Three troubles of Russian oncology
"Everyone knows how to treat cancer, and no one will tell you how to pay for it"
Irina Reznik, MedNovosti
Oncological care must be withdrawn from the basic CHI program. This, as one of the mechanisms for solving the problems of the industry, was stated during the XXI Oncological Congress by the country's chief oncologist. According to the professional community, the main troubles of Russian oncology are its "monstrous" underfunding, the dependence of the oncological service on regional authorities, and, as a result, personnel problems. The government believes that enough money is allocated for oncology, and in order to achieve the indicators of developed countries, Russian doctors simply need to set themselves more ambitious goals.
"We have everything: doctors, medicines, equipment"
Oncological diseases annually claim the lives of 300 thousand Russians. In the USA and Canada, this figure is twice as low, despite the fact that the incidence is twice as high. And these figures need to be explained to people somehow. According to the Deputy Prime Minister of the government Olga Golodets, Russia has everything in order to achieve mortality rates characteristic of the countries "with which we relate ourselves." "We have doctors, we have medicines, we have equipment. And what points you need to pay attention to in order to make a more ambitious step – everything is in our and your hands," Golodets said at the opening ceremony of the XXI Russian Cancer Congress.
From the point of view of the government, there is no shortage of funds in the country. "We are talking about what is covered by the budget of the Russian Federation, and in this sense, according to the assurance of the Ministry of Health, according to the assurance of the Compulsory Medical Insurance Fund, those types of care that relate to oncology are "closed" by budgetary funds, by means of compulsory medical insurance," Golodets said. In her opinion, it is necessary to increase the transparency of spending funds and establish the responsibility of doctors for "where, when a person is being treated, what medications are prescribed to him." "Today we need to see feedback, we need to understand why certain categories of patients suddenly did not receive medicines, why they were not provided with timely medical care if funds are aimed at this," the Deputy Prime Minister stressed.
According to her, in order for Russian patients to have access to all the achievements of world oncological science, a new organization of the oncological service is needed. "Your task is to find the program that in a tangible period of time – three years, four years – will bring us to the indicators of curability for oncological diseases worthy of Russia," Golodets addressed the participants of the Congress.
"Monstrous underfunding"
It is unlikely that oncologists planned to appeal to the deputy Prime Minister in advance, but the figures given in their reports spoke for themselves. Over the past 10 years, the number of cancer patients has increased by 21%, and no one can influence this figure – the population is aging. "We are seeing a catastrophic increase in cancer incidence. According to the statistical collection of the Herzen Institute, every fourth citizen of Russia will face cancer, every sixth will die for this reason," said the chairman of the Russian Society of Clinical Oncology, deputy. Sergey Tyulyandin, Director of Scientific Work at the Blokhin National Research Medical Center of Oncology.
At the same time, the absolute rates of cancer mortality in our country have not changed much. That is, if two thirds of cancer patients died in 1998, today every second person can count on life extension. And these results could be much higher, but so far the targets set in the state programs for the development of healthcare are absolutely not achievable, said Mikhail Davydov, the country's chief oncologist, director of the Blokhin National Research Institute of Oncology. This concerns both the survival rate of patients and the early (at 1-2 stages) detection of the disease. According to him, the decrease in one-year mortality rate does not indicate an early diagnosis of cancer, but that oncologists have learned to treat its stage 4. "Every year we talk about receiving specialized treatment at the initial stages of cancer, which I have not seen throughout my life," the academician said.
In addition, according to Davydov, today the medical community is not concerned about how to treat its patients, but about where to find money for it. "The main sore point is monstrous underfunding," he is sure. – Recently, at a conference in Madrid, I heard that the average cost per cancer patient in Europe is 300 thousand euros. For us, it looks like an absolutely impossible dream. Even as a percentage of GDP, government spending on healthcare in our country is twice as low as in Europe. As a result, targeted drugs for colorectal cancer are available to 3-5% of Russian patients. Many people do not get a chance to prolong life and improve its quality. No one talks about a cure, but even this is not done. Everyone knows how to treat today, no one will say how to pay for it."
Davydov cited foreign statistics on changes in the 10-year survival rates of patients: according to data obtained from the UK, a 60 percent increase in survival was achieved in those diseases (prostate cancer, breast cancer, etc.) for which a therapeutic alternative was found. Where there is no such alternative yet (lung cancer, pancreatic cancer, etc.), the indicators remained at the same level. The therapeutic alternative is expensive innovative medicines and radiotherapy, the need for which in our country, according to the most optimistic estimates, is provided only by 25%.
According to the chief oncologist of the Republic of Tatarstan, chief physician of the Republican Clinical Oncology Center Rustem Khasanov, the number of linear accelerators recommended by WHO is 3 units per 1 million population. In Russia, this indicator is only 0.7 units, while in the USA it is 14, and in Europe it is 5. But even the modern equipment that is available in the regions is often not used due to lack of funds for its maintenance. "For these purposes, from 3 to 10% of the cost of purchased equipment is required annually, in the Russian Federation it is up to 3 billion rubles a year. In addition, the equipment purchased under the national project is physically worn out and outdated," Khasanov said.
By the way, the fact that over the past period of 2017 there was a serious reduction in funding for the section "Healthcare" (by 42.9%) compared to the same period last year was reported on November 8 at a meeting of the Federation Council by the Chairman of the Accounting Chamber of the Russian Federation Tatyana Golikova. She drew attention to the fact that health care costs were reduced in the consolidated budgets of 84 out of 85 regions (in 20 of them – more than three times).
"Regionalization" of oncology
The fact that the Russian healthcare model is based on regional responsibility is another problem of Russian oncology, the Congress participants said. The result of this is a different level of care provision in different regions and the lack of manageability of the country's cancer service. As a result, it is impossible to talk about the Russian oncological service as such – there are only a few federal and regional oncological centers that solve the problems of their patients as far as possible.
"Today 93% of cancer patients are treated in state institutions. On the one hand, this is good, but on the other hand, it does not mean anything. The fact is that these functions are assumed by ordinary multidisciplinary institutions that have expressed a desire to participate in this process," Davydov said. The level of specialization and equipment in such clinics leave much to be desired. Many regional institutions do not even have their own pathology service, but use regional bureaus. At the same time, the advantage of treatment in specialized clinics over the general medical network is undeniable, and this is confirmed by both world and Russian statistics on the effectiveness of treatment and survival of patients, depending on the class of clinic.
The "regionalization" of healthcare has also affected the personnel potential. According to the executive director of the Association of Oncologists of Russia, Deputy Alexander Petrovsky, Director of scientific work at the N.N. Blokhin Oncology Research Center, today there are 10.5 thousand oncologists in Russia, 9.5 thousand of them are employed, 7 thousand people actually work for them. And such a combination has been going on for many years. However, when the issue of personnel training is raised, no one wants to pay for it. "The number of places in the residency is determined by applications," Petrovsky said. – So, for 2017, only 165 applications were received from regions where there are not enough 3 thousand specialists. In pediatric oncology, applications were received for only 22 places. And this is despite the fact that 27 regions do not have a single pediatric oncologist at all."
Today, regional health authorities are not even able to assess the need for oncologists, let alone monitor and plan personnel. The Association of Oncologists of Russia, at the request of the Ministry of Health, sent out questionnaires to all regions regarding the need for specialists (oncologists, radiotherapists, anesthesiologists, resuscitators) to form an application for budget places in residency for 2018, and 19 regions did not even respond to this. "In Russia, 95% of cancer patients are treated in state institutions, which means that most oncologists should come here. And more than half of our residents study on a commercial basis," Petrovsky said. In his opinion, the country needs a unified register of medical workers and a constant analysis of security. And in order for patients to get to oncologists at earlier stages, all primary care doctors must undergo a basic course of oncological alertness.
Russian oncology can be successful
All these measures are provided for in the National Strategy to Combat Cancer for the period up to 2030. The document was approved at the V All-Russian meeting of the profile commission on the specialty "oncology" on the eve of the opening of the Congress and sent for approval to the Ministry of Health. Among its other tasks: the introduction of screening programs, coverage of all patients with full-fledged treatment, strengthening the material and technical base of oncological institutions and their full-scale informatization.
According to Davydov, even our closest neighbors, Belarus and Kazakhstan, have approved and are funding their national cancer control programs. And in the United States, where the national cancer law appeared in the early 70s, a Strategy for the development of cancer services was created, headed by a single national cancer center, and $2.3 trillion was allocated for basic scientific research in 2016 alone.
Speaking about the mechanism of solving the problems of Russian oncology, Davydov emphasized three main steps: the adoption of a cancer control program and financing of its activities, the creation of a full–fledged registry of oncopatients, as well as the withdrawal of oncological care from the basic program of the CHI. "The total amount of the CHI Fund is one and a half trillion rubles, and the approximate need for diagnosis and treatment of oncology is 700 billions," explained Davydov. – And if you isolate these funds from the general fund and direct them to a well-tracked system (for example, the "7 nosologies" program), this can radically change the situation. Russian oncology can be successful. But the key to this success is the attention of the top officials of the state to it, the determination of the correct and achievable goals, the building of the management vertical of the oncological service and, most importantly, its priority and adequate funding."
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