How to create value with constrained budgets in oncological care? A narrative review

ABSTRACT

Introduction

As a result of an increasing focus on patient-centered care within oncology and more pressure on the sustainability of health-care systems, the discussion on what exactly constitutes value re-appears. Policymakers seek to improve patient values; however, funding all values is not sustainable.

Areas covered

We collect available evidence from scientific literature and reflect on the concept of value, the possible incorporation of a wide spectrum of values in reimbursement decisions, and alternative strategies to increase value in oncological care.

Expert opinion

We state that value holds many different aspects. For reimbursement decisions, we argue that it is simply not feasible to incorporate all patient values because of the need for efficient resource allocation. We argue that we should shift the value debate from the individual perspective of patients to creating value for the cancer population at large. The different strategies we address are as follows: (1) shared decision-making; (2) biomarkers and molecular diagnostics; (3) appropriate evaluation, payment and use of drugs; (4) supportive care; (5) cancer prevention and screening; (6) monitoring late effect; (7) concentration of care and oncological networking; and (8) management of comorbidities. Important preconditions to support these strategies are strategic planning, consistent cancer policies and data availability.

KEYWORDS:

• Healthcare costs
• oncology
• policy
• reimbursement
• value

1. Introduction

In recent years, many developments have taken place in oncological care in the field of diagnostics and treatments. Partly because of this and due to the aging of the population, the number of people living with and after cancer is increasing rapidly [1]. It is expected that the worldwide cancer rate will increase from 19 million in 2020 to 30 million in 2040 [2]. Cancer treatments are gradually becoming more successful, resulting in an increase in people who survive [1]. Examples are the cases of metastatic melanoma and hematological cancers. Novel targeted and immunotherapeutic drugs increased median survival for metastatic melanoma patients from 11.8 months in 2013 to 21.1 months in 2018 [3]. For hematological malignancies, a study from the Nordic countries (Denmark, Finland, Norway, and Sweden) revealed an increase in 5-year survival from 20% in a cohort from 1971 to 1975 to 50% in a cohort from 2016 to 2020 [4].

Due to increases in survival, patient-centered care is gaining increasing interest. The needs and desires of individual patients are increasingly driving forces behind health-care decisions and alternative quality measurements that now also include patient experiences [5–8]. However, because of the fast developments within oncology, the costs for oncological care are increasing rapidly. More expensive pharmaceuticals are getting on the market while post treatment costs are also increasing. Global costs on oncological medicine rose from 111 billion US dollars in 2017 to 185 billion US dollars in 2021 [9]. It is predicted that the costs will rise to 307 billion US dollars in 2026. This does not include the costs on other oncological healthcare spending or costs for comorbidities. Both would add very substantially to the cost burden of oncology.

Within the current era of patient-centered care and the increasing pressures on the sustainability of health-care systems, the question arises: How do these two relate and what constitutes value in health-care systems that are under pressure?

In this paper, we reflect on three aspects: (1) the concept of value within oncology, (2) the incorporation of values in reimbursement decisions, and (3) alternative strategies to increase value in oncological care.

2. The concept of value

We recently explored value-elements regarding new oncological treatments for patients with cancer and all stakeholders involved [10]. We found that clinical values are not the only ones that matter in the oncological field. We found a much broader range of values. Values that have come to the fore regard the impact on daily life and future of patient, costs for patients and loved ones, oncology specific quality of life, impact on loved ones, societal impact, and aspects regarding the quality of treatments [10]. Some examples of these values are presented in Table 1.

Table 1. Selection of examples of values for oncological patients and other stakeholders.

Impact on daily life and future of patients

Impact on future plans and choices

Ability to work

Ability to care for children

Costs for patients and loved ones

Additional care

Travel expenses patients/relatives

Loss of income

Quality of life

Hair loss

Neuropathy

Infertility

Fear (of recurrence)

Cognition and concentration

Depression

Relationship with (grand)children

Relationship with partner

Relationship with friends/family

Existential questioning

Impact on loved ones

Informal care

Work ability

Psychological impact

Societal impact

Work ability

(In)direct health-care costs

Societal balancing

Quality of treatment

Long-term health

Survival

Ease of use

Source: Vrinzen et al. [10].

Besides the values from our previous study, different frameworks already exist for evaluating the value of health interventions. These frameworks can be generic or oncology specific and can inform reimbursement decisions. Examples of generic frameworks are the framework of the Institute for Clinical and Economic Review (ICER) from the United States [11] or an HTA core model from EUnetHTA from Europe [12]. Besides these generic frameworks, two common oncology-specific value frameworks are the frameworks of the American Society of Clinical Oncology (ASCO) [13] and the European Society for Medical Oncology (ESMO) [14]. The frameworks do not entirely incorporate all extensive values found in our previous study. Our extensive exploration of values could add to more explicitly using the values that are specific for oncological care in the deliberative processes for the generic frameworks. In addition, these broad values could add to oncology-specific frameworks by presenting explicit values regarding the impact on daily life and future, costs for patients and loved ones, quality of life, and quality of treatment. In addition, the impact on loved ones and societal impact are often underrepresented in oncology-specific frameworks.

A proper recognition of values that count might in practice increase the perceived value of oncological care. However, in different contexts, different values are prioritized. Below we first discuss the incorporation of these values in reimbursement decisions and then discuss different strategies to increase value.

3. Which (patient) values should we include in reimbursement decisions?

Exact definitions of value intensify when health-care budgets are under pressure. Policy makers seek to provide universal access to high value health care for all citizens with a limited budget to their disposal. The available resources have to meet the needs of oncological patients, but also of all those with different health conditions. If a substantial and increasing amount of the budget is devoted to oncological care, this reduces the opportunity to invest in care for non-oncological patients. Economists call these the opportunity costs; more recently displacement (of more valuable treatments) is also used to describe this phenomenon. An example in the field of oncology is the rise in immunotherapies as a promising treatment for varies types of cancers. These drugs are often very expensive and reimbursement of these high costs of immunotherapy drugs can come at the expense of other treatments. Therefore, new expensive pharmaceuticals in oncology are increasingly hitting the willingness to pay thresholds of responsible regulatory agencies. For example, in the Netherlands, the new pharmaceutical drug for triple-negative breast cancer was recently declined for national reimbursement. This drug could increase survival by 5.4 months but has extremely high costs (2.9 million per patient) and an incremental cost-effectiveness ratio between 196,929 Euro and 241,231 Euro per Quality-Adjusted-Life-Year (QALY) [15]. The QALY is an uniform measure of value in which life years and the health-related quality of the life (HRQoL) are merged [16]. In the Netherlands, the maximum willingness to pay threshold is 80,000 Euro per QALY.

To ensure fair allocation of resources and maximize population health, it is important to set decision-making procedures with uniform value frameworks to assess health-care investments over different diseases. Over the past years, the role and limitations of value frameworks in health-care priority setting and resource allocations have been firmly debated. Different studies emphasize gaps in value assessment for new interventions [17]. For example, aspects such as hope [18] or the reduction in uncertainty by a new intervention is merely never incorporated [17]. The use of generic tools for the measure of HRQoL within the QALY is debated [19]. The HRQoL measures do not always seem adequate for mapping out all benefits. They might only contain subsets of the relevant outcomes [17,20]. Generic tools, for example the EQ-5D, generate utilities that are comparable across different diseases and therefore can most sufficiently provide fair resource allocation across different health-care areas. The downside of these generic tools is the reduced sensitivity to change and inability to capture heterogeneity in more condition-specific values between different patient groups. This stimulates the development for more patient-centered and condition-specific health utility tools in which values of the specific patient population are represented, for example the EORTC QLQ BR-23 tool for breast cancer. However, it could be questioned whether all relevant values could be measured and quantified in a way that the utilities are still comparable over all diseases. In addition, an increased variety of disease-specific tools decrease the ability to compare across studies or populations. Experts desire the use of generic value measures that are applicable to all diseases for efficient resource allocation [10].

Differences between countries exist in how and which values are considered in decisions on budget allocation. A study by Angelis et al. examined differences in eight European countries regarding assessment of the value of new medicines in the context of reimbursement decisions [21]. Most countries implement a type of economic evaluation in addition to the assessment of clinical benefit. The preferred health gain measure usually is the QALY. Additional values beyond the QALY concept are captured to a different extent between countriesfor instance, ease of use, public health benefit, ethical considerations, or social productivity. Often such values are already either explicitly or implicitly incorporated in reimbursement decisions. Differences in decision-making procedures contribute to the variability in the reimbursement for oncological drugs between countries [22]. Countries with lower rates of reimbursement incorporated cost-effectiveness analyses into reimbursement decisions. The methods and level of negotiations between payers and pharmaceutical companies that are used for cost containment result in these countries for an increase in the number of drug reimbursements.

Because the health-care budgets are under pressure and reimbursement decisions are focused on efficiently allocating resources to maximize value for the entire population, a comprehensive recognition of all individual patient values seems hardly feasible.

4. Alternative strategies to increase value of oncological care

Besides reimbursement decision on expensive drugs, different strategies could contribute to creating value in oncological care. Below we discuss different strategies.

4.1. Shared decision-making and information provision

Over the years, patient-centered care and shared decision-making are gaining increasing interest. Shared decision-making between physicians and patients increases incorporating patient values in treatment decisions, as well as decision aids and general information provision to patients during and after treatment or cancer [10]. Patients should be well-informed about treatment options, its advantages and disadvantages and decide together with the physician which treatment (or no treatment) fits best. For treatment choices, it is relevant to consider the patient’s individual context, values, and priorities. For instance, the patient’s desire to maintain physical capabilities (ability to sport or work), psychological well-being, phase of life (e.g. elderly, young parent, or a patient with a child wish), home situation, or education level [10]. Additionally, treatment choices depend on whether patients can still be curatively treated. It should be emphasized that treatment choices also include the option not to treat. A culture shift is needed to emphasize that treating a patient is not always the best option.

Different studies reveal that shared decision-making is not yet fully implemented and used to its full potential [23–25]. What could aid the broader implementation of shared decision-making is as follows: (1) more awareness for the benefits of shared decision making and incorporating this as a standard in the patient pathway, (2) generate more outcome information based in on real-world data to inform and empower patients to make well-informed decisions, and (3) the development and stimulation of tools that systematically address patient values and provide necessary information.

4.2. Biomarker and molecular diagnostics

Biomarker testing, including molecular diagnostics, in oncology has received a lot of attention and has become an integral part of cancer treatment. Molecular diagnostics enables precision medicine in which targeted treatment can be applied based on tumor genetics. In addition, prognostic markers can inform treatment selection [26]. For example, a KRAS mutation can predict a lower response to targeted therapies inhibiting the epidermal growth factor receptor (EGFR) in tumor cells [27,28]. A different example is circulating tumor DNA as a prognostic factor for the need of adjuvant chemotherapy to prevent recurrence after tumor resection in stage II colon cancer [29]. Based on biomarkers, clinicians can identify the most effective treatment options for the individual patients.

For many tumor types, a comprehensive genomic profiling using either Next-Generation Sequencing (NGS) or Whole Genome Sequencing (WGS) is beneficial [30]. NGS evaluates known genetic alterations, while WGS provides a more comprehensive view of the entire genome, enabling detection of known and novel genetic alterations, which facilitates research and potentially provides more future-proof genetic information.

The potential treatment benefit in terms of response rate and progression-free survival of comprehensive molecular diagnostics for the individual patient is great [31]. NGS is the most appropriate for patients with metastatic cancer with several identified molecular targets [31]. Additionally, NGS can offer options in patients with rare cancers and help navigate patients to clinical trials. A review by Tan et al. from 2018 found that NGS is effective for the identification of mutation(s) in cancer patients [32]. However, only a few cost-effectiveness studies were found with contradicting results. In addition, WGS could also be cost-effective, but more research is needed [33,34].

To spread and evolve molecular diagnostics, investments are needed to ensure an appropriate organization in which the high-quality diagnostics form an integral part of patient pathways for specific patient groups. It is of importance to organize access to molecular diagnostics for every eligible patient across a country. In addition, Molecular Multidisciplinary Tumor Boards and tools to support these teams are needed for interdisciplinary discussions to help with the interpretation of molecular results and optimize patient treatment [35–37].

4.3. Appropriate evaluation, payment, and use of drugs

After a positive reimbursement decision for oncological drugs, they may stay monitored after implementation. Drugs that are already on the market and reimbursed should be reevaluated based on real-world data from large national registries to gain insights in cost-effectiveness of these drugs in a real-world setting. It is known that real-world patient populations differ from the populations in pharmaceutical trials [38]. Besides this, costs calculations are often based on modeling studies and could additionally benefit from reevaluation based on real-world data.

Comparative cost-effectiveness studies to evaluate different treatment regimens in real-world data could contribute in which different treatments are compared in a routine practice setting [39]. Many countries have existing large cancer registries with rich observational data that can be used for comparative effectiveness studies. These could be used to assess benefits and harms of a treatment in a representative real-world setting.

Alternative payment models should be evaluated and stimulated like value-based pricing and risk-sharing. In value-based pricing models, also referred to as pay-for-performance models, drug prices are set after assessment of a drug’s value within the national threshold for cost-effectiveness [40]. Pharmaceutical companies could decide whether or not to market their drugs at that price. Risk-sharing models are agreements between pharmaceutical companies and payers which allow patients access to new drugs in a context of uncertainty of (cost-)effectiveness due to immature evidence. This ensures collection of more evidence on cost-effectiveness and allows prices of drugs to be aligned with their value. These flexible and personalized risk sharing models seem promising for increasing sustainability of oncological care [,41]. An example of this is the DRUG Access Protocol in the Netherlands, which enables providers access schemes to promising new medicine, which improves access to new drugs and can contribute to the collection of evidence [42]. This especially relevant for patient with rare cancers in which it is difficult to find enough patients for trials.

To ensure that value of investments is maximized, it is of great importance to stimulate appropriate use of expensive drugs after they are accepted for national reimbursement. The rise of precision medicine with molecular diagnostics could stimulate this. Patients who have the indication for a specific drug are identified and they could greatly benefit. In addition, attention should be paid to reducing ‘inappropriate’ care [40]. Studies suggest that a great deal of patients can receive inappropriate care at the end of life which are inconsistent with patient wishes, for instance provision of chemotherapy [43,44]. This can result in unnecessary toxicity and side effects, can decrease a patients’ quality of life and create unnecessary costs. A substantial portion of costs for oncological care is spent in these last weeks or days of life.

As patient-centered care and the sustainability of oncological care is already widely debated, many different initiatives already exist on maximizing patient value and ensuring efficient health-care delivery resulting in increase in healthcare quality and reduction of health-care costs. Initiatives can for instance include reduction of expensive medication waste, adjusting drug dosages or adjusting start-and-stop criteria. It is of importance to evaluate these initiatives and stimulate (inter)national spread.

4.4. Supportive care

The rapid developments in oncological care, increasing incidence and increasing survival rates is creating more awareness on the needs of supportive care for patients during and after the disease. To prevent and manage adverse effects of cancer and its treatment, supportive care should be integrated in the care pathway [45,46]. Supportive care needs for patients could, among others, be a psychologist, sexologist, or physiotherapist. Supportive care could, for instance, also include work rehabilitation. A rise in cancer incidence is mainly seen in the older population, however incidence is also rising in the younger population that is still working. More attention should be paid to working and work rehabilitation during and after cancerfor instance, by including an occupational physician in the care pathway.

At the moment, supportive care needs of patients are not always fully met which can result in worse HRQoL [47,48]. Clear arrangements should be made on who is addressing supportive needs of patients in the care pathway and when these are addressed. In addition, arrangements should be set on who refers to supportive care and to what supportive care is referred to. Patients often receive care from multiple care professionals and different care organizations. The continuity of the care pathway (and aftercare) also beyond the medical treatment is important in this aspect. Coordination and communication between the different professionals of this (supportive) care should be organized. It is important that patients are well-informed about possibilities for support during and after the treatments and cancer.

For patients with advanced cancer, advanced care planning (ACP) could additionally contribute to increasing patient-centered care and stimulate the on-time onset of palliative care. ACP enables patients to define and discuss their preferences for future treatment with family and health-care professionals. There are many different ACP designs, and research is needed on which intervention suits best for different scenarios and what facilitates ACP [49]. For instance, the use of an interdisciplinary group of health-care professionals or ensuring engagement across the entire illness trajectory could contribute to effective ACP interventions [50].

4.5. Prevention and screening

Screening is a crucial tool for early detection of various types of cancer. It can detect cancers at an early stage before symptoms occur, which increases the likelihood of successful treatment. Several cancer screening programs demonstrate cost-effectiveness. For example, a recent systematic review showed that, for high-risk populations, screening with low-dose computed tomography for lung cancer is cost-effective [51]. In addition, breast cancer screening is proven cost-effective, but risk-adapted screening is more effective than conventional screening [52,53]. The cost savings by screening, due to early detection of a cancer leading to less invasive and more effective treatment, can outweigh the initial screening costs. Screening programs for common cancers with higher incidence rates, such as breast cancer, have a greater impact on public health and cost-effectiveness compared to screening for rare cancers.

Prevention of cancer often includes lifestyle interventions that are aimed at reducing the risk of cancer. This includes promoting healthier lifestyle such as avoiding tobacco and excessive alcohol use, physical activity, or sun protection [54–56]. These interventions can reduce cancer incidence and incidence of other diseases and potentially reduce health-care costs. For example, interventions for smoking cessation are highly cost-effective, as quitting smoking not only reduces the risk of lung cancer but also lowers the risk of other smoking-related diseases [57,58].

It should be mentioned that evaluating cost-effectiveness of screening and prevention programs can be challenging because costs and outcomes are projected over large time horizons which introduces a lot of uncertainty. Additionally, discounting future costs and benefits is necessary to account for the large horizons but makes it more complicated the interpret results and impact of the screening. Nevertheless, it is important to research and invest in prevention and screening for different kinds of subpopulations.

4.6. Monitoring late effects

Cancer treatment has made significant advancements in recent years in terms of survival rates; however, cancer survivors may experience long-term effects caused by the cancer or the treatments [59]. A cancer diagnosis and cancer treatment can affect patient values regarding daily life and future, costs, quality of life, and impact on loved ones [10]. In addition, treatment for cancer can result in different diseases like secondary cancers or cardiovascular diseases [60].

As cancer survivorship is becoming a greater aspect of oncology care, understanding and addressing late effects is essential for comprehensive long-term management and emphasizes the need for guidelines. For these (ex-)patients, regular medical checkups are required for monitoring overall health and identifying any potential long-term effects. Generating risk profiles based on real-world data for (late-)effects of treatment should be stimulated. This could be used to inform patients and as input in shared decision-making. In addition, strategies on monitoring and supporting late effects should be explored. An example of late effects initiatives are the implementation of survivorship care or hospital clinics for patients who survived cancer (even after many years). A wide variation in support and health-care needs among cancer survivors [61] suggests a need for survivorship care that is tailored to individual patients. It has shown to be beneficial for patients who desire information about their disease [62].

4.7. Concentration of care and oncological networking

The fast innovation within the oncology field regarding treatment and diagnostics results in more complex care and precision medicine. As the complexity of cancer care increases it is of importance to concentrate knowledge, especially for rare cancer types, to ensure the quality of care remains high or increases. Many studies provide evidence on increasing volumes of care improving health outcomes [63–65]. Concentration of care in specialized institutions increase expertise; however, the importance of collaboration agreements between different hospitals should be emphasized. Patients should have access to the best possible care suited for that specific patient and should be referred to or discussed with specialized institutions, within a country or even internationally for rare cancer. For instance, the European Reference Network on Rare Adult Solid Cancers (EURACAN) connects health-care professionals and centers of expertise to improve access to diagnostics, treatments, and high-quality health care for rare adult solid cancer [66].

Collaboration agreements could be referred to as oncological networking or cancer networks. Several studies have been conducted in which the effectiveness of certain components of an oncological network was tested. Discussing patients in a multidisciplinary team [67,68] or centralization of care [69] increases survival, while multidisciplinary care pathways seem to improve the quality of care [70,71]. Although oncological networks seem beneficial for increasing quality of care [72–75], research in oncological networking that may prove this is complicated. There is a large variation in the organization and goals of oncological networks and in addition in the indicators and evaluation methods used [76]. The OECI European Cancer Network Quality standard can contribute in establishing principles and standards for evaluation the effectiveness of oncological networks [76]. Demonstrating the (cost-)effectiveness of oncological networking and the optimal way of implementation and governance is important.

4.8. Managing comorbidities

The number of comorbidities in oncological patients increase over time with 5% per decade [77]. On average, comorbidity prevalence in oncological patients is 33.4%. This varies for different cancer types such as lung cancer (46.7%), colorectal cancer (40.0%), prostate (28.5%), melanoma (28.3%), and breast (22.4%) [77]. Additionally, comorbidities increase health-care costs for oncological patients [78,79]. These high rates of comorbidities have major implications for the treatment and organization of cancer care.

Oncological patients with comorbidities receive different treatmentsfor instance, they are less likely to receive treatment with curative intent and receive less standard cancer treatments such as surgery, chemotherapy, and radiation therapy [80,81]. Additionally, postoperative complications, morbidity, and mortality are higher in patients with comorbidities [81]. In the era of centralization of oncological care, as described above, comorbidity management risks fragmentation between different health-care organizations. The high comorbidity prevalence should be incorporated in debates on centralization of care. The management of comorbidities requires collaboration between different professionals and health-care organizations. Patients need personalized treatment plans that address the cancer and comorbidity, additionally taking into account potential drug interactions and side effect. All medications should be reviewed regularly to minimize the risk of adverse effects or drug interactions.

4.9. Cancer policies

Nolte et al. studied the link of different cancer policies in a sample of 10 jurisdictions in seven high-income countries for seven cancers from 1995 to 2014 [82]. Among other things, the frequency and consistency of cancer plans varied. Some countries have successions of cancer plans that build on each other, while others have isolated plans. Countries that implement cancer control policies with consistent oversight and a clear development plan that build on previous policies (consistency) appear to associate with better cancer survival. This reveals that strategic planning is important for patient outcome improvement. Central bodies may play an important role in ensuring the consistency by providing follow-through of cancer plans and using funding to ensure implementation.

In addition, health-care systems are complex and fragmented systems with makes them resistant to change [83]. Within complex systems, it is expected that incremental steps have little impact and it is more effective to implement multiple of the strategies at ones to increase value in health care.

4.10. Data availability

Data availability can be a challenge in (oncological) care. While progress has been made in recent years to improve data collection and data sharing, there are still complications [84]. Data silos can limit accessibility and sharing of data across different health-care organizations. In addition, there may be a lack of standardized data formats across health system which results in a decrease in interoperability. Besides this, privacy plays a major role, as it can be restricted to share patient data due to confidentiality and security considerations. These limitations may hinder the improvement of health care at different levels: patient, physicians, and population.

At patient level, limited data availability may hinder patients’ ability to access all their health information. Access to personal health records empowers patients to participate in their care decisions. It can increase understanding of treatment options and an active participation in shared decision-making with health-care providers.

At physician level, inadequate access to data can hinder assessment of a patient’s condition. The availability of comprehensive patient data and full medical history is crucial for accurate clinical decision-making.

At population level, access to comprehensive big datasets is essential for conducting research. This data may, among other things, include electronic health records, genomic sequencing, treatments, outcomes, and costs. For efficient resource allocation and the evaluation of strategies discussed in this paper, it is of importance to perform research with large comprehensive datasets.

It is crucial to stimulate interoperability and secure sharing of data. Efforts like standardized electronic health records, national registries, and privacy-preserving sharing initiatives may all increase data availability.

5. Conclusion

This paper provides review-based suggestions on what constitutes value in cancer care. Health-care systems are under pressure due to rising health-care costs. A wide range of values exist in oncological care. However, the exact definition of value within the context of healthcare policy re-appears when health-care budgets are under pressure. Ideally, reimbursement decision should efficiently allocate budget across the entire (not only oncological) population. Different alternatives are suggested to increase value in oncological care.

6. Expert opinion

What constitutes value in cancer policy depends on the context. Patient-centered care is becoming increasingly important and individual patient values are increasingly driving forces behind health-care decisions. However, we have concerns to incorporate all individual patient values in reimbursement decisions regarding expensive oncological drugs. At the moment, existing frameworks and quality of life measures used for reimbursement decision do not entirely incorporate all value-elements relevant for oncological patients. The use of generic value frameworks and measures that are applicable to all diseases is desired for efficient resource allocation. In addition, costs of oncological care are increasing and health-care budgets are under pressure. In our opinion, the concept of value in reimbursement decisions is getting more narrow as more expensive drugs are entering the market. We believe that, to efficiently allocate limited resources and keep health-care sustainable, a more narrow concept of value is valid. Reimbursement decisions should be focused on efficiently allocating resources to maximize value for the entire population (not only the oncological population), and therefore comprehensive recognition of all individual patient values is unfeasible.

We argue that we should shift the value debate from incorporating ‘all’ individual patient values of ‘all’ cancer subpopulations in reimbursement decisions to creating more value by implementing alternative strategies that can contribute to increasing value.

We believe that cancer policy should shift focus to different strategies that can increase value for the entire oncological population as a whole. These strategies should be (1) greater implementation of shared decision-making in which patients are well-informed about treatment options and a patient’s individual context, values are priorities are considered; (2) studying, developing, and organizing biomarker testing and molecular diagnostics for the most promising subpopulations; (3) exploring and incorporating appropriate evaluation, payment, and use of expensive cancer drugs that already have a (temporary) positive reimbursement decision; (4) further development of management of supportive care needs during and after cancer treatments to increasingly meet the patients unmet needs; (5) research and implementation of effective strategies for cancer prevention and screening for different subpopulations; (6) developing and studying the monitoring and management of late adverse effects of cancer and its treatment; (7) stimulating and study optimal ways to concentrate oncological care and organize oncological networking to increase the accessibility and quality of care; and (8) developing effective management strategies for comorbidities in oncological patients with personal treatment plans and collaborations across different health-care professionals and organizations.

In our opinion, preconditions exist to increase value across the oncological populations. This includes strategic planning with multiple strategies simultaneously and the implementation of consistent cancer policies. Cancer policies should be implemented with consistent oversight and a clear development plan and build on previous policies. Central bodies should ensure the consistency by providing follow-through of cancer plans and using funding to ensure implementation.

In addition, we believe it is crucial to improve data availability. To overcome the limitations regarding data accessibility and data sharing, interoperability, and secure sharing of data should be stimulated. Initiatives like standardized electronic health records, national registries, and privacy-preserving data-sharing may all increase data availability.

Article highlights

• Clinical values are not the only ones that matter in the oncological field. A wide range of values exist.

• The concept of value in reimbursement decisions is getting more narrow as more expensive drugs are entering the market. In this narrow concept, there is limited room to incorporate all individual patient values.

• The value debate should shift from incorporating ‘all’ possible individual patient values in reimbursement decisions to creating more value for the entire oncological population as a whole.

• Many different strategies can increase value for the entire oncological population. These include shared decision-making, molecular diagnostics, appropriate use of cancer drugs, supportive care, prevention and screening, monitoring late effect, concentration of care and oncological networking, and management of comorbidities.

• Precondition for implementation of different strategies includes strategic planning, consistent cancer policies, and the facilitation of data availability.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.