'Community oncologists': out of hospitals to ensure continuous care for 3.7 mln patients

The lives of millions of women in the first instance and more generally of millions of patients around the world transformed by the intuition that Milanese physician Gianni Bonadonna had exactly fifty years ago. Who, in synergy with his American colleagues and on the strength of his experience at the Memorial Sloan-Kettering Centre in New York, introduced the 'leap' from the logic of the scalpel - followed until then to remove a tumour - to the pharmacological one. It was this historic turning point that led to the birth of medical oncology in Italia and, today, to treating the disease with over 300 different molecules, including chemotherapeutics, hormone therapies, molecular-targeted drugs and immunotherapeutics. The result: the profound transformation of cancer pathology - which has increasingly gone from acute to chronic - with a demand for services from patients that requires up-to-date and appropriate responses. In terms of organisational models, care settings and professional skills involved, but always keeping the bar straight on the therapeutic relationship that is the first ingredient of care. And so the watchwords become integration between hospital and territory, pathways that have finally been stripped of bureaucracy, and organisational and clinical innovation within the patient's reach. These are the indications coming from the hospital medical oncologists, gathered for the XXX congress in Rome.

It was to this disruptive innovation - officially launched with the publication in 1976 in the New England Journal of Medicine of Bonadonna's study that introduced the first combined chemotherapy schemes in adjuvant treatment, i.e. administered after surgery to reduce the risk of breast cancer recurrence - that the Italian College of Medical Oncology (Cipomo) decided to dedicate a commemorative postage stamp. Because that work, explain the specialists, was "destined to become an international reference and to mark a decisive methodological step: to demonstrate the systemic nature of tumours and the concrete possibility of reducing recurrences, opening up the prospect of a definitive cure for many patients". The personalised Congress cancellation bears the inscription Cipomo 1996-2026, underlining the 30th anniversary of the founding of the College, which was set up to promote the transfer of research results into clinical practice.

'That a medical treatment could cure and heal women who were undergoing surgery was a real revolution for which we have Bonadonna - and with him Veronesi - to thank, who turned the National Institute for Tumours in Milan into a world beacon,' stresses congress chairman Carlo Garufi, director of medical oncology at San Camillo Forlanini in Rome. 'Today we know that the probability of cure for many neoplasms is 50% if not more. In 1996, twenty years after that breakthrough, Cipomo was born, representing the branch that is the backbone of Italian medical oncology, by which millions of people are treated every day. Suffice it to say,' he continues, 'that in Italia there are around 390,000 new cancer diagnoses a year, to which must be added the hundreds of thousands of patients who have previously been treated. And we have the new population of healed patients: their needs require a completely new approach. This is why,' Garufi warns, 'our congress builds a bridge between the oncology of yesterday and all the challenges that await us: from reducing the burden of bureaucracy on physicians, in order to extend the fundamental treatment time in the relationship with the patient, to the necessary enhancement of the synergy with the territory, where adequate pathways must be built that fully include the general practitioner and community homes. A sphere of taking charge that is totally absent today, because oncology is still hospital-centric'.

Forms to be filled in, Aifa forms, personal data, appointments for subsequent examinations: the first oncology visit, which should trigger and enhance the therapeutic alliance with the patient (and caregiver), is 50% taken up by the bureaucratic burden. Administrative activities in fact 'steal' about 19 of the 38 working hours per week of oncologists. However, they consider as much as 90% of these tasks as delegable. The photograph taken of 24 wards in 12 regions by the Cipomo working group on de-bureaucratisation led by past president Luisa Fioretto - presented in Rome at the launch of the partnership with the advocacy group 'Health an asset to defend, a right to promote' - is an opportunity to ask the institutions to strike a blow. Simplifying and standardising procedures, in the face of do-it-yourself that varies from hospital to hospital, are the oncologists' two demands. But we are a long way off, because technology, electronic health records and the use of artificial intelligence are still marking time. As does a still inadequate corporate organisation, which would require - Cipomo warns - the training or recruitment from scratch of non-medical support figures: nurses, OSS or volunteers. 'The clinical value of the oncological visit remains central and irreplaceable: it must be protected,' explains Luisa Fioretto, 'because it is a moment of high clinical intensity, which cannot be reduced and cannot be delegated. For this reason, rethinking its organisation is a system priority. We must separate data collection from its clinical validation. The physician must validate already structured information, not enter it manually during the visit. This means introducing unique pre-visit checklists, digital pre-filling tools and clear processes before entering the clinic. We also need interoperable digital tools, identified and adopted nationwide, with a clear assessment of time, cost and organisational impact'.

Oncologists in community homes, therefore operating in the territory in full synergy with all the professionals who have always lived there, from family doctors to outpatient specialists. In the face of the 3.7 million people living with a cancer diagnosis in Italy - a number that increases by 1.5-2% every year - and considering that a different organisation of care would allow each patient to save about 150 kilometres a year, finally getting integrated care off the ground 'is a challenge that cannot be missed', explains Cipomo president Paolo Tralongo. Hence the 'pact' of the College of Oncology Chiefs with the Federation of Medical Orders (Fnomceo): the result is a five-point proposal, shared with family doctors and outpatient specialists (of the Fimmg and Sumai unions) to be presented to the Ministry of Health and the Agency for Regional Health Services (Agenas).
The recipe is made up of five levers: from the 'single governance' of the oncology networks, entrusted to a regional control room responsible for the entire care pathway, with uniform standards and monitoring of outcomes, to binding Pdta (diagnostic therapeutic care pathways), with clearly defined times and responsibilities. And again, from the full integration of the general practitioner with access to the single oncological medical record and an active role in the follow-up and management of minor problems to care plans structured for long-term survivors, in which follow-up, prevention, management of late effects and support services are defined. In this framework, the oncologist becomes 'transmural': a bridge-figure between hospital and territory, also active in homes and community hospitals. 'We are in transit, not only in Italia but worldwide,' Tralongo concludes, 'and the challenge is not to lose patients in this transition. This is the first document that also bears the signature of general practitioners who are asking to be trained, and we oncologists will be committed to this. Now that the disease is changing its natural history by becoming chronic, the best system for assisting the patient in oncology is the hospital-territory duo, and we ask the institutions to take action'.