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How to implement the national strategy for cancer

Paul Mulholland speaks to Director of the National Cancer Control Programme Dr Jerome Coffey about the implementation of the national cancer strategy and the current state of cancer services

It is 13 years since the publication of A Strategy for Cancer Control in Ireland. The cervical cancer screening controversy last year made it easy to forget the success achieved with this strategy, which was seen as a benchmark for other services to emulate. Chief among the reforms was the centralisation of cancer services to eight specialist centres, as well as innovations such as rapid access clinics and electronic referral. The National Cancer Control Programme (NCCP) was also established under the strategy to provide leadership and drive improvements in cancer care. 

In 2014, the Department of Health commissioned an independent evaluation group to examine how successfully the 2006 strategy was implemented and to assess the overall impact of the strategy on the burden of cancer. While the evaluation group was impressed with progress in the cancer control system since the publication of the strategy, it found that Ireland remained significantly behind the countries that are leading the way in cancer control.

Recommendations focussed on legislative/structural issues, such as the need for mandatory notification of cancer diagnosis and the introduction of a unique patient identifier; improvements to the IT infrastructure; a greater emphasis on prevention; and for the current model of service delivery to be re-examined and the establishment of comprehensive multidisciplinary oncology teams to be pursued. These, and other recommendations, were to be addressed by a new national cancer strategy, which was published in 2017.

Almost two years into the new strategy, the Medical Independent (MI) sat down with Director of the NCCP Dr Jerome Coffey to discuss progress made in its implementation and the state of cancer services in Ireland.

New posts

The NCCP’s budget for 2019 is €94.7 million, which marked an increase of €8.9 million compared to the previous year. The HSE National Service Plan 2019 noted that though the allocation increase should lead to service improvement, it “will not enable the service to match referral demands in areas such as radiotherapy, rapid access cancer clinics, and diagnostics”. The CEO of the Irish Cancer Society (ICS) Ms Avril Power recently told the Joint Oireachtas Committee on Health that the lack of funding provided for the national cancer strategy was “truly shocking”.

Though Dr Coffey is quick to admit the reality of financial pressures on the NCCP, he offers a more positive assessment of the Programme’s finances, pointing to the €2.75 million released at the end of last year for badly-needed new posts.

“Between last year and this year we got a significant amount of new funding,” Dr Coffey told MI.

“To give you a flavour of it, we had funding and approval from the end of last year to this year for about 20 new consultant posts. And that is split between medical oncology; haematology; radiology and pathology; surgical posts; and we have matched most of those to CNS [clinical nurse specialists] or ANP [advanced nurse practitioner posts] posts. On top of that we have four pharmacy posts; it is the first time we have ever recruited hospital pharmacists to support cancer services.”

The increasing complexity of care through systematic therapy makes the recruitment of new posts especially vital, he said.

“Our systemic therapy programme here has gotten bigger and bigger, and talking to hospitals, if you look at medical oncology, part of the capacity issue is day wards, part of it is staff, and an important part of the staffing is pharmacists and pharmacy technicians. We would aim to do that again and again until we have the capacity; those are the priority posts.”

According to Dr Coffey, the recruitment problems leading to consultant vacancies across the health service is not a particular issue in oncology.

“Generally when we have posts, they are filled,” he said. “They are so specific.”

Cancer strategy

Of the 52 recommendations contained in the National Cancer Strategy 2017-2026, some 37 come under the domain of the NCCP. Recently the first implementation report on the strategy was published by the Department of Health. It showed progress across a number of areas up until the end of 2018, such as the roll-out of the national cancer information system; progress towards a national skin cancer prevention plan; and publication of a model of care for oral anti-cancer medications, for example. However, some of the main recommendations are behind schedule, such as the plan for the NCCP to establish a national cancer research group by the end of 2017. The document stated this will not happen until 2019.

The ICS has also pointed out six out of seven interim key performance indictor (KPI) targets due to be met by the end of 2018 were missed. The only one that has been achieved is the interim target to reduce the proportion of adults who smoke daily. Targets that have not been met include one on timeframes for patients to be seen in rapid access and symptomatic breast disease clinics; and another on reducing waiting times for surgery.

“There are some very tight deadlines in the strategy,” according to Dr Coffey.

“But we had to prioitise, and we are getting there. It is a lot of new work on top of our day to day work; we were busy enough until 2017 and now this is entirely new. So we are bringing some staff in to manage the implementation.”

Dr Coffey said the NCCP knew where the pressures in the system were before 2017, but the strategy has provided a focus and framework for improving services.

“Even before the strategy came out, we knew where the pressures were and that we had to recruit more staff,” he explained.

“So those consultants will help with the implementation of the strategy, but actually they are also essential for the delivery of the service. The surgical posts will be lined up to the cancer centres and the other big project, which is also mentioned in the strategy, is where cancer surgery should be.

“We know that about 84 per cent of cancer surgery takes place in the cancer centres and the target is to get that up to 95 per cent in three years. To do that will require additional surgeons, we have some funding for that.”

Surgery centralisation

The need to further and consolidate the centralisation of cancer surgery was one of the major recommendations contained in the strategy. At the end of last year, this newspaper reported that the Department of Health was considering the second draft of the programme’s centralisation plan.

The NCCP submitted the first draft to the Department in 2017, but was asked to make a number of amendments, and the programme was required to draft a revised document. The plan was due to be finalised at the beginning of March. What has caused the delay in getting the plan approved and implemented, given a lot of cancer surgery, such as breast cancer, has already been centralised?

“I would say, the complexity,” according to Dr Coffey.

“It took us a while to get all the data together. We had to get that done, the next thing was international literature research, and the next thing was how do we implement it. It is okay having a plan, but how do you implement it, at a group level, at a cancer centre level, and that is the hardest question to answer. If you look at examples, there would have been large services that would have existed for decades, but don’t have to be in cancer centres. Head and neck cancer in Cork would be an example. You have got a large urology department in Tallaght, so the question is, how do we get that to be part of a designated cancer centre in St James’s? That will require even more detailed planning once we get the plan through the HSE down to the Hospital Group level and to the cancer centre level.”

Diagnoses

On the publication of the implementation report, the Irish Cancer Society highlighted that many patients were not getting diagnosed within the timeframes set out in the strategy. According to Dr Coffey, the issue is “a standing item” for the NCCP.

“We started a rapid access clinic diagnostic exercise a couple of years ago now, with a follow through in implementation, and last year, and probably the end of the previous year we put in additional staff in the centres, which required additional staff,” he said.

“We put in some nursing staff, some admin staff where required, and actually the new posts last year, some data management, some admin and nursing, which linked to the requirements in the clinics. If you look at the performance report for the last quarter of 2018, you will see there is very sustained improvement in the breast, lung and prostate diagnoses, that is the desired result from the effort over the previous year and a half.”

On the rising demands being placed on services, he said: “You do see in certain centres demand going up over time, and I think we have started to address that by putting the staff in. If you look at symptomatic breast disease clinics, they are seeing anybody with symptoms and most of those will not have breast cancer. So you have a demand there with a high volume, people coming in, that have the work-up, that will not have breast cancer. But we are measuring them as a metric.”

Access to diagnostics

Dr Coffey pointed out that Beaumont Hospital, Dublin, and St Vincent’s University Hospital, Dublin, regularly meet their targets for seeing breast cancer patients. He attributed this to the referral pathway employed by the hospitals, in which GPs are given access to mammography when required.

“My understanding is that Beaumont and Vincent’s over many years have given GP access to mammography and any mammogram that isn’t pristine gets flagged and goes to clinic,” he explained.

“So a lot of patients will get assessed by their GP, get a mammogram and will not need to go near the clinic. And the question is, if that works so well, should not the other cancer centres be considering it? We have a group working on it. We have a literature review done and my understanding is that a decision will be made before the end of the year should other centres move toward that pathway.”

Dr Coffey also referred to CT scanning in Cork University Hospital for lung cancer, which can be accessed before patients even attend the rapid access clinic.

“That may be the preferred model of care in the future,” he said.

KPIs

During the interview, Dr Coffey highlighted the importance of the NCCP receiving up-to-date data from cancer centres regarding their targets. Under the strategy, centres are required to send KPI data to the NCCP, which allows the programme to measure performance and see where there are deficiencies in service.

KPI data shows “how are things working, how busy are they, what do they need in the service plan cycle for next year”, according to the NCCP Director.

“Unless there is some sort of data coming in, it is hard to know exactly what their requirements are.”

MI has learned that the programme recently contemplated withholding funding from some hospitals due to delays in receiving the data.

At a senior management meeting in December 2018, the minutes of which were seen by MI through Freedom of Information law, it was noted that required KPI data had not been received from the Mercy University Hospital, Cork; St Vincent’s University Hospital; or Cavan General Hospital.

The minutes stated that Dr Coffey was to “send out follow-up letter to those hospitals in relation to withdrawing reimbursement (from January) if no data is forthcoming”.

However, Dr Coffey said the NCCP has not withdrawn reimbursement from these hospitals and that the data is now being received.

“It’s a question of if we write again and don’t get the data, what do we do next? That was a consideration, but we haven’t had to use that lever [withdrawing reimbursement],” according to Dr Coffey.

Issues around receiving data on medical oncology was also highlighted at the meeting, which was described as a “multi-factorial problem”.

He said that often delays in receiving data are due to a data manager leaving and that once the post has been filled, the data required is submitted.

An online portal went live last year, which allows hospitals to compare their data against national figures.

The portal is also designed to allow the NCCP to receive and process data in a faster and more streamlined manner. The new national cancer information system, which is also referred to in the strategy, is due to go live in the next number of months. The system is designed to ensure the optimal and safe delivery of systemic cancer treatment, including e-prescribing and e-administration of chemotherapy.

“It is a basic tool for pharmacies, day wards and hospitals, who need to get rid of transcription, so there is a safety benefit there, it will generate a database,” according to Dr Coffey.

“We have already configured it to have the drug protocols, so there will be pull-down menus and all the rest of it. It is a huge benefit to the hospitals and it will generate a lot of data that we can use.”

Dr Coffey said the system will “probably streamline with the drug reimbursement part as well”.

Reimbursement

Speaking in general about the process of reimbursement of cancer drugs, Dr Coffey admitted there are continuing issues around drugs approved for reimbursement for one indication, but not another, even when it could be beneficial in the latter case.

“If it is a rare situation where there is no anticipation of a large amount of convincing clinical evidence, but there are some publications showing it could be effective, how do we address that?” he outlined.

“The discussion would be how can we have a system that responds to those rare indications. We haven’t made any great strides here. And this will come up in other clinical areas that aren’t cancer, so it’s a wider issue.”

On the high cost of oncology drugs, Dr Coffey said again that the issue was not limited to cancer.

“Take something like rheumatological diseases, that [Clinical Lead of the HSE Medicines Management Programme] Michael Barry was talking about… those are as expensive, if not more expensive. We are part of the overall drugs process; there is a single appraisal process.”

Capital costs

In terms of capital funding, Dr Coffey was keen to emphasise the progress being made. He pointed out that construction work on a new radiation oncology centre in Cork University Hospital is nearing completion. In Galway, there are enabling works underway for another radiation oncology building. He also spoke about the success of the radiation oncology centre at Altnagelvin Hospital in Derry, which provides cross-border access for patients in the north-west. Dr Coffey said he does not expect Brexit to impact upon the service for Irish patients, with the NCCP examining service level agreements to ensure minimum disruption.

“What I would like to say is that the Altnagalvin centre is so well designed and has such potential, it is not a question of Brexit causing problems, but the centre offering more services to the region,” Dr Coffey argued.

“If you look at it, apart from having radiotherapy there, part of the agreement is on some access to chemotherapy, some inpatient beds and it would be interesting to see how cancer services in that region could be more aligned.”

The purchasing of new equipment, both additional machines and replacement machines, is also a priority for the NCCP. Last year St James’s Hospital was forced to suspend its family breast screening service due to problems accessing mammography, which has since been addressed. Dr Coffey also confirmed that other hospitals recently have had their mammography machines replaced and upgraded.

“When you look at the cancer strategy, there is a need to build up a rolling capital investment and replacement programme,” he said.

“And we can certainly do that once the big projects are out of the way. The next thing after Cork and Galway in radiation oncology is equipment that went to Dublin in 2011. In a couple of years that will have reached the 10-year point and need replacing. And there are plans to extend the radiation centre in Beaumont and there is a design team working on that at the moment, so we expect them to have their work done this summer, and potentially a planning application as well.”

Prevention and screening

The new strategy places a greater emphasis on cancer prevention than the previous strategy. Among the recommendations are that the NCCP will develop a cancer prevention function, working in conjunction with the broader Healthy Ireland initiative, and will lead in relation to the development and implementation of policies and programmes focussed on cancer prevention.

“It is a function we haven’t got into in a big way here until the strategy came out, but there is now a recommendation that we have to. Of any common cancer, lung cancer is probably one of the highest priorities.”

On lung cancer, policies to reduce smoking are obviously vital. There is also the matter of lung cancer screening. In 2017, The Lancet published a European position statement on lung cancer screening, which stated that lung cancer screening with low-dose CT can save lives and should be considered by health services in EU countries.

The International Association for the Study of Lung Cancer also issued a statement last year on lung cancer screening with low-dose CT based on results from the Dutch-Belgian NELSON lung cancer screening trial presented at the IASLC 19th World Conference on Lung Cancer in Toronto, Canada. The IASLC early detection and screening committee, recognising the importance of these results, now affirms the strength of evidence arising from two large, “well-designed” and “well-executed” randomised trials that LDCT screening in high-risk individuals can significantly reduce lung cancer mortality. The NCCP has been part of a literature review examining the current evidence, but Dr Coffey said that screening is not the direct responsibility of the Programme.

“It takes a couple of years to design a programme like this if you want to get into it,” according to Dr Coffey.

“So it is not something which needs a rapid response. It’s a case of looking at the current state of the science and the evidence, we need to use that.”

He said it is not the NCCP’s role to be making recommendations on the issue, although he admitted the new evidence looks very promising.

“We are not saying that we definitely need to do lung cancer screening in 2020,” he stressed.

Future of the strategy

In spite of the recent criticisms that funding for the strategy has been insufficient, Dr Coffey said that if the new funding made available over the last year, was made available every year, he would be confident that the strategy would be implemented in full. However, he realises that though a multi-annual funding plan would be ideal, it is not the way the system works.

“If we had funding for a 10-year strategy, that would be kind of utopian,” Dr Coffey said.

“It would make things a lot more certain, obviously. But that is not the way the system works, and we have to work with the system.”

The question of genetics

Cancer genetics is a complex area that is constantly evolving. Because of this complexity the NCCP has not decided upon the best model to adopt in Ireland. Waiting times for genetic tests in the Department of Clinical Genetics at Our Lady’s Children’s Hospital, Crumlin, are long, but it is not clear what new service should be provided. When asked what type of cancer genetics service he would like to see in Ireland, Dr Coffey told MI: “If this was our only priority we could say, let’s have an answer for next year, but there are a lot of moving parts and we don’t have an influence in all areas. So if we had a capital budget here that said we can justify a standalone lab for cancer genetics, or if somebody gave us a couple of million to do that and have staff, we would say grand… but we are not in that situation here. We are part of the broader HSE discussion on the future of genomic medicine.”

Dr Coffey highlighted the different issues that need to be considered when deciding upon a future model.

“Is it invest in a lab, invest in multiple labs, is it a blend of providing some services in-house and outsourcing stuff that is low volume or highly complex,” he said.

“Those decisions haven’t been made yet. It is interesting because it is science being applied very quickly. There is probably potential there for universities because there is a lot of genetic research in the universities, they wouldn’t necessarily be able to switch into a clinical service overnight. But there is potential there. We have had very peliminary discussions over the last year or so around this.”

Dr Coffey also referred to a national genetics information system, which the NCCP is currently planning to procure.

“We would need to have a software solution that supports the clinical service,” according to Dr Coffey.

“That is going to be hub-and-spoke across the country, so you will have one online service where you will have patient details in there, the requested test orders, etc. There is not one ideal commercial solution there, but we are working on it to figure out how we procure one.”

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