Integrated cancer control, part II:  

The case for comprehensive cancer care networks (CCCN)

This is a part II of Cancon Guide chapter Integrated cancer control (Cancon work package 6). See part I of the chapter.

See the full Guide and other chapters as pdf's.
Cancon Guide is the main delivery of the joint action.

Contents of Integrated cancer control part II:
A real-life, real-time example of creating a CCCN (Czechia)
Discussion
Conclusions
References

Integrated cancer control part I:
Introduction
Methods
Results
Building a CCCN
Operation of a CCCN

A real-life, real-time example of creating a CCCN (Czechia)

This section describes the CCCN pilot project initiated in 2015 in Czechia in close association with a newly introduced national cancer control plan. The sharply increasing prevalence of cancer in Czechia could only be managed if there was an effective infrastructure of care and a wellorganized networking of health care providers to maintain reasonable potential to improve patient flow in the system and to achieve equity in access to high-quality standards of care. Therefore, the mission of the project was to optimize the care of every cancer patient in the target region. 

As part of the process of setting up a CCCN, potential geographical areas were explored and the South Moravia and Vysocina regions were identified as appropriate in respect of demographic and epidemiological parameters. The structure of the CCCN is representatively wide and includes general hospitals, cancer centres, research and educational facilities. One purpose of the pilot was to verify that contractual agreements among network elements, structured collaboration with common governance, a common database encapsulating a unified patient information and quality assurance system, all characteristic of a CCCN, were compatible with full respect for established institutions.

Multiple access points to the network are controlled to help patients to receive timely treatment of equally high quality wherever they live. The sum total of researchers and clinicians in the pilot area are sufficient for participation in clinical trials, real world surveys and for the effective use of complementary expertise in cancer management.

All methodologies used and progress being made are fully reflected in two web portals (82,83). Using these platforms, patient-outcome data of the pilot CCCN will be promptly available and usable by the cancer care system in other regions of Czechia. So far we can confirm that the CCCN model is both viable and advantageous for cancer care management.

Background of the CCCN pilot

The CCCN pilot was established in an area covering a population of 1.6 million inhabitants (14 000 km2 population density 120 inhabitants/km2). The mean age of the population was 42 years, and 17% of people were older than 65 years. In 2013, there were 13 190 patients with newly diagnosed cancer, and serial data revealed a growing trend with an annual increment of 1.8%. 

Cancer is the second highest cause of mortality in the region (26% of all deaths), and cancer mortality (4089 in 2013) had been stable over several years. Increasing incidence with stable mortality suggests a significant increase in prevalence; in 2013 there were 88 340 patients with cancer (a 4.3% annual increment). As for most common cancer types, the incidence figures (per 100 000 inhabitants) were as follows: prostate cancer 133, breast cancer in women 125, colorectal cancer 77, lung cancer 52 and, renal cancer 29. In 2007–2014, there were approximately 2.8 million hospital admissions, of which 9.1% were for cancer as the primary reason.

Principles adopted for setting up the pilot CCCN

The CCCN model was developed within the Czech health care system with due regard to the following key principles, which can also be applied as policy recommendations:

• the formation of the CCCN was based on a voluntary decision of health care providers; political authorities favoured close collaboration among health care providers but there was no compulsion to take part in the CCCN;
• the CCCN was established not as parallel/alternative to other organizations in the chosen area but as the preferable global model; pre-existing cancer care facilities were never removed but, rather, were improved and, consequently, creation of the CCCN has not resulted in competition with other institutions;
• operation of the CCCN needed to be supported by new legislation so that hospitals that participated could do so legally; the legal framework also made it possible to centralize processing of clinical data: initially one of the major obstacles to be overcome;
• the CCCN was made up of not just the hospital sector but also diagnostic centres, primary care providers and palliative care units; it was facilitated by a common information system and cancer research and educational facilities were included;
• a legally binding written agreement was signed by the institutions that form the CCCN, defining its organization and governance; there is a shared system of multidisciplinary tumour management teams, common clinical protocols to which all must adhere, a common information system and a common database supporting a unified quality assurance system; and
• the objectives of the information system of the CCCN include the following: identification of inequalities in care, feedback control of effectiveness of interventions supporting equity, and population-based quantification of outcomes using uniform performance indicators.

Decision-making process in the creation of CCCN pilot

The CCCN is in harmony with the national health care organization and reimbursement mechanisms.

1. First, core members of the CCCN were certified by the Czech Ministry of Health as cancer centres. 
2. Second, based on a feasibility study, regional political authorities invited cancer care providers to become part of a CCCN. These two steps, certification and statement of political will, have been crucial for placing the CCCN on a solid foundation, pre-empting fragmentation European Guide on Quality Improvement in Comprehensive Cancer Control of resources among different providers.
3. Third, ad hoc legislation was passed in order to make it possible for a network (such as a CCCN) to be incorporated into the system as a reimbursement recipient.
4. Fourth, the centralized processing of data from individual institutions required legal authorization.
5. Finally, collaboration with high-volume university hospitals was optimized in order to provide the CCCN with an effective educational backbone.

CCCN pilot: structure

The CCCN incorporates one comprehensive cancer centre of high national repute (Masaryk Memorial Cancer Institute; www.mou.cz), three specialized cancer centres and four general hospitals. For the creation of a CCCN, the inclusion of the Masaryk Memorial Cancer Institute, which has all the features of a high-volume comprehensive cancer centre, has obviously been a major asset.

Together with the Jihlava Cancer Centre (www.nemji.cz), dominant in the Vysocina region, and two university hospitals (www.fnbrno.cz; www.fnusa.cz), these four institutions have been the core of the newly formed CCCN: they took responsibility for establishing binding cancer care protocols, as well as for the rules for the operation of multiprofessional teams and quality assessment standards. Collaboration with the four general hospitals enabled the CCCN to redistribute services with the aim of providing care as close as possible to a patient’s residence.

 

Most of the more common cancers are treated locally in any one of the eight institutions; whereas services for haematological malignancies, childhood cancers and other rare cancers are centred at university hospitals in Brno city. The CCCN is also closely associated with medical schools (Masaryk University, Medical Faculty, Brno City; www.med.muni.cz), cancer research teams, tissue banks and bioinformatics facilities.

CCCN pilot: monitoring outcomes

The CCCN pilot is supported by two key interactive web portals:

• a national portal (www.onconet.cz) centred on cancer care management that maps infrastructures and facilitates navigation for both public and professionals; and
• a web portal (www.cccn.onconet.cz) that outlines and details the structure of the CCCN and the rules according to which it operates; it includes methodologies, charts of patient pathways and data standards for outcome measures.

The portals have the dual purpose of providing information to patients and the public and facilitating communication among professionals and dissemination of the CCCN experience. As measures of success of this CCCN, we have identified the following end-points: improved equity of standardized care, improved continuity of cancer care pathways and adherence to shared protocols.

The portals reflect the progress of the CCCN with respect to these parameters and they focus on five crucial distinguishing features, all of them relevant to the national system of cancer care management.

• Complexity of CCCN activities. The portal mapping infrastructure (82) will cover all aspects of comprehensive cancer care in the area of interest.
• Impact of the CCCN over the entire extent of its catchment area. The portal (www.onconet.cz) will list and show graphically all services accessible within an acceptable distance from a patient’s residence. Online tools will provide real-time information on timetables and so on.
• Multilevel information system. This is implemented at each one of the CCCN component institutions. A full guide is available at the CanCon web site for Czechia (83).
• Common governance. The modalities and rules are detailed on www.cccn.onconet.cz in four layers: management rules, multidisciplinary tumour teams, cancer management protocols and e-learning/e-communication links.
• Common database reporting. This database enables professionals to monitor how patients progress along their management pathways. Equity in access and benchmarking of performance indicators are also monitored, and burden predictions periodically updated. The CanCon web site (83) combines interactive data views and compiled e-reports.

Discussion

Cancer networks are an innovative and efficient manner to streamline patient pathways at the regional, national and EU level because they facilitate multidisciplinary cancer care as well as prompt access to reliable diagnosis and specialized management of the complexity of the cancer care pathway.

One of the main challenges for the network approach is to balance organizational innovation against stability. In other words, it is essential to assess to what extent existing cancer care facilities fulfil the needs of the population of a certain region, with special attention to providing equality of access as well as quality of cancer care; where deficiencies are identified, these may warrant the innovative effort of establishing a CCCN.

The main potential advantages making the case for CCCNs are listed below.

• A well-integrated CCCN is more likely to achieve equity in access to good-quality care nearer home; indeed, studies have found that distance is a significant factor in not being able to attend a comprehensive cancer centre.
• A CCCN implements a patient-centred approach thanks to common principles, attitudes and management protocols agreed among professionals.
• A CCCN will be able to acquire resources that an individual hospital may not and allocate them more efficiently across the network; it will be able to avoid unnecessary duplication of facilities; and facilities that are underutilized in a particular site can be put to better use once a CCCN is in operation. All these factors will improve cost-effectiveness.
• A CCCN can capitalize on complementary expertise of individual professionals for both shortterm and long-term planning.
• A CCCN can provide a seamless care pathway, even for patients requiring unique or complex treatment procedures that need moving the patient to more than one place as part of the management pathway.
• A CCCN, through the units of which it consists, will be closer to primary care or even fully integrated with it and, therefore, in a good position to liaise with it.
• A CCCN gathers optimal conditions to conduct not only basic research but also translational research, observational studies, clinical research and health services research; this is made possible by having a critical mass of researchers and clinicians, a common patient information platform, standard operating procedures for tissue analysis, and shared biological resources and bioinformatics facilities. 

Conclusions

Many types of cancer network exist in Europe: some just on paper, others in reality. Here we have outlined in some detail a very specific type of network, the CCCN, characterized by a deliberate and comprehensive integration of activities, as defined at the start of this chapter. A CCCN is a highly integrated multicentre structure that works under a single governance and deals with the management of all aspects of cancer care.

When planning a CCCN, several indicators must be taken into account so that the CCCN is optimally tailored to local needs in terms of cancer epidemiology and pre-existing cancer care facilities. An essential characteristic of a CCCN is the establishment and operation of a multidisciplinary personalized approach based on tumour management groups encompassing specialized hospital and community care, including palliative care, psychosocial support, rehabilitation and survivor care planning.

Consequently, a CCCN can become a superior instrument for meeting the challenge of the increasing needs of the increasing numbers of cancer patients, providing equity, quality and cost-effective cancer care. A CCCN will adhere to existing guidelines with regard to the management of rare cancers. An articulate quality control programme must operate in a CCCN from the outset in order to pursue, maintain and improve the way its objectives are achieved.

In addition to the provision of cancer care, a CCCN will be ideally poised to conduct not just basic research but also translational projects, clinical trials and population-based research programmes. Of course, further studies will be needed to better quantify improvements in actual cancer care brought about by a well-structured CCCN in terms of patient general outcome, equity and cost-effectiveness.

In the meantime, it is encouraging that within the time frame of the CanCon Joint Action a CCCN as here defined has been set up and is now in operation in the south of Czechia.

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