National Audit Office: the start of cancer treatment should be accelerated, and the participation in cancer screening should be increased

12/14/2021 | 12:01 AM

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TALLINN, 14 December 2021 – Even though each week of delay in treatment reduces the rate of survival of an oncological patient by 1-3 percent, quite often cancer in Estonia is detected at its late stages. Insufficient participation in health screening is one of the reasons why malignant tumours are detected too late. However, according to the recent audit of the National Audit Office, even after a malignant tumour has been detected, there still might be delays in different treatment stages. The National Audit Office has recommended to intensify the messaging about the possibilities of taking part in cancer screening and to simplify screening registration procedures as well as to establish a smoother and faster pathway for patients with suspected cancer to diagnostics and treatment.

In the course of an audit, the rate of the access of patients to treatment was assessed with regard to four tumour locations: lungs, colon, cervix uteri, and breast. The Director of Audit of the National Audit Office Ines Metsalu-Nurminen has said that the first delay occurs at the stage of early cancer detection. “The lives of patients could be saved by means of early detection, and also by finding the possibilities to be referred to treatment as fast as possible. Depending on tumour location, at its initial stage, the disease is only detected in a half or even less than a third of cancer cases, which means that for many patients it is too late for efficient treatment”, said the Chief Auditor Ines Metsalu-Nurminen. For example, in 2018, only 29% of cervical cancer, 35% of colorectal cancer, and 49% of breast cancer were detected at an early stage of the disease.

“Even though cancer screening is the internationally acknowledged efficient method of prevention of advanced cancer cases, the rate of participation in such screening procedures in Estonia is insufficient, and just a half of the people invited actually take part in them”, the Director of Audit Ines Metsalu-Nurminen added. In 2020, just 52% of the target group took part in cancer screening related to breast cancer, 50% of the target group took part in screening related to colorectal cancer, and only 42% of the target group related to cervical cancer took part in cancer screening. Insufficient participation in 2020 could indeed be affected by the COVID-19 pandemic. However, in 2019 the rate of participation had not been much higher. The goal for the rate of participation in cancer screening in Estonia is at least 70% of the target group.

The rate of survival (likelihood of staying alive after five years) is different, depending on the location of a tumour. With regard to the locations of cancer covered by cancer screening programmes, the rate of survival is higher, but among patients with colorectal cancer and breast cancer it is still 10-13 percent lower than in the countries of the Northern Europe. The reasons for insufficient coverage of cancer screening programmes are the low level of education and low awareness of cancer screening programs, but also the fact that the messages about cancer screening is not aimed exactly at target groups, and recipients just do not get the invitations. In addition to that, people can mainly register for cancer screening by phone, since it is not possible to book the time via the digital registration portal. A positive example is the mobile mammography, which is a bus service that brings the service closer to people, and people are made well-aware of its services. In Jõgeva, Põlva, and Saare counties the mobile mammography has helped to increase the rate of participation in breast cancer screening.

“The second delay occurs at the stage of the start of the treatment”, the Director of Audit Ines Metsalu-Nurminen asserted. She said that in cancer treatment, it is recommended that the treatment should start within 9 weeks, or 63 days after the initial meeting of a patient with the doctor. “Only those patients with breast cancer, whose first treatment session started on the 52nd day after the first visit on the average received the treatment at the right time”. A delay on the way to treatment takes place both at the stage of family physicians and medical specialists with regard to all other locations of cancer under examination. It took about 100 days for cervical and lung cancer patients and 122 days for colorectal cancer patients to start the treatment.

On the basis of expert assessment carried out by the Estonian Society of Oncologists, for example, a family physician did not treat 24% and a medical specialist 12% of patient with colorectal cancer at the appropriate time. If the patient arrives at a cancer centre, there are much fewer delays. And still, according to expert assessment, cancer treatment specialists fail to treat 12% of patients with lung cancer in due time, and in 13% of cases there was a delay in the treatment of colorectal cancer even after the patients´ final diagnose was confirmed.

Delays mainly occur in dealing with patients: if a doctor makes a mistake in the course of physical inspection, when making the initial diagnosis, or sending patient to the appropriate examination. There are also cases when the queue for the examination is too long. Standstills in treatment may also be caused by patients themselves, i.e. sometimes they just do not show up at appointments. Besides, delays in the start of the treatment may also be caused by flaws in information exchange: case histories do not get uploaded into the information system, the information is of poor quality, etc. 

Each week of delay in treatment increases the death rate of patients. For example, earlier scientific research has shown that the delay in the start of the treatment increases the death rate by 1.2-3.2% per each week of delay.

The National Audit Office has discovered that the share of cancer treatment funding in the Estonian health care expenditure is one of the largest compared to other areas, but we fall behind many European states in terms of the supply of personnel and equipment related to cancer treatment. Cancer treatment expenditure in Estonia has increased by ca 10% per year as the number of patients has increased and new services and medicinal products have been added to the list of health care services. As a rule, in Estonia, cancer treatment expenditure is reimbursed even if it exceeds the originally planned budget for the area. Direct costs related to cancer treatment accounted for 5.8% of all health care costs in Estonia in 2018, remaining below the European average (6.2%).

The need for cancer treatment resources may increase even further in the coming years. Due to the pandemic, fewer people were screened and treated for cancer. Insofar as some people did not see a doctor in time and later treatment may be more expensive, cancer treatment expenditure may increase faster than before.

The period of time spent on making a decision concerning the need to compensate for the cost of new medications in Estonia is one of the longest in the OECD and among the EU countries. According to the data of the World Health Organization, the availability of cancer medications at the basic level in Estonia is guaranteed indeed, but in terms of availability of new medications we fall behind the OECD and the EU countries. According to the report of the OECD, among the observed medications, 62% of them are to be reimbursed, while in other countries this figure makes up 73% on the average. The period of time that is spent on adding medications into the list of reimbursed pharmaceuticals and health care services after obtaining a sales permit in Estonia is one of the longest among the observed countries: in Estonia it takes ca 40 months, while in other countries it takes 28 months on the average. The reasons for such a delay are the facts that the applications for compensation are filed several months after the marketing authorisation is obtained, and the proceedings for those applications in the medicinal products committee as well as agreeing upon prices later on also take a lot of time.

The National Audit Office has recommended to accelerate the proceedings related to compensation for new medications as well as to extend the range of institutions having the right to submit applications for adding new medications into the list of health care services of the Estonian Health Insurance Fund for the purpose of improving their availability.

In addition to that, the National Audit Office has recommended to simplify the participation in cancer screening for the people as much as possible, including to create the opportunity to book the time for cancer screening also in the national eBooking System. Moreover, the role of family physicians and nurses in the process of disseminating information about cancer screening as well as consultations and organising screening programs should also be increased whenever possible. The good practice of colorectal cancer screening could be used as an example, when a family physician gets in touch with the patient and provides consultation. 

The National Audit Office has recommended to provide the opportunity to cancer patients to come to appointments and to examinations within a shorter period of time. For the purpose of faster detection of cancer, the required medical guidelines should be established, and they should be integrated into the decision-making support application that family physicians use (a digital tool which helps to make better treatment decisions on the basis of medical records and health data). Furthermore, the patients suspected of having cancer should be referred to an appointment at a medical specialist via the system of e-consultation.

Background information

Within the past twenty years, the rate of deaths from cancer has increased from ca 3,200 cases per year to ca 3,900 cases. At the same time, the number of initial cases within the same time period has increased from ca 6,000 to ca 9,000 cases. Malignant tumours cause about one fourth of all deaths in Estonia.

For the purpose of prevention and early detection of cancer, breast cancer, colorectal, and cervical cancer screenings are held in Estonia.

In oncology, in 2020, the expenses made up 107.4 mln EUR, on the basis of the report for the financial year of the Estonian Health Insurance Fund.

The aim of the audit is to provide assessment as to whether or not the organisation of early detection of cancer allows to detect tumours in time, and whether or not cancer treatment starts at the right time, i.e. without undue delays.

The audit has been dealing with cancer screenings, i.e. the aspects of general health behaviour being a part of cancer prevention have been left out. From the perspective of cancer treatment, the audit has mainly focused on cancer diagnostics and the timeliness of the start of active oncospecific treatment.

In the course of the audit, expert assessment was carried out in cooperation with the Estonian Society of Oncologists, in which the timely detection of cancer location (breast, cervical, lung, and colorectal cancer) was analysed on the example of patient records of 400 patients.

Priit Simson
Head of Communications of the National Audit Office
+372 640 0102
+372 5615 0280
priit.simson@riigikontroll.ee
press@riigikontroll.ee
http://www.riigikontroll.ee/

  • Posted: 12/14/2021 12:01 AM
  • Last Update: 12/13/2021 11:55 PM
  • Last Review: 12/13/2021 11:55 PM

The National Audit Office has recommended to intensify the messaging about the possibilities of taking part in cancer screening.

Elmo Riig / Sakala / Scanpix Baltics

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