service facilities, expert treatment in tertiary centres and maintenance therapy and care for survivors in outpatient settings (4; Annex 2). A balance of centralized and decentralized services is required, to benefit from the assets of each level and integrated care (Table 8.1). Quality criteria should be established for the delivery of services according to the capacity and volume of facilities. Substandard cancer services can result in inferior cancer outcomes, with as much as 20% lower stage-specific survival in absolute terms, which is potentially equivalent to millions of lives lost each year from low-quality cancer care (5).
Centralized Decentralized
Benefits
•
Bring patients from district to high-volume hospitals with specialist surgical practice•
Standardized care, larger volume, allowing better evaluation of outcomes•
Economies of scale•
Availability of all cancer services•
Specialized multidisciplinary team•
Research and training to improve practiceBenefits
•
Better coverage and access for greater equity•
Reduced direct nonmedical and indirect costs to patients and families due to reduced travel time and productivity loss•
Specific pathways can be designed and followed•
Reduced delays in referral between presentation and definitive care•
Specialized multidisciplinary teams more complex but feasible with information technology•
Regular evaluation of treatment and outcomes only for the networkRisks
•
Reduced access and greater inequity for rural as compared with urban populations•
May encourage super-specialization and unbalanced distribution of the workforceRisks
•
Inefficient clinical services and duplication•
Poor coordination and access to higher-level centres and other oncology disciplines, resulting in delayed or no adjuvant care•
Low-quality care Section III 138Centralized cancer centres can provide leadership in care networks, concentrate expertise for training professionals and formation of multidisciplinary teams, promote efficient use of technology and evaluate outcomes more systematically.
Secondary hospitals can manage less complex, more frequent diagnostic and therapeutic procedures. The organization of cancer care pathways for easy referral within the network and coordination of clinical guidelines are key components of this model of care.
Until recently, centralization of cancer care in a limited number of facilities was practical, as, in the absence of rapid information flow or electronic health records, it allowed health care providers
to follow care pathways longitudinally and to coordinate care. Moreover, hyper-sub-specialization of medicine and frequent reliance on advanced technology and expensive therapy required aggregating services with high fixed costs and expertise in managing adverse effects (6).
Centralized models of care, however, are prone to be inequitable as specialized facilities may not be easily accessible (7,8).
Patients may have multiple fruitless contacts with the health system until they are referred to a specialized facility, which adds time and expense while increasing the probability of late-stage diagnosis. Alternative models of formally organized networks are necessary to increase access (Box 8.1).
Box 8.1. Alternative models of cancer care
•
Sweden. In 2010, the Swedish Government funded six regional cancer centres, which are regional hubs for cancer management. The centres developed supportive activities in collaboration with heath care providers and regional health administrators.In 2015, the Government launched a standardized cancer care pathway, in which diagnostic procedures and treatment options are allocated for each cancer, with a time frame for detection, diagnosis and treatment.
Care providers hold to each “time slot”, which creates a time-bound clinical guideline (9).
Addressing shortfalls in capacity and infrastructure is not straightforward; while central treatment facilities are necessary, without strengthened primary care and effective referral systems (10), patients will continue to present at late stages.
Strengthening primary health care and
Service delivery models should include strategies to address variations in cancer outcomes among populations of different socioeconomic status, gender, age, race or other factors. Patient navigators, for example, may improve timely access to and completion of cancer treatment, as can programmes to promote culturally
decentralizing care can reduce delays.
Primary care has several critical functions in cancer control (see Table 8.2; 11). Barriers to strengthening primary and secondary care include2 the cost of appropriate technology, lack of training for needed tasks and dysfunctional referral systems.
appropriate communication (12,13) with a more personalized approach to communication to increase coverage and to update services (14). Programmes and approaches to provide a supportive environment and address social stressors and financial difficulties may facilitate access to and completion of therapy (15,16).
Cancer continuum Examples of activities
Cancer prevention and health promotion
•
Comprehensive services for tobacco cessation•
Provide counselling on physical activity•
Provide brief psychosocial interventions for people with hazardous, harmful alcohol use•
Provide nutrition education and counselling•
HPV, hepatitis B virus vaccinationEarly diagnosis of cancer and screening for cervical cancer
•
Counselling on symptoms of cancer, evaluation of family history•
Identification of suspect signs and symptoms of cancer•
Timely referral after a cancer diagnosis•
Counsel, provide and/or refer for screening servicesRoutine care during cancer treatment
•
Provide comprehensive primary care, including management of co-morbid conditionsSurvivorship care
•
Support management of long-term and late effects of treatment•
Prevent second cancers, including with health promotion•
Detect early recurrencePalliative care
•
Manage symptoms, including pain, nausea•
Basic psychosocial support•
Enable social support systems, including care at homeTable 8.2. Examples of services that can be delivered in primary care
Section III 140
Other sectors
health workers * Health car
sector **
Health workforce equipped to deliver quality health services
Universal health coverage with safe, effective, person-centred health services
Employed
Policies on production (e.g. enrolment in schools) Policies to address maldistribution and inefficiencies (e.g. improve productivity, skill mix) Policies on address inflow and outflow of labour (e.g. migration)
Policies to regulate private sector (e.g. dual practice) Migration
Labour market dynamics Education sector
Fig. 8.2. Planning, educating, deploying, managing and rewarding health workers
Adapted from reference 21
Lack of trained health workers is a global problem, particularly in LMIC. In a survey of 93 countries in 2017, 8.6% did not have a single clinical oncologist; in 29%, an oncologist cared for approximately 1000 patients with a new diagnosis of cancer (25 countries in Africa, two in Asia, none in Europe or the Americas); in 42%, oncologists provided care for approximately 500 patients; and in 24%, an oncologist cared for approximately 150 patients (17). Demand for service will increase with the increasing number of patients and cancer survivors who require follow-up care (18).
For LIC, workforce strengthening may require international training to increase competence in oncological care. Such training should be suitable for the country with respect to differences in the scope of clinical practice (19). Strategies in MIC may be to optimize competence and increase capacity