​Time is of the essence in the fight against cancer, and prompt diagnosis and treatment can make a big difference in patients’ lives and treatment outcomes. Radu Komsa, an expert in health care policy, conducted a study as part of the “The End Is Not Here” project, which aimed to analyze the time that cancer patients spend waiting for treatment to begin. Radu Komsha also described the main state policy measures that can be taken to reduce the time on the therapeutic path.

1. Please briefly describe the research you have carried out in the case of the journey through the health care system in Romania and in the systems of other countries, in the case of patients with breast cancer.

The aim of the study, commissioned by Novartis, was to measure the length of time that breast cancer patients spend interacting with the health care system, from the first symptoms to the start of treatment. We divided this course into several stages and, using an anonymous questionnaire, asked patients from several treatment centers how much time they spent in each of them. We wanted to know what the duration of each stage is, as well as how the individual times are distributed from shortest to longest. In parallel, we consulted the international specialized literature to find out how long the relevant stages last in other member states of the European Union, Great Britain and North America. Knowing the times achieved in our country and in other countries, we were able to determine which phases are unnaturally long in our country and which require priority intervention. We also aimed to gain a useful experience that would help us reduce the time to access treatment.

1. Give some socio-demographic data about breast cancer patients.

Among the interviewed patients, the majority came from an urban environment, but not with a large difference compared to a rural environment. Another observation concerns studies completed: the sample included patients whose most recently completed form of education varied, namely gymnasium, high school, post-secondary school, and university. Most of them were high school and higher education graduates. Almost all patients were women, but it is important to emphasize that men can also develop breast cancer, although in much smaller numbers.

1. What is the clinical course of a patient with breast cancer, from the first signs of the disease to diagnosis and treatment, and what did you follow?

The considered clinical course included the period from the detection of the first signs of the disease to the start of anticancer treatment. Within its framework, the main stages are detection of the first signs, consultation of a family doctor, consultation of a specialist who causes suspicion of cancer, mammography, ultrasound, biopsy, pathohistological and immunohistochemical examination, imaging studies, diagnosis and treatment.

Ideally, the time between each of these milestones is known so that we can intervene on those that are taking too long. However, the data collected did not allow us to measure with this level of detail, as the patients did not accurately remember the corresponding calendar dates. Thus, with the reliable data that we had, we were able to divide the course of the patients into four phases, respectively: 1. the first signs – the first visit to a specialist that raises the suspicion of breast cancer; 2. the first visit to a specialist doctor – conducting a biopsy; 3. conducting a biopsy – establishing a complete diagnosis; 4. establishing a diagnosis – starting treatment (surgery, chemotherapy, hormone therapy, etc.).

1. How do the results in Romania compare with other countries?

Given that the survey was conducted in only three treatment centers and that the sample consisted of people who were willing to respond, we cannot say that its results can be generalized at the national level, but they provide a guideline that can be used to develop a representative statistical research. . In order to analyze them comparatively, we documented the trajectories of patients in five other countries based on published specialized papers and compared the times determined with those observed in Romania, where possible. These five were France, Poland, Spain, Great Britain and the United States of America. The studies in France, Spain, Great Britain and the USA were based on data from electronic patient registries, and in Poland – on interviews with patients, as in the case of the study conducted in Romania. The conclusion is that the duration observed in France, Great Britain, USA and Spain is significantly shorter than in Romania for all stages of the patient journey, while in Poland it is similar to ours.

1. To draw a general conclusion, how does Romania compare to other European countries in terms of the characteristics of the patient’s journey through the Romanian healthcare system?

In countries that work better than us, mechanisms that matter take longer to implement at the level of the health care system. For example, they all have systematic breast cancer screening programs where women are invited for periodic examinations. Thus, women are informed, the clinical pattern is well known to all involved physicians, and there is increased potential for rapid performance and processing of imaging and pathology studies. Also, patient-navigators help patients in Spain, Great Britain, and the United States to carry out and decipher the necessary consultations and research after raising a suspicion.

1. How does the duration of therapeutic courses differ depending on certain socio-demographic characteristics?

In the study sample, we found that the differences between the durations recorded by categories of studies completed were statistically significant. Patients with secondary and tertiary education took more days to start treatment than those with secondary and tertiary education.

The largest gaps were found in the stages between first symptoms and referral to a specialist, as well as between biopsy and full diagnosis. They suggest four main issues that can cause delays to be unnecessarily long:

• Insufficient awareness of patients;
• Insufficient awareness of doctors regarding accompanying patients along the clinical route;
• Lack of coordination of patients on the clinical route;
• Insufficient capacity to perform and interpret images and anatomical-pathological studies in an optimal time.

1. What do you think are the top 3 public policy measures that can be implemented in the short to medium term to reduce the waiting time for breast cancer patients on the therapeutic pathway?

Taking into account the results of the research carried out, as well as discussions with specialist staff, patient navigators and patients themselves, I believe that there are three areas of intervention that may benefit in the medium term (in the short term, these interventions should be regulated).

1. Coordination of patients on the clinical route after breast cancer is suspected. I believe that the health insurance system should pay patient navigators the same way they pay family doctors, specialists, or other categories of providers. Once we decide that this is a good solution and allocate the necessary funding, the next step is to determine the best implementation tool: navigators to be contracted with health insurance companies or to be hired by public hospitals.
2. Increasing the potential of providers of imaging and pathological studies. We need to bring in suppliers – public and private – to increase capacity and capability. Of course, this may involve hiring additional staff and purchasing equipment, but streamlining internal processes and incentivizing staff is often enough. In order to motivate providers in the desired direction, I believe that CNAS should pay for paraclinical outpatient examinations of patients with suspected cancer. Performance will be assessed between the appointment and the notification of the results of the investigation. Providers who meet pre-set national targets can receive a much more incentivized reward. In turn, suppliers must pay additional wages to deserving employees.
3. Informing patients and providers involved in the clinical pathway. It is clear that we need a national program of systematic breast cancer screening. Until it is implemented and matures, informing patients and health care providers will play an important role in ensuring that patients receive treatment as soon as possible. Patients should be instructed to pay attention to the signs of the disease and, if there are any, to urgently consult a family doctor. Family physicians and community nurses need to know how to refer patients further along the clinical pathway to the nearest specialists.

******

The End Is Not Here is a joint effort initiated by Novartis with the support of Point PA&PR, which aims to identify the challenges faced by patients with breast cancer and proposed methods to optimize their course in the healthcare system.

Article supported by Novartis Romania