Chain reaction

Why better cancer care will need us to look at every stage of the system

Illustration of scientists climbing DNA ladder

Policymakers and care providers around the world face complex challenges as they try to improve cancer care. Even before Covid-19, they were grappling with rising costs and how to improve access to care, and the pandemic did not help.

One of the complexities of cancer care is its numerous treatment phases. Any efforts to improve system efficiency and focus on high-value care have to take account of every stage; weakness in any part of the chain can undermine the whole system.

“Every stage of cancer care and control needs to be functioning well,” explains Rifat Atun, Professor of Global Health Systems at Harvard University. “The whole chain needs to be in place, with appropriate referral and counter-referral mechanisms and provision of care that is effective, efficient, equitable and responsive to the needs of users.”

Find the weakest links

Understanding which parts of the chain need to be improved starts with a frank assessment of how care systems are performing. “Health-system performance in relation to cancer is highly variable, both across and within countries,” says Professor Atun. “Take the US: there are huge differences in five-year net survival among different population groups.” Performance can also be very different between populations whose social contexts seem similar, such as those in some Latin American countries.

So, the weak links in the chain vary from one system to another, because every country is different. On the supply side, there are differences in how healthcare is organized institutionally, how it is financed and how resources are managed. And the demand side can be shaped by different social attitudes, expectations and demographics.

That means solutions and improvements have to be context-specific. “We cannot develop one-size-fits-all solutions or push new technologies into old systems,” says Professor Atun. That is particularly true with the emergence of innovative diagnostics and therapies, because, says Professor Atun, “there is not enough innovation in delivery”. As a result, innovations fail to reach those who would benefit.

Integrated networks are critical

While context matters, there is broad agreement about the features of effective cancer care systems, according to Professor Atun. These features include multidisciplinary teams and the delivery of care through cancer networks rather than single institutions such as hospitals. “It’s about the system as a whole,” says Professor Atun. “We need more integrated views of the care continuum. It’s no good having islands of excellence surrounded by oceans of poor care.”

Some European countries have made good progress here. The UK and some Scandinavian nations, says Professor Atun, are developing care networks that integrate oncology services and also build links with social services. That is an important shift, according to Professor Atun: “It takes care of the individual as a whole, as opposed to taking care of an episode of activity within the care continuum.”

A national approach gives countries a head start

Another valuable tool is a national cancer control plan. “A plan is a very useful starting point,” says Professor Atun, “because it brings together all the actors interested in improving care and control of cancer”.

Done well, a national cancer control plan clarifies responsibilities and accountabilities – but not all plans are done well. Some are silent, for instance, on crucial issues such as metrics and targets for the system’s performance, and on resourcing. Ignoring these issues will make it difficult to translate good intentions into action.

Countries with universal health coverage have clear advantages, says Professor Atun, because patients can access care throughout their cancer journey without facing barriers to particular services. “That in itself is a very important determinant of patient outcomes,” he says. “If there's a delay in presenting, if there's a delay in referral, and if there's a delay in treatment, then individuals receive care at a later stage of their cancer.” That makes treatment more complex, less effective and more costly – and reduces survival levels.

The advantages of a holistic approach are clear, insists Professor Atun: “This is the way to get more effective care, delivered in a more efficient way that is responsive to user needs.”