Unapređenja Kontrole Raka U Republici Srbiji Za Period 2020-2022. Godina

Objectives

The 2020–2022 Programme for Improving Cancer Control in the Republic of Serbia seeks to reduce cancer incidence and mortality, extend life expectancy and improve quality of life during and after treatment through an integrated continuum of prevention, early detection, diagnosis, treatment, rehabilitation, supportive oncology and palliative care.[1][2][3]Its quantified outcome target is to reduce the mortality-to-incidence ratio from 0.49 in 2016 to 0.45 by 2022, including targets of 0.38 for women and 0.52 for men.[4]

• Reduce exposure to modifiable cancer risks, particularly tobacco smoke, harmful alcohol use, unhealthy diet, obesity, physical inactivity, risky sexual behaviour, carcinogenic environmental exposures and infections such as hepatitis B and human papillomavirus.[2][5][6][7][8]
• Strengthen tobacco control through comprehensive smoke-free legislation, regulation of tobacco and novel products, pictorial warnings, cessation support and a new Tobacco Control Strategy.[6][9]
• Maintain high hepatitis B immunisation coverage and establish partial public financing for recommended vaccines, including human papillomavirus vaccination.[8]
• Prioritise organised population-based breast, cervical and colorectal screening, progressively extending it throughout Serbia in preference to opportunistic screening.[10][11]
• Improve access to evidence-based, multidisciplinary diagnosis and treatment, including surgery, medical oncology, radiotherapy, paediatric oncology, molecular and genetic testing, innovative medicines and specialised complex-care networks.[12][13][14]
• Integrate psycho-oncology, rehabilitation, supportive oncology and palliative care to address physical, psychological, social, spiritual and ethical needs of patients and families across diagnosis, treatment, survivorship and end-of-life care.[15][16][17]
• Strengthen cancer research and population-based cancer registration to guide resource allocation, improve treatment quality and support epidemiological and clinical research.[18][19][20]

The Programme is aligned with Serbia’s chronic non-communicable disease planning framework, the World Health Organization and European Commission principles, European guidance on quality national cancer-control programmes, and good-practice guidance for organised screening.[21][22]It adopts a population-based approach that combines health and environmental measures with targeted prevention, risk-based diagnosis, effective treatment and care.[3]

Implementation

Implementation relies on a sustainable, coordinated, comprehensive and team-based national model linking prevention, health promotion, screening, diagnosis, treatment, rehabilitation and palliative care.[1][2]Delivery combines decentralised screening through equipped health centres and secondary- and tertiary-level hospitals with referral to multidisciplinary teams and specialised centres for complex diagnostics and treatment.[10][11][23][24]

• Deliver breast screening for women aged 50–69 using mammography, cervical screening for women aged 25–64 using Papanicolaou testing, and colorectal screening for adults aged 50–74 using faecal occult blood testing followed by colonoscopy where results are positive.[25]
• Organise invitations to eligible populations through health centres, apply double interpretation of screening findings and provide continuing training for radiologists, radiographers, cytoscreeners, supervisors, internists and surgeons.[25][11]
• Expand screening capacity through mammography equipment and staff, centralised cytology laboratories, and continuous procurement of faecal occult blood testing kits.[26][27]
• Establish and finance tumour-specific multidisciplinary teams, centres of expertise, national reference networks and specialist collaboration arrangements, including tertiary support where local institutions lack complete teams.[12][13][18]
• Shift appropriate routine treatment and standard chemotherapy to secondary-level facilities while retaining complex diagnostics, targeted biological therapy, immunotherapy and highly specialised surgery at tertiary level.[14][28][24]
• Strengthen radiotherapy, pathology, radiology, cytology, biochemical, molecular and genetic diagnostic capacity, alongside staffing, clinical pathways and national clinical practice guidelines.[14][29][30]
• Expand home-based palliative care, palliative-care units and beds, provide continuing professional education across all healthcare levels, and maintain access to essential palliative medicines through compulsory health insurance.[31][32][33]
• Operate comprehensive adult and childhood cancer registries using standardised coding, enhanced notification and information-exchange systems, and data collection on tumour characteristics, stage, treatment and survival.[34][35][36]

The Ministry of Health leads designation of national and secondary oncology centres and may delegate implementation monitoring to the Institute of Public Health of Serbia “Dr Milan Jovanović Batut”.[37]The Cancer Screening Office coordinates primary prevention and organised screening, while the Republic Health Insurance Fund is responsible for cancer-treatment funds.[37][38]The Working Group for Cancer Prevention and Control and the Working Group for Prevention and Control of Chronic Non-communicable Diseases coordinate preventive activities.[5]Research planning involves the Ministry of Health, the Ministry of Education, Science and Technological Development and the Republic Expert Commission for Oncology; a Commission for the Use of Innovative Medicines in Oncology is intended to advise on indications and monitor effectiveness in routine practice.[38]

Monitoring uses 2016 or 2018 baselines and 2022 targets, primarily verified by the Institute of Public Health of Serbia, the Republic Health Insurance Fund, the Medicines and Medical Devices Agency of Serbia and the Ministry of Health.[4][39][32][40][33]Key targets include reducing adult smoking prevalence from 37% to 30%, increasing hepatitis B immunisation from 90% to 95%, increasing breast, cervical and colorectal screening coverage to 22%, 45% and 25% respectively, and expanding local government implementation of organised screening from 30% to 45%.[4][39]The Programme also targets a maximum 21-day wait to start systemic antineoplastic treatment and higher proportions of patients starting radiotherapy within 28 days of indication.[39]

National institutions must track each Action Plan measure as completed, ongoing according to plan, ongoing but delayed or not started, alongside expenditure and indicator performance.[41]The Institute of Public Health of Serbia prepares concise annual monitoring reports, while final reporting must assess achievement of objectives, expenditure against results, impact, outcome and output indicators, deviations and corrective recommendations.[41][42]

Financing is intended to combine healthcare-system resources, state budgets, donations and other lawful sources.[43]Health promotion, screening, other secondary-prevention programmes, cancer registries and oncology research are financed from the state budget, while outpatient and inpatient oncology care, rehabilitation and palliative oncology care are financed by the Republic Health Insurance Fund.[38]The 2020 Ministry of Health budget allocated 209,800,000 Serbian dinars to the Programme, including 2,000,000 Serbian dinars for Preventive Health Care and 204,800,000 Serbian dinars for Development of Health Institution Infrastructure.[43]

Monitoring & Evaluation

The Programme establishes an evidence-led cancer-control system combining population surveillance, organised screening monitoring, service-quality assessment and implementation reporting. Its principal outcome target is to reduce the mortality-to-incidence ratio from 0.49 in 2016 to 0.45 by 2022, including targets of 0.38 for women and 0.52 for men.[3][4]

• Maintain the population-based Cancer Registry as a continuous system for recording newly diagnosed cancer cases, tumour characteristics, stage, initial treatment, survival, incidence, prevalence and mortality trends.[19][44]
• Strengthen registry completeness, validity, coding consistency, data linkage and timeliness, using histological or cytological verification, death-certificate-only cases and the mortality-to-incidence ratio as data-quality measures.[34]
• Expand registry content to capture disease stage, treatment received, therapeutic procedures, final outcomes, and one- and five-year survival, addressing current limits on international comparison of diagnosis, treatment and outcomes.[45][36][46]
• Establish a separate national childhood cancer registry covering cancers diagnosed before age 18 and benign central nervous system tumours in children, supported by national reporting, CanReg4 software and internationally recognised coding methodologies.[35][36]
• Use active and passive case finding across hospitals, laboratories, outpatient providers, insurance-fund branches, private providers, death-cause reports and electronic health-information systems, while preventing duplicate registration.[44]

Organised screening is monitored through the Institute of Public Health of Serbia and its Cancer Screening Office, district public-health institutes, programme coordinators and the Ministry of Health.[25][11]Three breast and colorectal screening cycles and two cervical screening cycles were conducted during 2013–2018.[25]Performance evidence includes breast-screening invitation coverage of about 33.3%, mammography coverage of 11.6% and response to invitations of 34.4%; cervical-screening invitation coverage of about 52% and response of 59.9%; and colorectal-testing coverage of 11.2%, with a 52% response rate.[26][27]

• Increase breast-screening coverage to 22%, cervical-screening coverage to 45% and colorectal-screening coverage to 25% by 2022.[4]
• Expand the proportion of local government units implementing organised screening from 30% in 2018 to 45% by 2022.[4][39]
• Monitor tobacco prevalence among adults, aiming to reduce it from 37% to 30%, and raise hepatitis B immunisation coverage from 90% to 95% by 2022.[4]
• Monitor radiotherapy timeliness, targeting treatment within 28 days of indication for 40% of breast and cervical cancer patients, 52% of prostate cancer patients and 57% of lung cancer patients by 2022.[39]
• Track oncology capacity indicators, including surgical institutions, molecular laboratory availability, psycho-oncology services, specialist staffing, innovative-medicine access, clinical-trial participation, registry completeness and palliative-care provision.[32][40][33]

Quality monitoring should assess treatment pathways, multidisciplinary care and waiting times. Proposed indicators include the average time to begin chemotherapy or biological systemic therapy and the proportion of patients starting radiotherapy within 28 days.[45]Clinical guidelines and pathways should be reviewed and updated regularly, particularly because existing guidelines had not been updated during the preceding five years.[30]Hospital-based registries are intended to monitor hospital treatment quality, while the Commission for the Use of Innovative Medicines in Oncology should monitor effectiveness of innovative medicines in routine practice.[19][38]

Accountability is centred on the Ministry of Health, which may revise implementation in response to Institute reports, and on the Institute of Public Health of Serbia, which is expected to issue regular reports on structural and process indicators.[37]National institutions must track implementation status, expenditure and indicator results for assigned Action Plan measures.[41]Annual monitoring reports should classify activities as completed, on schedule, delayed or not started.[41]Final reporting should assess progress towards objectives, expenditure relative to achievements, impact, outcome and output indicators, contextual changes, deviations and corrective recommendations.[41][42]

Costing & Financing

Financing is distributed across the state budget, the healthcare system, the Republic Health Insurance Fund, donations and other lawful sources.[43]State-budget financing covers health promotion, screening and other secondary-prevention programmes, cancer registries and oncology research.[38]The Republic Health Insurance Fund finances outpatient and inpatient oncology care, rehabilitation and palliative oncology care.[38]

• Allocate 209,800,000 Serbian dinars through the 2020 Ministry of Health budget for Programme implementation.[43]
• Provide 2,000,000 Serbian dinars under Preventive Health Care and 204,800,000 Serbian dinars under Development of Health Institution Infrastructure in the 2020 Ministry of Health budget.[43]
• Finance medicinal treatment for eligible patients through the Health Insurance Fund of the Republic of Serbia under List C for innovative medicines.[14]
• Cover essential palliative opioids through compulsory health insurance.[31]
• Enable financial compensation from the Republic Health Insurance Fund for tertiary specialists supporting multidisciplinary teams where local institutions cannot form complete teams.[18]
• Establish financing for human papillomavirus vaccination from other sources by 2022, although no monetary amount is specified.[4]

Major resource requirements include procurement and maintenance of diagnostic and radiotherapy equipment, modern medicines, workforce recruitment and training, multidisciplinary teams, specialist networks, molecular diagnostics, screening infrastructure and expanded oncology services.[12][47][48]Diagnosis and treatment are identified as the Programme’s most expensive component, while equipment maintenance, equipment procurement and treatment provision are major oncology cost drivers.[12][47]

Resources are constrained, requiring prioritisation of interventions that produce the greatest population benefit.[13]Funding and availability gaps include smoking-cessation medicines not covered by the Republic Health Insurance Fund, inadequate payment for tertiary-centre consultations, insufficient innovative biological medicines, and limited access to immunotherapy.[6][14][49]Cancer research is also financially constrained, alongside shortages of human and technological resources.[46]

The Action Plan is intended to identify financial requirements and possible sources for each measure.[48]Existing funds cannot be reallocated for implementation, so resources for the selected option must be planned in budgets over the next three years.[48]Initial implementation is expected to require substantial investment, especially as screening expansion raises demand for diagnostics, biopsy, colonoscopy, pathology, surgery and treatment.[50][48]Cost reductions are anticipated only after several screening cycles, when earlier detection may reduce the need for prolonged and expensive treatment of advanced disease.[48]Longer-term economic benefits are expected through reduced sickness absence, improved productivity and reduced family care needs.[51]

No comprehensive multi-year budget, unit-cost schedule, quantified overall funding gap or detailed economic assumptions are specified beyond the stated 2020 allocation and financing responsibilities.[43]