Cancer is a major cause of disability and death in Canada. Based on 2010 estimates, 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 administer their own universal health insurance programs. The federal government contributes funding to the provinces and territories on a per capita basis. Furthermore, private insurance, held by about two-thirds of Canadians, covers services excluded from public reimbursement, such as prescription drugs, dental care, vision, home care, and private rooms in hospitals (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. An estimated 206,200 new cases of cancer and 80,800 deaths from cancer will occur in Canada in 2017SA4 (5). Cancer is the leading cause of death in Canada and is responsible for 30% of all deaths (5). Based on 2010 estimates: 1 in 2 Canadians (49% of men and 45% of women) is expected to develop 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). Increases in the costs associated with treatment were partially due to increased use of chemotherapy and radiotherapySA5 (6). Higher use of home care and rising costs for cancer-related surgeries also contributed to this upward trendSA6 (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 (2SA7 ).
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). Indeed, in a national survey undertaken by the Canadian Breast Cancer Network in 2004, 46% of respondents lived in a rural community and 20% had to travel over 200 km to see their doctor (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, since high out-of-pocket costs such as travel are of particular concern to rural residents (8). The most frequently cited example of a patient altering their treatment plan due to the cost of travel was a women SA8 with breast cancer choosing a mastectomy over breast-conserving surgery to eliminate the need for radiation treatment (9). Efforts have been made to address this, such as increasing investments in infrastructure of cancer care delivery and providing chemotherapy via satellite clinics (1). SA9
In the United Kingdom, where this is also a problem, the government 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 services they wouldn’t otherwise have been able to benefit 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 communitySA10 .
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, as the uninsured 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% SA11 of the gross domestic product compared to only 1.39% in Germany (12). Lack of private insurance is a problem for seasonally employed, part-time workers and the self-employed, all of whom do not qualify for employer-sponsored private insurance (11). In addition, due to differences in reimbursement policies, the availability of drug treatment varies across regions (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 taken the stance that pharmaceutical policy is a provincial responsibility and offers no financial assistance for provincial drug plans (14). All provinces rely on a patchwork of private and public drug plans that operate independently of each other and the rest of the healthcare system. Patients’ access to public drug coverage depends on their age, occupation and healthcare needs resulting in a system that leaves millions of Canadians with little or no drug coverage at all (14). Most OECD countries offer universal coverage of prescription drugs to the whole population. Virtually all European countries offer public and universal prescription drug coverage through funding based on taxation (through income tax) or on a social insurance principle (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, all citizens have their prescription drugs paid for and through better pricing and by reducing over-prescribing, the United Kingdom has managed to lower costs (16). In France, government coverage is divided into categories, from 100% for expensive drugs that treat serious illnesses to 15% for drugs that have little medical benefit and treat non-life-threatening illnesses and 0% for those that don’t have enough research behind them (17). Most drugs get 65% coverage (17).
Additionally, Canadians pay the second-highest drug prices in the world and pay significantly more for pharmaceutical drugs than consumers in many other developed countriesSA12 (18). Furthermore, for pharmaceutical companies in Canada, the ratio of research and development to sales has fallen to record lowsSA13 . 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, in countries such as the United Kingdom and France, drug prices are lower and research expenditures are far higher. SA14 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, this means that patients who require radiation or intravenous chemotherapy get treatment for free but those who are prescribed oral cancer drugs may have to pay thousands of dollars.
Patients are often faced with tough choices. Take for example Gary Pope, whose wife Judy was diagnosed with kidney cancer. Initially his company insurance policy paid for the pills she was prescribed but when his company changed insurers, Gary had to pay more than $3,000 per month (21). Not wanting to bankrupt her family, Judy decided to stop taking her cancer medication. She died in hospital about six months later (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. Slow regulatory and reimbursement approvals in Canada are affecting cancer survival (23). A new study has shown that more than 5,000 patients could have been negatively affected by delayed federal regulatory and provincial reimbursement approval for Avastin, Halaven, Jevtana, Tarceva and Torisel (five new oncology drugs approved in Canada between 2003 and 2011 for the treatment of advanced solid tumors) (23). If each of these patients had received the drugs, a monetary value of this extension in life was estimated to be between $339.2 and $559.6 million (23). In France and Germany, specific budgets are allocated to make innovative cancer drugs readily available. In France, costly new cancer drugs are paid for out of 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 do not have to choose between a cancer drug which extends life by a few months, and drugs for diabetes or heart disease (24). By protecting the budget for new cancer drugs France has made a clear statement that cancer care is a priority.
OECD Guidelines to Improve Cancer Care
The Organization for Economic Co-operation and Development (OECD) outlines various ways to improve cancer careSA15 . 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 quickly is critical when dealing with cancer, yet referral times to see a specialist and waiting times to start treatment can be long. More doctors means faster access for patients. Secondly, with an aging population and the increasing rates of cancer, the OECD recommends that countries look beyond survival and seek to optimize quality of life SA16 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 vital to ensure continuously improving care (1SA17 ).
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 vanSA18 . Initiatives like this could lessen the health burdens of isolated communities in Canada. If Canada were to adopt the beneficial healthcare policies of other countries, its healthcare system and quality of cancer care could be improved.