Cancer is a major cause of disability and death in Canada. Based on 2010 statistics, 1 in 2 Canadians is expected to develop cancer during their lifetime (1). Financially, it significantly affects patients as well as societies. In 2009, first-year costs for colorectal, lung, breast and prostate cancers combined for about 0.09% of Canada’s $1.5 trillion gross domestic product (2ms1 ). Furthermore, although Canada has relatively good cancer care outcomes, above average survival and average mortality rates compared with other countries part of the OECD (Organization for Economic Co-operation and Development), there is room for improvement (1). For instance, Canada is lacking in terms of access and funding for new cancer drugs. Also, geographical inequalities due to low population density in rural communities significantly affect health outcomes such as life expectancy. Many solutions to these problems can be found amongst other developed countries such as Germany, France and the United Kingdom. Indeed, with the implementation of European healthcare policies, cancer care in Canada can be improved.
The “Mirror, Mirror 2017” study initiated by the Commonwealth fund with the stated purpose of comparing healthcare system performance, ms2 found that out of eleven high income countries, Canada ranked ninth based on factors such as care process, access, administrative efficiency, equity and healthcare outcome (3). Canada’s inadequacy in certain aspects of its healthcare has prompted a comparative review of Canada’s healthcare system with other countries such as Germany, France and the United Kingdom. In order to facilitate the comparison, cancer care will be used to point out Canada’s flaws and to suggest possible solutions inspired from France, Germany and the United Kingdom. The ultimate goal of this review is to improve Canada’s cancer care through policies and education, by increasing access and quality while reducing costs.
Canadian Healthcare System
In Canada, the provinces and territories provide their own universal health insurance programs. The federal government administers funding to the provinces and territories on a per capita basis. Furthermore, services not included in public health coverage, such as medication, dental care, vision and home care are covered by private insurance. (4). Most physicians are paid fee-for-service, are self-employed in private practicesms3 and bill provincial governments directly. While primary care physicians act largely as gatekeepers in clinics, the majority of specialist care is provided in hospitals (4). This review will focus on problems with Canadian healthcare regarding geographical inequalities in the delivery of cancer care, lack of private insurance, poor prescription drug coverage and lack of access to new cancer drugs. It is important to note that one’s experience with cancer care depends greatly on the type of cancer one has, the kind of treatment one is prescribed, one’s age and one’s family income. All of these factors affect the quality of cancer care one receives.
Cancer Statistics and Costs in Canada
Cancer is responsible for significant worldwide morbidity and mortality; indeed, the disease burden of cancer is high. In 2017SA4 , in Canada, close to 200 000 patients were diagnosed with cancer and about 80 000 died from cancer (5). Cancer, the main cause of mortality in Canada, is responsible for about 30% of all deaths (5). In 2010, it was estimated that close to half of Canadians will be diagnosed with cancer during their lifetime (5). Cancer also has a significant financial burden on governments as well as on individuals. In the last decades, mean costs associated with breast cancer more than doubled (from $15 460 in 1997 to $35 977 in 2007) among younger Canadian patients (6). The higher cancer treatment costs were partially due to the increased need for radiotherapySA5 and chemotherapy (6). Other reasons for the increase in costs include the higher use of home care as well as the climbing costs for cancer-related surgeries (6). In 2009, overall costs from first year treatment for colorectal, lung, breast and prostate cancers, rose to roughly $484 million, $453 million, $267 million and $238 million respectively, which amounted to 0.09% of Canada’s $1.5 trillion gross domestic product (2SA6 ).
Geographical Inequalities in Delivery of Cancer Care
Another issue with cancer care in Canada is the geographical inequality in terms of the delivery and cost of cancer care (Figure 1). In 2004, the Canadian Breast Cancer Network found in a federal survey that almost half of respondents lived in a rural area while one-fifth had to travel more than 200km to see their physician (7). Also, the distribution of specialized institutions and professionals is sometimes a challenge to address, particularly in rural and isolated areas (1). Healthcare professionals have reported being concerned about patients who live in rural settings not seeking treatment due to high out-of-pocket costs such as travel (8). The most frequent example of a patient altering their treatment plan due to the cost of travel was a woman SA7 with breast cancer choosing a mastectomy rather than breast-conserving surgery to eliminate the need for radiation treatment and travel (9). Increasing investments in infrastructure of cancer care delivery and providing chemotherapy via satellite clinics have been proposed as possible solutions to this problem (1). SA8
This is also a problem in the United Kingdom and in order to solve it the government has launched a program to help rural communities. This project was called Fish Well and aimed to improve the health of fishermen in the coastal areas of Norfolk (10). Fishermen work long hours at sea, consequently making health choices more difficult and often making it impossible to plan health appointments. This initiative allowed local fishermen to access health services they would otherwise have had trouble benefiting from due to their long unpredictable hours. The Norfolk County Council’s Public Health and Occupational Health departments worked in partnership with the Fishermen’s Mission and the Health Trainer Service to bring together health improvement services using a mobile van on the quayside (10). The services included health checks, risk checks, information about men’s health and an examination of the dental needs of this population (10). Allowing fishermen to stay healthy by making better lifestyle choices enabled the fishermen to remain at work (and therefore financially independent) for longer. This initiative succeeded in offering health services to a rural, isolated communitySA9 .
Private Insurance in Canada
As mentioned previously, public insurance in Canada fails to cover a multitude of medical expenses which are then covered by private insurance. However, not all Canadians have private insurance and this lack greatly increases out-of-pocket expenses. Indeed, Canadians without private insurance are not reimbursed for the cost of drugs or medical devices (11). In 2016, out-of-pocket health spending in Canada amounted to 1.55% SA10 of the gross domestic product compared to only 1.39% in Germany (12). Canadians who are seasonally employed, part-time workers or self-employed are not entitled for employer-sponsored private insurance and hence often lack private insurance (11). In addition, since there are differences in reimbursement policies across provinces, the availability of drug treatment varies from region to region (1).
Prescription Drug Coverage in Canada
Prescription drug coverage is a big problem in Canada. Indeed, except for Canada, every developed country with a universal healthcare system also has universal coverage of prescription drugs (13). The Canadian federal government has decided that pharmaceutical coverage is a provincial responsibility and it offers no financial support for provincial drug plans (14). All provinces rely on a mix of private and public drug plans that work separately from each other and the rest of the healthcare system. Age, profession and health needs often determine to what extent a patient receives access to public drug coverage and this leads to millions of Canadians having very little or often no drug coverage at all (14). Most OECD countries offer universal coverage of prescription drugs to the whole population. In fact, almost all European countries offer public universal prescription drug coverage through one of two ways. Some countries fund their drug coverage program through income tax while others use a social insurance principle and fund it through pay deductions (14). Indeed, in Germany, almost every citizen belongs to one of 160 nonprofit insurance collectives which cover prescription drugs (15). In the United Kingdom, prescription drugs are funded for all citizens and the government has succeeded in lowering costs through better pricing and through a reduction in over-prescribing (16). In France, government coverage is divided into different categories. Drugs that treat serious illnesses are fully covered while drugs that treat non-life-threatening illnesses and have little medical benefit get 15% coverage. Finally, drugs that don’t have enough evidence behind them aren’t covered at all while most drugs get 65% coverage (17).
Additionally, Canadians pay the second-highest drug prices in the world and pay significantly more for pharmaceutical medications than consumers in many other developed countriesSA11 (18). Also, for pharmaceutical companies in Canada, the ratio of research and development to sales has fallen to record lowsSA12 . In fact, in 2015, Canada had a ratio of research to sales of only 4.4%, the lowest recorded since 1988 (18). In 2011, Canadian business expenditure on research and development in pharmaceutical industry as a proportion of GDP was 0.03%, compared to 0.30% in the United Kingdom and 0.15% in France and Germany (19). In other words, France and the United Kingdom have lower drug costs and more financial investments in research. SA13 Moreover, 10% of Canadians have difficulty affording their drugs compared to 6% of Germans, 3% of Dutch, and 2% of British patients (20). In Canada, patients who are prescribed oral cancer medication have to pay out of pocket while those that require chemotherapy or radiation get free treatment. Patients are often faced with tough choices. Take for example Judy Pope who was diagnosed with kidney cancer. Initially, her husband’s company insurance policy paid for the pills she was prescribed but when his company changed insurers, they had to pay more than $3,000 per month (21). Judy stopped taking her cancer drugs because she did not want to bankrupt her family. She died in hospital shortly after (21). Studies have indicated that the underperforming Canadian drug coverage system could be improved by a national Pharmacare program, similar to the ones in European countries (22).
Access to New Cancer Drugs in Canada
Another stark difference between Canada and France is access to new cancer medicines. Cancer survival in Canada is negatively influenced by slow regulatory and reimbursement governmental approvals (23). A new investigation has shown that slow provincial reimbursement and federal regulatory approvals for Jevtana, Tarceva, Avastin, Halaven, and Torisel (five new oncology medications treating advanced solid tumors) could have negatively affected close to 5000 Canadians (23). Had these patients received these oncology drugs, the financial value of this extension in life was approximated to be between $340 and $560 million (23). In France and Germany, specific budgets are allocated to make new cancer medications available faster. In France, expensive new oncology drugs are financed through a central budget (24). The French government voted a few years ago that new expensive treatments should be financially separated from the health budget so that hospitals did not have to choose between a cancer drug which extends life by a few months, and drugs for diabetes or heart disease (24). France has demonstrated that cancer care is of utmost importance by making sure that the budget for new oncology drugs was protected.
OECD Guidelines to Improve Cancer Care
The Organization for Economic Co-operation and Development (OECD) outlines various ways to improve cancer careSA14 . First of all, it recommends to increase the availability of cancer specialists, chemotherapy, diagnostic and therapeutic equipment as they are all critical to improving cancer care (25). While Canada only has 2.5 doctors for every 1000 people, the United Kingdom has 2.8, France has 3.1 and Germany has 4.1 (26). Starting treatment as fast as possible is very important when dealing with cancer, yet referral times for specialists as well as waiting times to start treatment can be long. An increase in doctors allows for faster access to patients. Secondly, with an aging population and the increasing rates of cancer, the OECD recommends that countries not only look at survival rates but that they also attempt to optimize quality of life SA15 for patients (1). Furthermore, monitoring and evaluation are vital. The OECD claims that feedback on provider performance contributes to improving quality of care across providers and helps to reduce practice and outcome variations (27). Canada could undertake systematic reviews of individual provider practices. Finally, comparing quality of care against international comparators and other countries is also essential for continuously improving care (1SA16 ).
The many problems with cancer care outlined above have possible solutions. Although every new solution brings about additional problems and no perfect system exists, Canadian healthcare problems should not be disregarded and should be dealt with. The lack of access to new cancer drugs and the geographical inequalities in terms of delivery of care affect Canadians every day. Potential solutions can be found amongst other developed countries such as Germany, France and the United Kingdom. For example, an increase in the number of doctors up to a number comparable to the one in Germany would cut waiting times and improve access. Universal drug coverage similar to the one in France would ease the financial burden of certain cancer drugs for patients. Finally, projects like the Fish Well initiative provide much needed care to isolated populations through a mobile vanSA17 . Initiatives like this could lessen the health burdens of isolated communities in Canada. It will be important to study the financial feasibility of these ideas and how they can be applied to Canada’s healthcare system. If Canada were to adopt the beneficial healthcare policies of other countries, its healthcare system and quality of cancer care could be improved.