First, the good news about enhanced effectiveness is that cancer death rates are falling from a combination of prevention, earlier detection, and treatment, 1.8 % a year for men and 1.4 % a year for women [2]. The main themes are targeted treatments to a specific pathway or ligand, harnessing of the immune system, and combinations of drugs. Table 28.2 lists some of the major advances of the past 10 years and is a harbinger of things to come as we understand both the mechanism of cancer growth, how it escapes immune regulation by masquerading as “self,” and how cancer growth can be modulated.

The bad news is the cost of cancer care in both the United States and Canada, and for those who have access to state-of-the-art care in Mexico, is escalating. Drugs make up about 10 % of the cancer care budget but are increasing in price. The most recent small molecules or antibodies to cancer cost over $13,000 a month, not including imaging such as PET or MRI scans, and lab tests. The best predictor for the cost of the new drug is the price of the last five drugs that came to market before it, rather than the effectiveness or originality of the new drug [3]. The drug companies that make the new drugs state that the cost of clinical trials is extraordinarily high and that the targeted drugs have a smaller market (for instance, only 1–3 % of lung cancers are anaplastic lymphoma kinase (ALK)-positive for an ALK-targeted drug.). Critics of the high prices point out that the costs of designing new drugs may be substantially less with techniques like X-ray crystallography allowing for easier design that can be used for multiple drugs; the much smaller trials in selected groups of patients with the target; that drug companies are still highly profitable; and that the best predictor of price is not efficacy but the price of the last drug to come to market [4]. With no transparency in the process, this argument will be unresolved for the immediate future. These issues are in all high-income countries, not just the United States and Canada.

There is no good solution to this crisis of high prices, although all parties agree that it needs be fixed [5]. There has been some recent progress in negotiating lower prices by large insurance companies forcing manufacturers to compete when there are alternative drugs, such as the new antivirals for hepatitis C [6]. The successful bidding has decreased the price to that paid in Europe, about one-third less. However, not all situations have competing drugs, especially with novel cancer treatments, and when insurance companies refuse to cover a drug it leads to calls of “rationing” and “death panels” in the United States. In Canada, the coverage of new drugs varies considerably from province to province, but with a mostly one-payer system, there appears to be more buy-in for a communal process. Most drugs approved by the provincial authorities for efficacy have made it belatedly, if at all, to the budget. In the United Kingdom, there have been multiple disapprovals of new drugs based on formal cost-effectiveness, with much public disapproval but not real recourse given a set budget.

Drugs make up only about 10 % of the total cancer budget; the most expensive part of treatment remains hospitalization [7]. This is where palliative care and hospice have become increasingly important as models of concurrent palliative care along with usual oncology care show improved symptoms, better quality of life, equal or longer survival [8], and lower cost in nearly all trials [9]. As shown in Table 28.3, palliative care has multiple opportunities to reduce the cost of care by at least 10 %, thus saving a substantial amount of money for advances in cancer treatment [10]. These include, but are not limited to—in addition to better care—prevented hospitalizations, lower cost per day if hospitalized, shorter length of stay, and reduced readmission rates.

These difficulties are not unique to the United States. Canada’s system has been called “a system in name only” with marked variation in available services [11]. Only half of drug costs are paid by the provinces; the rest by individuals. About 30 % of total health care costs are borne by individuals. There are substantial variations in cancer drug availability even after the drugs have been approved by the federal and provincial governments [12]. The same congestive heart failure patient in different provinces could spend $74–$1332 for $1200 worth of medicines [13]. Canada doubled real-value spending on health care in the last decade but remains tenth of 11 industrialized countries in a respected review by The Commonwealth Fund [14] suggesting that more fundamental reforms in the provision of care will be needed in the future.