‘Let’s put our heads together!’ Assoc. Prof. Arvīds Irmejs on the development of oncological care

What are the key priorities in the new oncological care plan?

We have discussed this at length, but it is clear that the plan has several crucial aspects. If you were to ask other professionals, they would say that data is the most important thing: without accurate data, planning and precision are severely limited.

All calculations, plans, potential growth, increases in resource planning, and so forth depend on having accurate data. It helps identify which areas are functioning well, where new technologies or additional funding are needed, and where funding isn’t used effectively. In such cases, it can be reallocated. It's similar to planning a family budget: we need to understand our monthly income, what we can or cannot afford, and what our specific needs are.

It may seem strange, because oncological planning is about patients and they should come first, but we cannot actually help patients and use our resources effectively until we have the data.

What contribution is Rīga Stradiņš University making to improving oncological care?

I would say that the University’s contribution is immense! Perhaps I have only realised this in the last few months, because apart from the fact that the Institute of Oncology and Molecular Genetics has long been a primary centre for oncology research, focusing on various tumours, including hereditary ones, the Institute of Public Health also contributes significantly to oncology research.

The Institute of Microbiology and Virology conducts important research in the field of oncology. Prof. Ivars Vanadziņš and I have spoken with the Institute of Occupational Safety and Environmental Health. They also have facilities and human resources.

After Midsummer, we organised a major international conference on breast cancer and hereditary breast cancer. We plan to meet with one of the lecturers to discuss collaboration, focusing on the influence of various environmental and harmful factors contributing to the development of oncology, potential interventions, and strategies to minimise these harmful effects.

How can we shift the perception of cancer from a fatal disease to a chronic condition?

If we talk about breast cancer, around 1,200 women are diagnosed annually, but the latest data from the cancer registry shows that 14,000 women survive treatment. Simple math would mean that with 1,200 diagnoses and 14,000 survivors, most women can effectively manage or even cure their condition. Treatment options are improving all the time and the number of survivors increases each year.

Why is public health awareness essential for cancer prevention?

It is not only breast cancer that has very good treatment results, but also prostate cancer with over 1,000 cases diagnosed annually. Many other common oncological diseases respond well to treatment. Working in a hospital and seeing various conditions (e.g., autoimmune diseases) that lack effective therapies, young people are also at risk of dying, because medicine hasn't yet found a solution. There are many other diseases that are much more dangerous, much more difficult to cure. In most cases, if cancer is detected early, it is not the most dangerous problem people face today.

There are two more factors – early diagnosis is essential, but prevention is even more effective. While we can't entirely prevent cancer through lifestyle changes, adopting a healthy lifestyle and strengthening the immune system significantly reduce the risk. If a person leads a healthy lifestyle and has a stronger immune system, their chances of being able to combat cancer cells are greater.

In Europe, a pilot project is currently underway to detect lung cancer early by combining CT scans with blood biomarkers. This initiative targets smokers specifically. Smoking is a well-known risk factor that increases the risk of developing cancer tenfold, particularly with high intensity and long duration of use. And it is a fact that each and every one of us can choose what we do or do not do for our health. Interestingly, in Norway, people visit a cardiologist seven times less often than in Latvia. Why is that? They are active, they devote enough time to physical rest and mental and psycho-emotional relaxation and recharging. What works for cardiovascular health also works for cancer prevention. It is clear that public awareness of screening is important, but awareness of a healthy lifestyle comes first. The best thing you can do is to help yourself.

What successes have emerged from the implementation of the previous oncological plan over the past three years?

Looking at the past three years, when the previous oncological plan was implemented, the breast reconstruction programme is definitely a success story. The public voted through the manabalss.lv platform, and the initiative was pushed at the political level. Also, the organisation of cancer patients has really succeeded over the three years, thanks to this activity and the cooperation between the Ministry of Health and the Latvian National Health Service. I wouldn’t say that something is lacking. However, challenges persist within the broader healthcare system, such as a shortage of anaesthesiologists, nurse anaesthetists, and surgical nurses, which impact the wait times for breast reconstruction surgeries. Access to innovative medicines is also improving. There has certainly been significant progress.

Speaking of palliative care, there is the hospiss.lv programme for palliative care at home initiated by the oncology council. This is an important step. There are also smaller steps in various areas, such as the introduction of patient coordinators who guide oncology patients through their time at the cancer ward. After they enter, patients no longer have to worry about how to make an appointment for an examination or where to find it – a doctor prescribes an examination and the patient coordinator tells the patient the time and place and brings the results back to the doctor. The patient is always informed about the next step. They don’t leave asking what they need to do next.

These are the main things I would like to highlight. I also definitely want to mention the genetic testing done within the rare disease programme in collaboration with the Children's Clinical University Hospital (CCUH) over the past three years. Although the tests are performed under the rare disease programme, this programme also includes an oncogenetics section, which is implemented by CCUH. Thanks to this, it is possible to determine if a patient’s breast cancer developed due to a pathogenic change or a mutation in their genes. If this is the case, a new innovative drug for the BRCA1-2 gene mutation was approved on 10 May this year. This brings us to personalised, precision medicine. Knowing gene mutations does not only mean precision medicine can be applied to treatment, but also that the patient has clear information about the risk of cancer in the other breast, the risk for ovarian cancer with all preventive measures, and, importantly, the ability to test adult blood relatives who are still oncologically healthy to determine if they have an increased risk too.

This has evolved from the previous oncological plan, where more than 150 oncologically healthy women with the BRCA1-2 gene mutation underwent annual breast cancer MRI screenings at the Breast Disease Centre of the Pauls Stradiņš Clinical University Hospital. This is a personalised screening, unlike the mammogram invitation women receive when they turn 50. But because a gene mutation has been detected in an oncologically healthy woman, she is included in a personalised screening programme.

What do decision-makers need to know when dealing with oncology legislation and funding?

It is a tough task, but in addition to everything that has already been said, there is no need to reinvent the wheel. We should look at examples from particular countries that have succeeded in certain fields.

Slovenia is a very good example; it has a population of about two million, similar to Latvia, and we can compare the territories. The Slovenian principle in screening was very simple: they were taught by the Germans, who were very strict and didn’t allow for deviations. The principle was as follows: they determined that there was a need for 20 screening locations nationwide. Rather than starting screening at all 20 locations to create the appearance of a comprehensive system, they established clear criteria for what would qualify as a screening location. There were around 70 criteria, including the requirement for three radiologist assistants, specific technical requirements for the mammograph, and data transmission, because mammograms are analysed at only two locations in the entire country. In other words, healthcare centres could only apply to conduct mammograms if they met all these criteria. The screening coordination centre would then verify compliance and approve the centre for screening/mammography. This process took many years to complete. The Slovenians now have a perfect success story in mammography screening – they never compromised on quality or system integrity.

In Latvia, when we adopt a Western model, we’ve followed the directions, but it still doesn’t work, so we sit in think tanks and discuss where the problem is. We've seemingly adhered to the instructions, yet something doesn't work. But if we don't fully follow the instructions and do things our way with different levels of understanding of how things should be, and then discuss this in think tanks, it's not efficient, in my opinion.

To summarise, at the end of the day, everyone wants what’s best. One person might suggest changes to the mammography screening process, another might advocate for general practitioners to get more involved, and a third might propose a different approach. But at the end of the day, everything has already been written and the instructions are clear. Until we follow them, it's like assembling furniture. Without a manual, we might wonder why the cupboard is unstable. If we've done everything right, but something doesn't work, then we need to put our minds together.