Name of subproject:
Oncology prevention and implementation of effective anticancer technologies in Lviv region

Characteristics of the object

Non-communicable diseases are the main cause for the disability and mortality of the population in Ukraine and in the Lviv oblast (cardiovascular, pulmonary, oncological, gastrointestinal diseases and diabetes mellitus).

Malignant neoplasms are on the second place in the structure of mortality in the Lviv oblast - 12.8%, trailing only to cardiovascular diseases - 40.8%. It is noteworthy that in urban areas the proportion of mortality caused by cardiac diseases goes down, and the level of mortality caused by oncological diseases increases, which an evidence of the increase of the risk factors associated with malignant diseases due to lifestyle, harmfulness and the food composition of the residents.

The level of primary disability among adults in the Lviv oblast is highest for malignant neoplasms (7,92 per 10 thousand people), while for ischemic heart disease - 4.92, cerebrovascular disease - 4.98, injuries - 4.41. Among the working population, these figures are the following: for cancer - 6.8, for ischemic heart disease - 4.87, for cerebrovascular disease - 4.11, for injuries - 5,78. Therefore, malignancies cause significant disability of the working population in the oblast and impose the burden on the health care system.

Incidences of malignant tumours in the Lviv oblast have a straightforward dynamics of increase from 1993 to 2013. The level of diseases increased almost by 40% (or more precisely - by 38.1%) and reaches the average value in Ukraine.

Oncological diseases in the Lviv oblast and in Ukraine in general are characterized by high mortality rate due to late diagnosis, significant level of disabilities, and by budgetary funding of palliative care for cancer patients.

In the structure of the morbidity with malignant neoplasms (MN) in the Lviv oblast, the first 7 places are occupied by the following types of cancer: skin cancer, breast cancer, lung, colon, stomach, rectum and prostate cancer, which account for over 50% of all incidences of cancer.

The largest share of deaths from malignant tumours in younger women accounts for cervical cancer (according to the Regional Cancer Registry in the Lviv oblast, as to the death causes, according to the number of deaths from cancer among women aged up to 45 the first place accounts for cervical cancer (21%), the second - for breast cancer (15.6%), the third - for ovarian cancer (11%); with 250 cases of cervical cancer in the invasive stage being detected each year in the Lviv oblast, and about 80% of patients being detected in the I-II stages of the disease. A significant proportion of incidences of cervical pathology is diagnosed in the pre-invasive stage.

It is important to note the dynamics of decline in diagnosis of cervical dysplasia and Ca in situ at the simultaneous increase in the level of invasive cervical cancer which requires more careful monitoring of cytological screening.

Breast cancer is the type of cancer most often diagnosed in women and is the leading cause of deaths from cancer among women. Among the female population it accounts for 23% of the total number of all the detected incidences of diagnosis of cancer, and for 14% of deaths from cancer. Every year over 700 cases of breast cancer are detected in the Lviv oblast.

Significant loss of labour force in the Lviv oblast caused by oncological diseases could be reduced through preclinical diagnosis of certain types of cancer, enhancement of efficiency of antitumour technologies, and through preventive measures. Scientifically proven methods of early detection of cancer are associated with introduction of screening and have been developed on the evidence-based level for cervical cancer and for breast cancer; for this purpose the methodological framework and recommendations for screening have been introduced, for example, European guidelines for quality assurance in breast screening, European Guidelines for Quality Assurance in Cervical Cancer Screening, A Practical Manualon Visual Screening for Cervical Neoplasia.

 Of particular importance in preventive oncology is systemic implementation of the types of oncological screening in order to identify precancerous conditions and early stages of cancer: cytological screening of cervical pathology, supported by information systems for carrying out personalized computerized control over the screening coverage of the population, for mammographic screening of breast cancer pathology.

Cervical cytology screening is conducted on the basis of the Papanicolaou smear taken from the cervix, since just a single PAP test of women aged 35-40 reduces the risk of mortality from cervical cancer by 25-35% («Screening, survival and mortality for cervical cancer», HealthataGlance: Europe2012). Starting with 1960, cervical cytology screening with the use of Papanicolaou test has been introduced in the Lviv oblast. All health care facilities in the oblast conduct gynaecological examinations of women seeking medical treatment and carry out active screening with mobile medical brigades of obstetrician gynaecologists in rural outpatient units and medical and obstetric centres. The data of the female population registered at the units are entered into the "Passport of the unit" in a hardcopy format and according to the results of the analysis, the share of screening coverage in the districts of the oblast does not exceed 50%. In view of the cumbersome paper documentation control and the need for a differentiated approach to the level of screening of women of different age and gynaecological condition, the real state of screening cannot be monitored objectively. Isolation of cytology examination from the primary and secondary levels of the health care sphere increases such complexity of work: delivery of feedbacks on cytology examination result is delayed through hardcopy format documentation.

To improve the results, it is necessary to develop a screening control program (Registry of the female population) and to introduce it to the work of the obstetrician-gynaecological and cytological medical units, to retrofit the oblast-level office for cervical pathology and to impose on it the function of control for cervical pathology screening. It is necessary to merge the obstetrician-gynaecological and cytological units into one functional information structure by means of a computer program for accounting and screening control of cervical pathology.

Mammology screening is intended to incorporate software (Registry of the female population) and human resources of the obstetrician-gynaecological, cytology and oncology medical units. To implement mammology screening it is necessary to equip the Lviv Oblast-level Cancer Facility and oncology departments in Drohobych, Chervonograd and Sambir, at the units of which the qualified mammologist and cytologists are placed, with modern mammography devices; this is required for additional examination and specialized treatment of breast cancer patients. The use of digital mammography for examination of women aged 45-65 with an interval of 2 years will allow to cover 30% of women from the target group with mammography screening during the period of project implementation (currently, mammography screening coverage in the Lviv oblast is below 5%). The use of MRI examination for the patients from the family risk group and for young women aged around 45 makes it possible to set diagnosis of hereditary and family breast cancer more efficiently and accurately even before the occurence of "screening" mammographic period.

Treatment of malignant tumours at the Lviv Cancer Treatment and Diagnostics Centre is mainly focused at tertiary level. The Lviv Oblast-level Cancer Facility is a highly specialized institution, which according to the order of the Ministry of Health care of Ukraine as of 20.12.1996, provides inpatient care and consultation for the population of Lviv, Ternopil, Volyn, Ivano-Frankivsk, Rivne and Transcarpathian oblasts. Every year over 25 thousand new cases of malignant neoplasms are detected in these oblasts. The structure of the centre includes 16 clinical departments (11 Surgical, 3 radiological, a diagnostic-therapeutic department and a chemotherapy department) designed for 540 beds, 130 of which are for radiological department, and 18 - for resuscitation department. There are 3 laboratories in the Centre - (clinical, cytology and a radioisotope laboratory), functional units, units for radiological and instrumental diagnostics (endoscopy, bronchoscopy, ultrasound, radiology, computed tomography, thoracic and urology offices, ECG, echocardiography). The Centre serves as a clinical basis for Danylo Halytsky Lviv National Medical University.

Every year over 18,000 patients receive specialized inpatient medical care at the Oblast-level Caner Facility. Nearly 6 thousand surgeries take place in the Centre on a yearly basis. Over the recent years the number of patients who received treatment is the following: in 2014 - 18,055 of patients, in 2013 - 19,370, in 2012 - 18,680, in 2011 - 17,177, and in 2010 - 15,932 of patients. The number of surgeries performed is the following: in 2014 - 6580, in 2013 - 6373, in 2012 - 5922, in 2011 - 5979, in 2010 - 6351.

There are 152 doctors working at the Centre, 53 of whoь have qualifications of a higher level.

The budget of the institution in 2012 amounted to 40 million UAH. An important contribution to the treatment of cancer patients is being made by the State Program "Oncology", in connection with which the Centre received chemotherapy medication valued at more than 8 million UAH in 2012.

The Lviv oblast-level Cancer Facility has a complete arsenal of radiological equipment to treat cancer patients in Western Ukraine: radionuclide department provides diagnostic and medical care to patients from 20 oblasts of Ukraine. In 2008, a modern apparatus "Teraham" for remote gamma-therapy was introduced. In 2009, the first Clinac linear accelerator was brought into commission in western Ukraine, purchased with state funds by the Ukraine Ministry of Health at a cost of 33 million UAH.  In 2009 another CT device was brought into commission. In 2009 another CT device was brought into commission.

Also, in the radiological department of Lviv Oblast-level Cancer Facility the system of contact radiological therapy of malignant neoplasms has been installed (the system includes IBt-BebigMultiSource, a 20-channel apparatus for brachytherapy, C-arch mobile X-ray device, the planning system with software for planning radiological field); with total value of 4 225 million 455 thousand UAH. Every year around 650-700 gynaecologic oncology patients receive contact radiological therapy treatment in the Lviv Oblast-level Cancer Facility.

Currently, specialists in the Lviv Cancer Treatment Centre have begun to master methods of organ-saving treatment at early stages of breast cancer (radical sectoral resection) and cervical cancer (diathermocoagulation and trachelectomy), but the primary and secondary levels of health care in the Lviv oblast are not able to detect these types of cancer at pre-clinical and early clinical stages (0, stage I and II), which makes it impossible to provide such treatments on a large scale. To improve the situation, it will be necessary to direct more effort both towards diagnosis and toward medical technologies in the oncology sphere in the Lviv oblast.

Materials:
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