OBJECTIVES: In contrast to the US, several European countries have health technology assessment programs (HTA) for drugs, many of which assess cost-effectiveness.  However, restricting access to pharmaceuticals is controversial, particularly for life-threatening diseases. Therefore the objective of this study was to assess whether economic evaluation as part of HTA restricts access to anticancer drugs. METHODS: We undertook a systematic comparison of US and UK coverage decisions on anticancer drugs taken by the US Centers for Medicare and Medicaid (CMS), the Veterans’ Affairs (VA), the Regence Group (US), the National Institute for Health and Clinical Excellence (NICE) (UK), and the Scottish Medicines Consortium (SMC) ( UK). We noted the timing and outcome of coverage decisions made for all anticancer drugs approved by the Food and Drug Administration (FDA) between 2004 and 2008. RESULTS: Since 2004, the FDA has approved 51 anticancer drugs, of which 39 have been approved by the European Medicines Agency (EMEA).  On average, the FDA licensed these drugs 127 days earlier than EMEA.  The CMS and the VA covered all 51 drugs from the FDA license date.  The Regence group also covered all 51 drugs, although coverage decisions that considered cost-effectiveness sometimes took longer.  Relative to the EMEA license date, coverage decisions for anticancer drugs by NICE averaged 774 days (SMC: 231 days).  In the US, most drugs were available without clinical restriction, but NICE made positive coverage decisions for just 33% of licensed drugs (SMC: 51%).  However, US patients face substantial copayments, whereas drugs are free for UK cancer patients. CONCLUSIONS: The use of economic evaluation does lead to more restrictions on the use of anticancer drugs. However, the major difference between the UK and US is not whether there are restrictions on access to anticancer drugs, but how these are applied and who bears the decision-making burden.