Context:- In high income countries the costs of delivering high quality equitable care are outstripping present budgets. This article reviews the affordability of cancer care in these countries with particular reference to the United Kingdom (U.K.). The question remains as to whether patients should contribute to their cancer treatment through the introduction of user charges, and whether such payments can be assimilated without undermining efficiency and equity of health care access. Methods:- In our review we analyse the drivers of increased cancer care utilisation, the current policies designed to control rising costs, and the potential impact of introducing patient user charges. The article also explores whether our understanding of behavioural economics could be used to create “nudge” policies that drive rational health care consumption. Findings:- The costs of cancer care in the U.K. are increasing at an unprecedented rate, driven by demographic changes, innovation (radiotherapy, drugs and imaging) and consumerism within health care. Budgets are tightly constrained and health technology assessments designed to ensure coverage of high value interventions have come under significant public and political scrutiny. User charges potentially provide a framework to “nudge” patients from low value care of limited effectiveness towards high value cost effective treatment, thereby increasing overall efficiency. However supply side controls are equally relevant with greater focus on physician test ordering, and improving the quality of doctor–patient communication, especially when discussing treatment options towards the end of life. Conclusions:- Fiscal sustainability of health care financing remains a key public policy concern. Attempts at ensuring coverage of cost effective treatments have been continuously challenged and without new policies, sustainability trade-offs may be necessary with potential rationing of high value treatments. User charges provide a potential means of sustaining spending proportional to the projected rise in number of cancer cases, whilst embracing technological innovations which could potentially improve outcomes.