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The pilot of the National Oncological Network, which is currently carried out in four voivodeships – Dolnośląskie, Pomorskie, Świętokrzyskie and Podlaskie, is to be transformed into a nationwide systemic solution from January 2022. According to its assumptions, each patient, regardless of where they live, will be able to receive oncological care based on the same standards. These standards are developed by Dr. hab. n. med. Adam Maciejczyk Lower Silesian Cancer Center. We talk to him about the successes and problems of the new formula of operation, tested in the difficult conditions of the coronavirus pandemic.
- The pandemic may cause “accumulation” of patients who have not previously visited an oncologist and there will be more patients with more advanced disease – the expert predicts
- Dr. Maciejczyk talked about the pilot of the National Oncological Network in Lower Silesia
- – Improving the quality of cancer treatment is not a problem only for oncologists. This is a social problem, he says
- You can find more such stories on the TvoiLokony home page
Monika Zieleniewska, MedTvoiLokony: The media are sounding the alarm that there is an increase in cancer incidence ahead of us. Do you already notice him?
Prof. Adam Maciejczyk: In oncology, everything can be calculated and predicted on this basis. The number of cancer patients has been increasing every year for a long time and this is not a surprise to us. The incidence is fairly predictable and we are able to predict how many patients will visit hospitals in a given year. We can also estimate the percentage of people who do not report for preventive examinations in time and, as a result, will come to us only with advanced cancer. Therefore, the number of neoplasms will be more or less in line with earlier forecasts, but there may be temporary “accumulation” of patients who have not previously consulted an oncologist, and changes in the structure of incidence of certain cancers, eg there will be more patients with more advanced disease.
The relationship between the deterioration of oncological diagnostics and the coronavirus pandemic is also emphasized.
The situation of cancer patients changed during the pandemic. During the first wave, i.e. in the period March – May 2020, we were dealing with a different situation than during the second and third waves. In the first period, when the pandemic surprised everyone, it was necessary to develop a new form of treatment organization and to create a series of new in-hospital procedures. After the guidelines of the National Health Fund, preventive examinations were suspended, and we did not perform mammography and cytological examinations at that time. However, prophylaxis started again in May. On the other hand, the remaining processes of oncological care in oncology centers – diagnostic tests (CT, NMR, PET-CT), implementation of oncological procedures, chemotherapy and radiotherapy were constantly carried out despite the pandemic.
oncologist, specialist in the field of oncological radiotherapy. Director of the Lower Silesian Oncology Center, head of the Radiotherapy Clinic of the Medical University in Wrocław, president of the Polish Oncological Society and president of the National Association of Public Cancer Centers and Institutes.
So, from March to May 2020, only the number of preventive examinations decreased?
Prophylactic examinations, e.g. mammography, are mainly used to detect patients with breast cancer at an early stage. Fewer mammograms have resulted in a reduction in the number of detected cases of the disease – we have recorded these changes nationwide. As a result, the number of surgical procedures was reduced, followed by radiotherapy and systemic treatment. These declines are a consequence of the failure to diagnose breast cancer in the period from March to May last year, which is only now visible. Everything is shifted in time according to the treatment sequence.
- See also: Why more and more women get breast cancer? The doctor explains
What about patients with other types of cancer?
In the case of lung cancer, it is completely different, because this cancer grows faster. Here, too, prevention was difficult, but for other reasons – early detection of lung cancer using low-dose computed tomography is not yet widely used in Poland. Additionally, a significant part of pulmonary hospitals was transformed into covid hospitals. Such organizational changes made it difficult to contact pulmonologists and thoracic surgeons.
The situation is still different with liver cancer, which is diagnosed and treated in infectious diseases hospitals. Access to cancer treatment was the most difficult there. This is a much smaller population compared to patients with breast and lung cancer, but it is a group in which we will certainly notice the negative effects of the pandemic in the form of at least a higher percentage of patients with more advanced disease.
Each type of cancer requires different treatment. Is it possible to heal the sick in accordance with the standards?
Yes, provided that we monitor the entire process, we analyze the number of people reporting for cancer treatment diagnostics. When we have knowledge and awareness of the problem – we can react faster and more effectively. If we see that a standard-compliant procedure has been overlooked in the treatment process, we can very quickly adjust the path of treatment. That is why we have to monitor the situation of patients on an ongoing basis and base our actions on current data, not those from a few months or years ago. Due to the fact that Lower Silesia was included in the pilot program of the National Oncological Network, from February 2019 we are aware of the current problems that our patients face and we try to solve them as soon as possible.
So the pilot should be extended to the whole country?
Absolutely yes. Improving communication with patients and implementing the process of coordination of oncological care throughout the country should be introduced as soon as possible. Remember that the system improvement process is complicated, time-consuming and requires the involvement of many environments. Improving and then maintaining the quality of treatment requires constant, systematic action by the National Health Fund, the Ministry of Health, hospitals, many specialists, as well as patients.
This is not just a problem for oncologists. Cancer is a social problem. The media also play a huge role, especially in terms of communication with patients. We are still encountering information that exacerbates the fear of visiting an oncologist. It should be remembered that many people learn mainly from the media and accept information uncritically. We should remember that a visit to an oncologist is a traumatic experience for many people and any unjustified fomenting fear or anxiety is irresponsible.
How is Dolnośląskie doing piloting?
During the entire pandemic period, Lower Silesia was at the forefront of provinces with the highest number of infections. Despite the periodically very difficult situation, it was possible to maintain the continuity of oncological treatment. Coordination significantly improved contact with patients and cooperation between hospitals in the voivodeship.
The number of diagnosed patients is constantly increasing. At present, the situation is worse in the surgical wards, that is, in the first line of the fight against cancer, where diagnostic biopsy and surgical procedures are performed. As a result of the earlier inhibition of the diagnostic process and therefore the delay of the treatment, an accumulation of more patients should be expected. Unfortunately, we have no influence on this. This will contribute to longer queues, especially for surgery.
Patients with severe symptoms visit an oncologist and it is obvious that they want to be operated on as soon as possible, and this is not always possible, because in many facilities there have been organizational changes related to the pandemic. The process of restoring standard surgical procedures in many hospitals is still going to take place, which is why coordination, communication and appropriate organization are so important and necessary. We are not able to suddenly eliminate queues completely, but we can effectively improve the operation of the system.
How?
If hospitals cooperate and constantly communicate the current situation, we will be able to relieve downtime earlier. Such a solution is already operating as part of the pilot project of the National Oncological Network. If a facility has a problem, e.g. cannot perform procedures, it should signal it and transfer patients to another. In our voivodeship, during the pandemic, such measures were successfully implemented. Especially in the case of lung cancer, such coordination was essential. We have created an additional diagnostic fast path outside the pulmonary hospital. A special hotline number for patients with lung cancer made it possible to organize a faster diagnosis and treatment path. An additional helpline was also launched for family doctors, who could call us, as well as send an e-mail or SMS through a special gateway as part of the Onkoskop IT system. POZ doctors also had the opportunity to directly provide the DiLO card number (diagnostics of oncological treatment), and we were already arranging the patient for tests and treatment ourselves.
How long was the waiting time for an appointment at your facility – the Lower Silesian Cancer Center?
During the pandemic, the most difficult situation was in the case of urological patients. The longest waiting time for the first visit for a urological patient who required urgent oncological diagnostics was nine days. We monitored 5 cancers in a pilot study, in addition to prostate cancer – cancer of the lung, breast, colon and ovary. In the remaining group of neoplasms, the waiting time ranged from zero to four days.
And what was the access to diagnostics?
Access to CT (tomography) and NMR (magnetic resonance imaging) was even easier as fewer non-oncological patients showed up. At the moment, the number of commissioned tests is growing rapidly. Let us remember that they are financed by the National Health Fund in an unlimited way. We currently expect an extension of the waiting time for radiological examinations.
What do you consider to be the success of the pilot program?
From the patient’s point of view – shortening the waiting time for the first visit to the oncologist. A voivodship hotline has been introduced, so in each of the 16 hospitals that deal with oncology in Lower Silesia, we can schedule appointments with a specialist.
A very important success is the expansion of the scope of activities of oncological coordinators – a new professional group – which supports patients in the implementation of individual examinations and consultations from the level of oncological diagnostics.
The standardization of the oncological diagnosis and treatment process is also a great success. As part of the pilot project of the National Oncological Network, we have developed a number of action plans that greatly improved the work and organized procedures.
It’s good to hear that an area has avoided problems during the pandemic.
We did not avoid problems. Hospitalization of patients turned out to be a big challenge. We have difficult housing conditions, the buildings were built in the XNUMXth century. The infrastructure is difficult to adapt to the challenges of the XNUMXst century, let alone a pandemic. In large, multi-person rooms, we had to reduce the number of patients, which resulted in a significant reduction in the number of places available. On the other hand, outpatient treatment or treatment combined with the patient’s stay in the hostel takes place without any major problems. The situation is not dramatic due to the fact that we cooperate with each other. We maintain communication with patients and doctors all the time.
How do you reach patients?
We inform from April to today, non-stop in various places, that we conduct diagnostics and oncological treatment, that the patient can search for information on our websites, that we apply an effective sanitary regime. Not a single week goes by without contact with the media. In cooperation with the Onkologika foundation, we conduct an extensive educational campaign, record films, and educate children and youth. We make people aware of how to take care of their own health, but also of the health of parents or grandparents. A few days ago, in cooperation with MPK Wrocław, we launched a “traveling prevention campaign”. The bus, covered with information, will remind you about examinations for the next year and encourage you to visit the oncologist.
You also focused on computerization.
The information on our website is constantly updated. We also invented additional forms of communication. In the second half of last year, we implemented the DCO mobile application. It concerns the prevention of cancer. Thanks to it, you can find out which tests are recommended, where in our province to perform them and which are financed by the National Health Fund. You can also plan a route or make an appointment for a specific date. When using the application, you only need to enter your age and gender, then we obtain information about the preventive examinations recommended by us. And it works. I would like to add that the functionality of our application is constantly being developed – in the future it will additionally serve patients in the post-treatment control process. After implementing the KSO, we will be able to transfer this solution to other provinces.
Does the media dramatize it when it writes about the situation of cancer patients in Poland?
Looking at the nationwide data, it can be seen that the situation in terms of access to an oncologist during a pandemic is better than in some Western countries. Statistics from Lombardy or even Great Britain look more dramatic than in Poland. However, the queues for surgical procedures have now increased by about 10-15 percent. The number of specialists dealing with oncology has decreased, mainly in multidisciplinary hospitals. Obviously, access to oncologists depends on the region, type of cancer or type of therapy. Now radiotherapists are waiting for the patients. Currently, at DCO, access to radiotherapy is immediate due to postponement of treatment processes after the first wave of the pandemic.
When will we see how the National Cancer Network pilot is doing? It’s about the number of patients cured.
In oncology, the most important form of presentation are the results 5 years after the end of treatment. If the patient started treatment in 2019, it would last a year, one and a half, counting all the sequences: surgery, chemotherapy and radiotherapy. Few of the pilot patients have already completed all stages of treatment. You have to wait for the results. However, we constantly check the effectiveness of the introduced organizational changes – we check the number of histopathological and radiological examinations carried out in a given time and whether they comply with the standards. We also monitor the toxicity of treatment, early mortality after chemotherapy, radiotherapy and surgery. There was no increase in mortality during the pandemic. It is true that the nationwide data from the end of last year indicate a slight increase in mortality in the group of patients with diagnosed cancer, but it is probably not caused by cancer, but by the consequences of virus infection, which also affected patients with oncological disease, especially in the older age group.
So where does the increase come from?
Mortality reporting in Poland is not precise. If we add the information that in this age group cancer was more common in this age group, we have this slight increase in mortality, but due to COVID- 60. Cancer rarely kills within a few months. If the pandemic started in March last year, then the death rate during this time period can only increase from a rapidly progressing cancer, such as lung cancer. The increase in mortality in cancer patients due to limited access to oncological care during the pandemic is not visible in the current data. We will see him at the end of this year at the earliest, and this is in the most dynamic neoplasms.
Maybe the media were in too much haste with alarmist messages about the situation of cancer patients?
It should be emphasized that maintaining relatively stable access to oncological care comes at a price – the entire staff is under a heavy burden, both physically and mentally. Effective coordination and efficient organization in such difficult conditions required an enormous effort. We worked at top speed, in great mobilization. It charges. There have been necessary changes in the way a number of services are provided – each patient must be tested for coronavirus infection before treatment, all procedures and treatments have become longer. This situation also resulted in a significant increase in hospital costs. Growing financial problems hinder the operation and organization of oncology centers.
Is there a chance that this increase will be covered by the National Health Fund?
I do not know. The NHF makes the decision to improve tariffs dependent on the calculations and valuations analyzed at the Medical Assessment and Tariffs Agency. Unfortunately, retarifications are implemented with a long delay. We need immediate support in this regard. Changing the valuation of benefits is a time-consuming process; for oncology to survive and continue to carry out diagnostics and treatment of oncology, rapid changes are needed. It should be emphasized that not only the staff in covid hospitals worked non-stop, so did oncology. We didn’t have any lockdown. Employees are exhausted. Working conditions are difficult and, additionally, badly financed. Unfortunately, at present, the more underestimated procedures we perform, the greater we generate a financial deficit – and there are more and more patients …
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