Analyses

Cancer care is a complex process in which multidisciplinary evaluations and treatment regimens can mean communication between professionals with different specializations, in different locations and often across different levels of facilities. Not only can this be particularly overwhelming for the individual and/or families to navigate and access, but such a complex and dynamic process can be prone to bottlenecks and delays at different points.¹

This complexity can also exacerbate barriers to accessing healthcare services. Factors such as the physical distance (and associated transport costs) from these services, language barriers or job insecurity due to illness-related absences can further impact access to healthcare. Evidence suggests that barriers to healthcare disproportionately affect racial and ethnic minorities as well as lower-income communities, widening the inequity gap.²

In this article we will explore how two European countries, Malta and Austria, took different approaches to improving cancer care pathways, making the most of their geographic, political and healthcare organizational conditions. Malta, as a small Island nation, prepared a nation-wide response, while Austria took advantage of its organization in smaller federal states.

Hindrances in cancer care pathways often lead to worse cancer outcomes across the population 

Delays in cancer care are a concern for most healthcare systems worldwide. Available evidence showing that hindrances in the cancer care pathway, from bottlenecks to difficulties in navigating and accessing the services, have a negative impact on cancer outcomes, including on mortality.^3–7

A systematic review looking at seven types of cancer (bladder, breast, colon, rectum, lung, cervix, and head and neck) and three treatment approaches (surgery, systemic treatment and radiotherapy) found that even small delays of four weeks increase the risk of death. As the weeks progress, the impact on this probability increased with a 12-week delay representing an increase in the risk of death of 26%. When translating this individual risk to impact on the overall population, authors estimated that a 12-week delay for all patients with breast cancer for a year would translate to 1400 excess deaths in the UK.³

As such, optimizing cancer care pathways, making them easier for people with cancer to navigate, while making transition between levels of care more seamless with fewer delays is a promising policy option and is included as a recommendation in the EBCP. As these pathways are so complex and across multiple levels, it is crucial to consider the journey of a cancer patient through all these services and apply a systems approach to improving quality. For example, improving access to screening programmes at a primary care level and not considering bottlenecks or physical access to hospital-based treatment when needed will not translate to population health gains.^8,9

Malta established a National Directorate for Cancer Care Pathways with a patient navigation programme

In 2020 cancer represented around 25% of the deaths in Malta. Due to the high cancer burden in the population, the government established a National Cancer Plan for the Maltese Islands 2017–2021.¹⁰ Delays along the cancer care pathway were identified as one of the key aspects negatively influencing cancer outcomes¹¹ and, as such, Malta established a specific Directorate for Cancer Care Pathways alongside a wide-ranging set of activities to improve the quality of cancer care.

One of the key activities led by the new National Directorate was the establishment of patient navigation programmes alongside the establishment of nurse-led follow-up clinics. Patient navigation programs are aimed at helping patients access services and overcome barriers to receive timely and quality care. These can be led by professionals (who can be healthcare or social workers) or by trained lay persons. In cancer care they can be particularly relevant as patients navigate the care continuum across different stages, all the way to survivorship. Additionally, they can help to address inequalities when supporting vulnerable and disadvantaged populations as well.¹²

Limited evidence suggests these programmes improve access and continuity of care.^12,13 For example, a systematic review found that most programs were effective at increasing the uptake of cancer screenings and attendance to follow-up medical appointments. Additionally, this review found some evidence of cost-effectiveness. However, most evidence seems to be focused on the earlier stages of the cancer care continuum, particularly screening and diagnosis stages.¹⁴ As such, there is a need for further evidence evaluating the cost-effectiveness of navigation programmes that expand across the whole cancer care continuum. 

Another key issue to understand before implementing a patient navigation programme is developing appropriate educational standards and clear objectives for the programme. In the case of Malta as specialized nurses were employed, more clinical-focused tasks such as expert advice could be incorporated. In programmes aiming to support more hard-to-reach populations with the use of community peers, the range of activities and educational standards of the navigators need to be very clear.

A regional network has been established to strengthen care pathways and provider communication in Austria

Cancer represents the second-largest cause of death in Austria, with lung cancer being the top cancer cause of death.¹⁵ Despite having a slightly higher life expectancy at birth compared to the EU average, there are stark inequalities in life expectancy and health outcomes in Austria, particularly across different socioeconomic levels.¹⁶

The federal government and the nine federal states divide health system governance responsibilities, with the states being responsible for providing and organizing hospital care.¹⁵ As such, regional responses can be a valuable tool to address specific public health issues.

Recognizing the potential advantage of this regional organization while trying to address inequalities across its population, the Upper Austrian region established a regional oncology network. As the unstructured collaboration between regional hospitals had been previously identified as a weakness, this network led to improved communication channels across healthcare establishments providing critical oncological care that ultimately led to better efficiency in patient transfers and coordination of care. This was also made possible by developing a set of procedures to guide referrals and communication.

Despite early promising results in Austria, other cancer care networks such as the NHS Cancer Networks or the Brazilian Breast Cancer Care Network reported fragmentation of the services across the network.^17,18 To avoid this, policymakers should include in their implementation plans the development of clear quality standards and guidelines for the referral system across institutions and detail how communication channels should work.

Understanding the potential “breakpoints” across the cancer care continuum is key

Not all countries or regions will experience the same “breakpoints.” Therefore, developing health needs assessment or researching conceptual models to map out the interactions across the different levels of cancer care⁹ can help tailor the policies and ultimately improve the quality of cancer care pathways. In Malta, delays across the pathway were identified as a crucial weakness, which led to the establishment of a specific Directorate and patient navigators to help the journey of the patient across the different levels of care. In Austria, the lack of structured collaboration across regional hospitals was considered a key issue in the care pathway so the regional strategy was directed towards improving that specific hindrance.

Strategies to improve cancer care pathways need additional considerations to decrease inequities

The impact of navigation programmes on bridging the inequality gap is uncertain. An analysis of the Boston Patient Navigation Research Program showed that women with barriers to accessing healthcare services and under a patient navigation programme still took longer to manage cancer screening abnormalities compared to women in the same program but without documented barriers.²⁰ 

Improving patient transfers across varying levels of care also does not necessarily translate to decreasing inequalities across the population; for example, hard-to-reach groups who might struggle to access care might not even enter the care pathway. As such, in addition to a collaborative cancer care network such as the one established in Upper Austria, initiatives aiming to improve access to cancer services should be implemented.

Ensuring the sustainability of initiatives in cancer care can include closer collaborations to pool resources or alignment with broader national policies

In Upper Austria, the creation of a network across regional hospitals has allowed for common budgeting and pooling of resources, which contributes to the cost-efficiency and therefore sustainability of the initiative. In Malta, aligning the programme with the country’s general National Cancer Plan has contributed to its sustainability.

Conclusions 

Both countries recognized the burden and health system inefficiencies that can be associated with delays and bottlenecks across cancer care pathways. As such, the importance of initiatives that continuously attempt to make cancer care pathways as seamless as possible:

1. Malta addressed this by implementing a series of initiatives encompassing the whole care pathway.
2. Austria focused on a specific hindrance in the pathway it had identified, which was the inefficiency of its cross-hospital collaborations.

Both policy initiatives show a tailoring of the solution not just to the bottlenecks identified but also to the unique conditions of the country. Malta as a small island nation led a national response that included a small yet very specialized number of navigators. Austria makes the most of its regional organization, implementing a localized initiative to strengthen local bonds and communication across institutions.

References