Do all cancer patients have the same chances of accessing quality care, regardless of their place of residence, in France, in 2024? The answer to this question is obviously negative. In any case, this is the conclusion reached by the experts from the Academy of Medicine, who recently published a report on the provision of adult cancer care. Despite the progress made over the last twenty years, thanks to the various cancer plans and now the ten-year strategy, “there are difficulties and territorial inequalities in care throughout the care pathway”, they note. Inequalities which particularly affect, of course, patients residing outside the largest urban areas. For all these patients, access to cutting-edge care – which they have every right to expect – remains uncertain. Member of the Academy working group, Professor Eric Lartigau, general director of the Oscar-Lambret Cancer Center in Lille, explains why the situation remains worrying, and how to remedy it. Interview.
L’Express: More than twenty years after the adoption of the first cancer plan, what is your assessment of the reorganizations that have changed the care of patients in France?
Professor Eric Lartigau: Much has been done, and we have made enormous progress. But for the Academy, a certain number of subjects deserve to be explored in greater depth. We note that it can sometimes be complicated for patients to fully understand the different stages of their care, which do not necessarily take place in the same establishments. Real inequalities remain for patients in more rural, less well-resourced areas, where the organization of care, between local hospitals and more specialized establishments, is not always optimal. There are still too many places where the courses are not sufficiently structured.
Not all care can be provided locally, as we know, and patients must be referred to more expert centers, sometimes quite far from their home. This must be explained and organized. However, we realize that this is not always the case.
Does this mean that a certain number of patients do not have access to all the necessary care?
Exactly. Inequalities appear because they will have been initially taken care of in a structure which does not offer all the practices. Unfortunately, if redirection to another hospital, for this or that somewhat specialized procedure, is poorly explained, or poorly supported in the event of economic difficulties, or for reasons of age, patients may refuse them.
Is it not also because some hospitals may be tempted to “keep” their patients, for economic reasons?
Unfortunately, this is indeed the case. This is a limit to activity-based pricing: hospital budgets are valued based on the procedures they perform. This does not encourage patients to be referred to other establishments. As a result, the organization of care is not sufficiently fluid across territories, at least not everywhere. This generates inequalities in care, for access to certain surgical or radiotherapy techniques, or even to innovative molecules, particularly in the context of clinical research. Even today, a significant proportion of patients are not offered the care they need, due to this lack of organization at the regional level.
What are the solutions?
It is up to the regional health agencies (ARS) to recognize that the different structures must establish links and commit to transferring patients according to their needs. Depending on the pathologies and the care required, the pathways must be identified, known and above all contractualized. The agencies issue authorizations to establishments to practice oncology: in this context, they can ask them to commit to referring or welcoming patients who come from other centers.
They don’t do it?
Not enough. But we must see that these developments take place in two stages. The first, which is in progress, is the definition of establishments authorized to practice this or that act. The criteria that existed until now have been reworked by the National Cancer Institute, with the aim of strengthening them, and the ARS are now in the process of implementing them in the field.
Concretely, this means that for cancer surgery, for example breast or ovarian cancer, minimum volumes of procedures have been established: if they are below, hospitals no longer have the right to operate. Once this stage is completed, the ARS will have to use the means at their disposal, regulatory but also economic, to impose these contracts between the different establishments. In most cases, all oncology practices, even the most innovative, are accessible within a radius of 200 kilometers, which is really what we need to offer patients.
Today, this structure only works well at the national level, for the rarest cancers…
In so-called “major recourse” situations, absolutely. Pediatric oncology for example: no more children are treated in a local center today. It may have existed, but it no longer exists. But we are talking about 2,500 patients per year. For common cancers, this network functioning does not exist, or only slightly.
You mentioned the thresholds above which hospitals can be authorized to operate on certain cancers. This is an old question, which had aroused strong resistance. Are these thresholds considered high enough today?
These criteria existed for several years and they have been tightened. For example, for excisions of breast tumors – and we are indeed talking about excisions even though these thresholds have long included simpler procedures such as biopsies – we have gradually gone from 25 to 70 minimum operations per year. And indeed, some experts would like us to reach at least 150 per year. Always for this same reason: we only do well what we do often. There is a direct correlation between the number of procedures performed by an establishment, and by a surgeon, and patient outcomes, including in terms of survival.
Now that this debate has been opened, it will not stop, and the thresholds will continue to increase, even if it takes a little more time. That being said, there is a political reality and a territorial reality that must also be taken into account. Establishments must have time to restructure, redefine their objectives, their positioning, etc. Secondly, transfer contracts between establishments, in one direction or the other (from proximity to recourse and vice versa), could really become enforceable.
But for a certain number of medium-sized establishments, this poses serious challenges: if you no longer have breast surgery, you have fewer surgeons specializing in gyneco-obstetrics, so the maternity unit can also potentially find itself in difficulty. . The risk of a snowball effect is not negligible, and it is the entire job of the ARS to make these delicate decisions. And then, it will be necessary to ensure that the economic conditions of the transfers are there.
How to do it?
Today, if I transfer a patient after having incurred diagnostic costs for example, so that he can have an operation elsewhere, I lose the remuneration linked to the operation and receive nothing in return. The ARS should be able to organize financial compensation between establishments, or better, for the public authorities to establish per-course financing, in which several actors can intervene and be remunerated commensurate with their interventions. It is the role of the Academy of Medicine to draw the attention of public authorities to these issues because as long as this financial question is not resolved, we will see resistance to these developments.
What other subjects do you warn about?
On the pricing of certain oncology procedures, that is to say the remuneration paid by Health Insurance to establishments for these procedures, and in particular surgery. They are undervalued today, and we are losing money on all the surgeries we perform, which is a real problem.
We are also concerned about bed closures due to lack of staff, particularly in hematology departments in larger cities. Leukemia and lymphoma are therapeutic emergencies, and if patients cannot be received at the right time due to lack of available beds, there is a real loss of opportunity for them. This is, for the Academy, a real matter of concern.
You also point out the lack of effectiveness of screening and prevention policies: for what reasons?
Take organized breast cancer screening. We are unable to reach more than 40 to 50% of the population concerned, despite all the efforts made by a multitude of actors. However, when you carry out screening campaigns, the objective is to improve the survival of the population screened, which is not the case today for breast cancer. All studies show that to achieve this objective, 80% of the target population would need to be screened. As we are far from it, our policy is not effective and we give arguments to those who criticize this screening. We absolutely need to change gear. The same goes for vaccination campaigns against the HPV virus. [NDLR : papillomavirus] responsible for various cancers, particularly that of the cervix. Vaccination rates among adolescents are not taking off, and we can see that it will take more than a few radio campaigns, which are nevertheless essential, to achieve the objectives that have been set.
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