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National Guidelines for the Treatment of Breast, Prostate and Colorectal Cancers – summary

These guidelines contain recommendations for breast, prostate and colorectal cancers. The recommendations concern prevention, diagnostics, curative treatments (such as surgery, radiotherapy and drug treatment), nursing and palliative treatment.

The conclusions of these guidelines are based on a group perspective and also contain assessments of the financial and organisational consequences of the recommendations and indicators for monitoring.

A few important recommendations

Multidisciplinary conferences and contact nurses

The healthcare provider should always evaluate different treatment options for patients with breast or prostate cancer, or colorectal cancer, in a multidisciplinary conference. An assessment made through a multidisciplinary conference creates opportunities to provide the best treatment for every patient.

Healthcare providers should also offer a contact nurse to all patients with breast, prostate or colorectal cancers. Follow-up with a contact nurse, who can also provide psychosocial support, is important for the patient's experience and management of their illness and situation. This measure could also shorten unnecessarily long waiting periods.

Breast cancer treatment

It is already standard procedure to give women with stage III and IV (isolated skin metastasis to the breast area) breast cancer drug treatment in preparation for their surgery (also referred to as neoadjuvant therapy). The National Board of Health and Welfare is now recommending that the same treatment be offered to women with stage II breast cancer with aggressive tumours, since it allows for a higher proportion of breast-conserving surgeries.

Healthcare providers should also increase the scope of drug treatment with several drugs before or after surgery or radiotherapy; firmly establishing a reduction in the risk of relapse and mortality, and prolong survival.

To increase the chances of demonstrating whether or not the breast cancer has spread to the axillary lymph nodes, healthcare providers should supplement the diagnostic investigation with sentinel lymph node mapping prior to the initiation of drug therapy or conventional surgery without neoadjuvant therapy. This should be performed because clinical symptoms alone or conventional diagnostic imaging results are insufficiently sensitive and lack specificity.

An example of other important recommendations is for healthcare providers to treat women who have been operated with breast-conserving surgery with hypofractionated radiotherapy. This means that treatment is delivered at a higher daily dose on fewer occasions, compared with conventional radiotherapy, but resulting in the same disease control.

The molecular markers, used for prognostications and therapy selections, in primary breast cancer may alter, if compared with the status in the same patient in the metastatic setting. By taking biopsies from the recurrent patient management will change in about one to seven to one to six patients.

Prostate cancer treatment

The National Board of Health and Welfare recommends that healthcare providers offer active surveillance as the primary treatment option for low-risk or very low-risk prostate cancer. Active surveillance is a method used to identify, over time, cancer that needs to be treated. This means that unnecessary or inappropriate treatments can be avoided.

Healthcare providers should thus avoid offering radical prostatectomies or radical radiotherapy to patients with very low-risk prostate cancer, as there is no research to support that such measures would benefit the patient, and the treatment may entail lasting side effects. Surgery or radiotherapy will primarily be an option in more advanced cancers, or if the cancer is developing more rapidly than expected.

An example of other important recommendations is that healthcare providers should add more treatment options to the curative treatment of high-risk prostate cancer, since there is a great need for early curative treatment. Healthcare providers can also offer palliative drug treatment to patients with castration-resistant prostate cancer. This type of treatment leads to good palliation and to prolonged survival.

Colorectal cancer treatment

One important recommendation is that healthcare providers should offer PET-CT scans in preparation of curative surgeries for patients with colorectal cancers that have spread to nearby organs (locally advanced cancer). This measure should also be offered prior to surgeries for localised relapses or liver metastases. The assessment of the National Board of Health and Welfare is that this measure would entail more effective care, which in the long term can compensate for the cost of the increased number of examinations and the required investments.

Healthcare providers should also operate on patients with colorectal cancers using either open surgery or laparoscopy (keyhole surgery). An increased number of laparoscopic surgeries will require major training initiatives.

New drug therapies for metastatic colorectal cancers that potentially can be resected allow more surgeries to lead to long-term cure. For example, healthcare providers can treat patients who have localised relapses or potentially resectable liver metastasis of colorectal cancer with cytostatic drugs and EFGR inhibitors to facilitate the surgery if the tumour is RAS wild-type or with a triple combination if mutated.

The consequences of these recommendations

In the assessment of the National Board of Health and Welfare, these recommendations signify generally increased short-term costs for the healthcare sector. This cost increase is deemed to be moderate. Some of the costs stem from investment in technical equipment or staff training, and some are the result of increased drug implementation. On the other hand, healthcare providers will be able to reduce some of the initial costs by providing the correct care to the right patient.

It is also the assessment of the National Board of Health and Welfare that several of these recommendations will lead to organisational consequences as they require altered practices or coordination between healthcare authorities. In the long term however, several of these recommendations are expected to result in better and more individually tailored treatments for patients suffering from these forms of cancer, which in some cases will lead to prolonged survival and a better quality of life. It can also lead to lower costs.

However, the National Board of Health and Welfare has assessed that the costs of new drug treatments will increase in both the short and long term.

Follow-up indicators

In connection with the work on these guidelines, the National Board of Health and Welfare has also updated and supplemented the existing indicators from the 2007 guidelines. The indicators are intended to reflect the most important recommendations of the guidelines, as well as different aspects of good healthcare.

Target levels have been set for some of the indicators. The target levels indicate a predefined proportion of patients with a certain condition that should be treated with a certain measure. The target levels provide further clarification of the recommendations, and healthcare providers can evaluate their results in relation to the targets set by the National Board of Health and Welfare.