OBJECTIVES: Different jurisdictions organize their health technology assessment (HTA) capacity in different ways. In theory, a centralized approach offers the potential to pool the scarce resources devoted to HTA and national recommendations can be issued to encourage a uniform development of services across the whole country. On the other hand, a regional approach could help in tailoring recommendations to local needs. The objective of this study was to compare the assessment procedures in England (centralized approach) with Spain (regional approach). METHODS: We compared the assessments of the same cancer drugs in the two jurisdictions from 2000 to 2015, extracting data on the availability of an HTA, the indication(s) studied, the comparator(s) considered, the cost-effectiveness assessments produced and the reimbursement recommendation (recommended with no restrictions, optimized or denied use). RESULTS: The indications studied and the comparators considered were similar in the two jurisdictions. In England an HTA with a cost-effectiveness estimate was available for 105 drug/indication pairings: recommended (32%), optimized(30%) and denied(38%). The Spanish HTA for pharmaceuticals is characterized by a high decentralization and lack of coordination. Decisions at national level were based on effectiveness and safety but no clear recommendations were made. Therefore we used data from two regional Governments (Andalucía and Cataluña) and a pharmacy scientific society (SEFH) where recommendations were stronger and considered cost-effectiveness. For the period of 2011-2014 a total of 43 indications were assessed in Cataluña: optimized (86%) exceptional use (14%).  CONCLUSIONS: Due to a relative lack of central coordination, the approach to HTA in Spain leads to a less standardized approach for technology assessments of cancer drugs than in England. In addition, cost-effectiveness evidence is less frequently generated. However, a lower proportion of drugs receive a negative recommendation, which may reflect both the lower level of cost-effectiveness scrutiny and a relatively higher willingness-to-pay.