Background Postpancreatectomy hemorrhage grade C (PPH C) is a dreaded complication after pancreaticoduodenectomy (PD) with high mortality rate. Concurrent risk factors for PPH C have been difficult to recognize. Connection between postoperative pancreatic fistulas (POPF) and PPH C is well known, but POPF is often unknown prior to the PPH. The aim of this retrospective study was to define potential predictive factors for PPH C. Methods Retrospectively, 517 patients who underwent PD between 2003 and 2018 were included in the study. Twenty-three patients with PPH C were identified, and a matched control group of 92 patients was randomly selected. Preoperative data (body mass index, cardiovascular disease, history of abdominal surgery, biliary stent, C-reactive protein (CRP), ASA-score), perioperative data (bleeding, pancreatic anastomosis, operation time), and postoperative data (CRP, drain amylase, POPF, biliary fistula) were analyzed as potential predictors of PPH C. Results High postoperative CRP (median 140 mg/L on day 5 or 6) correlated with the development of PPH C (p <0.05). Postoperative drain amylase levels were not clinically relevant for occurrence of PPH C. Grade C POPF or biliary leak was observed in the majority of the PPH C patients, but the leaking anastomoses were not detected before the bleeding started. Discussion High postoperative CRP levels are related to an increased risk of PPH C.

Background and Aims: Pancreatic cancer is the seventh leading cause of cancer-related deaths worldwide. Checkpoint immunotherapy has not yet shown encouraging results in pancreatic cancer possibly because of a poor immunogenicity and/or an immune suppressive microenvironment. The aim of this study was to develop patient-derived xenograft (PDX) models, compare their genetics to the original biopsies, and assess if autologous tumor-infiltrating lymphocytes (TILs) would have antitumoral activity in pancreatic cancer. Methods: We subcutaneously transplanted tumors from 29 patients into NOG mice to generate PDX models. We established TIL cultures and injected them into PDX mice. We analyzed histology and genetics of biopsies and PDX tumors. Results: Tumor growths were confirmed in 11 of 29 transplantations. The PDX tumors histologically resembled their original biopsies, but because stromal cells in the PDX model tumors were from mouse, their gene expression differed from the original biopsies. Immune checkpoint ligands other than programmed death ligand-1 (PD-L1) were expressed in pancreatic cancers, but PD-L1 was rarely expressed. When it was expressed, it correlated with tumor take in PDX models. One of the 3 tumors that expressed PD-L1 was an adenosquamous cancer, and another had a mismatch repair deficiency. TILs were expanded from 6 tumors and were injected into NOG or human interleukin-2 transgenic-NOG mice carrying PDX tumors. Regression of tumors could be verified in human interleukin-2 transgenic-NOG mice in 3 of the 6 PDX models treated with autologous TILs, including the adenosquamous PDX model. Conclusion: PDX models of pancreatic cancer can be used to learn more about tumor characteristics and biomarkers and to evaluate responses to adoptive cell therapy and combination therapies. The major benefit of the model is that modifications of T cells can be tested in an autologous humanized mouse model to gain preclinical data to support the initiation of a clinical trial.

Background: Improvements in surgery, imaging, adjuvant treatment, and management of metastatic disease have led to modification of previous approaches regarding the risk of recurrence and prognosis in colorectal cancer. The aims of this study were to map patterns, risk factors, and the possibility of curative treatment of recurrent colorectal cancer in a multimodal setting. Methods: This was a cohort study based on the COLOFOL trial population of patients who underwent radical resection of stage II or III colorectal cancer. The medical files of all patients with recurrence within 5 years after resection of the primary tumour were scrutinized. Follow-up time was 5 years after the first recurrence. Primary endpoints were cumulative incidence, site, timing, and risk factors for recurrence, and rate of potentially curative treatment. A secondary endpoint was survival. Results: Of 2442 patients, 471 developed recurrences. The 5-year cumulative incidence was 21.4 (95 per cent c.i. 19.5 to 23.3) per cent. The median time to detection was 1.1 years after surgery and 87.3 per cent were detected within 3 years. Some 98.2 per cent of patients who had potentially curative treatment were assessed by a multidisciplinary tumour board. A total of 47.8 per cent of the recurrences were potentially curatively treated. The 5-year overall survival rate after detection was 32.0 (95 per cent c.i. 27.9 to 36.3) per cent for all patients with recurrence, 58.6 (51.9 to 64.7) per cent in the potentially curatively treated group and 7.7 (4.8 to 11.5) per cent in the palliatively treated group. Conclusion: Time to recurrence was similar to previous results, whereas the 21.4 per cent risk of recurrence was somewhat lower. The high proportion of patients who received potentially curative treatment, linked to a 5-year overall survival rate of 58.6 per cent, indicates that it is possible to achieve good results in recurrent colorectal cancer following multidisciplinary assessment.

Background: Circulating Tumor Cells (CTC) are prognostic in breast- colon- and prostate cancer [1–3] and may represent promising biomarkers of pancreatic carcinoma as well, although standardized methods are not yet defined.[4] The aim of the study was to demonstrate a statistically significant porto-arterial difference of CTC during periampullary cancer resections. Methods: A commercially available instrument (IsofluxR) was used to quantify blood content of CTC in 17 patients with periampullary cancer. Portal and arterial blood were simultaneously collected intra-operatively after surgical dissection close to division of the pancreas for tumor removal. Quantitative CTC analyses were performed according to standardized protocols for immune-magnetic enrichment. Flow cytometry was used for qualitative evaluations of CTC markers. Results: There was a statistically significant difference in numbers of CTC collected in portal blood [58±43 cells per 100mL (±SD)] versus arterial blood [24±22 cells per 100 mL P<0.0025]. A fractional uptake at 40% across liver and lung compartments of assumed CTC corresponded to the appearance of around 400 tumor cells per minute during pancreatic resections based on estimates of hepatic blood flow, tumor cell mass and proliferation activity. Conclusion: A significant uptake across liver and lung compartments of potentially CTC from pancreatic carcinoma may be used to capture, define and characterize cell clones with high metastatic potential in liver and lung tissues during surgical resections. References [1] Giuliano M, Giordano A, Jackson S, De Giorgi U, Mego M, Cohen EN, et al., (2014), Circulating tumor cells as early predictors of metastatic spread in breast cancer patients with limited metastatic dissemination., Breast cancer research. [2] Iinuma H, Watanabe T, Mimori K, Adachi M, Hayashi N, Tamura J, et al. , (2011), Clinical significance of circulating tumor cells, including cancer stem-like cells, in peripheral blood for recurrence and prognosis in patients with Dukes' stage B and C colorectal cancer. , Journal of clinical oncology. [3] Thalgott M, Heck MM, Eiber M, Souvatzoglou M, Hatzichristodoulou G, Kehl V, et al. , (2015), Circulating tumor cells versus objective response assessment predicting survival in metastatic castration-resistant prostate cancer patients treated with docetaxel chemotherapy., Journal of cancer research and clinical oncology. [4] Tjensvoll K, Nordgard O, Smaaland R., (2014), Circulating tumor cells in pancreatic cancer patients: methods of detection and clinical implications. , International journal of cancer.

BACKGROUND:Resection of the primary tumour is a prerequisite for cure in patients with colorectal cancer, but hepatic metastasectomy has been used increasingly with curative intent. This national registry study examined prognostic factors for radically treated primary tumours, including the subgroup of patients undergoing liver metastasectomy.METHODS:Patients who had radical resection of primary colorectal cancer in 2009-2013 were identified in a population-based Swedish colorectal registry and cross-checked in a registry of liver tumours. Data on primary tumour and patient characteristics were extracted and prognostic impact was analysed.RESULTS:Radical resection was registered in 20 853 patients; in 38·7 per cent of those registered with liver metastases, surgery or ablation was performed. The age-standardized relative 5-year survival rate after radical resection of colorectal cancer was 80·9 (95 per cent c.i. 80·2 to 81·6) per cent, and the rate after surgery for colorectal liver metastases was 49·6 (46·0 to 53·2) per cent. Multivariable analysis identified lymph node status, multiple sites of metastasis, high ASA grade and postoperative complications after resection of the primary tumour as strong risk factors after primary resection and following subsequent liver resection or ablation. Age, sex and primary tumour location had no prognostic impact on mortality after liver resection.CONCLUSION:Lymph node status and complications have a negative impact on outcome after both primary resection and liver surgery. Older age and female sex were underrepresented in the liver surgical cohort, but these factors did not influence prognosis significantly.

Introduction: Patients with limited hepatocellular carcinoma (HCC) and well-preserved liver function can be treated by liver transplantation, resection or ablation. Transplantation offers good long-term results, but with a relatively high post-operative morbidity and long-term complications. Liver resection is associated with a high risk of recurrent cancer. Liver ablation has increased lately, both as a single curative option and while waiting for transplantation, as complication rates are favorable. Our objectives were to compare outcome after liver transplantation, resection or ablation respectively, in relation to tumor stage, liver function and comorbidities. Methods: Prospectively collected data was retrieved from national Swedish Quality Registry (SweLiv) for HCC-patients, treated 2008-2016 in Sweden. Overall survival and cumulative incidence of tumor recurrences were analyzed for each treatment group. Preliminary results: During 2008 - 2016, 3590 patients were diagnosed with HCC; 31% by surveillance, while 11% were incidental radiologic findings. Curatively aiming treatments were given in 1253 patients (35%); transplantation in 273, resection in 544 and ablation in 436 patients. Median time from diagnosis to treatment was 223, 83 and 107 days respectively. Five year overall survival was 52% for patients who had resection, 76% for transplantation and 35% for ablation. After 2 years, the probabilities for recurrence and for death without recurrence were 9% and 5% respectively after transplantation, 36% and 12% after resection and 44 and 14 % respectively after ablation. Conclusion: Recurrences and deaths without recurrence were more common after resection/ablation than after liver transplantation. Adjusted subgroup analyses will be done.

There are several suggestions that centralization of care improves outcome for rare cancers, particularly when optimal treatment requires complex surgery or high-technology radiotherapy equipment. Diagnosis and treatment in reference centers are expected to be more accurate because they benefit from large numbers of cases discussed in a multidisciplinary tumor board with a well-run pathway. However, centralization is sometimes moderately perceived by oncologists as a solution to be endorsed for rare cancer patients; disadvantages of centralization are the need for patients to move and the risk of a longer waiting list, with discomfort and possible negative effects on outcome. It is difficult to find single experts on rare cancers: all the more it will be difficult to find a multidisciplinary panel of experts, and the role of the surgeon is to be a functional part of it. On the other side, from a surgical point of view, the quality of the initial management of many rare cancers directly impacts the final outcome; surgery of rare cancers may not necessarily be more demanding than the average from a technical point of view, but the lack of cultural knowledge about the disease can well lead to inappropriateness even in the lack of major technical challenges. Care for rare cancer patients must be organized in pathways that cover the patient's journey from their point of view rather than that of the healthcare system, and pathways must follow the best evidence on diagnosis, treatment and follow-up.

BACKGROUND:Both patient survival and the proportion of patients diagnosed with thin cutaneous malignant melanoma (CMM) have been steadily rising in Sweden as in most Western countries, although the rate of improvement in survival appears to have declined in Sweden at the end of the last millennium.OBJECTIVES:To analyse the most recent trends in the distribution of tumour thickness (T category) as well as CMM-specific survival in Swedish patients diagnosed during 1997-2011.METHODS:This nationwide population-based study included 30,590 patients registered in the Swedish Melanoma Register (SMR) and diagnosed with a first primary invasive CMM during 1997-2011. The patients were followed through 2012 in the national Cause of Death Register.RESULTS:Logistic and Cox regression analyses adjusting for age at diagnosis, tumour site and healthcare region were carried out. The odds ratio for being diagnosed with thicker tumours was significantly reduced (P < 0·001) and the CMM-specific survival significantly improved in men diagnosed during 2007-2011 compared with men diagnosed during 1997-2001 (hazard ratio = 0·81; 95% confidence interval 0·72-0·91; P < 0·001), while the corresponding differences for women were not significant. Women were diagnosed with significantly thicker tumours during 2002-2006 and a tendency towards decreased survival was observed compared with those diagnosed earlier (during 1997-2001) and later (during 2007-2011).CONCLUSIONS:In Sweden, the CMMs of men are detected earlier over time and this seems to be followed by an improved CMM-specific survival for men. Women are still diagnosed with considerably thinner tumours and they experience a better survival than men.

Background: A worse outcome has been reported for cutaneous malignant melanoma (CMM) patients with low socioeconomic status. We have investigated the association between level of education, clinical stage at diagnosis (stage at diagnosis) and CMM-specific survival in Sweden.Methods: We identified 27,235 patients from the Swedish Melanoma Register diagnosed with a primary invasive CMM between 1990 and 2007 and linked data to nationwide, population-based, health and census registers with a follow-up to 2010.Results: The odds ratio (OR) of higher disease stage at diagnosis was significantly increased in lower education groups (OR stage II versus I = 1.6; 95% confidence interval (CI) = 1.5-1.7. OR stage III-IV versus I = 2.3; 95% CI = 1.8-2.9). The risk of dying of CMM, was significantly increased in patients with low (hazard ratio (HR) low versus high = 2.02; 95% CI = 1.80-2.26; p < 0.0001) and intermediate (HR intermediate versus high = 1.35; 95% CI = 1.20-1.51; p < 0.0001) level of education. After adjustment for age, gender, stage at diagnosis and other known prognostic factors, the HRs remained significant for low versus high (HR = 1.13; 95% CI = 1.01-1.27; p = 0.04) but not for intermediate versus high (HR = 1.11; 95% CI = 0.99-1.24; p = 0.08) education. The HR associated with low level of education was significantly higher among female patients, patients <55 years, patients with truncal tumours and during the first 5 years after diagnosis.Conclusion: Lower level of education is associated with reduced CMM-specific survival, which may at least partially be attributed to a more advanced stage at diagnosis. These results emphasise the need for improved early detection strategies. (C) 2013 Elsevier Ltd. All rights reserved.

The first multidisciplinary consensus conference on colon and rectal cancer was held in December 2012, achieving a majority of consensus for diagnostic and treatment decisions using the Delphi Method. This article will give a critical appraisal of the topics discussed during the meeting and in the consensus document by well-known leaders in surgery that were involved in this multidisciplinary consensus process. Scientific evidence, experience and opinions are collected to support multidisciplinary teams (MDT) with arguments for medical decision-making in diagnosis, staging and treatment strategies for patients with colon or rectal cancer. Surgery is the cornerstone of curative treatment for colon and rectal cancer. Standardizing treatment is an effective instrument to improve outcome of multidisciplinary cancer care for patients with colon and rectal cancer. In this article, a review of the following focuses; Perioperative care, age and colorectal surgery, obstructive colorectal cancer, stenting, surgical anatomical considerations, total mesorectal excision (TME) surgery and training, surgical considerations for locally advanced rectal cancer (LARC) and local recurrent rectal cancer (LRRC), surgery in stage IV colorectal cancer, definitions of quality of surgery, transanal endoscopic microsurgery (TEM), laparoscopic colon and rectal surgery, preoperative radiotherapy and chemoradiotherapy, and how about functional outcome after surgery?

You are a young doctor in the career to become a surgical oncologist. Does it make any difference where you choose to work and does the leadership of the department play any role? Surgical oncology is a speciality where not only surgical skill but also knowledge in basic science, multimodality treatments and communication is of importance. You shall look for a department and a team where senior surgeons are mentors, have large experience but also are eager to be up to date with diagnostics and treatments.

Recently an analyses of research and development in global cancer surgery (Purushotham et al, Ann Surg 2012) showed that surgical oncology (SO) represents only 9% of all cancer research. Clinical trials and studies represents only 6% of published SO papers but six European countries are the most productive with over 10% and in the US, as a comparison, only 5% of published SO papers are clinical trials and studies.

Background: About 50% of patients with primary colorectal cancer (CRC) will develop liver metastases (CLM). Currently, carcinoembryonic antigen (CEA) is the most common tumour marker for CRC and CLM. However, the sensitivity and specificity of this marker is not optimal, as almost 50% of patients have tumours that do not produce CEA. Therefore there is a need for better markers for CRC and CLM.Methods: The circulating levels of type IV collagen were measured in patients with CLM, primary CRC and in healthy controls. The expression pattern of type IV collagen was studied by immunofluorescence in CLM and normal liver tissue. The metastatic volume of CLM in the liver was estimated from CT.Results: In CLM tissue type IV collagen is highly expressed in the areas of desmoplasia. Patients with primary CRC (Dukes' A-C) did not show any increase in circulating type IV collagen compared to healthy controls. However, patients with CLM have significantly elevated levels of circulating type IV collagen when compared to patients with primary CRC and healthy controls. The levels of type IV collagen decreased during chemotherapy and increased at the time of disease progression. The circulating levels of type IV collagen seem to reflect the tumour burden in the liver.Conclusions: Type IV collagen has the potential to be used as tumour associated biomarker for CLM. These results indicate the importance of interaction between cancer cells and the stroma in the tumour microenvironment. (C) 2011 Elsevier Ltd. All rights reserved.

The last two decades have seen steady improvements in the quality of cancer care. We have embraced multidisciplinary team working, site specialised by focussing expertise on specific cancer subtypes, increased the power, reliability and quality of the clinical trials which underpin our evidence base, and taken this forward into the production of practical management guidelines. The EuroCare studies, published in this Journal [1.Berrino F. The EUROCARE Study: strengths, limitations and perspectives of population-based, comparative survival studies.Ann Oncol. 2003; 14: v9-v13Abstract Full Text PDF PubMed Scopus (57) Google Scholar], have shown a trend of increasing survival, which has been attributed to earlier detection and better treatment. There is wide variation in outcomes when we compare international mortality figures but no clear explanation to account for this disparity, although there have been speculative claims correlating survival with access to new drugs and radiotherapy equipment, or the number of oncologists, or the overall cancer spend [2.Wilking N. Jönsson B. A pan-European comparison regarding patient access to cancer drugs.Ann Oncol. 2007; 18: 1-75Google Scholar]. It has been estimated that if we could improve UK’s cancer survival figures to those of European leaders, say Sweden, thousands of lives would be saved every year—quite a prize for any health economy. There is no doubt that the challenges facing the cancer community reflect a subset of the major problems that afflict general Health Services in all of Europe’s nation states:-Unwarranted variation in quality and patient experience-Patient harm even when quality is high-Waste, namely the consumption of resources that do not add value for patients-Inequities and inequalities in care-Inadequate focus on prevention Furthermore, every major European cancer service has to face the additional critical challenges of rising demand and increasing need, which must be met within significant financial constraints. It is clear that these problems cannot be solved solely by further scientific advances or by spending more and more money, even if that were an option. We estimate that the total cancer spend across Europe’s population of ∼850 million citizens is of the order of 75 billion Euros. These problems cannot be solved by reorganising the bureaucracy of health care, which usually achieves superficial change rather than transformation. We believe that these challenges can be solved by intelligent and committed clinical leadership which takes account not only of the individual patient whom we review in the clinic but also of the wider population of patients whom we serve within our community. What is needed is revolution, not reorganisation, in the way that people who manage health services think, make decisions and act. In UK, the current Health Reform Bill has two dominant philosophical themes, embracing clinical outcomes as a truer means of assessing the quality of care delivered by our National Health Service (NHS), and an information revolution that promises to put these clinical data into the public domain, not just for professionals, but in a way that empowers patients. Provision of locally, nationally and internationally benchmarked clinical information will allow us to compare the efficacy of local care pathways and whether they meet our needs. For example, if you moved to a new area and had a family member living with cancer, you would be able to select the general practise/hospital that publishes and offers the best outcomes for their particular condition, leading to increasing competition between health care providers in what has been an enormous State-run monopoly. Furthermore, and perhaps more importantly, peer pressure and professional pride will mandate that cancer clinicians respond to benchmarked data to improve performance relative to their peers if they have been shown, publicly, to deliver suboptimal care [3.Liberating the NHS: Legislative Framework and Next Steps. UK Dept of Health, 2011Google Scholar]. Providing information to citizens about the clinical outcomes that return most health gain, in an accessible format, will create a health atlas covering the major diseases—think of an ordinance survey map, contoured by health rather than height above sea level! If we overlay this atlas with Programme Budgeting information, then we have a tool, which will prove integral to patients, purchasers and commissioners of cancer care to ensure cost-effective outcomes. The Swedish Health Service has provided a strong lead in this field. The Swedish association of local authorities and regions and the National board of health and welfare publish an annual report called Quality and Efficiency in Swedish Health Care—Regional Comparisons [4.Quality and Efficiency in Swedish Health Care—Regional ComparisonsSwedish Association of Local Authorities and Regions ISBN 978-91-7164-320-9, Swedish National Board of Health and Welfare Artnr. 2008-131-3Google Scholar]. The purpose is to give the public an insight into health care and to compare health care quality and efficiency in every Swedish County Council by using national performance indicators. Indicators are added every year and the 2010 report contains 134 indicators of medical outcomes, but also patient experience and efficient use of resources. For some indicators, comparisons are also done over time and at hospital or department level. Results are assessed for men and women to disclose possible gender inequalities. The report has successfully managed to stimulate the public debate on health care issues and it also forces local efforts to improve their services (Figure 1, Figure 2, Figure 3).Figure 2Rectal cancer—reoperation within 30 days. 2001–2005. Percent. Source: the Swedish rectal cancer registry from Quality and Efficiency in Swedish healthcare—regional comparisons, 2007.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Proportion of patients with high or very high rating of visit to hospitals (planned visits), 2006. Percent. Source: Population and patient survey, SALAR from Quality and Efficiency in Swedish healthcare—regional comparisons, 2007.View Large Image Figure ViewerDownload Hi-res image Download (PPT) There are several factors that can lead to wide variation in clinical outcomes; heterogeneity in the biology of disease, case mix, co-morbidities, deprivation, host genetics, etc. all of which will continue to be the focus of further research and of increasing engagement with public health specialists; unwarranted variation, however, depends on disparities in clinical knowledge, allocation of resources, organisational culture and access to appropriate care (quality of multidisciplinary teams, availability of latest drugs and equipment, etc.). Making the clinical outcome data public will allow patients and their families to monitor improvements in their own health community or choose alternative health care providers. Clearly, priority must be given to the selection of those health indicators, which will return the greatest length and quality of life and where that evidence is weak, generate the research to confirm or refute their worth. Hard outcomes like recurrence and survival rates and 30-day mortality rates could be combined with patient-reported outcome measures to ensure that patients could describe their sense of the service delivered—Were they given adequate information? Were they treated with dignity and respect? Were the hospital wards and clinics clean? etc. See “Iwantgreatcare.com” for an excellent example of how this might be done and how we might follow the Swedish lead. Part of the challenge will be explaining the pattern of these clinical outcome measurements to our patients and their families. This means that we need to explain the concept of an average and its distribution and why there will always be an element of random variation in clinical measurements that depend on factors that we cannot easily manage, as mentioned previously. The analogy might be height, in which there is obviously a range from short to tall, and a national average. One can imagine a political pledge, “no-one deserves below average healthcare!,” perhaps not grasping the concept of a distributed mean. The challenge we face is to shift from a broad flat curve (A) to a taller narrower distribution (B), with better average outcomes, reduced unwarranted variation within a value-driven health system. This is at the heart of the quality revolution, which we need to promote across Europe, and although we cannot eradicate all variation in health outcomes, just as we cannot all be 2 m tall, we believe that our philosophy, coupled to the necessary structural reforms, will deliver a European model of cancer care that leads the world and is affordable. There is invariably a call from the European cancer community for more and more resources to be made available. Of course, when we look to the east we see an increasing disease burden and inadequate infrastructure, which requires thoughtful investment to provide the most cost-effective care. However, we believe that substantial savings might be made in those relatively wealthier nations to reduce waste by identifying those areas of expenditure or use of resources, which do not add recognisable value. A conservative estimate of the cancer spend in Europe’s wealthier nations is ∼1.5 billion Euros per 10 million of her population. UK’s NHS has recently published an Atlas of Variation of expenditure and resource utilisation in each of its districts [5.NHS Atlas of Variation UK Dept of Health, UK Dept of Health 2010Google Scholar]. Inpatient stays (as measured by the number of bed-days) are the single largest component for cancer expenditure, accounting for almost half of the cancer budget. There is a twofold variation in the number of cancer bed-days per 1000 of the population. When the 5 districts with the highest and lowest rates were removed (from a total of 165 districts), the variation ranges from 40 to 65 bed-days per population. Similarly, there is a greater than twofold variation in cancer inpatient expenditure, ranging from ∼20 000 to 44 000 Euros. Significant reduction in elective bed utilisation and therefore rational cost savings could be better managed with increased use of day care enhanced surgical recovery programmes, developing discharge protocols and improved uptake of ambulatory care. Another example of savings could come from the 250 million Euros, which are estimated to be spent each year on hospital-based follow-up of cancer patients in UK. The evidence base supporting the value of follow-up is weak [6.Scholefield J.H. Steele R. Value of follow-up in the management of recurrent colorectal cancer.Eur J Surg Oncol. 1991; 17: 530-535PubMed Google Scholar] and there are more modern means of loosely monitoring the patient through telemedicine and so on. with a rapid referral route if the patient noted a particular cluster of symptoms and signs to which they had been alerted. Spiralling drug costs is another area of immediately identifiable savings if a transparent, rational and evidence-led approach, such as is practiced by The National Institute for Clinical Excellence (NICE) (www.nice.org.uk), is taken. Without dipping into the controversy as to how drugs are priced and the relative inefficiencies of the pharma industry, NICE has established a robust and scalable methodology to evaluate the cost-effectiveness of new anticancer drugs, which could be applied across the spectrum of rich and poor nations—it merely depends on where the citizens of any health community, in concert with their government, set the value on the relative return offered by any therapeutic intervention and how much they are willing to pay in the face of competition from other elements of the health service, e.g. hip replacements. Cost-effective care does not mean poor care, quite the opposite as it implies that any new health technologies will be contextualised within a wider framework of societal benefits. For example, there are trials comparing different dose schedules for chemotherapy and radiotherapy, which demonstrate that fewer radiotherapy fractions can be used for treating cerebral metastases with the same clinical outcomes and improved quality of life [7.Priestman T.J. Dunn J. Brada M. et al.Final results of the Royal College of Radiologists trial comparing two different radiotherapy schedules in the treatment of cerebral metastases.Clin Oncol. 1996; 8: 308-315Abstract Full Text PDF PubMed Scopus (145) Google Scholar]. The results of such research, if widely implemented, could save tens of millions of Euros per annum across Europe. There is no doubt that further research should be carried out to explore the growing field of personalised medicine through which biomarkers are used to select patients who are most likely to benefit from a specific therapeutic agent. This compartmentalisation of patient populations means that we treat fewer patients who are unlikely to respond and therefore suffer needless toxicity and focus scarce resources on those patients most likely to enjoy a survival advantage [8.Walther A. Johnstone E. Swanton C. et al.Genetic prognostic and predictive markers in colorectal cancer.Nat Rev Cancer. 2009; 9: 489-499Crossref PubMed Scopus (527) Google Scholar]. If a population view is taken, it is very clear that those who pay for cancer care face a number of significant challenges, notably:•Increasing need—our European population is an ageing one and cancer is, predominantly, a disease of the elderly.•Increasing demand—given the extraordinary investment in cancer research from governments, charities, academia and industry, there is an ever growing exaggeration and hyperbole, fuelled by elements of the media, as each modest advance made is hailed as a ‘breakthrough’, further increasing demand for marginally effective treatments or unnecessary scans or ever more aggressive surgery.•Carbon constraints; carbon will become as important as finance in the next 20 years and the person wishing to build a linear accelerator will not only have to raise the money but the carbon credits.•Demand from citizens for openness and transparency (empowered by the Internet).•Financial constraints imposed by the global recession; economists predict that significant growth is unlikely in any major European Health Service in the next decade. The solutions provided by the last 20 years, namely better management, more research and better education all need to continue, perhaps with a sharper focus on cost–utility. It is very unlikely that increased funding, even if it were available, would be sufficient to solve these problems. What is needed is a new approach that embraces the following elements:•Move from the doctor as focus to the patient as focus•Move from individual institutions to networks•Move from being driven by finance to being driven by knowledge•Move to being judged on clinical and patient outcomes rather than process driven targets•Move to trial recruitment being the norm rather than the exception•Move towards prevention and early detection and regard presentation with advanced disease as a systems failure•Move towards a transparent system of evaluating the cost-effectiveness of new diagnostic and therapeutic interventions and away from marketing•Move to engage clinical teams to redesign pathways of cancer care with a view to eliminating inefficiencies•Engage with patients to explain that efficient or value-added care is not the same as poor care Those who pay for or manage health care need a new agenda. Those who manage cancer care should be urged to engage more fully with the clinical community and rely not only on the management skills of the 21st century but also on:•Engaging patients as co-producers•Using the potential of the Internet to maximum effect•Managing knowledge as carefully as they manage a radio of activity or money, knowledge from research, called evidence, knowledge from data analysis, called information, and knowledge from experience.•Developing clinical systems, networks and pathways.•Working explicitly to change the culture from one that is focused solely on quality to one that embraces value, with value being the relationship between outcome and expenditure. We believe that the European community must embrace a value-oriented revolution in the delivery of cancer care, involving citizens, patients and health care workers so that there is a consistent and rational approach taken to communicating its necessity and benefits. Innovative policy initiatives can be developed and existing knowledge can be applied, but Governments need to be prepared to add value as the key dimension to any future cancer planning initiatives, regardless of the relative wealth of the host nation. This must be led by the medical professions involved in multidisciplinary cancer treatment as the public would be otherwise deeply suspicious that the Government was merely interested in cost containment. One possible way to establish such a framework might be that if very effective new investigative or therapeutic modalities became available through research, then the funding necessary to introduce these into the clinic should have to come from disinvesting in areas which do not add value. This approach needs to be applied across the spectrum of any cancer plan and encompass awareness raising, prevention, screening and early detection, treatment and palliative care. In summary, we believe that value can be introduced into the cancer policy lexicon without detracting from quality and that the management tools, evidence and methodology are available to effect this transformation throughout Europe. To this end, we propose the following plan:-Support national governments in a drive to publish cancer outcome data, which is accessible to patients and professionals.-Support national governments that wish to publish the cost of delivering cancer care in individual health authorities or districts.-Establish a high-level clinical working group to explore the concept of value-driven investment in cancer care and develop a robust methodology to deliver value that can be used by funders of care, cancer centres and clinicians.-Communicate to citizens of Europe that value-driven cancer care is not poor care. M. Gray and N. Bacon are directors of the company, iWantGreatCare. The remaining authors declare no conflicts of interest.