Cancer Strategy of the Spanish National Health System 2009

Objectives

The 2009 Cancer Strategy of the Spanish National Health System aims to optimise cancer prevention, diagnosis and treatment, strengthen information and research, and improve services for people affected by cancer in accordance with quality, equity and cohesion. It seeks to reduce the cancer burden and geographical inequalities across Spain while improving health interventions, outcomes and healthcare delivery.[1]

• Address seven strategic lines: health promotion and protection, early detection, adult care, child and adolescent care, palliative care, quality of life, and research.[2]
• Reduce modifiable cancer risks by prioritising tobacco control, healthy diet, healthy weight, regular physical activity, reduced harmful alcohol use, and protection from occupational and environmental carcinogens.[3][4][5]
• Expand organised early detection, including continued biennial mammography for women aged 50–69, cervical screening, and population-based colorectal screening using faecal occult blood testing for people aged 50–69.[6][7][8]
• Strengthen risk-based surveillance, genetic assessment and counselling for people and families with clinically applicable hereditary breast, ovarian or colorectal cancer syndromes.[7][8]
• Improve integrated adult cancer care through multidisciplinary treatment, clinical practice guidance, coordinated follow-up, timely diagnosis and treatment, and reduced unwarranted variation between territories and specialties.[9][10][11]
• Provide comprehensive paediatric oncology care that supports treatment, education, psychosocial wellbeing and survivors’ physical, psychological and social development into adulthood.[12][13]
• Deliver palliative care based on evidence and best practice, adapted to patients’ needs and timing, and coordinated with social care while respecting autonomy and bioethical principles.[14]
• Improve quality of life through psychological support, rehabilitation, nutrition support, management of lymphoedema and ostomies, and assistance with social, employment-related and family consequences of cancer.[15][16][17]
• Consolidate cancer research across basic, clinical, epidemiological, translational and applied fields, with stronger research capacity, networks, tumour banks, registries and links between research and health services.[18][19]

Implementation

Implementation is based on cooperation between the Ministry of Health and Social Policy, Autonomous Communities, the National Health System Interterritorial Council, technical and institutional committees, scientific societies, patient and voluntary organisations, healthcare professionals, research bodies and information institutions. The 2009 update incorporated conclusions from the first evaluation and available scientific evidence.[20][2][1]

• Govern through a Technical Committee that analyses cancer in Spain, defines common strategy lines and objectives, and drafts recommendations, alongside an Institutional Committee representing the 17 Autonomous Communities and the National Institute of Health Management for Ceuta and Melilla that assesses feasibility and appropriateness.[2]
• Coordinate monitoring through the Strategy Monitoring and Evaluation Committee and Technical Secretariat, using information from Autonomous Communities, the Healthcare Information Institute and national health information systems.[21][2]
• Implement prevention through regulatory, fiscal, health-promotion and cessation measures, with tobacco action involving public institutions, healthcare professionals, civil society and international partners.[22][23]
• Organise screening through population-based programmes, common quality standards, defined eligibility and referral pathways, adequately resourced diagnostic and treatment centres, and the Spanish Cancer Screening Programs Network.[6][7][8]
• Provide multidisciplinary adult care through tumour committees or functional units, designated professional contacts, care-management nursing, shared clinical practice guides and annual review of treatment intervals.[10][11]
• Apply timeliness expectations so that diagnostic confirmation for well-founded breast or colorectal cancer suspicion begins within two weeks, while progressively aligning treatment initiation with maximum intervals of two weeks for surgery, one week for chemotherapy and four weeks for radiotherapy planning and delivery.[10]
• Deliver paediatric cancer services through a three-level network linking primary care, regional hospitals, paediatric oncology units and highly specialised reference centres, supported by national protocols, registries and psychosocial and educational support.[24][13]
• Organise palliative care across specialist and primary care, hospitals, healthcare districts, social resources, sociosanitary centres and home care, with each Autonomous Community describing its planned service organisation and facilities.[25][14]
• Support research through hospital-integrated units, accredited Health Research Institutes, the Carlos III Health Institute, cooperative networks and the Consortium for the Support of Networked Biomedical Research, which provides common clinical-trial infrastructure.[26][27][18]
• Measure progress through indicators on risk factors, screening participation and detection, diagnostic and treatment processes, surgery outcomes, paediatric reference units, palliative-care capacity and training, psychosocial and rehabilitation support, mortality, incidence, survival and research output.[28][29][30][31]
• Disaggregate indicator data by gender where possible and use sources including the National Health Survey, hospital records and audits, population-based cancer registries, the National Childhood Tumour Registry, screening networks, the Spanish National Institute of Statistics and Autonomous Community systems.[32][28][30][31]

Monitoring & Evaluation

The Strategy establishes a national monitoring and evaluation approach intended to assess progress against objectives, identify improvement actions and incorporate scientific evidence into subsequent updates. It combines indicator-based assessment with specific information collected through agreed questionnaires, coordinated by the Monitoring and Evaluation Committee.[21][33][28]

• Use the Monitoring and Evaluation Committee, established in 2007, to define the evaluation system, agree information-collection methods and identify reference data sources.[21]
• Collect information from Autonomous Communities and the Ministry of Health and Social Policy through the Health Information Institute under the National Health System Quality Agency.[2][33]
• Use National Health System information systems, clinical-record audits, hospital data, national health surveys, population-based cancer registries, the National Childhood Tumour Registry, the cancer screening programme network and the Palliative Care Strategy as data sources.[28][29]

The first evaluation process began in early 2008 and collected indicator data from Autonomous Communities before the Monitoring and Evaluation Committee approved its report in May 2008. The National Health System Interterritorial Council approved the first evaluation in June 2008; a subsequent full evaluation was planned four years later, with an interim evaluation after two years.[33][34][21]

The indicator framework spans prevention, screening, care, quality of life, palliative care and research. It includes smoking, obesity and alcohol measures; participation in breast, cervical and colorectal screening; diagnostic and treatment timeliness; cancer mortality, incidence and survival; hospital mortality after selected surgery; paediatric oncology reference units; psychological support and rehabilitation; palliative-care capacity, training and research; and research-network participation and publications.[28][29][32][30][31]

• Monitor tobacco prevalence, ex-smoking, smoking initiation and at-risk drinking through National Health Survey data, disaggregated by Autonomous Community and gender where possible.[32][35][36]
• Monitor breast screening through participation, additional examinations, detection rates and population mammography coverage, with annual Autonomous Community reporting for programme indicators.[37][38]
• Monitor colorectal screening through participation, faecal occult blood test positivity, high-risk adenoma detection and invasive cancer detection, with annual reporting by Autonomous Community.[39][40]
• Monitor adult cancer care through audits of multidisciplinary protocols, tumour committees, diagnostic and treatment intervals, clinical-record review, surgical outcomes and conservative breast surgery.[41][42][43]
• Monitor paediatric cancer through the National Childhood Tumour Registry, reference-unit listings and five-year survival, while using registries, tumour committees and clinical trials to support follow-up.[12][24][43]

Population-based cancer registries provide the surveillance infrastructure for incidence, prevalence, survival, early-detection assessment and research on risk factors. Mortality surveillance uses National Statistics Institute data, while international comparisons draw on sources including the International Agency for Research on Cancer and EUROCARE-4.[44][45]Registry data also reveal geographic, sex-specific and temporal variation in cancer burden, supporting assessment of inequalities between Autonomous Communities.[46][47][48]

The Strategy recognises important information gaps. Existing sources mainly describe hospital activity, procedures, citizen surveys and deaths by cause, with limited information on pre-hospital care, primary care, specialist outpatient care, coordination and organisational effectiveness. Computerised clinical records and committee-agreed qualitative criteria are proposed to improve information capture and assessment.[28]

Accountability is primarily exercised through committee review, Interterritorial Council approval, national and Autonomous Community reporting, screening-network evaluation and clinical audits. Indicator data are intended to be gender-disaggregated where feasible, consistent with the requirement to integrate equality into health information systems.[33][7][32]The source does not specify a single comprehensive public reporting timetable or sanctions framework for all strategy lines.[28][29]

Research evaluation uses external assessment, peer review and measures of scientific output, productivity, collaboration and objective achievement. Clinical-trial centres are expected to oversee participant recruitment, treatment, supplementary care and long-term outcomes, reporting data to coordinating centres.[16][26][49]

Costing & Financing

The Strategy does not provide an overall costed implementation plan, total budget, resource-allocation formula or quantified funding gap. However, it identifies material resource needs across screening, radiotherapy, specialised cancer care, psychosocial and rehabilitation services, palliative care, information systems and research infrastructure.[50][7][8][17][19]

• Allocate sufficient diagnostic, treatment, personnel and information-system resources to support population screening, referral pathways, diagnostic confirmation and follow-up, although no monetary requirement is specified.[6][7][8]
• Recognise that colonoscopy is resource-intensive and that high participation is necessary for colorectal screening to achieve population-level cost-effectiveness.[51]
• Address shortages of cancer-specific staff and limited psychosocial, nutritional and rehabilitation resources, alongside the higher economic costs associated with newer diagnostic methods, medicines and treatment strategies.[9][50]
• Provide stable administrative and economic support for cooperative cancer research networks, hospital research units, tumour banks, registries, infrastructure, technical personnel and training.[52][18][19]

Smoking is described as generating substantial healthcare and social costs, alongside economic considerations related to taxation, production and employment. The cited evidence suggests that tobacco-price increases and cessation support can be cost-effective, but the extract does not assign a tobacco-control budget or financing source.[3][22][23]Health-promotion strategies in European Union member states were reported to receive, on average, less than 1% of healthcare expenditure in 1997.[53]

Cancer research funding is identified as a major weakness. Spain reportedly invested 38 million euros directly in cancer research in 2004, compared with a cited European average of 3.9 million euros; the United Kingdom, Germany and France were each reported to invest more than 100 million euros annually.[52]Spain’s investment was reported as less than one euro per citizen and 0.0048% of gross national product, below the cited European figure of 0.017%.[52]

Specified network funding includes annual funding of 6,763,606 euros for the oncology Theme-Based Cooperative Research Network during 2003–2006, 4.8 to 5 million euros in 2007, and 6 million euros in 2008.[54][55][56]International project funding cited includes 30 million euros for the International Regenerative Medicine Alliance, 15 million euros for the Ultrasequencing Platform and 10 million euros for the International Cancer Genome Consortium over five years.[52]

Research proposals call for significant, realistic and stable funding aligned with agreed objectives, but no dedicated financing framework, funding source or quantified resource gap is specified for the wider Strategy.[16][52][18]