Oncological prevention means prediction and prevention of undesirable events in relation to the occurrence and progression of malignant tumours. The preventive doctrine for fighting malignant tumours must be complex and must concern not only the origination and early detection of malignant tumours but also the implications of progression and treatment of tumour illness. Oncopreventive measures can be broken down to four categories or levels:
Primary Prevention
Aims at reduction in incidence of malignant tumours by way of decreasing or better yet eliminating the risk factors having an evincible and direct influence on the formation of malignities. The indicator for the assessment of primary prevention level is the trend in incidence of malignant tumours.
At the current level of knowledge, the following must be supported:
- Fight against smoking, especially among younger age groups and women
- Stop-smoking schemes and programmes for tobacco addiction treatment
- Fight against alcoholism, especially chronic indulgence in spirits consumption
- Protection of the skin against immoderate exposure to sun light
- Eradication of stomach infection by Helicobacter pylori
- Vaccination against hepatitis
- Vaccination against papilomaviruses
- Education towards correct dietary habits and healthy lifestyle, starting at school level
- Analysis and assessment of commercial products as to their potential cancerogenity
- Analysis of the environment and its cancerogenous elements, especially water sources
Secondary Prevention
Is aimed at detection of malignant tumours at early and fully curable stadium. The indicators of its level are: the ratio between localized tumour stages to other more advanced stages and the trend in malignant tumour mortal rate.
It is currently necessary to support or advance upon:
- Screening of breast cancer
- Screening of cervical cancer
- Screening of colon and rectal cancer
- Campaigns for the detection of reprobating melanotic morphs, especially in post-summer season
- Dispensation of individuals with increased hereditary risk of carcinoma occurrence on the basis of family anamnesis, ontogenetic consultation and genetic testing in indicated cases
- Preventive oncological examinations reflecting age-specific oncological risks
- Field-specific precancerosis and early carcinoma detections in stomatology, ORL, pneumology, gastroenterology, gynaecology, urology or haematology
- Pilot and targeted studies aimed at methodology of early detection of prostate cancer
- Pilot and targeted studies aimed at methodology of early detection of lung cancer among risk groups
- Pilot and targeted studies aimed at early diagnostics of liver, bile duct, pancreas and kidney carcinoma
- Pilot and targeted studies aimed at early diagnostics of tumours affecting seniors as a specific group with high oncological risk and limited possibilities of combined treatment
It must be realized that the effort put into secondary prevention can bring good results only if data audit of parameterized records is carried out. Only such programme of secondary prevention that encompasses data audit and also code and payment differentiation of asymptomatic individuals can be assessed as screening.
At the moment only screening of breast cancer exists in the Czech Republic. In the course of this screening, carried out at more than fifty accredited mammodiagnostic units, over a thousand of early breast carcinoma cases are detected annually. Those cases later hold the best prospects for total cure. Information on the rules and results is made public at http://www.mamo.cz. It is one of Czech Republic’s paradoxes that this only successful screening programme must be repeatedly defended from the bottom, especially against Ministry of Health and its leadership. In recent past attempts to lower the quality of screening by administrative means – abolition of accreditation criteria - had to be faced. Currently irrational limits hindering higher participation level of women in the screening programme are being set. According to data provided by NOR (National Oncological Register), in the past years a significant increase of first stage ratio was recorded while breast cancer mortality is falling even though the rate of incidence is continuing to grow.
The share of first stage carcinoma of colorectum and cervix is unfortunately not showing change. The effort to create an organised scheme for timely detection of both of these types of tumours is hampered by numerous organizational weaknesses. Data audit and code separation of screening examinations is missing. When it comes to cervical cancer a consensus on the methodology has yet to be reached, preventive examinations are undertaken and charged by gynaecologists significantly more often but with lower effect compared to countries of reference where incidence and mortality are substantially lower than in the Czech Republic.
The effort of practitioners to devote more attention to preventive oncological examinations is left without support from top ranks of the Ministry of Health and medical insurance companies. The ordinance on preventive examinations is outdated, ill-conceived in general and therefore little respected. The proposal for concept of age-specific oncopreventive examinations based on data on age distribution of tumours in NOR and tabled by Departmental Oncology Institute of Masaryk Memorial Cancer Institute (www.prevencenadoru.cz a www.mou.cz) couple of years ago is virtually without response.
Central and long-term conceptual support for specific pilot projects aiming at expansion of possibilities of early tumour detection is currently tepid and even grant agencies do not view this area of preventive health care organization as sufficiently “scientific.” This is partly due to the absence of continuous and qualified discussion on the subject and lacking information on the part of the often-changing responsible government ministers.
Tertiary Prevention
Aims for timely, and therefore at a treatable stage, detection of possible return of tumour illness after primary treatment and asymptomatic interval. The basic premise for successful tertiary prevention is the recognition of patient responsibility and gradual abolition of dispersive system in which due to the excess of examinations often carried out at different locations the unifying approach to the oncological patient is often disappearing. This often leads to late diagnostics of tumour recurrence, misinterpretations of findings or wrong assessment of further treatment possibilities.
Improvement will not be achieved through creation of new capacities, new laboratory or imaging methods, but primarily through better organization of dispensary care and better communication between professional specialists and practitioners. The name of medical facility and of doctor responsible for dispensarization of the individual oncological patient must become part of the diagnostic and treatment algorithm of every tumour illness. Dispensatory doctor naturally takes advantage of several examination methods and cooperation with other professionals but he integrates all the information into one conclusion for which he is responsible and with regard to which he offers the patient a solution. A principle should be established that in relation to every oncological patient a consultation record of a specialized oncological workplace with suggestion on how to proceed should exist. That should be the case even with patients where cure is not foreseeable and therapy will only be for example symptomatic. Many patients with reoccurrence of tumour illness do not receive active treatment that could save them or at least prolong their life or improve its quality.
Another persisting weakness is secondary prevention in relation to the oncologically ill, particularly the early detection of other tumours than the one for which the oncological patient is dispensarized. Dispensary examinations tend to be concentrated even for years at the previously treated organ and the most common locations for metastases, but the patient often lacks other preventative examinations. As a consequence women after being treated for colorectal cancer do not receive, often for years, preventative mammography, men after being treated for prostate cancer lack examinations for occult haemorrhaging in the stool and so on. So as a result, many oncological patients in reality receive less preventive oncological care than individuals in fine health even though the risk of occurrence of another tumour of different provenience is generally substantially higher than in general public.
In the framework of tertiary prevention, taking advantage of rather economic tools of health insurance companies than simple administrative directions, it is necessary to support:
- Duty to indicate the medical facility and the doctors responsible for the dispensarization of oncological patient after primary treatment
- Duty to consult every case of reoccurrence of a tumour illness in one of 18 certified oncology centres, whatever the expected procedure may be
- Provide the oncological patient dispensarized with one type of tumour preventative examinations for early detection of also other types of tumours, i.e. secondary prevention, being aware of the increased risk of double or triple tumour illnesses in regard to these genetically or by underwent treatment stigmatized individuals.
The quality indicator for tertiary prevention is mainly the period of overall survival of ill with tumours primarily diagnosed in I.-III. clinical stages.
Quaternary Prevention
Stands for the anticipation and prevention of consequences of progressing and incurable tumour illness that can shorten remaining life or reduce its quality. Though we are not accustomed to speaking of prevention in regard to progressed and incurable cases of tumour illnesses, preventative thinking and preventative methods are necessary here as well, in somatic, mental and social aspects.
Secure provision and continuous availability of analgesic treatment and specialized algesiological care must be contemplated even before the pain fully develops. Various derivative actions by endoscopic stentation or operationally must be indicated and carried out before acute stages of impassability arrive. Similarly it is necessary to bear in mind the stability of the skeleton and preservation of mobility of the patient with bone metastases. This could be done through timely targeted radiotherapy or even orthopaedic interventions. It is necessary to solve alimentary measures, psychological and social support on time.
In order to secure quaternary prevention, it is necessary to:
- Accept that preventive thinking and processes concern also cases of tumour illnesses in advanced stages while having only different organizational and medical tools than abovementioned preventive actions related to healthy and successfully cured patients
- Ensure that all oncologically ill with an incurable tumour illness are given the possibility of consulting a specialist algesiologist and oncologist specializing in palliative medicine
- Ensure that according to his individual needs the patient is given timely psychological, spiritual and social support
The quality indicator of quaternary prevention is above all the continuous evaluation of questionnaires on quality of life adjusted to the particular type of illness. Those have to be introduced and evaluated regularly.
