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Setting the bar higher for cancer services
[ by Niall Hunter, Editor www.irishhealth.com]
The head of Ireland's cancer services says while huge strides have been made in reorganising and improving care in recent years, there is still much distance to be travelled before we achieve fully achieve a world-class service, showing better survival rates.
"You can never say anything is perfect but things are certainly much better now. The challenge is for us to continue to develop more enhanced services driven by national standards and guidelines on best practice," Dr Susan O'Reilly told irishhealth.com
Dr O'Reilly, who succeeded Prof Tom Keane as head of the National Cancer Control Programme (NCCP) in 2010, is continuing the cancer services reorganisation started by her predecessor back in 2007.
She feels that despite all the controversy that attended some of the reconfiguration, there is a general sense among the public that things have improved, and there has been a dramatic reduction in reports of missed or delayed diagnoses.
Stressing the need to have the bulk of cancer treatment focused in a limited number of expert, multidisciplinary centres, she rejected any suggestion that major breast cancer services might return to Sligo Hospital, despite some promises made at the last election by Fine Gael politicians.
Dr O'Reilly said the NCCP was not happy that Limerick University Hospital fell well below the official target time of 100% of patients seen within 10 working days for an urgent breast cancer assessment and within 12 weeks for an non-urgent assessment in December.
However, she anticipated that following taken by hospital management, these figures for access will have improved by now.
Generally, she said, all the eight centres for breast cancer assessment achieve their waiting time targets almost all of the time.
Dr O'Reilly, in an interview with irishhealth.com, also said the NCCP is developing new assessment guidelines for GPs to cut down on the number of women being unnecessarily referred to breast clinics.
She said Ireland's cancer survival rates compared poorly to those of some developed countries, but great strides were being made in breast cancer survival. Future figures for cancer survival were likely to show some improvements as a result of the cancer service reorganisation over the past five years.
The cancer chief also warns that with a likely 100% increase in cancer incidence over the next 20 years, it will be a challenge to meet capacity needs to deal with this explosion in new cases.
Like her predecessor, Susan O'Reilly worked with the British Columbia Cancer Agency in Canada, where she was Vice-President of Cancer Care.
Dr O'Reilly, who grew up Wales, was also Professor of Medical Oncology at the University of British Columbia. She completed her medical degree at Trinity College Dublin and having done her early training in Dublin hospitals, moved to Canada to specialise in cancer care.
Reorganisation of cancer services
In general, says Dr O'Reilly, huge strides have been made in reorganising and improving our cancer services since the process was initiated under her predecessor. Under this process, breast cancer services were moved to eight designated hospital centres.
"This is continuing on trajectory and a number of other surgical services have been progressively centralised into major hospital centres."
"We are continuing to make progress with this. For example, the national pancreatic cancer centre was opened at St Vincent's Hospital in Dublin in November 2010 and it was agreed that there would be a hub and spoke model with Cork. We are very pleased with the way this is running. Pancreatic cancer has a dismal outcome and by having very sophisticated and timely assessment you give those patients who might be suitable for curative surgery the best chance, as they will be handled in expert locations."
Dr O'Reilly says by centralising pancreatic cancer in an expert centre, you are also endeavouring not to inflict radical surgery on people who cannot be helped. "In the past, people might have had unnecessary surgery for pancreatic cancer - often patients were opened up but could not be operated on or would not have a proper resection."
Other cancer areas that have been reorganised include neuro-oncology (for brain tumours etc), now based at Beaumont and Cork University Hospital. Lung cancer treatment has been rationalised into four centres, as has oesophageal cancer.
"Prostate cancer is now treated in seven centres - we are aiming for six - and rectal cancer is treated in 10 centres - we aim to reduce this to eight centres."
Breast cancer services, in the most controversial of the rationalisations, has for some time now been provided in eight designated centres.
Dr O'Reilly says she is pleased with how the rationalisation has progressed across the various type of cancer.
She is particularly pleased with the improvement in services effected by moving breast cancer treatment to the eight designated centres.
Susan O'Reilly is in no doubt that despite strong opposition in some quarters, centralising cancer services was the right decision.
"The advantage of centralising services is you have high volumes, multidisciplinary team consultation where cases are discussed across a wide range of specialties, the diagnosticians in pathology and radiology are expert at interpreting results, and you have high quality clinical opinion and management of patients. etc."
"With the bigger centres, you also have a more sustainable service, Because one of the big challenges with stand-alone single-handed surgical facilities is that if a person retired or is on sick leave it interrupts the delivery of care. Also, you do not have ancillary back-up such as plastic surgery, supportive care etc."
Nobody likes change
When major cancer services were being transferred from smaller hospitals, there was often strong local opposition to this. Susan O'Reilly believes the best indicator of how public opinion has largely changed on this is that you don't hear very much now about local resistance.
"By implementing a cancer control programme you are establishing a national brand and the brand has a very good reputation, so there is a general sense out there among the public that cancer services have improved. We have also seen a dramatic reduction in reports about missed diagnoses, and delayed diagnoses. You can never say that everything is perfect but things are certainly much better now. The challenge for us is to continue to develop more enhanced services driven by national standards and guidelines on best practice."
She points out that with medical oncology treatment (treating patients with drug and hormonal therapies) once the initial treatment is started at the designated centre, the remainder of the treatment can usually be carried out in a smaller centre. "There are 19 such centres quite capable of delivering this. This is already happening in smaller hospitals. These services were never withdrawn and it has always been the intention of the NCCP to retain them."
"A national medical oncology programme we are introducing will include evidence-base protocols for the correct use of cancer drugs. There will be a centralised national cancer drug budget run through the current demand-led schemes for both hospital and outpatient drugs."
And what about Sligo?
There has been considerable opposition to the removal of major breast cancer services from Sligo General Hospital to Galway, and at the last election promises were made by members of the current majority party in Government to restore these services. What are the chances of this happening?
"It's definitely not going to happen", says Dr O'Reilly.
She says a patient satisfaction survey has shown that women from Sligo were generally very satisfied with the service in Galway. Patients can be transported by a free bus service.
Dr O'Reilly said there had been only one breast cancer surgeon in Sligo. "There was nothing wrong with the staff there but you cannot run a sustainable service on that basis. With cancer, your first shot is your best shot and you need to be in a designated centre, treated speedily under a multidisciplinary team."
The rationalisation of radiation oncology treatment services, according to Dr O'Reilly, has also made great strides.
This reorganisation too has not been without controversy, as it involves the eventual closure of the highly-popular St Luke's Hospital in Rathgar, Dublin, as a major treatment centre.
"Last year we opened two state of the art radiation facilities with new treatment equipment including linear accelerators at Beaumont and St James's and these are now up and running under the title of the St Luke's Radiation Oncology Network."
The Rathgar hospital is continuing to operate as a treatment centre along with Beaumont and St James's - however, it is eventually due to cease carrying out radiation therapy as the Radiation Oncology Programme develops nationally.
"St Luke's will cease doing radiation therapy in around five to six years time and that is contingent on further development on the Beaumont and St James's sites. We have already increased the potential radiation oncology capacity in the Dublin area by 50% as a result of this programme. Under the Government capital programme we will be funded for the next five years to develop radiation oncology facilities."
The longer-term national plan, Dr O'Reilly says, is to have six public radiation oncology hospital units.
"Currently, there are five publicly-funded radiation oncology centres - St Luke's, Beaumont, St James's, Cork and Galway. In addition we purchase services from private centres in Limerick and Waterford. The longer term strategy is to have public facilities in these cities. St Luke's will eventually close when the full Dublin capacity is realised."
The shorter term plan, Dr O'Reilly says, involves upgrading treatment facilities for radiation therapy in Cork and Galway and adding to capacity at Beaumont and St James's in Dublin, and the necessary funding has been promised for this.
Asked about the closure of St Luke's, Dr O'Reilly says it was developed decades ago when the role of radiation in cancer treatment was often more palliative than curative.
"Nowadays, most of the work we do is in curative radiation. Radiation treatment has become very complex, it is often given along with chemotherapy and is associated with significant immediate toxicity that needs good medical management for some patients, so it makes more sense to have radiation on a general hospital site."
Dr O'Reilly stresses that the research is there to back up the policy of moving cancer services to general hospital sites. "With really complex radiation oncology, for example, you need to have the patient treated on a general hospital site.
Access to breast clinics
Susan O'Reilly believes the reorganisation of breast cancer services into eight designated centres nationally with rapid access for women with worrying symptoms has been a success story.
"The major function of the new centres is to have any woman who has any breast symptom, including symptoms that are worrisome such as a palpable lump, to be referred to the clinic by her GP. Many clinics now do electronic referral from GPs. The consultant then triages that referral. The GP may tick the box saying urgent on the referral form and the clinic would accept that, but whether it is ticked or not the surgeon will read the referral and if they have any alarm bells from this the women can be slotted into the urgent category and seen within the target time 10 working days or less."
"If it is deemed not urgent - if it is likely to be an assessment that turns out to be something relatively uneventful, that has a target time of 12 weeks for an assessment."
However, recent figures show that while the majority of centres have a nearly 100% record in sticking to their target wait times for a breast assessment, the Limerick centre has recently been lagging behind. Latest figures show that in December, only 67% of women were being offered an appointment within 10 working days or less in urgent cases, and only 36% were being offered an appointment within 12 weeks in non-urgent cases.
The year overall average for 2011 for the Limerick clinic was 96% of urgent cases seen within target time and 79% of non-urgent cases.
Asked about this, Dr O'Reilly said: 'generally speaking, all the hospitals achieve their targets almost all of the time. Occasionally, you might see a little bit of a decline, particularly if the surgeon is on leave of if there are some real pressures on the system. As regards non-urgent referrals, when women are triaged into the non-urgent category the likelihood of them turning out to have a cancer is extremely low. If there are pressures on the system the priority is to maintain the urgent referrals as rapid referrals within 10 days."
The HSE says there have been issues in Limerick University Hospital with radiology/mammography capacity and additional clinics had been introduced recently to cope with the demand.
Dr O'Reilly said the Limerick centre was taking action to address the low December figure for non-urgent cases being seen within target.
"Limerick was down on the urgent cases too in December and weren't happy with that. However, the new CEO there is keeping a close eye on that and I am anticipating the figures will improve. I haven't seen the follow-up figures for January, but they will be produced soon."
Dr O'Reilly says the statistics for access to the breast clinics are reviewed on a monthly basis and if there is is an issue identified, it is usually the case that the hospital is already dealing with it. "If they need to start more clinics or if there is a struggle with the number of mammographers then this will be addressed. You typically don't see a poor performance in the next month's stats, which usually tells you they are catching up."
She says every hospital emphasises the need to see the urgent referral within 10 working days and if there is pressure on services there may be a decline in the non-urgent statistics, but this always recovers. Where there was an intractable logjam it was possible to move patients to other centres.
'Worried well' women
Dr O'Reilly says the NCCP is trying to refine the referral process under which GPs send in women to breast clinics.
"We have found that we see a bit too many women in the breast clinics who are really ok, and their problems can be managed by their GPs. But GPs are aware that if you tell a woman she is fine and don't refer her to a breast clinic and then she turns out to have cancer they are in trouble, but we need to reassure GPs about who does not need to be referred."
She says the NCCP is developing GP guidelines, for example, on how to treat breast pain. "This is because breast pain is almost never a symptom of cancer and doesn't usually necessitate a referral. We are also developing clear referral guidelines for women who may be at real family risk of breast cancer. For those with a significant family history of breast cancer, it is important that they get into an early monitoring programme. However, the clinics have been seeing a little too many patients who would not even cross the threshold for family risk."
Rapid access clinics
In addition to rapid access breast clinics, the NCCP introduced rapid access lung and prostate cancer clinics in mid-2010. "There are currently eight of these clinics and they have been a great success. We are seeing a huge number of referrals and huge numbers of patients being diagnosed."
Both types of clinics saw over 4,400 patients last year and the diagnosis rate for both lung and prostate cancer was 38%. In the longer term, Dr O'Reilly says, more rapid access clinics may open in areas such as colo-rectal cancer, but the priority is to get a national screening programme for this type of cancer up and running first.
For prostate cancer, she said it is not always about rapid treatment, as this type of cancer is usually slow to progress. "Often the best treatment might be active surveillance of the disease and no intervention if the patient has low-grade disease."
This too, according to Dr O'Reilly, is why mass screening for prostate cancer is not recommended. You would, she says, end up over-treating a large proportion of patients and run into serious long-term side effects like impotence and incontinence post-surgery for many patients who made not have needed treatment.
Budget cuts and cancer
Dr O'Reilly says in the wake of budget cuts and staffing difficulties, it is very important that the HSE local managers and regional directors of operation can prioritise posts that need filling urgently, because some posts may be suppressed in the drive to conserve resources.
"But for frontline posts essential for the delivery of care the intent is to staff them appropriately to continue delivering this care. I would anticipate that cancer services ought not to see a major impact with the budget cuts but it's something we will be paying close attention to."
Dr O'Reilly admits that Ireland has some way to go before matching other developed countries in improving its cancer survival rates. She points to a paper published in the Lancet journal in December 2010 for colon, lung, breast and ovarian cancer which showed that while we have roughly the same survival rates as most of the UK, we are trailing behind most Scandinavian countries, in addition to parts of Canada and Australia, for the years from 2000 to around 2007.
"What this tells me is that for age-adjusted five year survival there is potential for us to close that gap with other countries."
Dr O'Reilly says the key to improving survival rates is diagnosing people early enough when their disease is more likely to be cured and being treated in an expert centre by a multidisciplinary team. She said the Lancet paper showed that the only cancer there had been an improvement in during the period in question in Ireland was breast cancer.
"That can be linked to the early development of breast screening in the east of the country, and better treatments including better drug treatments."
Comparing Irish survival rates with those of British Columbia in Canada, where she formerly worked, Dr O'Reilly said Ireland is lagging behind by 10%. She points out that British Columbia, which has a similar population to Ireland, has had a highly organised cancer system for decades, something we have only begun to implement here.
Dr O'Reilly says she would expect that when the next five-year survival rates are published, the Irish cancer service reorganisation that began in 2007 will have borne fruit. "I would think patients diagnosed in 2012 would have a better chance of survival when we look at their outcomes in 2017."
She points out that if Ireland had been having the same impressive cancer outcomes as some other developed countries back in 2007, the argument for reorganisation of services would have been weak. "But the figures show we are not having the these outcomes. Out outcomes to date have been pretty ho-hum, relatively speaking"
Ireland's cancer explosion
But while cancer survival rates here are set to improve, the number of new cancer cases diagnosed over the next 20 years is set to explode, Dr O'Reilly warns.
She says Ireland has the fastest growing incidence of cancer in Europe and the key factors here are our rapidly ageing population (cancer generally being a disease of older people) and our relatively high smoking rates. "While in other countries, their 'baby boomers' started ageing some time ago, this is only starting in Ireland. Another very cogent factor is our 29% smoking rate which drives up a variety of cancers."
'"Our own cancer registry predicts a 100% increase in cancer incidence between 2010 and 2030. We are going to see higher volumes of patients coming through and we have to do the groundwork now. I think that argument was accepted by Government when we got the necessary capital funding to develop radiation oncology. We will certainly need to increase our capacity quite significantly."
She admits it will be a challenge for future governments to meet the capacity needs to deal with the explosion in new cancer cases.
Colorectal cancer screening delay
"In some ways, starting this programme in the final quarter rather than in the summer as originally planned is probably giving us a little more breathing space to organise things," Dr O'Reilly says.
The programme will initially screen all 60 to 70 year-olds through a home fecal testing kit and if necessary, a follow-up colonoscopy.
"We have predesignated 15 hospital centres for the colonoscopy testing, contingent on them achieving agreed standards. A review of the centre has just got under way and we are currently recruiting nurses to be trained up as colo-rectal nurses."
Dr O'Reilly said the predesignated 15 hospital centres may not all be ready for the programme when it begins.
Is screening beneficial?
She believes the benefit of screening for cancers such as breast and colo-rectal has been proven. "While the NHS recently implemented a review of the data for breast screening, the driving factor behind this was more around whether patients were well-informed about the risk of not having breast cancer but having to go through umpteen biopsies that find nothing sinister."
"The question that keeps coming up is, that for all the effort that goes into breast screening, does it do a lot of harm by putting a lot of women through emotional distress, trauma, scarring etc? What we have to reflect on is that most, but not all studies show a significant benefit in early detection, and it should be stressed that the death rate from breast cancer has been plummeting across the world. There are multiple reasons for this, and screening is likely to be one, as this detects patients early. New drugs that work better and older drugs that are now used more correctly are also major factors."
"Another factor is increased patient awareness. Women are now much more likely to go to their GP if they have a concern about their breast rather than just ignoring it. Breast cancer survival rates are high - 80% of women in Ireland diagnosed with breast cancer are alive and well after five years.
Dr O'Reilly says that of the nearly 38,000 women seen at symptomatic breast clinics last year, 5.5% turned out to have cancer, in addition to 0.6% of women screened under the the national screening programme, BreastCheck, detected with cancer.
Susan O'Reilly does not believe the planned phasing out of the HSE and the establishment of new healthcare structures will derail the cancer strategy or the NCCP. "The Minister for Health has enormous respect for what the NCCP has done and he is very committed, for example, to the colo-rectal screening programme rolling out despite the fiscal difficulties. My view is the NCCP is a sufficiently well-established entity and will continue to thrive."
"I am only 18 months into my five-year contract and I'm quite confident I am going to be steering this through."
|Anonymous Posted: 14/03/2012 15:39|
I do understnad the strategy and the logic of it bt it is still very hard on those in rural areas of the Northwest to access care, - frequent long stressful journeys, often by public transport while ill, oftne with mounting expense.
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