Improving cancer care in Poland

16 Jun 2009

Cancer is responsible for much of the health differential that still exists between eastern and western Europe. Citizens of former communist countries are still more likely to contract, and die from, many types of cancer than their counterparts in the west. Yet many of these countries have maintained, throughout a century’s political turmoil, a good record of cancer treatment and care.

Poland, for example, is home to one of the first specialist cancer institutes in Europe. The Institute of Oncology in Warsaw was opened in 1932 by the double Nobel laureate Marie Sklodowska-Curie with a gift of radium from the USA. This institute, originally known as the Radium Institute, was destroyed during the war but completely rebuilt soon afterwards: it has flourished during and beyond the Communist era as the Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology. It holds the official cancer registry for Poland and maintains a comprehensive programme of research, treatment and care for cancer patients covering all treatment modalities and tumour types.

After the war, too, branches of the Institute were set up in two cities of southern Poland, Krakow and Gliwice. Each has a separate director and most decisions are taken independently. Both these cities are located in the south of Poland, the richer and more highly populated part which was, in communist days, the centre of Polish heavy industry. The heavy pollution caused by these industries has been reflected in a higher cancer incidence compared to other regions, a discrepancy which – in spite of twenty years’ de-industrialisation – has not yet disappeared. There are also sixteen regional oncology centres in Poland, which hold local cancer registries and treat most, if not all, cancer types.

Barbara Jarzab is professor of endocrinology and nuclear medicine at the Oncology Institute in Gliwice. This is not a typical mix of disciplines, in Poland or elsewhere. A centre for the treatment of thyroid and other endocrine cancers with radioactivity was set up in Gliwice in the mid-50s. The first few decades were very difficult ones financially; Jarzab remembers how tight money was when she started work there in 1992. "The budget for the year would run out as early as August, and some patients had to wait up to two years for treatment." The situation has improved slowly but steadily since the mid-90s. "We can always do with more money – no oncologist is ever satisfied – but the improvement has been dramatic", says Jarzab. She now has access to modern, comprehensive equipment for treating all benign and malignant thyroid tumours, and the only fully functional clinical microarray lab in Poland, using gene expression profiling to evaluate molecular profiles of cancer. She is also able to diagnose medullary thyroid cancer and other rare endocrine tumours. Position emission tomography (PET-CT) equipment is another recent acquisition. "We couldn’t introduce these facilities in the ‘90s as they were far too expensive", says Jarzab. "We can now see advantages in this delay, as all the machines we have now installed are up-to-date". And in June 2009 a cyclotron facility will open in Gliwice, producing radio-isotopes for the Institute. A recent European survey named thyroid cancer as the only one of ten cancer types studied where the reported outcomes are better than the European average.

Leszek Miszczyk, vice-head of the department of radiotherapy in Gliwice, is also satisfied with the "international standard" facilities available in his department. He is concerned, however, about poor access to radiotherapy in other parts of the country. "Even though there are fewer people in Northern Poland, there are still fewer people per radiotherapy centre than there are in the South, and many of those centres are poorly equipped", he says. Some of the problems are being addressed by the growth of smaller, private radiotherapy centres with two or three units; all treatment is still free at the point of care.

Compared to the rest of Poland, the Gliwice centre is in a privileged position. The Institute is well funded and radiotherapy is a priority area for new investment. Its director is looking to introduce equipment for tomotherapy, where radiation is delivered "slice by slice", but is waiting for this technology to drop in price. "If a new technique appears, and there is a sensible clinical rationale for introducing it, then we can do so – but not necessarily immediately", he says. He is able to recruit and train radiotherapists up to the best European standards, and can now pay them decently.

Given the excellent facilities and reasonable salaries, it is surprising that there is no queue of oncologists wanting to work in Gliwice. Instead, Miszczyk and his colleagues worry that there are barely enough. Other less well funded and equipped centres really struggle to recruit qualified staff. One problem is that the training of young doctors in Poland is cumbersome and bureaucratic. After six years of medical school, newly qualified doctors have to work for a year and then pass an exam before they can specialise. "In the whole of Europe, only Poland and Serbia have this exam. A very newly qualified Polish doctor can find work in Germany or the UK but not in Poland, and many choose to move to richer countries at that point", says Miszczyk. Specialisation also takes a long time, up to 9-10 years for doctors based in the smaller centres. "The exposure to new technologies and other disciplines that is necessary for qualification is difficult to obtain in a small centre, and the poorer centres cannot spare their young doctors for long enough to be trained elsewhere", he adds.

Julian Malicki, director of the regional cancer centre for Wielkopolska (Greater Poland), based in Poznan, is also worried about a shortage of doctors. He cites a different reason for this: the relative unpopularity of oncology as a specialisation. "Oncology is introduced quite late on in the Polish medical curriculum, at a time when many students have already chosen their preferred specialities", he says. "Also, it is seen as a discipline with a low success rate, and doctors prefer to work with patients who will almost always be cured."

Access to prescription drugs in Poland is controlled by an organisation similar to the UK’s National Institute for Clinical Excellence (NICE). The main difference is in the amount of money in the system. Piotr Wysocki, a clinical oncologist at the Wielkopolska cancer centre, is frustrated by the lack of access to the most effective drugs. "We have to calculate whether to treat a few patients with novel drugs or many more with the less effective standard treatments", he says. "It is an almost impossible decision." Although this problem is familiar to oncologists throughout the developed world, there is a difference in scale, and the situation is exacerbated by a lack of access to "off label" and experimental drugs. "None of the Big Pharma companies have research bases in Poland and despite significant improvements in our economy in the last decade we are still seen as a 'poor developed country'. Companies don’t have any interest in giving us access to experimental drugs – they would rather work nearer to their main research bases", adds Wysocki.

All regional cancer centres in Poland conduct clinical and translational cancer research: the website lists over four hundred ongoing and recent clinical trials for cancer with recruitment sites in Poland. Andrzej Mackiewicz of the Wielkopolska centre is developing a cancer vaccine for use in melanoma. "We are now commercialising the vaccine ready for Phase III clinical trials, which must first be approved by EMEA", he says.

Basic cancer research is carried out in a few departments of the main Oncology Institutes, as well as in Academy of Science institutes and universities. Emeritus professor Mieczyslaw 'Ray' Chorazy joined the Gliwice Institute in 1951, and spent his whole career in basic research, studying the molecular biology of tumour development; he was head of the Department of Tumour Biology there from 1963-95. He acknowledges the importance of international links in his career. "Even in the late 50’s – following the political liberalisation after Stalin’s death – I was lucky enough to be awarded Rockefeller fellowships for research and training in cancer medicine, firstly at the University of Wisconsin and then at the Memorial Sloan-Kettering Cancer Center in New York", he says. After his return he supported many of his colleagues in finding similar opportunities overseas, and he has set up a small fellowship program to host scientists from eastern European countries at the Institute. This is generously supported by the National Cancer Institute, NCI, Bethesda, USA and the Polish National Committee UNESCO.

Marek Rusin, who leads a small carcinogenesis research group in Gliwice, is one younger colleague who has benefited from Chorazy’s international links. "He [Chorazy] helped me establish my collaboration with the Laboratory of Human Carcinogenesis at NCI Bethesda, and I visited there several times in the 1990s", he says. "This experience was invaluable when I started my own lab as an independent investigator here a few years later."

Poland is also investing heavily in screening and cancer prevention. A "National Program to Fight Cancer" was established in 2007 with a budget of 3bn Zloty (c.700M Euro) over ten years. Half of this has gone into equipment, mostly to improve access to treatment in the poorer east and north of the country, and half into education and screening. Chorazy has been involved in developing the education side. "I have been stressing the importance of involving schools, and using children to spread information about how to prevent cancer into the wider community."

And cancer prevention is necessarily an important part of a Polish anti-cancer strategy. Almost every cancer case is entered in both a regional and a national cancer registry, and these registries are as complete as in many more established Western democracies. The picture painted by the statistics, however, is a depressing one. Although patterns of cancer incidence are very similar to those in Western Europe, many rates are higher. Lung cancer is a particular problem, as cases of this cancer picked up today are reflecting the extremely high smoking rates – at least 70% of male adults – prevalent in the 1980’s and earlier.

Witold Zatonski, an epidemiologist at the Institute of Oncology in Warsaw, has devoted much of his research career to cancer prevention, and particularly to tobacco control. He was one of the principal developers of the country’s now extensive anti-tobacco strategy. "Tobacco control strategies became established in Poland in the early 90’s, as our mass media developed in the wake of the democratic revolution", he says. "In some ways, our strategy is ahead of countries such as Germany and the UK; cigarette advertising has been completely banned in Poland since 1998-9. We have also banned vending machines, and instigated bans on smoking in public places." As a result, the percentage of male smokers has roughly halved, to 35%, and male lung cancer rates are at last beginning to drop. Unfortunately, however – in a pattern that is common throughout Europe – the reduction in women smokers has been much less dramatic, from 30% to 25%.

Extensive programmes for screening appropriate populations against breast, colon and cervical cancer have been introduced in Poland in recent years. Theoretically, at least, mammography is available for all women over the age of 40, which is earlier than in many countries. The campaign to set up this facility and encourage its use has been spearheaded by community organisations including the 'Amazonki' (Amazons), a self-help network for women with breast cancer. Wieslawa Kunicka, from the Amazon “club” in Poznan, explains that "Our main aim is to help and support women diagnosed with breast cancer, particularly those who have undergone mastectomies. We are also very active in promoting access to screening and to modern drugs." There are still problems, particularly with persuading eligible people to come forward for screening. Miszczyk believes that one reason for this is the distances they need to travel: "We need to move screening facilities nearer to the people." Zatonski stresses the importance of education. "Cancer is still a topic that is not discussed in public in Poland, and many people don’t yet understand the benefits of screening. This is a particular problem with cervical cancer, which affects disproportionate numbers of poorly educated women, who are also the least likely to be screened", he says. In the absence of a high profile human-interest story – a Polish Jade Goody, maybe – he believes that the Polish government needs to invest far more in high quality journalism, particularly TV journalism, to reach these women.

Seven years ago, the director of the UK’s Action on Smoking and Health told The Lancet of a "big political commitment" to the prevention and treatment of cancer in Poland. Despite financial challenges, this is still true today. And even as the world recession bites, it is possible to be optimistic that the momentum will still be maintained.