The rapid increase in cancer cases gave rise to long-term cancer prevention and control programmes. The National Cancer Control Strategy pursued to achieve 5-year survival rates close to the results of other EU developed countries. Another objective is to improve early detection of cancer and hence to reduce cancer rates. Also the Strategy highlighted the need to develop new organisational solutions to improve cancer diagnostics and treatment process.
Malignant cancers in Poland pose a serious health, social and economic problem. Approx. 170 thousand cancer cases and over 100 thousand related deaths are reported every year. Cancers are the second death cause in Poland (after cardiovascular diseases). Currently more than 1.17 million Polish people live with cancer – 440 in every 100 thousand citizens heard this diagnosis.
For patients diagnosed in 2015-2019, the 5-year survival rates in Poland slightly exceeded 55%. In the past two decades, the survival rate improved continuously. In 2015-2018, as compared with 2000-2004, the highest survival rate was reported for the prostate cancer and the lowest one for the lung cancer. The general cancer rates in Poland are lower than the EU average both for men and women. The ratios are 30% higher for men and 25% higher for women which implies problems with early detection and treatment of cancers.
Previous NIK audits of 2018 and 2019 indicated a failure of the cancer care system, missing coordination of cancer care and little interest among Polish people in prevention programmes.
The NIK audit of 2019-2023 was conducted in the Ministry of Health, Headquarters of the National Health Fund and 22 medical entities. It mainly aimed at verifying if the access to public-funded comprehensive cancer treatment was provided. Specifically, if effective measures were taken to improve early cancer detection, diagnostics and treatment and to enhance their organisation. Also, if the patients’ health needs were met in terms of health prevention programmes as well as cancer diagnostics and treatment.
The audit results reveal that the actions taken were not fully effective, e.g. with regard to early cancer detection, standardisation of pathology reports, defining measures of cancer treatment quality and creating new organisational structure of medical entities.
Ineffective efforts of Health Minister to improve early cancer detection
The Minister of Health, despite his awareness of low reporting rate for screening tests for a dozen or so years, failed to take effective measures to change the situation. Moreover, the documents developed in the Ministry of Health show that for the prevention programmes for women to be effective, at least 70% of persons should take part in them (acceptable level) up to over 75% (desired level).
In 2019-2023, the share of persons participating in prevention screening tests did not increase, although nearly PLN 136 million was spent on social campaigns which were to raise social awareness related to early cancer detection.
The reporting rate for cervical screening tests dropped from 16% in 2019 to 11% in 2023. For breast cancer it went down from 39% to 27% in the same period. As for the colon cancer prevention, the reporting rate was 14% in 2019, 10% in 2020 and nearly 17% in 2021. Funds earmarked for the “Colon cancer screening programme” implemented in 2019 as part of the National Cancer Prevention Programme were used only in about 56%.
The programme was continued in the following years as part of the National Cancer Control Strategy. However, due to delayed implementation of the Health Minister’s regulation on guaranteed benefits as part of health programmes, the colon cancer screening tests made by means of colonoscopy, were not financed for the first 10 months of 2022. As a consequence, only 116 colon cancer cases were diagnosed in 2022, i.e. about 3.5 times less than the average yearly detection rate for 2019-2021 (that is about 405).
Besides, the Minister of Health failed to implement FIT, the fecal immunochemical test, a new generation method for early detection of colon cancer. In 2019-2021, a pilot programme for this method was carried out to verify reporting rate for colon cancer screening tests, depending on strategies applied, taking FIT – apart from colonoscopy – into consideration. The pilot programme indicated that the test may be an alternative for colonoscopy. Though, despite experts’ recommendations saying that this method is more effective than colonoscopy, it did not become a commonly used method for colon cancer screenings. It needs to be noticed that the FIT reporting rate as part of the pilot programme in 2021 exceeded 31% and was significantly higher than the colonoscopy reporting rate.
In 2020, as part of the strategy, a pilot programme was planned to test the method to increase participation in mammography and cytology prevention programmes in selected provinces/ regions. In 2021, target solutions were to be implemented. Because of the COVID-19 pandemic that task was postponed and finally it was given up due to “the concept change”. NIK evaluated the above negatively, in particular considering the fact that the efforts taken to increase the share of persons participating in prevention screening tests proved ineffective.
NIK positively evaluated preparation of legal solutions extending the population covered by the programme for breast and cervical cancer screening tests.
Insufficient supervision of Health Minister over the strategy pilot programme
By assumption, the National Cancer Control Strategy was to be a new cancer care model based on the network of specialised facilities divided into three reference levels, depending on their potential and qualifications of medical staff.
Over 6 years passed from the onset of the strategy pilot programme which cost over PLN 130 million. Despite that fact and involvement of many experts, necessary information to facilitate its implementation was not provided. That is why, the strategy implementation deadline was postponed by over a year – to 1 April 2025.
That situation resulted mainly from the Health Minister’s ineffective supervision over the project implementation. Having been aware that the data from medical entities was incomplete and incomparable, he did not take effective steps to improve the situation. Also, that was inconsistent with the Public Finance Act.
The data that would be key to develop significant elements of the reform, including executive acts to the National Cancer Control Strategy Act, were not obtained.
What is particularly important, no indicators or their target values were defined to assess the cancer care quality. The key recommendations for clinical proceedings were not specified, either.
Without passing all essential executive acts to the National Cancer Control Strategy Act, it will not be possible to monitor healthcare quality, among other things to define quality measures and indicators and specify an algorithm for cancer care procedures. According to NIK, without any progress in these key areas, the risk is high that the cancer care quality in Poland – and hence the cancer death rates - will not be improved.
Impaired access to cancer care
The National Health Fund took efforts to provide access to cancer care services. A range of negative phenomena was found, though:
- only about 15% of medical entities providing cancer surgery services ensured comprehensive cancer care;
- considerable disparities were identified between individual provinces (up to 50%);
- disparities also concerned the number of oncology-related specialties in individual provinces (up to 452%);
- more cancer care services were provided as part of the cancer care package after the deadline for diagnostic tests (in case of initial diagnostics it was 25%-34% services and for enhanced diagnostics it was 24%-28%).
National Cancer Register (NCR)
Improving the quality and accuracy of data reported to the National Cancer Register (NCR) will be of key significance for successful reform of the cancer treatment system. Though, at the end of 2023, only 111 medical entities (about 3% of service providers who signed cancer treatment agreements with the National Health Fund) integrated their IT systems with the NCR and thus enabled providing Malignant Cancer Reports electronically. Only 18 hospitals integrated their hospital IT systems with the e-NCR system which allows sending required data in a completely automated way (without the participation of medical staff), upon minimising the risk of errors. The above shows that medical entities are not prepared to implement the cancer treatment reform.
Organisation of cancer care services in audited medical entities
Cancer care services were provided in accordance with the law in 18 of 22 audited entities. Cancer diagnostics and treatment procedures as well as treatment plans were established. Medical staff were properly qualified, all required organisational units operated in the medical entities’ organisational structure. Each audited entity had model radiological procedures in place, and in 21 of 22 cases they were consistent with the law.
It needs to be emphasised that patients were not treated equally - in seven audited entities up to 80% of patients received medical care outside the cancer care package. Those patients’ waiting time for the diagnostics was about 20%-30% longer than it was the case of patients being part of the package. This implies the risk of unjustified, unequal treatment of cancer patients. NIK already highlighted that phenomenon during its audit in 2017: “Preparation and implementation of the cancer care package”.
Recommendations
To the Minister of Health
Bearing in mind the system defects of cancer care in Poland, NIK recommends implementing a full-fledged reform of cancer care, guaranteeing equal access to medical services and complex treatment. The following in particular will be needed:
- standardisation of pathology reports,
- defining measures of cancer treatment quality,
- increasing the share of persons participating in screening tests designed for early detection of malignant cancers.
To medical entities
To improve cancer care conditions as well as the system functioning organisation, the following are necessary:
- admission schedules and waiting lists for medical care services and for patients with the Cancer Diagnosis and Treatment Card (from Polish: DiLO Card) need to be run properly;
- cancer diagnostics and treatment services should be provided on a timely basis;
- data in Malignant Cancer Reports need to be filled in properly and then transferred with due diligence to the National Cancer Register;
- internal clinical audits should be carried out in medial entities applying medical radiological procedures, referred to in the Nuclear Law Act.
