The topic that I have been asked to talk about is:
What happens to women diagnosed with ovarian cancer in Denmark?
How does the Healthcare System in Denmark address the following topics?
• Prevention
• Early Detection (screening)
• Diagnosis
• Management Strategies
• Rehabilitation
• Follow-up visits Prevention
Since it has not yet been discovered what causes this disease, I find it difficult to talk about prevention. The Danes are advised not to smoke, drink moderately, exercise and eat healthy. I very much doubt that any of this can prevent ovarian cancer, but of course this is sensible advice that we all ought to adhere to.
Early Detection
In my opinion here is where the real problem lies. And the Danish healthcare system has not moved very far within the last 10 years.
The disease is difficult to diagnose, and therefore when it is finally discovered it has often reached stage III or IV. The patients in Denmark have to first consult their general practitioner. Although we have centres with doctors working together, there are no gynaecologists attached to these
centres. Therefore the physician will often try to diagnose the patient himself without referring the patient to a gynaecologist. This means valuable time lost. By the time the patient is finally referred to a gynaecologist, several months might have elapsed.
When there is finally a real suspicion of cancer, the patient has a right to be treated according to a new patient plan adopted by the government and implemented in 2009. This plan specifies when which measures should be taken, and within days the patient has had the necessary blood tests taken, has been scanned (MR+ X-ray of thorax/PET-CT/CT ) and has been scheduled for either surgery or chemotherapy. This procedure is not working 100 % yet, but is a good step in the right direction.
Unfortunately, in spite of these measures the disease has had 4 – 5 months to develop since the patient first saw her general practitioner. This is where the problem lies, and this has not changed much over the past 10 years.
Screening
However, if an actual screening of a certain age group of women was introduced, which is the case for breast cancer in Denmark; this might prevent the severe cases of ovarian cancer. Several trials are carried out e.g. in USA (ROCA) and UK (UKTOCS including about 200.000 women; results to be published in 2014) with new screening methods, and in Denmark a screening monitoring group has been established, which is to prepare a survey and evaluation of the Danish possibilities of a screening situation.
Introduction of a screening method for ovarian cancer may have an enormous effect on the outcome of the cases of ovarian cancer.
Diagnosis
The marker CA 125 and various scanning methods are used in the diagnosis for ovarian cancer.
The marker CA 125 is, however, not a 100 % certain method. The CA 125 is also used at follow-up visits to the hospital (follow-ups are carried out every 4 – 5 months over a period of 5 years) in order to ascertain if there has been a relapse of the disease. If the patient’s normal level of the CA125 marker is known, it is actually a rather good marker for follow-up visits.
The actual diagnosis often takes place through an operation or a biopsy.
Management Strategies
If an operation is possible, this will be carried out and is often followed by several sessions of chemotherapy. If an operation is not possible because the disease is too far advanced, the patient will be offered some sessions of chemotherapy before the operation, and then again after the operation.
There are now several different drugs in use for chemotherapy such as paclitaxel, carboplatin, calyx, gemcitabine etc. in various combinations. In the futures a combination of paclitaxel, carboplatin and Avastin may be used.
When the patient has finished her chemotherapy, she is sent home and everybody is hoping for the best. The patient is often not told that there is such a thing as a relapse.
Rehabilitation
A few patients will have a chance of going to a rehabilitation centre, and some municipalities also have initiatives to help rehabilitate patients, but this is still not organized very well.
The Danish Cancer Society
In this respect, I ought to mention the Danish Cancer Society, which is a society working with patient associations all over the country, giving advice and also helping the associations financially.
They carry out research and have telephone lines where patients and their next of kin can call and get advice.
I would now like to talk about the role KIU has played in all of this. KIU was founded in 2001 by women with various types of reproductive cancers. It is an association with voluntary counsellors in many of the offices belonging to the Danish Cancer Society all over Denmark and also at many hospitals. Women with reproductive cancers can call these centres or turn up during the day when the offices are open.
About 500 women are diagnosed with ovarian cancer a year in Denmark. 75 % of these women have ovarian cancer in stage III or IV. Up until 2007 there were 32 hospitals that performed surgery on these patients. Needless to say, some of these hospitals did not have much routine in
operating these often very sick women. It was said that the survival rate of Danish women with ovarian cancer at the time was the same as that of women in Ethiopia. This was most likely a wild exaggeration; however, this allegation got the media’s attention.
In 2007 KIU took the initiative to hold a seminar concerning ovarian cancer at the University of Southern Denmark in Odense.
Several of the leading researchers, surgeons and oncologists came and gave a speech. Among them was a professor from Odense University hospital, Ole Mogensen, who had single-handedly decided to travel to the Mayo Clinic in USA to study their methods of surgery. He discovered that with very extensive operations the women lived longer. He came back and started to introduce this method at Odense University Hospital.
This seminar got a lot of attention from the media – not least due to the comparison of the survival rate of women in Ethiopia with ovarian cancer with women with the same disease in Denmark.
The 32 hospitals were finally reduced to 5 hospitals, though there were many protests from the hospitals that had to give up operating the disease. Gradually, professor Ole Mogensen’s methods of surgery were introduced at the other 4 hospitals, and this increased the life expectancy and survival rate of the stage III and IV patients.
In 2010 KIU held another symposium on ovarian cancer with almost the same prominent
researchers, doctors and oncologists and a few politicians. We were all pleased to learn that things have now improved in Denmark, but there is still a long way to go.
What is still needed is
• Better screening methods so that the disease is detected earlier
• More efficient chemotherapy drugs or other treatment measures
Follow-up Visits
Patients have the right to follow-up visits to the hospital every 3 – 4 months for 5 years. There are plans to change this system, however, and the question is being asked whether these follow-up visits are actually beneficial to the patient. As far as ovarian cancer is concerned, even a cancer- free period of 5 years is no guarantee that the disease might not come back.
Progress
What has the Danish government done over the last 10 years to improve the situation for cancer patients?
Cancer Plan I adopted in 2000 dealing with
• shorter waiting lists and better treatment methods
• Purchase of new screening equipment, scanners etc.
Cancer Plan II was adopted in 2005 dealing with
• Increased focus on the reduction of smoking
• Better organization of the patient’s pathway through the system
• Improvement of cancer surgery
Cancer Plan III was adopted in 2010 dealing with
• Prevention
• Rehabilitation
• Early detection
We can hope that this last initiative (early detection) may lead to a better survival rate and life expectancy for women with ovarian cancer in Denmark.
