Country context

Taiwan (Republic of China), an island in the West Pacific, has a high-income economy with a single-payer National Health Insurance (NHI) system that is universal and mandatory. It is widely regarded as comprehensive and equitable, with a public satisfaction rating of over 90 percent. However, NHI’s fiscal sustainability is under question as Taiwan transitions into a “super-aged” society by 2025—at which point 20 percent of the population will be at least 65 years old—and the incidence of non-communicable diseases (NCDs) increases. Cancer was the leading cause of death in 2022, and lung cancer, specifically, was the top cause of cancer death, with a mortality rate of 222.7 per 100,000 population as of 2020. Lung cancer was the second most common cancer among men and women in Taiwan in 2020, with incidence rates of 44.7 per 100,000 men and 34.6 per 100,000 women. Smoking remains a primary cancer risk factor, although smoking rates among adults decreased from 20.0 percent in 2009 to 13.1 percent in 2020. As with other countries in the region, men tend to smoke at higher rates—23.1 percent—compared to women—2.9 percent—as of 2020. In the past few years, there has been an increasing trend of e-cigarette use among youth and younger adults, which over time could add to the risk of lung diseases among this demographic.

In recent decades, Taiwan’s lung cancer control has reaped measurable successes, with five-year lung cancer survival rates improving from 22.1 percent survival between 2006 and 2011 up to 54.9 percent between 2015 and 2020. These improved survival rates can be attributed to early intervention efforts and greater public awareness of symptoms, which have led to the earlier detection of lung cancer cases. Nevertheless, a 2023 Nature study showed that the incidence rates for lung adenocarcinoma, a particular type of lung cancer, in Taiwan increased from 1997 to 2017, including among nonsmokers. The upward trend in incidence may result from an increase in lung cancer screening among nonsmokers, exposure to outdoor and indoor air pollution, and contact with soil contaminated by heavy metals such as arsenic, copper, nickel, and zinc.

Based on data from 2007 to 2017, lung cancer’s cost per patient in Taiwan was estimated to be USD 42,481 in the first three years after diagnosis. Around 55 percent is attributed to costs associated with productivity losses and premature death, with medical expenses borne by both the NHI and patients accounting for the remaining costs. NHI has been looking at ways to ease the burden of increasing cancer treatment costs, with plans to introduce a co-payment scheme for expensive cancer drugs in addition to other strategies.

Assessing policies and programs

The primary legislation addressing Taiwan’s cancer burden is the Cancer Control Act, first introduced in 2003, and amended in the intervening years, most recently in 2023. The Act covers all cancers and seeks to standardize an integrated nationwide approach to cancer treatment and mitigation. The plan takes a whole-of-society approach, encompassing all stages of the patient journey, including educational and preventive measures; cost-effective screening programs; patient-centered care; high-quality hospice and palliative care services; research and development of new drugs, diagnostics, and treatments; the training of medical personnel; and addressing data gaps through the maintenance of regional and national databanks. A Cancer Control Policy Committee—including representatives from government, the public and private health sectors, and academia—evaluates performance and budget allocation and suggests updates to the policies and programs guided by the Act.

Since the Act took effect, there have been four National Cancer Control Programs (NCCPs) seeking to improve patients’ access and advance effective and innovative measures. Notable short-term objectives in the 2019–2023 Program include developing precision and “smart” medicine for cancer and AI technologies assisting in cancer screening interpretation. Aligned with these objectives, Taiwan has identified the precision health industry as one of the six strategic industry priorities in its industrial development strategy. As of February 2024, the NHI plans to expand its coverage to include next-generation sequencing (NGS) tests for cancer patients at initial diagnosis or if secondary or tertiary treatments fail. NGS testing is applicable for 19 types of cancer, including lung cancer, with a projected budget of TWD 1 billion (USD 30.7 million). NHI currently provides coverage for single-gene tests targeting mutations such as epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) in lung cancer patients. Moreover, NHI supports 26 targeted therapy options that are designed to treat 10 types of cancer. As of mid-2024, the Health Ministry is set to create a cancer drug fund amounting to TWD 6 billion (USD 185 million) to expand patients’ access to innovative drug treatments, although lawmakers have raised concerns about the availability of resources for the fund.

Outside of the current NCCP, Taiwan does not have a specific lung cancer control program, although it has implemented policies targeting lung cancer. Specifically, Taiwan introduced a low-dose computed tomography (LDCT) screening program for high-risk individuals in 2022, becoming the first government to offer screening for individuals with a family history of lung cancer and for heavy smokers. The decision to offer the screening program was informed by the results of clinical trials in Taiwan, particularly the Taiwan Lung Cancer Screening for Never-Smoker Trial (TALENT), as well as a review of global empirical evidence. In addition, the Tobacco Hazards Prevention Act, enacted in 1997, was amended in 2023, banning the manufacture and use of e-cigarettes and increasing regulation of heated tobacco products. It has also increased the legal smoking age from 18 to 20 years old.

In addition to behavioral risks, environmental risk factors are associated with the development of lung cancer, with nearly half of the global lung cancer cases among nonsmokers linked to air pollution. Taiwan recorded an annual average PM2.5 air concentration of 13.8 µg/m³ (micrograms per cubic meter) in 2023, which is three times the WHO’s recommended air pollution limit. In accordance with the Air Pollution Control Action Plan 2024–2027, the government is seeking to curb air pollution and reduce environmental hazards that can exacerbate lung cancer risk, aiming to reduce annual PM2.5 concentration to under 13 µg/m³ nationally and to 15 µg/m³ for central and southern Taiwan. Moreover, the regional disparity of air quality has been a cause of concern for the Taiwanese people, particularly those living in Southern Taiwan. A 2019 study showed notably higher incidence of lung adenocarcinoma cases in Southern Taiwan than in Northern Taiwan, which could be linked to higher recorded air pollution in the southern region. Reductions in air pollution across Taiwan, especially in areas with pre-existing higher pollution levels, are vital to promoting good health and decreasing the environmental risks associated with lung cancer and other NCDs.

FIGURE 2

GRIP: Gains, Risks, Innovations, Prospects in Policies and Programs

Opportunities ahead

With its sights set on becoming a global leader in precision medicine, Taiwan has one of the more advanced cancer care strategies in the Asia Pacific region. However, there are enduring challenges to overcome as lung cancer incidence remains high, particularly in lung adenocarcinoma. The demographic transition to a rapidly aging society warrants additional policy measures that improve budget sustainability. An aging population is set to impact government health spending, forecasted to more than double by 2050 from its 2019 value of USD 1,195 per person, which portends fiscal strains in the coming decades. There are also regional inequalities to address, such as varying levels of air pollution quality between Northern and Southern Taiwan, which can exacerbate health disparities among populations and undermine the overall effectiveness of lung cancer prevention and mitigation efforts.

Another challenge that warrants policy attention is the long process of approval and reimbursement for new innovative drugs, which delays patients’ access to potentially life-saving medicine. The use of new cancer drugs could lead to TWD 3.51 million (USD 108,000) in annual cost savings per patient. Based on data from 2007 to 2014, a 2020 study found that the Taiwanese population experiences on average a delay of 15.1 months for medical reimbursements, which is greater than in other high-income countries such as Japan and the United Kingdom. Responding to these findings, the government plans to implement strategies to accelerate its drug approval and reimbursement processes starting in 2024. Strategies include implementing a temporary payment system for critically needed drugs, establishing a health policy and technology evaluation center, and conducting a parallel review system for companies to apply for both NHI and Taiwanese Food and Drug Administration (FDA) approval.

To ensure a patient-centric approach to lung cancer control in Taiwan, the mental health of patients also needs to be prioritized. For instance, a 2023 study on mental health showed that cancer patients who had a mental health condition before their cancer diagnosis spent less on medical care than those who did not have a known mental health condition, suggesting that they were less likely to follow their treatment plans after cancer diagnosis. Meanwhile, patients with post-cancer mental health conditions had the highest medical expenses among the groups studied, implying that a tailored approach is needed. Aside from tapping precision care technologies, high-quality cancer care calls for an integrated whole-of-society approach that supports patients at every stage of their journey, from diagnosis to survivorship care. Taiwan has shown its agility in responding to policy gaps when evidence is available, and thus it is well poised to demonstrate a proactive approach to these evolving health challenges.