In order to improve cancer patient outcomes, which according to the National Cancer Registry data, are generally lower in Ireland than in the rest of Europe, Ireland recommended establishing the National Cancer Control Programme (NCCP).
The National Cancer Strategy "A Strategy for Cancer Control in Ireland, 2006", recommended establishing the NCCP with four cancer control networks, each with two centres delivering high volume specialised surgery with equitable access to all other cancer treatments based on population needs. Evidence shows that patients derive more benefit when the expertise that is necessary to treat cancer patients is concentrated in specialist centres. It indicates that a centre doing complex cancer care at high volume had better outcomes than a centre that is doing it intermittently.
Cancer treatment is a complex process where the diagnosis assessment, radiological investigation, surgical treatment chemotherapy and radiation treatment all have to be integrated. This can only be achieved successfully through concentrating clinical leadership and resources in specialist cancer centres. While this approach is not always the easy or most popular option, it is the best option for patients to ensure we deliver safer, quality cancer care. Patients benefit by having a higher chance of survival and by living longer with cancer. Additional resources and staff have been put in place to deliver specialised breast cancer treatment within the eight centres. The NCCP was established by the HSE in 2007 and Prof. Tom Keane appointed as Interim Director for a two year period on secondment from the British Columbia Cancer Agency.
Centralisation of Breast Surgical and Diagnostic Services
Significant progress was made in 2009, with the centralisation of breast cancer diagnosis and surgery remaining the highest priority for the NCCP. Over the twelve months the NCCP completed four separate transfers of initial breast diagnostic and surgical services into designated centres. This phased approach allowed the NCCP to ensure that no transfer occurred unless the necessary resources were in place and the designated hospitals were in a position to provide quality assured services for patients. In April, initial diagnostic and surgical services were successfully transferred from Our Lady of Lourdes Hospital, Drogheda to Beaumont and the Mater Misericordiae Dublin. A new medical oncology unit was officially opened in Our Lady of Lourdes Hospital Drogheda and a new medical oncologist appointed to the unit. This further confirmed the commitment of the NCCP to the provision and development of medical oncology services in local hospitals.
In early August services were transferred from Sligo General Hospital to Galway University Hospital. Services were also successfully transferred from Tallaght Hospital to St. James Hospital and St. Vincents University Hospital, Dublin in late August. In December, one of the most ambitious amalgamation and transfer processes was completed with the formal opening of the new Symptomatic Breast Cancer Service and Diagnostic Cancer Day Unit by the Minister for Health & Children, Ms. Mary Harney, TD, at Cork University Hospital (CUH). This involved the amalgamation of breast cancer services from South Infirmary and Mercy Hospital Cork to CUH. The new Symptomatic Breast Cancer Unit at CUH will be the largest in the country seeing more than 10,000 patients annually and diagnosing approximately 520 patients with breast cancer. Having set out to transfer 90 percent of surgical and diagnostic breast cancer services by the end of 2009, the NCCP successfully exceeded this target with the full transfer of all relevant services completed by early December. This contrasts sharply with the position in 2007 when 33 hospitals were providing breast cancer services across the country.
Among the transfers completed in 2008, led by the NCCP were those from Mayo General Hospital in Castlebar to GUH; from Kerry General Hospital, Tralee to CUH; from Clonmel, Kilkenny and Wexford to Waterford Regional Hospital. With the first full audit of the symptomatic breast cancer services carried out by HIQA (Health Information and Quality Authority) during the year, the eight centres were being measured on timely and prompt access to services for patients. By December the access target for urgent and non urgent cases was being exceeded. Nationally, by December, 98 percent of urgent cases were being seen within two weeks, while 96 percent of non urgent cases were being seen within the twelve week target.
Centre for Pancreatic Cancer
National Surgical Centre for Pancreatic Cancer St. Vincents University Hospital, Dublin was designated as the National Surgical Centre for Pancreatic Cancer in May 2009. Prior to arriving at this decision, the NCCP sought expressions of interest from designated centres currently performing this surgery. Following a review of the capacity of individual cancer centres to take on this commitment, it was decided that all pancreatic surgery should be centralised in one hospital as specific by the Advisory Group to the National Cancer Strategy.
Pancreatic surgery is highly complex requiring a sophisticated surgical team and support services to achieve optimal outcomes. International evidence suggests that optimal survival and reduced operative morbidity and mortality are achieved when surgery is restricted to institutions performing significant volumes of surgery, performed by experienced personnel. Almost all major pancreatic cancer surgery is currently performed in six hospitals nationally St. James, the Mater Misercordiae, Beaumont, Tallaght, St. Vincents University Hospital, Dublin and Mercy Hospital, Cork, with a total of approximately 100 specific surgeries carried out annually. St. Vincents University Hospital, which houses the National Hepatobiliary Unit, already has a significant concentration of the necessary infrastructure and medical expertise to facilitate this development.
Rapid Access Cancer Clinics Prostate Cancer
A significant part of the explanation for poor cancer survival rates in Ireland relates to late diagnosis of cancer. Comparison with other jurisdictions shows that advanced stage of disease at presentation is problematic. Based on the symptomatic breast cancer experienced, the NCCP decided that access to early diagnosis and multi-disciplinary decision making must be enhanced for both prostate and lung cancer.
The national guidelines for the diagnosis and management of prostate cancer were completed during 2009. These guidelines together with patient pathways or diagnosis and treatment provide a framework for national standards which will be monitored on an ongoing basis through the reporting of key performance indicators. The guidelines were disseminated to GPs through the NCCP Community Oncology Programme in collaboration with the Irish College of General Practitioners.
Approximately 2,400 men develop prostate cancer in Ireland annually. Around 550 men die each year from the disease. The previous pathway for the diagnosis of prostate cancer was through the referral of patients to general urology clinics across 20 hospitals. In many cases, there was no formal triage process and this produced unacceptable delays in diagnosis. Given the large number of suspected cases, it was agreed that patients at higher risk based on agreed clinical criteria should be fast tracked directly into Rapid Access Diagnostic Clinics in the designated cancer centres. Having set out to open four Rapid Access Prostate Clinics in 2009 and four in 2010, the NCCP oversaw the opening of clinics in St. James, Galway University Hospital, the Mater and St. Vincents University Hospital in 2009. These clinics provide men with quick access to medical teams to ensure they get a diagnosis as early as possible. Patients therefore have a definitive diagnosis established within two weeks of initial appointment and if confirmed as cancer, they have immediate access to a multi- disciplinary specialist cancer consultation to establish appropriate management of their case.
The new Rapid Access Clinics at Galway University Hospitals and St. James Hospital, Dublin were jointly opened by the Minister for Health and Children, Ms. Mary Harney TD in June 2009. GUH now has a full range of expertise for the management of prostate cancer, including complex urological surgery and curative radiation therapy with external beam radiation and brachytherapy (radioactive seed implant).The hospital has the capacity for seeing up to 24 patients per day at the rapid access clinic with up to 12 patients provided with biopsy and a further 12 attending for review. GUH has seen an increase in suspected prostate cancer patients in recent years. In 2006, 820 new patients were seen, while in 2007 that number rose to 1100. The relevant increase in actual prostate cancers also rose from 272 in 2006, to 365 in 2007.
Rapid Access Cancer Clinics Lung Cancer
Lung cancer incidence continues to increase in Ireland. Survival at five years is currently at nine percent which is significantly below the best performing countries. There is as yet no evidence to support screening for lung cancer. In Ireland, 40 percent of all cases receive no specific cancer treatment presumably because of the advanced stage of disease at presentation. The pathway to a lung cancer diagnosis had been almost exclusively through referral to a respirology clinic staffed by respirologists. Only a small number of the general respirology clinics in 20 hospitals nationally were specifically set up to address the diagnostic challenge of lung cancer. The majority of referrals to these general clinics relate to general respiratory ailments and only a small minority of referrals have an eventual diagnosis of lung cancer.
In consultation with the Irish Thoracic Society, the NCCP agreed that patients with defined symptoms should be fast tracked to lung cancer diagnostic clinics in one of the eight designated cancer centres where they will have a diagnosis established within two weeks. On a parallel basis with the prostate clinics, the NCCP agreed to open four Rapid Access Lung Cancer Clinics in 2009 and another four in 2010. On that basis, four Rapid Access Clinics were opened at St. Vincents University Hospital, Mater Misercordiae Hospital, Beaumont Hospital and St. James Hospital Dublin during the year. These clinics provide patients with quick access to medical teams to ensure they get a diagnosis as early as possible. These patients have a definitive diagnosis established within two weeks of initial appointment and if confirmed as cancer, they have immediate access to a multi disciplinary specialist cancer consultation to establish appropriate management of their case.
There is widespread agreement that rectal cancer surgery which is technically demanding must be performed by trained rectal cancer surgeons. At the request of the NCCP, the National Cancer Registry, in collaboration with the Royal College of Surgeons of Ireland has performed the first national audit of rectal cancer surgery. The audit showed that in 2007, 577 patients had rectal cancer surgery performed by a total of 86 surgeons in 41 hospitals. The audit showed that 58 surgeons operated on less than six cases each and only 17 surgeons operated on more than 12 cases. The NCCP accepted a recommendation from the Irish Society of Coloproctology that the number of hospitals performing rectal cancer surgery should now be reduced to 13 public hospitals with a goal of reducing this number to the eight designated cancer centres as surgical capacity is created.
Agreement has been reached with staff and management at both Beaumont and Cork University Hospital to create a single National programme for the management of brain tumours and other central nervous system tumours. International best practice suggests that concentration of this service is necessary to achieve optimal outcomes and cost effective care. In total there are between 120 and 150 surgical cases per year and these are currently distributed across six or more institutions. It is proposed that all such surgery be performed in a single national specialist centre.
National Plan for Radiation Oncology
Significant progress has also been achieved on the National Plan for Radiation Oncology with the objective of achieving a national network for radiation oncology services. Development work began on two of the sites for new radiation oncology facilities at St. James and Beaumont in Dublin last year. Once this first phase of the national radiation oncology programme is complete, radiation therapy services for period 2011 to 2014 will be provided on three sites in Dublin Beaumont, St. James, and St. Lukes. These three sites will then function as a single network of radiation facilities providing the service to approximately 60 percent of the national population.
The second phase of the expansion of radiation therapy facilities and the ongoing replacement of expensive infrastructure to meet projected expanding national needs for radiation treatment was approved by Government as a PPP funded project in 2005. Since then the project has been progressed by the NCCP working closely with the NDFA. The project is complex and involves six sites: St. James, Beaumont, Cork- CUH, Galway, Waterford and Limerick.
Community Oncology Programme
Significant progress was made in the development of the NCCP Community Oncology Programme during 2009. The Community Oncology Programme formally sets out to create capacity and knowledge among health professionals in the community and to promote best practice in cancer control. Priority in 2009 was given to the development of referral guidelines for GPs in the areas of breast cancer, prostate cancer and lung cancer. In March the new National Breast Cancer Referral Guidelines were formally agreed. The National Prostate Cancer Referral Guidelines were agreed in October and National Lung Cancer Referral Guidelines in December.
All the new guidelines take into account the findings of the National Cancer Strategy 2006, specific evidence based research and relevant national standards and protocols including the National Quality Assurance Standards for Symptomatic Breast Disease Services. The finalisation of the guidelines was achieved through the commitment and professionalism of the multi disciplinary oncology teams in the designated centres, the input of the Irish College of GPs, the NCCP Community Oncology Team and representative bodies including the Irish Thoracic Society. The NCCP is overseeing the roll out of electronic referral for all guidelines for GPs. Agreements with IT vendors were signed in 2009 that will allow for the full roll out of the electronic referral system nationally in 2010.