OBJECTIVES: To identify similarities and differences in HTA decision-making processes and outcomes, and explore the criteria driving these decisions in different settings analysing a sample of cancer drugs. METHODS: This study applied a validated methodological framework built on a mixed methods approach to systematically compare HTA recommendations for a sample of 15 cancer drugs in four countries (England, Scotland, Sweden and France). All decision-making criteria were identified and compared at each stage of the decision-making process: the evidence appraised, its interpretation and influence on the final decision. Qualitative data collection and analysis was conducted using the NVivo software. RESULTS: Across the sample, the same primary trials were generally appraised to determine the treatment’s clinical efficacy (93% common to all). From the same trials, heterogeneity was seen in the subgroup analyses (n_subgroup^NICE=25, n_subgroup^HAS ₌