Prof. Branko Zakotnik, MD, PhD, Slovene NCCP coordinator
CANCER CARE IS MORE THAN JUST TREATMENT
The second period of the NCCP (2017 – 2021) has started and here are some views and opinions on it by prof. Branko Zakotnik, MD, PhD, medical oncologist from the Institute of Oncology in Ljubljana and the Slovene NCCP coordinator.
What is the significance of the Slovene NCCP?
The majority of European countries have their NCCP, therefore there is little doubt about the importance of this document. I would like to make it clear that there is more to cancer care than just treatment as one might imagine. Comprehensive cancer care includes epidemiology, primary prevention, early detection, screening, diagnostics, treatment, rehabilitation, palliative care and much more. Cancer is a modern world plague we are all faced with and it can only be put under control if it is addressed by the whole society, not just doctors and nurses.
What are the most important objectives of the Slovene NCCP?
The first and absolutely the most important objective is to lower the incidence of cancer. That is not a hopeless battle. The Slovene NCCP began in 2010 and the incidence of some cancer sites has already dropped. This is due to primary and secondary prevention which are both an important part of the NCCP. I would particularly like to point out the case of colorectal cancer, cervical cancer and lung cancer in men; the figures are very optimistic. On the other hand, however, the situation is still very grim in cancers which there are neither any screening programmes nor any preventative measures for.
What is the role of quality control?
That is very important, too, and is as such included in the NCCP. Quality control is a measure which will help us establish where and why the suspicion- to- diagnosis time span is so often too long. The unacceptably long waiting lists are very often mentioned and brought up in public, however, it is my impression that they are discussed somewhat without any solid argument. Only with precise figures and with the IT support can we change the situation for the better.
In cancer care, it is the quality of life that matters as much as survival rates.
By all means! The prevalence of cancer in Slovenia today counts up to about a hundred thousand people and quality of life is of the utmost importance to all of them. However, very little has been done in this area. Unfortunately, the situation is similar in all chronic diseases. One of the reasons is the lack of properly educated professionals. Another issue is rehabilitation; it has not even been adequately defined yet as to what rehabilitation should comprise. Only when this has been done, will we know how much staff we need for a particular area of work. This objective will most probably be one of the most difficult to achieve along with palliative care, which is also very poorly developed.
Apart from the NCCP, the Slovene cancer care platform includes all three screening programmes, a very good cancer registry, treatment guidelines, a multidisciplinary approach to treatment, access to all registered drugs, yet the 5-year relative survival rate remains in the middle of the world survival scale. Why?
Survival rate is influenced mostly by the stage of the disease at diagnosis, access to treatment and sufficient number of health care professionals. CONCORD-3 has just published the data comparing survival in all countries in the world. Slovenia, as we can see, has been steadily climbing up the scale. As far as the most common three cancers (lung, colorectal, breast) are concerned, Slovenia is comparable to the neighbouring countries and a lot has been done in recent years. Access to treatment is very good for these three cancers, which has of course favourably influenced the survival rates of these three cancers. In the future, the results are to even improve due to very successful screening programmes provided the response remains the same or even improves.
What about mortality? There is still a lot to be improved.
True. The latest OECD data has revealed the unfavourable situation as far as the mortality in men is concerned, while it is better in women. Some cancers already have very good survival rates (breast, prostate, colorectal) while others, such as pancreatic or lung cancers for instance, remain at the bottom of the survival rate regardless of the country. If a lot of people become ill with these cancers, the mortality rate will be high, too. A lot of Slovene men have lung cancer therefore the mortality rate in men is the highest, although the situation has steadily been improving. In the second place is colorectal cancer where more men than women become ill and colorectal cancer mortality occurs mostly in those patients who have been diagnosed in advanced stages. The national screening programme (SVIT), healthy eating habits and excersise are a possible solution in order to lower the mortality rate as fewer people will become ill and more people will have precancerous lesions removed or will be diagnosed in early stages which are curable. Prostate cancer comes in third. This is the most common male cancer, but men die because of it at a very old age. In order to lower the mortality rate, the incidence rate should be decreased and survival rate improved.
All cancer patients in Slovenia have access to the best treatment possible, but treatment is very disseminated. Is this the future trend, too?
One of the objectives of the NCCP is to have several medical centres where cancer patients will be treated as there are too many patients to be treated just in one or two centres. All patients should be presented to a multidisciplinary team of doctors before the first treatment; this is the first objective. As far as the waiting time is concerned, patients need to wait a short time for surgery in some cancers and for radiotherapy. There is no waiting time for systemic treatment. The situation is far from ideal, but accessability is reasonably good. There is also a problem due to the shortage of medical oncologists. The aim is to create a transparent system in which we could see at any time where the bottlenecks are and why so we can work on them.
Good IT support is needed for that.
Exactly, and that is also one of the objectives of the NCCP. Traceability is only possible if there is good IT support and that is a very important part of cancer care. For better quality, a good quality control to detect and remove any weak points is necessary.