Olivia Pagani Clinical Director Breast Unit and Institute of Oncology of Southern Switzerland

1. Can we reasonably address and overcome cancer care inequalities across Europe? THE WORK OF THE EUROCHIP3 WP7 on BREAST CANCER Olivia Pagani Clinical Director Breast Unit and Institute of Oncology of Southern Switzerland

2. Breast cancer survival in EU(1999-2007) by region and age 5 year mortality Age-specific 5 year mortality EUROCARE 5 Lancet Oncol. 2014;15(1):23-34

3. Some «worrying» evidence Peter F. Health equity & social justice. J Applied Philosophy, 2001. 18 (2): 159-170 Global sales ($M) 2007-2012

4. Are we going this way?

5. EUROCHIP-3 mission Reducing inequalities in cancer incidence and cancer care across Europe by improving cancer information

6. WP7 Rationale Could cost constrains be a significant factor explaining why patients do so much worse in some countries or regions than in others?

7. WP7 Objectives • availability of cost-effectiveness data • possibility to consider cost effective alternatives • role of costs in the cancer health strategy for reducing survival disparities in the EU

8. WP7 Methods (1) • Early Breast cancer (Stage I and II) • Advanced Breast cancer (stage III and IV)

9. WP7 Methods (2) multidisciplinary setting: clinicians epidemiologists health economists

10. WP7 Methods (3) • Screening • Diagnosis • Pathology • Surgery • Medical Oncology • Radiotherapy • Rehabilitation & Supportive care

11. WP7 Methods (4) • The care components were classified in: • minimum requirements for acceptable care • additional tools for improvement of care

12. Breast Health Global Initiative www. portal.bhgi.org Breast 2013;22(5):593-605

13. The WP 7 Discussion Template For each WP7 tool, a discussion template was created covering: Definition Purpose Target Efficacy Caveat

14. The WP 7 Red List

15. Obj1: availability of cost-effectiveness data To reach objective 1, a HTA protocol of literature revision was developed by health economics experts for the revision of available data on the different economic impact linked with the WP7 Red list

16. Obj 2: the possibility of cost effective alternatives To reach objective2, the WP7 discussion template was applied to the proposed alternatives An alternative was defined as a diagnostic or management tool with same outcome to that of a given tool but bearing lower costs

17. Obj3: the role of costs in the cancer health strategy for reducing survival disparities in the EU Comparable information on costs and cost effectiveness across the EU is not sufficiently available in scientific literature to answer this question

18. WP7 FOCUS - early BC

19. WP7 FOCUS – advanced BC

20. Conclusions (1) The creation of a system able to include cost in the evidence evaluation of the different components of cancer care is a EU priority

21. Conclusions (2) More research must be promoted to ensure that cost information is included in the model we use for monitoring delivery of affordable quality and equitable care across the EU

22. Conclusions (3) The “minimal requirement tools for acceptable treatment” constitute an innovative approach to enable public health authorities to identify those core health priorities able to change outcome disparities especially in low income settings, before investing in additional tools

23. WP7 Final Remarks the WP7 model is EFFECTIVE to identify problem areas and expand access especially to minimum requirements of care

24. WP7 multidisciplinary team The Clinical Group : Olivia Pagani, Antonella Richetti, Institute of Oncology of Southern Switzerland, Ospedale Beata Vergine, Mendrisio CH; Carlos A. Garcia-Etienne, Humanitas Cancer Center, Istituto Clinico Humanitas – IRCCS, Milan, Italy; Stefano Ciatto, retired professor, ISPO, Florence, Italy; Christine BARA, Institut National du Cancer, Boulogne Billancourt cedex, France; Valérie MAZEAU-WOYNAR, Institut National du Cancer, Boulogne-Billancourt Cedex, France; Riccardo Masetti, Policlinico Gemelli Universita' Cattolica Roma, Italy; Pietro Folino Gallo, Italian Medecines Agency (AIFA) Roma, Italy; Roberto Agresti, Fondazione IRCCS “Istituto Nazionale Tumori” Milan, Italy. The Epidemiology Group: Andrea Micheli, Milena Sant, Fondazione IRCCS “Istituto Nazionale dei Tumori” Milan, Italy; Riccardo Capocaccia, Silvia Francisci, Italian Institute of Public Health, ISS Roma, Italy; Magdalena Bielska Lasota, Dominik Maslach, National Institute of Public Health and Hygiene, Warsaw, Poland. The HTA group: Luciana Scalone, Paolo Cortesi, CHARTA Foundation, Milan, Italy; Agnese Cangini, Luisa Muscolo, Italian Medecines Agency (AIFA*) Roma, Italy; Bogusława Osińska, Agency for Health Technology Assessment in Poland, Warsaw; Anna Nachtnebel, Ludwig Boltzmann Institut Health Technology Assessment, Wien, Austria; Sabine Vogler and Nina Zimmermann, Pharma Team, Gesundheit Österreich GmbH Wien, Austria; Joan Rovira, Department of Economics, Autonomous University of Barcelona, Barcelona, Spain; Vladimir Stevanovic, Alan Diener, Franco Sassi, OECD, Paris, France; Rafal Halik National Institute of Public Health and Hygiene, Warsaw, Poland. Special thanks to the external referees from SIOP-E, EUSOMA, ESO, the EUROCHIP partners , the EPAAC Consortium and the European School of Oncology and Cancer World Magazine for support throughout.