Lung cancer policy & care in the Netherlands

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1. Introduction

In the twentieth century, there have been enormous changes in the field of health and healthcare in the Netherlands. Since the introduction and acception of technologies as x-radiation, pacemakers and the heart-lung machine, a huge improvement of healthy(Centraal Bureau voor de Statistiek, 2014a) and regular life expectancy has presented(Centraal Bureau voor de Statistiek, 2014c). The great disadvantage of the urge to get older and older, is that high age also is a main risk factor of cancer(A.M. Gommer, 2014; Merck Manual, 2003d).

Cancer has grown to the most lethal disease in the Netherlands, with around 43.000 deaths per year(Centraal Bureau voor de Statistiek, 2013). Furthermore, the incidence rate in 2011 was around 100.000 cases(A.M. Gommer, 2014). It can form almost everywhere in the human body, resulting in many different types of cancer, and most of them having different specific characteristics. As there are so many different types of cancer, the disease is hard to cure, which can be backed by the high mortality rate. Cancer does also cost an enormous amount of funds. The expenditures on cancer in 2010 were 5,3% of the total costs of dutch healthcare(A.M. Gommer & M.J.J.C. Poos, 2014b).

The origin of cancer is found in mostly one cell(Merck Manual, 2003c). When a cell loses his normal regulatory mechanisms, which is caused during cell division by a change in the DNA-structure of a cell, abnormal growth mechanisms can become activated. This process causes a constant growth and cell division, which takes place faster than it normally would(Merck Manual, 2003b). Consequently, a cell clump will develop, increasing in size, causing an increasing chance of metastasis(Merck Manual, 2003c).

As said earlier, age is a great risk factor of cancer. In the United States of America, around 60% of the people who have cancer are older than 65 years(Merck Manual, 2003d). Genetics is also an important risk factor(Merck Manual, 2003d). The presence of so called tumour-promoting gens in DNA can raise the chance on developing cancer. For example, the presence of BRCA1 or BRCA2 can cause a six until eight times higher risk on developing breast cancer in women(Radboud UMC, n.d.). Lifestyle is also an important risk factor(Merck Manual, 2003d). Drinking too much alcohol can increase the chance on cancer in the oesophagus and liver, while eating too much fat can increase the chance on colon-, breast- and prostate cancer. Another lifestyle risk factor is smoking. One of the cancer types which get a highly increased risk because of smoking is lung cancer(Merck Manual, 2003d), of which 80 until 90% is caused by smoking(Merck Manual, 2003a).

Lung cancer is, as it is quite clear in itself, the form of tumour cells in the lungs. This causes the lungs’ function to deteriorate severely, since the tumour cells kill normal lung cells and multiply themselves in their place. When the tumour is still small, a patient will not notice much of it, which makes early detection hard(Merck Manual, 2003a).

Lung cancer has a large prevalence in the Netherlands. In 2011 there were around 20.000 lung cancer patients in the Netherlands, while each year around 12.000 new patients develop the disease(A.M. Gommer & M.J.J.C. Poos, 2014a). Lung cancer is the cancer with the largest burden of disease in the Netherlands. With other diseases included, Lung cancer comes on the sixth place with 169.120 disability-adjusted life-years (DALY) lost(A.M. Gommer & M.J.J.C. Poos, 2014a). This is mostly caused by the high death rate – each year, around half of all lung cancer patients, around 10.000, die(A.M. Gommer & M.J.J.C. Poos, 2014a). As these numbers suggest, lung cancer has a high impact on society, as it is very lethal. Because of this, the focus of lung cancer control in the Netherlands is on prevention.

That is why in this essay the Dutch policy on prevention of lung cancer will be described and evaluated. Besides the care of people with lung cancer, how lung cancer care is financed and what the economic impact is will be shown.



2. Smoking and lung cancer prevention

There are several methods used in the Netherlands to prevent lung cancer. In this paragraph, the Dutch anti-smoking policy is described, aswell as the prevention of other risk factors of lung cancer. Furthermore, the accomplishments of these policies will be evaluated and the last part will be about financing the policies.

Anti-smoking policy
As stated before, one of the main causes of lung cancer is smoking. Apart from ‘normal’ smoking, passive smoking or second-hand smoking can be a cause of developing a lung tumour(J.A. Burgers, 2014). For that reason, the Dutch anti-smoking policy is not only aiming to stop people from their smoking habit, but also to prevent the youth to stop smoking and to protect non-smokers from exposure to tobacco smoke(M.M. Harbers & D. Segaar, 2013).

The anti-smoking policy is to be achieved by four methods, which will be explained now. Firstly, legislation is a powerful means used to achieve the previously stated aim. In the Netherlands, the ‘Tabakswet’ (Rijksoverheid, n.d.), the tobacco law, is a powerful means to discourage smoking. The law describes for example that smoking is not allowed in any public space including restaurants and pubs, and that smoking is prohibited at work. Furthermore, it states that tobacco cannot be sold to minors and that most forms of advertising for tobacco is prohibited. Violation of this law results in high fines which can cost up to 4.500 euros for individuals and up to 45.000 euros for firms(Nederlandse voedsel- en waren autoriteit, n.d.-a, n.d.-b). Next to fining, duties are levied on the purchase of tobacco. Currently, §3,31 from the §6,00 of a pack of cigarettes are duties(Jellinek, n.d.).

The second method for discouraging the use of tobacco is education. The use of education is practised in the way of executing national campaigns, the use of informational websites, and setting up school education programs. The goal of all this, is to decrease the amount of smokers and to protect non-smoking citizens by informing them about the impact of smoking on health(M.M. Harbers & D. Segaar, 2013).

The third method is signalling bad smoking behaviour, giving advice about certain behaviour and giving a helping hand to people who want to quit smoking. To reach this, a complete treatment was developed, which can be practised in a multidisciplinary team of general practitioner, nurse practitioner and specialist. Besides, the psychological and pharmaceutical healthcare around quitting smoking is fully compensated by the health insurer(M.M. Harbers & D. Segaar, 2013).

The last method is to influence the social and physical environment of smokers, since a smoking social environment can push fiercely to maintain the bad smoking behaviour. Also for the physical environment, smoking can be very unhealthy(M.M. Harbers & D. Segaar, 2013). That’s why an intervention was started about children growing up in a smoke-free environment. The main goal of this intervention was to educate parents about the possible threat to children with their bad smoking behaviour.

Other preventative actions
Not only smoking can increase the risk of lung cancer. Asbestos, for example, also was a main cause of the development of it. Asbestos was a widely used building material, which has now been banned due to the hazardous impact on the lungs. The bottleneck of it, is that a asbestos contamination can only have its presentation in the form of lung cancer over decades later(W.P. Jongeneel, R. Bogers, & P.H. Fischer, 2014). Since many buildings still contain asbestos, lung cancer due to asbestos appears, albeit in less numbers(H.F. van der Molen, M. van der Noordt, Eysink, R. Bogers, & P.H. Fischer, 2014).

As said earlier, another risk factor of lung cancer is genetics(J.A. Burgers, 2014). Some people have higher chances to develop lung cancer, due to their genome. However, since there is no way of preventing additional cases of lung cancer through genetics yet, no preventive measures are and can be taken against it.

Accomplishments
However, despite all these different ways of taking away important risk factors of lung cancer in society, no relieve in number of diagnosed lung cancer is reported(Integraal kankercentrum Nederland, 2012). However, a vast decrease in smokers in the Netherlands has shown(Centraal Bureau voor de Statistiek, 2014b). The reason for this is that smoking cessation does not have an immediate effect on the decrease in lung cancer. A large study in the United Kingdom(Peto et al., 2000) has shown that the earlier one quits, the less cumulative risk on long cancer one has.
Knowing this, we can assume that quitting is a favourable outcome for the Dutch smoking prevention policy. So here the question arises what are the effects of Dutch anti-smoking policy?

First of all, the effects of legislation on tobacco use cannot be supported by numbers, but there have been studies which state that a smoke-free working environment lowers the tobacco-consumption of smokers and causes a higher success rate of stop attempts(Fichtenberg & Glantz, 2002; International Agency for Research on Cancer, 2009). Another study researched the effect of duties on the smoking habit. It seemed that raising duties is an effective way for decreasing the amount of smoking. The study has shown that a 10% duty raise, can produce 60.000 quitting individuals, lowering the smoking prevalence by 0,5%, and with that achieving 34.000 quality-adjusted life years (QALY)(van Baal, Brouwer, Hoogenveen, & Feenstra, 2007).

As for education, secondly, some programmes were more successful than others. It is said that the differing knowledge of the campaigns are mostly due to the differences in available budget(M.M. Harbers & T.L. Feenstra, 2014). A national quitting-campaign with a high budget gained a publicity of 88% and caused 1,1 until 1,4 attempts to quit, of which 25% were still successful after a year(G. Nagelhout, M. Willemsen, B van den Putte, M. Crone, & H. de Vries, 2009). Educational campaigns on schools have shown less successful results. A study has shown that they delay the starting age of smokers at best, and cannot prevent smoking youth at all(M. van den Berg & C.G. Schoemaker, 2010).

Third, the medical care around smoke-quitting is effective but not very popular. Several studies have tested the effectivity of the medical care programme and say that quitting is more likely to take place when undergoing a medical programme(M.M. Harbers & T.L. Feenstra, 2014). Other studies have shown that insurance-coverage, as is the case in the Netherlands, show higher quit-rates and show high health gains(T. Feenstra et al., 2005).

Fourth, the campaigns which effect social and physical environment were quite effective. The campaign on creating a non-smoking social norm, raised the norm for people to smoke outside from 74% of the people to 83%. The campaign on not smoking in the presence of children was not effective; the percentage of people who said they wouldn’t smoke in a kids presence remained 90%.


Financing of preventative measures
Since the prevention of lung cancer translates into the prevention of risk factors of lung cancer, technically no costs are made in favour of prevention of lung cancer. As the costs of prevention of asbestos use are rather political and legal costs, it is hard, if not impossible, to quantify these costs. As for smoking prevention, there is some information available.

In 2007 13,6 million euros was spent on smoke-prevention. On the control of abidance to laws and rules, 1,49 million euros was spent. On farmaceutical alternatives to cigarettes, which are covered by Dutch health insurance, 4,48 million euros was spent(M.M. Harbers & M.C.M. Busch, 2010). The rest was spent on campaigns and education. The costs of medical programmes however, are not available.

The question then arises, is smoking prevention cost-effective? The mentioned interventions were mostly cost-effective. In the Netherlands a norm is accepted that a won QALY may cost at maximum 20.000 euros(M.M. Harbers & T.L. Feenstra, 2014). The rise of duties on cigarettes showed a cost of 5.000 euros per QALY(E.A.B. Over et al., 2014), which is then cost-effective. Some of the school programmes show cost-effectiveness, and others show cost-ineffectiveness, whereas the insurance coverage of medical programmes costs between 4.500 and 7.000 euros, thus being cost-effective.



3. Lung cancer care

When a general practitioner redirects a patient with symptoms to a specialist, and it appears to be lung cancer, the cancer is mostly in a far-developed state(Antoni van Leeuwenhoek - Nederlands Kanker Instituut, 2014d). This makes prevention even more important. If prevention has come too late, however, different treatments are possible. In this paragraph, these treatments will be discussed and afterwards, the financing and costs of lung cancer care will be treated.

Treatments
An often used technique for removing lung cancer tumours is by dissection of the tumour. Especially smaller tumours which have not been metastasized into the body can be cut out of the body. In around 10% until 35% of the cases, a lung tumour can be removed by dissection(Merck Manual, 2003a). However, a dissection has to be performed during an operation, which brings in certain risks like infection possibility, and a long revalidation time(Antoni van Leeuwenhoek - Nederlands Kanker Instituut, 2014b). A chemotherapy is sometimes given after the operation, to make sure that the tumour will be entirely gone(Antoni van Leeuwenhoek - Nederlands Kanker Instituut, 2014b).

Chemotherapy is another possible way for curing a lot of types of cancer, including lung cancer. In chemotherapy, a medicine which inhibits the cell growth in the body’s cells gets injected into the body. With this, cancer cells are not able to develop, but so do normal functioning cells. Due to this, chemotherapy causes a lot of heavy side-effects, explaining why it could be a high burden to patients undergoing this(Antoni van Leeuwenhoek - Nederlands Kanker Instituut, 2014a).

Radiotherapy is the treatment of tumours with radio-active radiation, which is also used as a curative or palliative treatment for lung cancer. With radio-therapy, a specific targeted beam is sent to the exact place of the tumour, causing almost no damage to healthy cells(Antoni van Leeuwenhoek - Nederlands Kanker Instituut, 2014e). Also radiotherapy is sometimes combined with chemotherapy(Antoni van Leeuwenhoek - Nederlands Kanker Instituut, 2014a).

A more experimental treatment is called immunotherapy. With immunotherapy is aimed to strengthen the immune system of a patient, so that the body self can destroy the tumour cells by itself. Unfortunately, immunotherapy on its own can hardly cure cancer, and is thus mostly used as palliative care(Antoni van Leeuwenhoek - Nederlands Kanker Instituut, 2014c).

After the undergone treatment, of course, there is also recovering and revalidation time needed for the patient. Especially after an invasive operation, this time might be substantial. At the other therapies, the impact on health might not be as direct as with an operation. It also depends on each patient how bad the symptoms are presenting(Antoni van Leeuwenhoek - Nederlands Kanker Instituut, 2014a). This means that it depends on each patient whether it can recover at home or in hospital.

For palliative patients, the health care might be even more intensive. First of all, it is because of the palliative therapy which is still given in most of the cases, and second of all because of the long hospital stay, as palliative patients need more intensive care.

Financing of lung cancer care
In the Netherlands, there is a social health insurance system, in which every citizen is obliged to buy a health insurance. The fee a citizen has to pay depends on the income and capital, so poorer people have to pay less than more affluent people. This system makes health care open to everyone.

This means that in lung cancer care most treatments are being covered by health insurance.
Which treatments are covered, is determined by the government. Because of this, treatments with too little evidence of effectivity or too expensive treatments are not covered, and thus almost never used(L. Hakkaart- van Roijen, S.S. Tan, & Bouwmans, 2010). Especially immunotherapy is still being developed a lot, as it is a young technology. This causes some immunotherapies not to be covered yet.

Technologies used in treatment for lung cancer are often expensive. Chemotherapy for example can cost from 3.000 euros up to 15.000 euros (Universitair Medisch Centrum Groningen, 2014). However, this includes the whole treatment by nurses, the injection of the medicine, the care for the patient, and any material or organization costs of the hospital or hospital department. As most of the times more than one chemotherapy is needed, these costs can get higher and higher. Apart from technology costs personnel and hospital availability costs also have to be paid, which is done directly through the Dutch health department.

After all, In the Netherlands in 2011 the costs for lung cancer care were 401 million euros, of which 330 million euros went to hospital and specialist care(M.J.J.C. Poos, 2014). This amount is 8,4% of the total spendings on cancer care, and 0,4% of the total Dutch healthcare costs(M.J.J.C. Poos, 2014). Assuming that the costs of medical prevention programmes is included in the total costs for lung cancer care, the calculation can be made what the total costs of lung cancer prevention and care costs. In total, these costs will be 417 million euros.

As stated in the introduction, 80% until 90% of lung cancer is caused by smoking, and thus that same percentage is caused because of an individual’s choice of committing to a bad habit. This does also mean that around that same percentage of costs would be unnecessary and could be prevented if smoking was banned.





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This article was written as part of a course for the BSc Health Sciences.