks in specialist breast nurses,scrubbed nurses (for operating theatres),“team members” and the administrativesupport necessary to free up clinical prac-titioners from bureaucratic functions.Nursing staff made it very clear at arecent conference that, in their experi-ence, frontline clinical care is beingdirectly affected by staff cuts despiteassurances from the government to thecontrary.

In the Netherlands staff cuts are reduc-ing the healthcare support available tocare for patients in their own homes.

Survey respondents from Spainmention longer waiting lists for diag-nostic procedures and consultationswith a specialist, as well as greaterrestrictions on access to health carefrom home support teams. Though it’shard to quantify, it is clear that staffinglevels are being steadily eroded througha virtual freeze on new appointmentscombined with the loss of many staffwho were on fixed-term contracts.Cuts of 10–20% are planned forhospital staff who are not directly

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to keep the budget for care as it isnow,” she says. “We are told not tospend extra, but to try to be creativewith what we have, so we are reallyevaluating the way we are reimbursing.Can we reduce the costs of reim-bursement if we increase efficiency?Can we economise to have new fund-ing to do new things?”

Greater integration is one focuspoint. “We pay for psychologists in can-cer care, but can we also use them forother things?” Evaluating value formoney is another. “Breast implants arevery well reimbursed in Belgium, butthey have a risk. Might it be better touse breast reconstruction with own tis-sue – isn’t it more efficient becauseyou have fewer complications and pro-cedures in the longer term?” The optionof adapting levels of reimbursement toencourage use of generics rather thanexpensive brands, where appropriate, isalso under consideration.

One important spin-off of thisproactive approach, says van Hoof, isthat the Belgian Cancer Centre is ableto back up its proposals for actions toinclude in the Cancer Plan with strongarguments and detailed data derivedfrom the continuous eval-uation of this plan. Shebelieves robust cancerplans that have their ownbudgets and areclosely monitored

and evaluated will be key to safe-guarding the best quality carefor cancer patients as Europemoves forward. She is glad thatin Belgium they managed toget such a plan up and fundedbefore the debt crisis struck.

But what of the countries thatdidn’t? In Greece, John Spiliotis fullyaccepts that decades of virtually uncon-trolled spending on healthcare, withthe highest doctor-to-nurse ratio inEurope and no restrictions on pre-scribing, has contributed to the currentcrisis. He recognises the importance ofa more sustainable, planned approachto delivering cancer services; he wel-comes prescribing guidelines andgreater use of generics; he is commit-ted to cutting the list of lab tests, short-ening the list of imaging procedures,cutting hospital stay, and using pallia-tive rather than aggressive treatmentsnear the end of life. He and his fellowsurgeons are even shunning expensivetechnologies where it is safe to do so,going back to the manual proceduresthey haven’t used for years, just to cutcosts. “But we can’t turn the clock backto the ’60s or ’70s in cancer treat-ments,” he says. “This is a big problem

that started 30years ago. We

cannot correct itin the three to five

years that Europe isdemanding of us.”

In Portugal, Car-doso believes there is

huge scope for concen-trating resources where

they are most needed. “Ifthere were proper guidance

so governments understand howto calculate overall cost-effectiveness,rather than just looking at the price ofdrugs, I think we could cut at leastone third of the cost without affectingthe quality of care,” she says, “and wehave to do it wisely and in a fair way.”That guidance, she adds, has to comefrom collaboration between healtheconomists and the people who deliverfrontline care.

She is acutely aware of how muchmoney is being wasted, for instancewhen vials of expensive drugs areopened, partially used, then thrownaway because guidance says they can’tbe stored once opened. Coordinatingthings so that all patients receivingthese drugs get them on the same daywould help. However, drug companiesmust also cooperate in providing accu-rate data about the stabilisation of drugsand time-frames for use, she says.

In her own particular area, Car-doso is now focusing her efforts onadvocating for all patients to be treatedin breast units. “If you centralise treat-ment with people who know what theyare doing, they will spend less,” shesays. She is also encouraging patientgroups to speak with one voice andfocus their demands on the bare essen-tials: access to best treatments; no cutstomedications that cannot be replaced;no cuts that affect the quantity andlong-term quality of life.

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“If you centralise treatment with people who

know what they are doing, they will spend less”