Estrategia en Cáncer del Sistema Nacional de Salud

Objectives

Spain’s 2021 National Health System Cancer Strategy provides an evidence-based, agreed national framework to improve the effectiveness, quality, outcomes, equity and cohesion of cancer prevention, diagnosis, treatment and care. It updates the Strategy in light of the 2014 evaluation, current epidemiological information and scientific, technological and healthcare advances.[1][2][3][4]Its purpose is to identify cancer-control needs and establish common objectives and care actions for application across the National Health System.[5]

• Promote health and prevent cancer by addressing tobacco, alcohol, diet, physical inactivity, overweight and obesity, ultraviolet radiation, occupational carcinogens, radon and infection-related cancers.[6][7][8]
• Deliver organised, population-based breast, cervical and colorectal screening with quality assurance, equitable access, complete follow-up of positive tests and evaluation of programme outcomes.[9][10][11]
• Improve rapid diagnosis, pathological and molecular testing, precision oncology, timely treatment, multidisciplinary care and equitable access to therapeutic innovation.[12][13][14]
• Strengthen long-term follow-up, rehabilitation, psychological and social support, survivorship care, fertility-preservation advice and palliative care for patients and families.[15][16][14]
• Provide distinct, coordinated care for children and adolescents with cancer, including concentration of care in experienced paediatric onco-haematology units and planned transition to adult services.[17][18]
• Enhance cancer information, population-based registration, research capacity and outcome assessment, including incidence, prevalence, survival, stage, multimorbidity and recurrence information.[19][20][21]

Implementation

Implementation relies on cooperation between the Ministry of Health, Spain’s autonomous communities, the National Institute of Health Management, scientific societies, patient organisations, professional experts and research institutions, under coordination and approval arrangements involving the Interterritorial Council of the National Health System.[1][22]The Strategy combines population prevention, organised screening, networked multidisciplinary services, reference-centre arrangements, information systems, research and formal monitoring to promote consistent care while allowing regional delivery.[5][23][24]

• Coordinate governance through a Technical Committee, an Institutional Committee and a Monitoring and Evaluation Committee, with scientific and technical coordination provided through the Ministry of Health.[22][25]
• Implement prevention through intersectoral Health in All Policies action across health, employment, education, urban planning, environmental and transport sectors; link primary-care counselling to community resources and public information.[26][27]
• Operate screening through organised programmes that identify and invite eligible populations, provide testing, investigate positive findings, ensure treatment access and monitor coverage, participation, detection and quality.[9][28]
• Organise care through hospital tumour committees and multidisciplinary units, shared primary and specialist-care pathways, case-management roles, shared electronic records and coordinated referral arrangements.[29][30][31]
• Concentrate rare tumours and highly complex procedures in designated regional reference units and National Health System Centres, Services and Units of Reference, while using networks to limit travel to cases where referral is medically necessary.[32][23][33]
• Strengthen paediatric governance through an autonomous-community coordination committee, designated paediatric onco-haematology units, regional networks or cross-regional referral agreements, multidisciplinary teams and continuity from diagnosis through transition to adult care.[17][34][35]
• Use population-based registries coordinated through the Spanish Network of Cancer Registries, the Spanish Registry of Childhood Tumours, National Health System information systems, surveys, hospital data and clinical audits to support planning, surveillance and research.[36][19][24]
• Monitor delivery through indicators covering risk factors, vaccination, screening, referral and diagnosis intervals, treatment initiation, hospital outcomes, tumour-committee review, paediatric service capacity, survival, equity and cancer-research funding.[24][37][38][39]
• Apply stated performance standards where specified, including at least 70% participation in breast and cervical screening, at least 65% colorectal-screening participation, 90% compliance with key rapid-diagnosis and treatment-time thresholds, and 100% availability targets for several screening, multidisciplinary-care and paediatric-care structures.[10][31][40][28]

Monitoring & Evaluation

Monitoring and evaluation are integral to Spain’s National Health System Cancer Strategy, combining a Monitoring and Evaluation Committee, National Health System information-system data, autonomous-community reporting, audits, questionnaires agreed with the Committee, cancer registries and targeted surveillance programmes.[22][24]The Strategy was updated following the 2014 evaluation and review of scientific evidence.[3][4]

• Measure prevention through population surveys and registries, including diet, physical inactivity, alcohol and tobacco use, occupational asbestos exposure, radon, and hepatitis B and human papillomavirus vaccination coverage.[24][41]
• Monitor breast, cervical and colorectal screening through invitation coverage, participation, detection and test-result indicators, using National Health System and autonomous-community programme information systems.[42][43][37]
• Require annual screening-programme evaluation reports from autonomous communities and autonomous cities, with an indicative standard of 100% for both information-system availability and annual reporting.[28]
• Assess screening quality across the full pathway, including target-population identification, invitations, tests, follow-up of positive findings and treatment.[9][44]
• Track rapid diagnosis and treatment intervals through audit-based indicators, including first hospital assessment within seven days of primary-care referral, pathological confirmation or exclusion within 15 days, molecular diagnosis within four weeks, and treatment initiation within 15 days for surgery, seven days for systemic treatment and 30 days for radiotherapy.[45][40][46]
• Evaluate multidisciplinary care through the proportion of hospitals with tumour committees, the proportion of patients reviewed by them, documentation of decisions, and clinical audits.[31][47][48]
• Use reference-centre oversight mechanisms, including pre-designation audits and annual monitoring of activity, procedure and outcome indicators for Centres, Services and Units of Reference.[32][49]
• Monitor service quality through hospital outcomes such as stage-specific survival, recurrence and surgical mortality within 30 days or the same admission, with feedback to professional teams and tumour committees.[18]
• Strengthen cancer intelligence through population-based registries coordinated by the Spanish Network of Cancer Registries, with priorities for improved coverage, timeliness, stage, multimorbidity and recurrence data.[19][50]
• Use incidence, mortality, prevalence and survival measures, disaggregated where possible by sex, age, tumour type and autonomous community. Adult survival uses five-year observed and net-survival measures, while childhood monitoring uses the Spanish Registry of Childhood Tumours.[51][52][53][54]
• Monitor childhood and adolescent cancer care through regional coordination committees, designated units, annual case volumes, tumour-committee review, network arrangements, direct access, research participation and continuity of care.[55][56][34][57]
• Assess research through cancer’s share of Health Strategic Action funding, funded projects, average project funding, coordinated and multicentre projects, publications, non-commercial trials and postgraduate training plans.[58][59][60][61][62][63]

Indicators are generally expressed as percentages, ratios, counts or binary yes/no measures, with sources including the Ministry of Health, autonomous communities, the National Statistics Institute, registries, audits and programme records.[24][41][64][65]Although extensive indicator specifications are supplied, the extracts do not set out one consolidated reporting calendar or a single overarching accountability framework for all strategy areas.[14][66][67]

Costing & Financing

The Strategy does not provide a consolidated national cancer budget, detailed costing methodology, quantified funding gap, or economy-wide financing plan.[1][22][25]Financing is instead addressed through selected mechanisms, resource pressures and monitoring priorities.[32][13][68]

• Finance inter-autonomous-community referrals for highly specialised care through the Health Cohesion Fund.[32]
• Identify cancer research as a funding priority through the Carlos III Health Institute, autonomous-community programmes, the Spanish Association Against Cancer and other public and non-profit sources.[20][21]
• Monitor annual cancer funding through the Health Strategic Action, including cancer’s share of total funding, year-on-year change, funded projects and average project funding, without reporting monetary values in the supplied material.[60][61]
• Recognise that the SCReN Clinical Trials Platform has very limited funding.[69]
• Identify a lack of defined financing for implementing precision oncology in Spain, while citing France’s National Cancer Institute-funded network of 20 centres as an international example.[13]
• Recognise that cancer-treatment expenditure is rising faster than treatment costs for most conditions, increasing pressure on health budgets and the resources required for therapeutic innovation.[68]
• Assess clinical benefit alongside cost, affordability, survival, quality of life and toxicity when considering innovative cancer therapies; medicine prices are not necessarily aligned with measured clinical benefit.[68][70]
• Identify smoking-cessation programmes delivered through the health system as cost-effective, while tobacco use generates direct morbidity and mortality costs and indirect productivity and social costs.[71]
• Describe colorectal screening as one of the most cost-effective screening interventions, but provide no programme budget or quantified savings.[72][73]
• Require assessment of cost-effectiveness, diagnostic costs, resource requirements and feasibility before any lung-cancer screening implementation decision.[74][75]
• Call for estimation of the healthcare cost of work-attributable cancer, without presenting a quantified estimate.[8][76]

Additional resource needs are identified for radiotherapy renewal, proton therapy, screening capacity, registry consolidation, psychological and social support, paediatric services and survivorship care, but no allocations, unit costs or funding-gap amounts are specified.[15][19][14][66][67]