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1199_pagina_56-63_systemsandservices

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Published by Kathi Apostolidis
A Cancer World Survey on frontline cancer care in Europe
A Cancer World Survey on frontline cancer care in Europe

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Published by: Kathi Apostolidis on Sep 05, 2012
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09/05/2012

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 Patientspay a pricefor spending cuts
§
Anna Wagstaff 
Austerity measures brought in to tackle the debt crisis are affecting frontline healthcareservicesinmanycountries,particularlyinthecomplex,expensivefieldofoncology.
CancerWorld
askeditsreaderstosharetheirfirst-handexperiences.
D
octors are sounding thealarm about the pricecancerpatientsarepay-ing for dramatic cuts inpublic spending. In thecountrieshardesthitbyEurope’sdebtcrisis,servicesarehitfrommanydirec-tionsatonce:staffingcutsleavesomeoperating theatres and linear acceler-ators idle, while patients flood intothepublicservicebecausetheycannolongeraffordprivatehealthinsurance.Patientsarealsoincreasinglyunabletoget hold of drugs they need, as phar-maceutical companies withhold sup-plies due to unpaid bills – a problemwhich may be exacerbated by a grow-ing re-export trade in which drugsbought at a lower price negotiated by debt-stricken governments find theirway onto international markets to besold at a profit. JohnSpiliotis,adirectorandchair-manoffirstdepartmentofsurgery,andpresident of the scientific council of the Metaxa Memorial cancer hospitalinPiraeus,Athens,describesthesitu-ation as working in “wartime condi-tions”. His hospital has seen a 50%cut in its budget over the last three years,whileadmissionshaveincreasedby more than 30%. “If you comparethese two figures, the conclusion ismaybewehaveacrisisinthemanage-ment of cancer patients,” he says.Public sector employment rulesthat permit only one position to bereplaced for every 10 that are lost arecreating acute staff shortages thatimpactdirectlyonpatientcare.AttheMetaxa Memorial hospital two out of six operating theatres are now unusedbecausetherearetoo
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few scrub nurses.The inevitable resultis long waiting lists.Spiliotissayshejusttoldapatient diagnosed with col-orectalcancertocomebackin45 days. Waiting times forradiotherapy are evenlonger, he says. In the fourmain cancer hospitals and nineother public hospitals with radio-therapyequipment,thewaitinglististhreetofourmonths.“Itisverydif-ficulttoproposeneoadjuvantchemoradiation forpatientswithrectalcan-cer with waiting timeslike that. So the patienthas to get this treatmentfromprivatepractice.”Supplies of essentialcancer medicines, includingTaxotere,Temodal,Avastin,HerceptinandMabthera,aredryingup,saysKathiApostolidis, a breast cancer andpatientsrightsadvocate.Shedescribesdriving around the hospitals andpharmacies of Athens for a friend, insearchofsuppliesofZometa(zoledronicacid for controlling bonemetastases). Pharmaceuti-calcompaniesareinsistingon advance payment fromhospitalsandpublichealthinsurance, she says, whilepharmacies are refusingto deliver medicines topatients on credit.She believes patientsare being held hostagein the battles between theMinistryofHealth,pharmaceu-ticalcompaniesandpharmacists.There are worries too thatfinancial concerns are leadingpatientstodelayvisitstoadoctor.“We have a problem that 15–20%of patients do not consult a physi-cian. We compared results from2007to2009,anditseemsthatweareseeingcancerpatientsatamoreadvanced stage than three years ago,thoughwedonothavestatisticallysig-nificantdataonthisasyet.Iftrue,thiswould mean that not only are fewerstaff having to care for more patients,using fewer resources, but a higherproportion of patients are presentingwith cancers that are more com-plex, more expensive to treatand more likely to be fatal. While Greece isundoubtedlyatthesharpend of Europe’s debtcrisis, it is by nomeans alone. Withausterity the pre- vailing watch-word, public spending is being reinedin everywhere. Although countriessuch as Spain, Italy, Portugal and Ire-landareinthefrontline,countriessuchas France, Belgium, UK and theNetherlands are not far behind. EvenGermany, the strongest economy inEurope, has plans to cut public sectordebt by 
80 bn by 2014.As healthcare accounts for a highproportion of public spending,and cancer accounts for asizeable chunk of healthcarespending – with its need forcomplex multidisciplinary approaches to care, heavy use of expensive imagingtechniques,andrelianceonsomeveryexpensivedrugscancerservices are under pressure as neverbefore.For patients, many of whom at thebest of times feel they have to fight forquickaccesstothebesttreatments,themost urgent question is to what extentthefinancialpressuresonEurope’scan-cerservicesareaffectingfrontlinecare.Inanefforttoanswerthatquestion,
Cancer World
askeditsEuropeanread-ersforfeedbackonhowtheEuropeandebt crisis is impacting on cancercare in their own countries. Ninety responses from 20 European memberstates suggest that there is a strongperceptionthatthedebtcrisisishavinga direct impact on patient care wellbeyondthecountriesfacingthetough-estcuts(seebox
overleaf 
).Drawingoncommentsappendedtothesurveyandoninterviewswithsomeoftherespon-dents reveals a patchy picture acrossEurope, but patterns are emerging.
Systems&Services
    A    L    A    M    Y ,    C    O    R    B    I    S
 
A
CCESS TO DRUGS
Access to certain cancer drugs ischanging across Europe. Fatima Car-doso, director of the Breast CancerUnit at the Champalimaud CancerCentre in Lisbon, reports that somedrug companies have started to with-holdsuppliesfromhospitalsthathavebeen slow paying their bills. The gov-ernmenthasbeentryingtointerveneincaseswherethehospitalshavenoalter-natives,butCardosoexpectsthisprob-lem to get worse.Somedoctorshavebeenreducedtolying to patients because they don’twant to admit there is no money topay for the drugs they need, she says.Cardoso cites the case of a patientwhose bone metastases, which causeextreme pain and increase the risk of fracture, were being left untreated.“She had been told there are notenough data to support the use of bis-phosphonates,becausepeoplearenotfrankenoughtosay:youshouldreceivethis drug but we have no money togive it to you.”AswithGreece,publiccancerhos-pitals and oncology departments inPortugalarefindingthemselvesfloodedwith people who have had to give upprivate medical insurance. But eventhose who retain their private insur-ance can no longer afford the drugstheyneed,saysCardoso.“Evenaftersomanyyearsonthemarket,thepriceof trastuzumabissoshamefullyhighthatmost private health insurance barely covers the cost of one year of treat-ment, leaving nothing over to pay forthe chemotherapy and all the otherthingspatientsneed.Foradjuvantther-apy people sometimes do desperatethings such as selling their houses toget the money for one year of treat-ment. But if you have to go on and onfor as many years as possible,what can you do?”In Italy, Anna Costato,who is being treated foradvanced breast cancer,but is also a GIST patientadvocate as a parent of achildwithpaediatricGIST,reports that access to newdrugstakeslongerandcandepend heavily on where you live. This is because regionalhealth authorities have the final say onwhatwillbereimbursed,soanewmedicine may be restricted even afterapproval by the European MedicinesAgencyandthenationalItalianagency AIFA.Patients with rare cancers are hitparticularlyhardbymeasuresthatreg-ulate the prescribing of drugs for off-label use. Costato believes that themeasures,introducedin2007,arenowbeingwronglyusedtorestrictaccesstoexpensive drugs. She gives the exam-ples of sorafenib (Nexavar), dasatinib(Sprycel), and nilotinib (Tasigna),
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Peoplearenotfrankenoughtosay:youneedthisdrugbutwehavenomoneytogiveittoyou
WHAT THE SURVEY FOUND
Asurveyof 
CancerWorld 
readers,askingabouthowpublicspendingcutsareimpactingonfrontlinecancercare,attracted90responsesfrom20ofthe27Europeanmemberstates.Overall only 10% of respondents reported no impact on the quality of care cancer patientsreceive,withthevastmajorityreporting“someimpact(around40%)or“quiteanimpact(around 35%), and a little under 15% reporting “a huge impact”.Asmightbeexpected,accesstoanti-cancertherapies(regardlessofspeedofaccess)showedthe least impact, with almost 35% reporting no impact, a slightly higher proportion report-ing“someimpactandonly25%reporting“quiteanimpact”or“ahugeimpact”.Accesstoothertypesofcare,suchassupportivecareandrehabilitation,appearstobetakingmoreofahit,withonly20%reporting“noimpact”andmorethan40%reporting“quiteanimpact”or a “huge impact”.Patientsinmanycountriesarealsohavingtowaitlongertogetaccesstotheservicesthey need.Theimpactseemstobegreatestforspecificcancertherapies,suchassurgeryorradio-therapy,withalmost40%reportinga“hugeimpactor“quiteanimpactandonly20%report-ing“noimpact”.Butmanypatientsarealsofacinglongerwaitingtimesforseeingaspecialistandgettingthenecessarydiagnostictests(around25%and30%respectively reporting the top two impact categories).Interpretationofthesefindingsaresubjecttoalltheusualwarningsaboutself-selection of respondents and the subjective nature of the responses.

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